Scribd Logo
Upload

Welcome to Scribd!

  • Pass Hojaye

    Uploaded by

    shabeershaabdulsalam
    80 views451 pages
    Acute viral hepatitis is more common with hepatitis A. The risk of maternal death with acute fatty liver is related to all of the above. Acute fatty liver of pregnancy is associated with all except dihydrolipoamide dehydrogenase deficiency. After delivery, liver function deterioration of acute fatty liver of pregnancy halts, nevertheless you recommend continued intensive maternal surveillance due to the approximately 20% risk of developing acute pancreatitis in the days after delivery. Acute fatty liver of pregnancy has the capacity to demonstrate the most prominent alterations of normal hepatic, renal, hematological, and coagulation laboratory studies. Hypolipidemia is the only liver-related change that is physiological in pregnancy.

    Original Description:

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    Acute viral hepatitis is more common with hepatitis A. The risk of maternal death with acute fatty liver is related to all of the above. Acute fatty liver of pregnancy is associated with all except dihydrolipoamide dehydrogenase deficiency. After delivery, liver function deterioration of acute fatty liver of pregnancy halts, nevertheless you recommend continued intensive maternal surveillance due to the approximately 20% risk of developing acute pancreatitis in the days after delivery. Acute fatty liver of pregnancy has the capacity to demonstrate the most prominent alterations of normal hepatic, renal, hematological, and coagulation laboratory studies. Hypolipidemia is the only liver-related change that is physiological in pregnancy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    80 views451 pages

    Pass Hojaye

    Uploaded by

    shabeershaabdulsalam
    Acute viral hepatitis is more common with hepatitis A. The risk of maternal death with acute fatty liver is related to all of the above. Acute fatty liver of pregnancy is associated with all except dihydrolipoamide dehydrogenase deficiency. After delivery, liver function deterioration of acute fatty liver of pregnancy halts, nevertheless you recommend continued intensive maternal surveillance due to the approximately 20% risk of developing acute pancreatitis in the days after delivery. Acute fatty liver of pregnancy has the capacity to demonstrate the most prominent alterations of normal hepatic, renal, hematological, and coagulation laboratory studies. Hypolipidemia is the only liver-related change that is physiological in pregnancy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 451

    1.

    Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    sregar
    dingacut
    evi
    ral
    hepat
    it
    isi
    scor
    rect
    ?
    Low-
    gradef
    everi
    smor
    ecommonwi
    thhepat
    it
    isA

    2.Ri
    skofmat
    ernal
    deat
    hwi
    thacut
    efat
    tyl
    i
    veri
    srel
    atedt
    owhi
    choft
    hef
    oll
    owi
    ng?
    Al
    loft
    heabov
    e

    3.Mat
    ernal
    acut
    efat
    tyl
    i
    verofpr
    egnancyi
    sassoci
    atedwi
    thal
    lexceptwi
    thoft
    he
    f
    oll
    owi
    ngr
    ecessi
    vel
    yinher
    it
    edabnor
    mal
    i
    tiesofmi
    tochondr
    ial
    fat
    tyaci
    doxi
    dat
    ion?

    Di
    hydr
    oli
    poami
    dedehy
    drogenase

    4.Af
    terdel
    i
    ver
    y,t
    hel
    i
    verf
    unct
    iondet
    eri
    orat
    ionofacut
    efat
    tyl
    i
    verofpr
    egnancyhal
    ted.
    Nonethel
    ess,
    yourecommendcontinuedi
    ntensi
    vemater
    nalsur
    v ei
    l
    lanceduetothe
    appr
    ox i
    matel
    y20%riskofdev
    elopi
    ngwhichofthefol
    l
    owinginthedaysafterdel
    i
    very
    ?
    Acut
    epancr
    eat
    it
    is

    5.Whi
    choft
    hef
    oll
    owi
    ngpr
    egnancy
    -rel
    atedcompl
    i
    cat
    ionshast
    hecapaci
    tyt
    o
    demonstr
    atethemostprominental
    ter
    ati
    onsofnor
    mal
    hepat
    ic,
    renal
    ,hemat
    ologi
    cal
    ,
    andcoagul
    ati
    onlabor
    atoryst
    udies?
    Acut
    efat
    tyl
    i
    verofpr
    egnancy

    6.Al
    lEXCEPTwhi
    choft
    hef
    oll
    owi
    ngl
    i
    ver
    -r
    elat
    edchangesar
    ephy
    siol
    ogi
    cal
    inpr
    egnancy
    ?
    Hy
    pol
    i
    pidemi
    a

    7.Thi
    simageshowst
    het
    ypi
    cal
    nodul
    ar,
    fibr
    oti
    cappear
    anceofaci
    rr
    hot
    icl
    i
    ver
    .Whati
    s
    t
    hemostcommoncauseoft
    hiscondi
    ti
    oni
    nthegener
    alpopul
    ati
    on?

    Al
    cohol
    exposur
    e
    8.From anet
    iopat
    hogenesi
    sper
    spect
    ive,t
    hepr
    egnancyf
    att
    yli
    verpi
    ctur
    ed
    her
    eis
    anal
    ogous t
    o whi
    ch chi
    l
    dhood
    i
    ll
    ness?
    Rey
    e-l
    i
    kesy
    ndr
    omes

    9.Whi
    choft
    hef
    oll
    owi
    nghav
    ethebestdat
    afort
    reat
    mentofi
    ntr
    ahepat
    icchol
    est
    asi
    sof
    pr
    egnancy
    ?
    Low-
    chol
    est
    erol
    diet

    11.Youarecari
    ngforapregnantpati
    entwi t
    hmi t
    ral
    stenosi
    s.Sheisabletoper
    form
    mostacti
    vit
    iesofdai
    lyl
    i
    vingwithoutsignif
    icantl
    i
    mitati
    on.Onechocardi
    ogram,her
    eject
    ionf
    racti
    onis50%andhermi tr
    alv al
    veareameasures1.8cm2.Whi choft
    he
    f
    oll
    owi
    ngv
    ari
    abl
    esi
    smostpr
    edi
    cti
    veofahi
    ghr
    iskf
    orcar
    diaccompl
    i
    cat
    ionsdur
    ing
    t
    his
    pr
    egnancy
    ?
    Herdegr
    eeofl
    eft
    -si
    dedobst
    ruct
    ion
    12.Whi
    choft
    hef
    oll
    owi
    ngcondi
    ti
    onsusual
    l
    yimpr
    ovesdur
    ingpr
    egnancydue
    t
    o
    pregnancy-
    induced
    hypervol
    emia?
    All
    oft heabove
    13.
    Int
    heUni
    tedSt
    ates,
    whati
    sthemostcommoncauseofaor
    ti
    cst
    enosi
    s
    Bi
    cuspi
    daor
    ti
    cval
    ve

    14.
    Whichofthef
    oll
    owi
    ngdoesnotcont
    ri
    but
    etot
    he40%i
    ncr
    easei
    ncar
    diacout
    put
    seendur
    ingnormal
    pregnancy
    ?
    I
    ncr
    easedl
    eftv
    ent
    ri
    cul
    arcont
    ract
    il
    it
    y
    15.I
    napr
    egnantwomanwhohaspr
    evi
    ousl
    yunder
    goneahear
    ttr
    anspl
    ant
    ati
    on,
    what
    i
    s
    the approxi
    mat
    eri
    sk f
    orsuf
    fer
    ing a r
    eject
    ion epi
    sode dur
    ing
    pregnancy
    20%
    16.
    Whi chofthefol
    l
    owi
    ngt
    her
    api
    esi
    ssaf
    einpr
    egnancyt
    otr
    eatacut
    esupr
    avent
    ri
    cul
    ar
    tachycar
    dia?
    Al
    loft
    heabov
    e
    17.
    Whichofthefol
    l
    owingbestdescr
    ibest
    her
    emodel
    i
    ngoft
    hehear
    tthatoccur
    sin
    nor
    mal pr
    egnancy?
    Eccent
    ri
    clef
    tvent
    ri
    cul
    armassex
    pansi
    onwi
    thspher
    ical
    remodel
    i
    ng

    18.
    Apat i
    entwithaterm gestati
    onandahi
    storyofcr
    it
    icalaort
    icst
    enosispr
    esentsi
    n
    acti
    velabor.Whichofthef ol
    lowi
    ngmanagementstrat
    egiesisadv
    isabl
    ewhilecar
    ing
    forherinherlaborcourse?
    Al
    loft
    heabov
    e
    19.
    Apr
    egnantwomanpr
    esent
    stot
    heemer
    gencyr
    oom i
    nanobt
    undedst
    ate.Shehasa
    fev
    ert
    o102.
    6°F.Onexam,a4/
    6mur
    muri
    snot
    ed,shewi
    thdr
    awsf
    rom pai
    ndur
    ing
    her
    abdominalexam,andt r
    ackmar ksarenotedonherar msandl egs.Herf undal
    hei
    ghtis
    approxi
    matel
    y32cm.Anemer gentechocardi
    ogr
    am i
    sobtai
    ned,whi
    chdemonst ratesa
    mitr
    alvalv
    evegetat
    ion.Whati
    sthemostlikel
    yor
    gani
    sm under
    lyi
    ngherdiagnosis?
    St
    aphy
    lococcusaur
    eus

    20.
    Whatassoci
    atedcondit
    ionthepat
    ientwit
    hanunrepai
    redvent
    ri
    cul
    arseptal
    def
    ect
    ,
    consi
    der
    ingpregnancy
    ,isathighr
    iskfordev
    elopi
    ngbasedonherhi
    story
    ?
    Bact
    eri
    alendocar
    dit
    is

    21.
    Youobt
    ainanechocar
    diogr
    am ont
    hepat
    ienti
    npost
    del
    i
    ver
    yper
    iodwi
    thnew-
    onset
    cardi
    omyopat
    hy.Herej
    ecti
    onfracti
    oni
    sfoundtobe20%withnosi
    gni
    fi
    cant
    str
    uctur
    alorv
    alvul
    ardi
    seasenoted.Whi
    chhormonehasbeenimpl
    i
    cat
    edinthe
    devel
    opmentofthi
    scondit
    ion?
    Pr
    olact
    in
    22.
    Youar ecar
    ingf
    ora28- year
    -ol
    dG1wi t
    hahistoryofmoder atemit
    ralstenosiswho
    presentedi
    nacti
    velaborandisnow8cm di l
    ated.Shedesiresanaturallaborand
    decli
    nespainmedicat
    ionsduri
    nglabor.Ashercontract
    ionsgetcl
    osert ogether
    ,she
    r
    epor
    tsincreasi
    ng pai
    n,i
    svi
    sibl
    y uncomf
    ort
    abl
    e,and i
    nter
    mit
    tent
    ly becomes
    t
    achy
    car
    dic
    to130beat
    spermi nut
    e.Shesuddenl
    ybegi
    nscomplainingofshortnessofbreat
    h
    and
    heroxy
    gensatur
    ati
    ondecli
    nest
    o90%onr oom ai
    r.Whatisyourbestcourseofacti
    on?
    Al
    loft
    heabov
    e
    23. Youobt
    ainachestr
    adi
    ogr
    aphf
    ort
    he30-
    year
    -ol
    dG2P0A1pat
    ientat14
    weeks’
    gestation.Shehasar heumaticheartdiseaseandamechani calval
    verepl
    acementat
    age
    20.Shewaspr eviousl
    yonwar fari
    n7.5mgdai l
    y,butstoppedtaki
    nghermedi cati
    onwhen
    shef oundoutshewaspr egnant.Nowshehasaper sist
    entcoughandshortnessof
    breath.Whi chofthefol
    lowingparamet er
    swouldindicateanextr
    emelyelev
    at ed
    mat ernalandfetalri
    skduri
    ngpr egnancy?
    Pul
    monar
    yar
    ter
    ial
    pressur
    e50mm Hg

    24.Youar
    etheon-
    cal
    lhospi
    tal
    i
    stwheny
    our
    ecei
    veanur
    gentcal
    lfr
    om t
    hepost
    par
    tum
    fl
    ooraboutapatientwhoi scomplaini
    ngofchestpainandshort
    nessofbreat
    h.She
    hadanuncompl i
    catedv agi
    naldel
    iveryt
    hepreviousdayandhasnosigni
    fi
    cantpast
    medicalorsur
    gicalhist
    ory.Youobtainastatchestx-
    ray
    ,whichi
    sshown.Basedon
    thef
    indi
    ngs,whatar eyoumostconcer nedfor
    Car
    diomy
    opat
    hy

    25.Thecy
    tochr
    omeP450sy
    stem i
    sal
    ter
    edbywhi
    choft
    hef
    oll
    owi
    ngdur
    ingpr
    egnancy
    ?
    Al
    loft
    heabov
    e
    26.Lact
    ati
    oni
    scont
    rai
    ndi
    cat
    edf
    orwomeni
    nfect
    edwi
    thwhi
    choft
    hef
    oll
    owi
    ng
    HI
    V
    27.Whati
    sthei
    nci
    denceandr
    ecur
    rencer
    iskofacut
    efat
    tyl
    i
    verofpr
    egnancy
    ?
    1i
    n10,
    000pr
    egnanci
    es,
    andr
    ecur
    rencei
    srar
    e

    28.Ri
    skofmat
    ernal
    deat
    hwi
    thacut
    efat
    tyl
    i
    veri
    srel
    atedt
    owhi
    choft
    hef
    oll
    owi
    ng?
    Al
    loft
    heabov
    e
    29.TheSoci
    etyf
    orMat
    ernal
    -Fet
    alMedi
    ciner
    ecommendedwhi
    choft
    hef
    oll
    owi
    ng
    agent
    sforwomenwi
    thhi
    ghhepat
    it
    isBv
    iral
    loadsi
    npr
    egnancy
    ?
    Tenof
    ovi
    r
    30.Whi
    choft
    hef
    oll
    owi
    nghepat
    icenzy
    mesi
    sincr
    easedi
    nnor
    mal
    pregnancy
    ?
    Al
    kal
    i
    nephosphat
    ase

    31.Whi
    choft
    hef
    oll
    owi
    ngcombi
    nat
    ionsr
    epr
    esent
    sappr
    opr
    iat
    escr
    eeni
    ngf
    orhepat
    it
    is
    Ci
    npr
    egnancy
    ?
    15-
    year
    -ol
    dwomanwhosemotherwasachr
    onici
    ntr
    avenousdr
    uguseranddi
    edofl
    i
    verf
    ail
    ure
    whenthepat
    ientwas4y
    ear
    soldscr
    eenedv
    iahepat
    it
    isCRNA

    32.Whi
    choft
    hef
    oll
    owi
    ngpr
    egnancy
    -rel
    atedcompl
    i
    cat
    ionshast
    hecapaci
    tyt
    o
    demonstr
    atethemostprominental
    ter
    ati
    onsofnor
    mal
    hepat
    ic,
    renal
    ,hemat
    ologi
    cal
    ,
    andcoagul
    ati
    onlabor
    atoryst
    udies?

    Acut
    efat
    tyl
    i
    verofpr
    egnancy

    33.Whi
    choft
    hef
    oll
    owi
    ngv
    iral
    inf
    ect
    ionshasbeenassoci
    atedwi
    thamar
    kedi
    ncr
    easei
    n
    t
    her
    iskf
    ori
    ntr
    ahepat
    icchol
    est
    asi
    sofpr
    egnancy
    ?
    Hepat
    it
    isC
    34.Mat
    ernal
    acut
    efat
    tyl
    i
    verofpr
    egnancyi
    sassoci
    atedwi
    thal
    lexceptwi
    thoft
    he
    f
    oll
    owi
    ngr
    ecessi
    vel
    yinher
    it
    edabnor
    mal
    i
    tiesofmi
    tochondr
    ial
    fat
    tyaci
    doxi
    dat
    ion

    Di
    hydr
    oli
    poami
    dedehy
    drogenase

    35.Whi
    choft
    hef
    oll
    owi
    ngv
    aluesi
    snotanor
    mal
    ser
    um cr
    eat
    ini
    nei
    npr
    egnancy1.
    0

    mg/
    dL

    36.Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    saboutpol
    ycy
    sti
    cki
    dneydi
    seasei
    s:

    10%oft
    hosewi
    tht
    hisdi
    seasedi
    efr
    om r
    upt
    ureofani
    ntr
    acr
    ani
    alber
    ryaneur
    ysm.

    37.Apr
    egnantpat
    ientwhopr
    evi
    ousl
    ydonat
    edaki
    dneyandnowhasonl
    yoneheal
    thy
    ki
    dneyi
    satr
    iskf
    orwhi
    choft
    hef
    oll
    owi
    ngobst
    etr
    iccompl
    i
    cat
    ions?

    Gest
    ati
    onal
    Hyper
    tensi
    on

    38.Whati
    sthel
    eadi
    ngcauseofsept
    icshockdur
    ingpr
    egnancy
    ?

    Py
    elonephr
    it
    is

    39.I
    ncaseofur
    inar
    ytr
    actobst
    ruct
    ionwhatdi
    agnost
    icopt
    ioni
    sthemet
    hodofaf
    ir
    st
    choi
    ce?

    Renal
    sonogr
    aphy
    40.I
    ntheset
    ti
    ngofaggr
    essi
    vef
    lui
    dhy
    drat
    ion,
    whatper
    cent
    ageofpr
    egnantwomenwi
    th
    py
    elonephr
    it
    isdev
    elopacut
    eki
    dneyi
    njur
    y?
    5%

    41.Whi
    choft
    hef
    oll
    owi
    ngcompl
    i
    cat
    ionsi
    snoti
    ncr
    easedi
    npr
    egnantpat
    ient
    swi
    th
    nephr
    oti
    csy
    ndr
    ome?

    Post
    ter
    m pr
    egnancy

    42.Whi
    choft
    hef
    oll
    owi
    ngdoesnotchar
    act
    eri
    zenephr
    oti
    csy
    ndr
    omes

    Hy
    per
    albumi
    nemi
    a

    43.A32-
    year
    -ol
    dnul
    l
    igr
    avi
    dapr
    esent
    sforpr
    econcept
    ioncounsel
    i
    ngduet
    oci
    rr
    hosi
    s
    wit
    hesophageal
    var
    ices.Whi
    choft
    hef
    oll
    owi
    ngshoul
    dbei
    ncl
    udedi
    nyour
    counsel
    i
    ng?

    Al
    loft
    heabov
    e

    44.Thef
    oll
    owi
    ngar
    evi
    ral
    ser
    ologi
    esoft
    hepr
    egnantpat
    ient
    .Whati
    sherdi
    agnosi
    s?

    1.I
    gAAnti-
    Hepat
    it
    isBcor
    eantibody+
    2.Hepat
    it
    isBsurf
    aceant
    ibody–
    3.Hepat
    it
    isBeanti
    gen+

    Chr
    oni
    chepat
    it
    isBi
    nfect
    ion,
    sti
    l
    lact
    ive

    45.A29-
    year
    -ol
    dpr
    imi
    grav
    idapr
    esent
    stoy
    ouf
    orpr
    enat
    alcar
    e.Shei
    sknownt
    ohav
    e
    hepat
    it
    isCwit
    hnoknownr i
    skfactor
    s,andyourprenatall
    absconf
    ir
    m pr
    esenceof
    hepat
    it
    isCRNAandant i-
    hepat
    it
    isCant i
    body.Comparedtoawomanwi thanti
    -
    hepat
    it
    isCant
    ibodywhoi sRNA-negati
    ve,whichofthefol
    lowi
    ngismoreli
    kel
    yto
    compli
    cat
    eherpregnancy?

    Ver
    ti
    cal
    transmi
    ssi
    onofhepat
    it
    isC
    46.A27-
    year
    -ol
    dmul
    ti
    grav
    idacomest
    oyouf
    orherpost
    par
    tum v
    isi
    t.Bot
    hof
    her
    pregnanci
    eswerecompli
    catedbyi
    ntr
    ahepati
    ccholest
    asisofpregnancy
    .She
    desir
    es
    anotherchi
    ldi
    nabout2y
    ears.Whi
    choft
    hefoll
    owingmethodsofcont
    racept
    iondoy
    ou
    recommend?

    Copperi
    ntr
    aut
    eri
    nedev
    ice
    47. Howdoyoucounsel
    theear
    lypostdel
    i
    ver
    ypat
    ientr
    egar
    dingherf
    oll
    owi
    ngv
    iral
    ser
    ologi
    es?

    • I
    gAAnti-
    Hepat
    it
    isBcoreanti
    body+
    • Hepat
    it
    isBsur
    faceant
    ibody–
    • Hepat
    it
    isBeanti
    gen+

    Shehasanacti
    vev i
    rusthatcanl
    eadtoci
    rr
    hosi
    sanddeath,
    andy
    ouwi
    l
    lref
    erhert
    oa
    hepat
    ologi
    stf
    orlong-t
    erm managementr
    ecommendat
    ions.

    48. Apr egnantwomanpr esentswithfl


    ankpain.Sheisafebr
    il
    ebuttachycar
    dicfrom
    pai
    n.Herserum creati
    ninei
    selevatedto5mg/ dL.Imagesfrom hermagnet
    icresonance
    imagingar
    epr esent
    edbelow-hy dronephr
    osi
    s.Whi chofthefol
    l
    owi ngi
    sthebestplanof
    care?

    Per
    cut
    aneousnephr
    ost
    omyt
    ube

    49. A32-year-
    oldG2P0presentsat19weeks’ gest at
    ioncomplai
    ningofbackpainthat
    radi
    atesforward.Sherepor
    tsthatthepainisint
    ense, andshelooksveryuncomf or
    tabl
    e.Shehas
    notbeenfebril
    e.Aur i
    nal
    ysi
    sissignif
    icantonl
    yforredbl oodcell
    s.Animagef r
    om herrenal
    ult
    rasoundisprovidedbel
    ow.Youdi agnosethepatientwi t
    hakidneystone.Whichofthe
    fol
    lowingisthebestmanagementopt i
    onforthepatientatthi
    sti
    me?

    Anal
    gesi
    aandi
    ntr
    avenoushy
    drat
    ion

    50. An18- year-


    oldG1P0pr esent
    sat30weeks’ gest
    ati
    onwit
    hfeverof39oC,
    chi
    l
    ls,
    vomit
    ing,dysuri
    a,andfrequenturi
    nati
    onfor3days.Sheisal
    soexper
    ienci
    ng
    cont
    racti
    ons.Whati shermostl i
    kel
    ydiagnosi
    s?

    Py
    elonephr
    it
    is

    51. Youar econsul


    tedabouta19-year
    -oldpr
    imigr
    avi
    daat18weeks’gest
    ati
    on.The
    pat
    ientwasdi
    agnosedatherfi
    rstpr
    enatalcar
    evisi
    twit
    hasympt
    omat i
    cbacter
    iur
    ia.Her
    pr
    ovi
    dert
    reat
    edherwi
    thni
    tr
    ofur
    ant
    oin100mgt
    wicedai
    l
    yfor7day
    s.Thepat
    ient
    was
    seenamont haftertreat
    ment,andherrepeaturi
    necult
    urewasnegati
    ve.But
    now, a
    uri
    neculturesenti
    nerrorisposi
    ti
    vef
    or>100,000col
    ony-
    for
    minguni
    ts/
    mLgr amnegati
    ve
    rodsagain.Sheremainsasymptomati
    c.Herprovi
    deri
    snotsur
    ewhattodo.Whatisthe
    bestresponsetothisconsul
    t?

    Recur
    renceofasymptomat i
    cbacter
    iur
    iai
    s30%regardl
    essofant
    ibi
    oti
    cregimenandi
    t
    mayindicat
    ecovertuppertr
    acti
    nfecti
    on,
    sotr
    eatthepati
    entwi
    thni
    trof
    urantoi
    n100mg
    bymouthatbedtimef or21days
    52.
    Whi
    choft
    hef
    oll
    owi
    ngphy
    siol
    ogi
    cal
    responsesi
    sty
    pical
    l
    yseeni
    npr
    eecl
    ampt
    icpat
    ient
    s?
    I
    ncr
    easedsensi
    ti
    vi
    tyt
    oangi
    otensi
    nII

    53.Amongfol
    lowi
    ngchoosecor
    rectst
    atementconcer
    ninggest
    ati
    onal
    hyper
    tensi
    on.
    blood
    pressur
    eret
    urnst
    onormalby12weekspostpart
    un
    bl
    oodpr
    essur
    eret
    urnst
    onor
    mal
    by12weekspost
    par
    tum

    54.
    Causeofconv
    ulsi
    oni
    neclampsia
    Cer
    ebral
    anoxi
    aduetoar
    ter
    ialspasm

    55.Whichofthefol
    lowi
    ngangiogenicf
    actor
    sar
    eel
    evat
    edi
    nwomenwhopr
    oceedt
    odev
    elop
    preecl
    ampsia?
    sFlt
    -1(
    sol
    ubl
    ef ms-l
    i
    ketyrosi
    nekinase1)

    56.Bestr
    egi
    menf
    orecl
    ampsi
    ais
    MgSo4

    57.A39-
    year
    -ol
    dG3P2pr
    esent
    sat30weeks’
    gest
    ati
    onwi
    thhy
    per
    tensi
    on,
    prot
    einur
    ia,
    andheadache.Shei sdiagnosedwithsever
    epreeclampsia,
    andinducti
    onoflabori
    s
    i
    ndicated.Herpregnancyiscompl i
    cat
    edbythefetalkar
    yotypeshownbelow.Whatist
    he
    possibl
    eex pl
    anati
    onforherincreasedri
    skforpr
    eeclampsiawiththebel
    owfetal
    karyoty
    pe?

    I
    ncr
    easedant
    iangi
    ogeni
    cfact
    orl
    evel
    s

    58.Thety
    picalbl
    oodvol
    umeofagr
    avi
    daatt
    ermis4500mL.I
    npat
    ient
    swi
    th
    preecl
    ampsia,
    whichoft
    hef
    oll
    owi
    ngwoul
    dbetheexpect
    edbl
    oodv
    olume?

    3200mL

    59.Whichofthefollowi
    ngnut
    ri
    ti
    onal
    suppl
    ement
    shasbeenshownt
    oreducet
    he
    inci
    denceofpreeclampsi
    a?
    Noneofthement ioned

    60.Al
    larefeat
    uresofHELLPsy
    ndr
    omeexcept
    Eosi
    nophil
    i
    a

    70.Whatper
    cent
    ageofpr
    egnanci
    esar
    ecompl
    i
    cat
    edbyhy
    per
    tensi
    on?
    10-20%

    71.Thefol
    lowi
    ngcomputedtomographyi
    mageshowscerebr
    aledemainapostpar
    tum
    pati
    entwit
    hhypert
    ensi
    on,v
    isi
    onchanges,andconf
    usi
    on.Whatassoci
    atedmor
    bidi
    tyi
    s
    thepati
    entatr
    iskf
    or?
    Tr
    anst
    ent
    ori
    alher
    niat
    ion

    72.DOCf
    orhy
    per
    tensi
    oni
    npr
    egnancy
    Labet
    alol

    73.Whi
    choft
    hef
    oll
    owi
    ngi
    sthoughtt
    opl
    ayasi
    gni
    fi
    cantr
    olei
    nthedev
    elopmentof
    pr
    eecl
    ampsi
    a?
    Al
    l heme
    oft nt
    ioned

    74.Whatpr
    opor
    ti
    onofmat
    ernal
    deat
    hscanbeat
    tri
    but
    edt
    ohy
    per
    tensi
    vedi
    sor
    der
    sin
    pr
    egnancy
    ?
    1i
    n6

    75.Whichstat
    ementbestdescri
    besrenalperfusionandglomerul
    arfi
    lt
    rat
    ionr
    atesi
    n
    womenwi thpreecl
    ampsi
    athathasnoty etprogressedtosever
    edisease?
    Si
    milarcomparedtonormalnonpregnantvvalues

    76.Ant
    ihyper
    tensi
    vecont
    rai
    ndi
    cat
    edi
    npr
    egnancy
    ACEinhibi
    tor
    s

    77.Whichoft hefol
    lowi
    ngisnotapathophy
    siol
    ogi
    cal
    changet
    othecar
    diov
    ascul
    ar
    system seeninthesett
    ingofpr
    eecl
    ampsia?
    Incr
    easedpr el
    oad

    78.A19-year-
    oldG1P0womanat39weeks’ gestat
    ionisdi agnosedwi thpr eecl
    ampsia
    basedonbloodpr essur
    eof150/90mm Hgand2+pr oteinuriaonur i
    nedi psti
    ck.The
    pati
    entispl
    acedonmagnesi um sul
    fat
    e,anddevel
    opsflushi ngandf at
    igue.Sheasks
    abouttheneedf orthemagnesi
    um sul
    fat
    e.Youexplai
    nt hatitist opr
    eventt heseizur
    es
    thatmaycompl i
    catepreecl
    ampsiaandmayevencausedeat h.Thepatientaskshow
    seizur
    esassociatedwit
    hpreecl
    ampsiacancausemor t
    al i
    ty.Whi chofthef oll
    owingis
    themostcommonmechani sm?
    I
    ntr
    acer
    ebr
    alhemor
    rhage

    79.A33-
    year
    -ol
    dwomanat29weeks’
    gest
    ati
    oni
    snot
    edt
    ohav
    ebl
    oodpr
    essur
    esof
    150/90and2+prot
    einuri
    a.Theplat
    eletcountandli
    verfuncti
    ontest
    swer
    enor
    mal
    .
    Whichofthef
    oll
    owingisthebestmanagementf orthi
    spatient?
    Expect
    antmanagement

    80.Whati
    stheunder
    lyi
    nget
    iol
    ogyoft
    hepr
    otei
    nur
    iaseenwi
    thpr
    eecl
    ampsi
    a?
    I
    ncr
    easedcapi
    l
    lar
    yper
    meabi
    l
    ity

    81.A21-
    year
    -ol
    dpr
    imi
    grav
    idapr
    esent
    sat36weeks’
    gest
    ati
    onwi
    thnew-
    onsetheadache.
    Herbl
    oodpressureis150/
    90mm Hg, herser
    um cr
    eat
    ini
    neis0.
    8mg/ mL,
    ASTi s32U/L,
    andpl
    atel
    etcountis28,
    000/μL.Whi
    chofthefol
    l
    owingcri
    ter
    iaf
    orsev
    erepreecl
    ampsi
    a
    i
    smet?
    Thr
    ombocytopeni
    a

    82.A29-year-
    oldG1P0womanat28weeks’ gest
    ati
    onisadmi
    ttedtothehospi
    tal
    for
    preecl
    ampsia.Herbl
    oodpressur
    eis150/100mm Hgandherpr ot
    einexcr
    eti
    onis500
    mgi n24hours.Onhospi
    talday7,shei
    sdiagnosedwit
    hsever
    epreeclampsi
    aandt he
    decisi
    onismadet oadmini
    stermagnesium sul
    fat
    eanddeli
    vert
    hebaby.Whichoft
    he
    fol
    lowingfi
    ndingsi
    smostlikel
    ypresentint
    hispati
    entascr
    it
    eri
    aforsev
    ere
    preecl
    ampsia?
    5gofpr ot
    einuri
    aexcret
    edi
    na24- hourperi
    od

    83.A21-year-
    oldG1at36weeks’ gestat
    ionpresentsforhercli
    nicvi
    sitandisnot
    edto
    haveabloodpr essureof148/88mm Hg.Ar epeatbloodpressure30mi nut
    eslat
    eri
    s
    146/92mm Hg.Herbl oodpressur
    esthroughoutpregnancyhav ebeenbelow140/90
    mm Hg.Shedeni esanycomplaint
    s,andurinal
    ysisi
    snegat i
    veforprotei
    nuri
    a.Whati
    s
    themostlikel
    ydiagnosis?
    Gestat
    ionalHyper t
    ensi
    on

    84.Whi
    choft hefol
    lowi
    ngisthebestmanagementofan18-
    year-
    oldG1P0womanat28
    weeks’
    gestati
    onwithabloodpressur
    eof160/110mm Hg,el
    evatedl
    iv
    erf
    unct
    iont
    est
    s,
    andaplat
    eletcountof60,
    000/uL?

    a.Magnesi
    um sul
    fat
    ether
    apyandi
    nduct
    ionofl
    abor

    85.A23- year
    -ol
    dprimigravi
    dapresentswithabl oodpressureof160/ 104mm Hg, 3+
    prot
    einuria,
    andrightupperquadrantdiscomf or
    t.Shehasav aginaldel
    i
    verycomplicated
    bybilater
    alsul
    caltearsandanest i
    matedbl oodlossof1500mL.Shepr oduces110mL
    ofurineinthefi
    rst4hour spost
    par t
    um andherser um creat
    ininerisesfr
    om 0.98mg/ dL
    to1.42mg/ dL.Whati sthemostlikel
    yexplanati
    onf orthi
    sfinding?
    Postpar
    tum hemor
    rhage

    86.A21- year-
    oldpri
    mi gr
    avi
    daat32weeks’gest
    ationhasnew-onsethyper
    tensi
    onand
    protei
    nur i
    a.Sheinqui
    resastowhet
    herornotinit
    iat
    ionofananti
    hypert
    ensiveagentmay
    behelpf ul
    .Whichofthefol
    lowi
    ngcomplicat
    ionsismoreli
    kelywhenlabetal
    oli
    sinit
    iat
    ed
    forpreeclampsia?
    Fet
    algr
    owt
    hrest
    ri
    cti
    on

    87.A24- year-
    oldprimigr
    avi
    dapr esent
    sat37weeks’gestati
    onwithheadache,ablood
    pressureof170/ 102mm Hg, andsever
    eri
    ghtupperquadrantpai
    n.Sheisdiagnosed
    withHELLPsy ndromeandunder goesanuncompli
    catedinducti
    onoflabor
    .Herr i
    ght
    upperquadr antpainper
    sists,andacomputedtomographyscanofherabdomen/ pel
    vi
    s
    i
    scompl et
    edwi ththefi
    ndingsasshownbelow.Whati sdenotedbytheasteri
    sk(*)?
    Subscapul
    arhaemat
    oma

    88.A28-y
    ear -ol
    dG1at38weeks’ gestat
    ionpresentswi
    thcomplaintofcont
    ract
    ions.Her
    bl
    oodpr essureisnot
    edtobe148/ 90mm Hgand152/ 96mm Hg.Shehasaur i
    ne
    pr
    otei
    n:creati
    ninerat
    ioof0.
    4,acreati
    nineof1.04mg/dL(baseli
    ne0.48mg/dL),normal
    ASTandALT,andpl
    ateletcountof110,
    000/
    μL.Shedeni
    esanysy
    mpt
    oms.Whatcr
    it
    eri
    a
    forsev
    erepr
    eecl
    ampsiadoest hi
    spati
    entmeet
    ?
    El
    evat
    edcr
    eat
    ini
    ne

    89.Apat
    ientat28weeksgestat
    ionwi
    thsev
    ereabdomi
    nal
    pai
    n,bl
    eedi
    ngandhy
    per
    tensi
    on.
    Themostli
    kel
    ydiagnosi
    sis
    Abr
    upt
    iopl
    acent
    ae

    90.Pl
    acent
    aisanchor
    edt
    othemy
    omet
    ri
    um par
    ti
    all
    yorcompl
    etel
    y

    Pl
    acent
    aincr
    eta

    91.Pl
    acent
    apr
    evi
    aischar
    act
    eri
    zedbyal
    loft
    hef
    oll
    owi
    ngexcept

    Pr
    esent
    sin1stt
    ri
    mest
    er

    92.Whi
    chmaneuv
    ersbel
    owshoul
    dbeper
    for
    medwhenr
    epai
    ri
    ngacer
    vical
    lacer
    ati
    on?

    Al
    loft
    hement
    ioned

    93.Thepostpar
    tum pati
    entwi
    thsev
    erehaemorrhageaft
    eral
    lnecessar
    ymeasur
    es
    undergoesahyster
    ectomyand5unit
    sofpackedredbloodcel
    lsaregiv
    en,
    butbl
    eedi
    ng
    conti
    nues.Whatisthemostli
    kel
    yeti
    ologyoft
    hebleedi
    ng?

    Di
    l
    uti
    onal
    coagul
    opat
    hy

    94.Whi
    choft
    hest
    atement
    sbel
    owaccur
    atel
    ydepi
    ctst
    hedi
    ff
    erencebet
    ween
    consumpt
    ivecoagul
    opat
    hyanddi
    ssemi
    nat
    edi
    ntr
    avascul
    arcoagul
    ati
    on?

    Al
    loft
    hement
    ioned

    95.Whati
    stheappr
    opr
    iat
    emanagementofv
    ulv
    ovagi
    nal
    hemat
    omas?

    I
    fbl
    eedi
    ngceases,
    smal
    ltomoder
    ate-
    siz
    edhemat
    omascanbet
    reat
    edex
    pect
    ant
    ly

    96.Fr
    om t
    hef
    oll
    owi
    nggr
    aph,
    whi
    choft
    hef
    oll
    owi
    ngst
    atement
    sconcer
    ningmor
    bidl
    y
    adher
    entpl
    acent
    a(MAP)i
    saccur
    ate?

    Thehi
    ghestr
    iskf
    orpl
    acent
    apr
    evi
    aiswi
    thy
    our5t
    hpr
    egnancy

    97.A32-
    year
    -ol
    dwomani
    sseeni
    ntheobst
    etr
    ical
    uni
    tatt
    hehospi
    tal
    .Shei
    sat29weeks’
    gest
    ati
    on,wit
    hachiefcompl
    aintofsignif
    icantv
    aginal
    bleedi
    ng.Shehadastil
    l
    bir
    thwi
    th
    herpr
    iorpr
    egnancyduetopl
    acentalabrupti
    on.Thepati
    entasksthephy
    sici
    anaboutt
    he
    accur
    acyoful
    tr
    asoundi
    nthedi
    agnosi
    sofabr
    upt
    ion.Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    s
    i
    smostaccurat
    e?

    Fet
    alul
    tr
    asoundi
    snotsensi
    ti
    vei
    ndi
    agnosi
    ngpl
    acent
    alabr
    upt
    ion

    98.Whi
    choft
    hef
    oll
    owi
    ngi
    sthemostsi
    gni
    fi
    cantr
    iskf
    act
    orf
    orabr
    upt
    iopl
    acent
    ae?

    Tr
    auma

    99.A25-year-
    ol dwomanat34weeks’ gestati
    onisnot edtohav eapl acent
    aprevi
    a,af
    ter
    shepresentedwi thvagi
    nalbleedi
    ngandhasunder gonesonogr aphy.At37weeks,she
    hasascheduledcesar ean.Uponcesar eansecti
    on,bluishti
    ssuedensel yadher
    ent
    betweentheut erusandmat ernal
    bladderisnoted.Whi chofthefoll
    owi ngi
    sthemost
    l
    ikel
    ydiagnosis?

    Pl
    acent
    aper
    cret
    a

    100.A22-year-
    oldG1P0womanat34weeks’ gestationpr
    esentswit
    hmoderat
    evagi
    nal
    bleedi
    ngandnout er
    inecont
    ract
    ions.Herbl
    oodpr essure(
    BP)is110/60mm Hgand
    heartr
    ate(HR)103beatsperminute(bpm).Theabdomeni snontender
    .Whi
    chofthe
    foll
    owingsequenceofexami
    nati
    onsi smostappropriat
    e?
    Ul
    tr
    asoundexami
    nat
    ion,
    specul
    um exami
    nat
    ion,
    digi
    tal
    exami
    nat
    ion
    101.A24-year
    -ol
    dwomanunder wentanormalvagi
    nal
    deli
    ver
    yofat er
    minfantf
    emale.
    Aft
    erthedeli
    very
    ,thepl
    acentadoesnotdel
    i
    verevenaf
    ter30minut
    es.Whichofthe
    fol
    lowi
    ngwoul dbethenextst
    epforthi
    spati
    ent
    ?
    At
    temptamanual
    ext
    ract
    ionoft
    hepl
    acent
    a

    102.A34-
    year
    -ol
    dwomani
    snot
    edt
    ohav
    esi
    gni
    fi
    cantut
    eri
    nebl
    eedi
    ngaf
    terav
    agi
    nal
    deli
    ver
    ycompli
    catedbyplacent
    aabrupt
    ion.Shei
    snotedtobebl
    eedingfr
    om mult
    ipl
    e
    veni
    punct
    uresi
    tes.Whichofthefol
    l
    owingisthebest(
    eti
    opat
    hol
    ogycal)t
    her
    apy?

    Cor
    rect
    ionofcoagul
    opat
    hy

    103.A23-year-
    oldG1P0womanat38weeks’ gestat
    iondel
    iv
    ereda4.3kgbabyboy
    vaginal
    l
    y.Upondeli
    veryoftheplacent
    a,t
    her ewasnot edtobeaninvert
    eduter
    us,whi
    ch
    wassuccessfull
    ymanagedi ncl
    udingr
    eplacementoft heuter
    us.Whichoft
    hef ol
    l
    owing
    placent
    ali
    mplantat
    ionsit
    eswoul dmostlikel
    ypr edi
    sposetoaninv
    ertedut
    erus?

    Fundal

    104.A32-year-
    oldwomanhassev erepostpart
    um hemorr
    hagethatdoesnotrespondto
    medical
    therapy.Theobstet
    ricianst
    atesthatsurgi
    calmanagementi
    sthebesttherapy.
    Thepati
    entdesiresfut
    urechildbear
    ing.
    Whi chofthef
    oll
    owingismostappropri
    ateto
    achi
    evethetherapeuti
    cgoals?
    Hy
    pogast
    ri
    car
    ter
    yli
    gat
    ion

    105.Whichoft
    hefol
    l
    owingphy
    siol
    ogi
    coranat
    omi
    cchar
    act
    eri
    sti
    cspr
    edi
    sposet
    o
    prepuber
    tal
    vul
    vov
    agini
    ti
    s?

    Al
    loft
    hement
    ioned

    106Apr i
    marygoal
    oftherapyorcentr
    alpr
    ecoci
    ouspuber
    tyi
    ncl
    udespr
    event
    ionof
    whichofthef
    oll
    owingconsequences?

    Shor
    tSt
    atur
    e

    107.Whi
    chofthef
    oll
    owinggener
    all
    yoccur
    sfi
    rstamongt
    hemaj
    ordev
    elopment
    al
    event
    soffemal
    epubert
    y?

    Thel
    arche

    108.Whatappr
    oxi
    mat
    eper
    cent
    ageofmal
    i
    gnantt
    umor
    sdi
    agnosedi
    nchi
    l
    dhoodar
    eof
    ovar
    ianor
    igi
    n?

    1per
    cent

    109.A14- year-
    oldadolescentisbroughtinorexami nat
    ionduet oherl ef
    tbr eastbei
    ng
    noticeabl
    ylargerthanherrightwhenshei sundr essed.Thebr eastsareot herwise
    normal duri
    ngex aminati
    on.Thelarcheoccurredatt heageof11. 5y ears.Shecannot
    thi
    nkofanyspeci f
    ictr
    aumat otherightbr
    eastorchestwal l
    .Shehasnev erhadany
    surgery.Cosmeticall
    y,t
    hedi f
    fer
    encei snotobv i
    ouswhenshei sclothed.Whi chofthe
    fol
    lowingisthemostcommonet i
    ologyofasy mmet ricbreastgrowthi naf emale
    adolescent?

    I
    diopat
    hic

    110.Whi
    choft
    hef
    oll
    owi
    ngi
    sani
    ndi
    cat
    ionorani
    nter
    nal
    vagi
    nal
    exami
    nat
    ionofachi
    l
    d?

    Al
    loft
    hement
    ioned

    111.Accessor
    ynippl
    es,whenpr
    esent
    ,arel
    ocatedal
    ongtheembryoni
    cmi
    lkl
    i
    ne
    ext
    endingfrom t
    heaxi
    ll
    atothegr
    oinbi
    lat
    eral
    l
    y.Thei
    rpresencei
    ster
    medwhi
    choft
    he
    fol
    lowi
    ng?

    Pol
    ythel
    i
    a

    112.Whichofthef
    oll
    owi
    ngst
    atement
    sist
    ruer
    egar
    dingpel
    vi
    canat
    omyi
    nthef
    emal
    e
    i
    nfantandchi
    ld?
    Presenceofanendomet
    ri
    alstr
    ipeorf
    lui
    dwithi
    ntheendomet
    ri
    alcav
    ityoft
    he
    newbornuterusi
    sanormalf
    indingwi
    thsonogr
    aphy.

    113.Whi
    choft
    hef
    oll
    owi
    ngi
    sthemostcommoncauseofcent
    ral
    precoci
    ouspuber
    ty?

    I
    diopat
    hic

    114.HowdoBMIcor
    rel
    atewi
    thpuber
    tal
    dev
    elopment
    ?
    Hi
    gherBMIcor
    rel
    atewi
    thear
    lydev
    elopment
    115.Whi
    choft
    hef
    oll
    owi
    ngi
    str
    uer
    egar
    dingi
    sol
    atedpr
    emat
    uret
    hel
    arche?
    I
    tismostcommoni
    ngi
    rl
    syoungert
    han2y
    ear
    s.
    116.Abnor
    mal
    breastdev
    elopmentmaybeduet
    oei
    therf
    asci
    aladher
    encet
    othe
    underl
    yi
    ngmusclel
    ay erorduetohi
    gh-
    doseexogenoushormoneexposureduri
    ng
    pubert
    y.I
    nsuchcases,breast
    shaveexcessiv
    eforwar
    dbutli
    mitedl
    ater
    al gr
    owth,
    whi
    ch
    causesanabnor
    mal shape.Thi
    scondi
    tionisref
    err
    edtoaswhichoft
    hef oll
    owi
    ng?
    Tuber
    ousbr
    east
    s
    117.Whi
    choft
    hef
    oll
    owi
    ngor
    gani
    smsi
    smostl
    i
    kel
    ytocausepr
    epuber
    tal
    vul
    vi
    ti
    s?
    Gr
    oupAβ-
    hemol
    yti
    cst
    rept
    ococcus
    118.Whenanindiv
    idual
    exper
    iencesdi
    ff
    icul
    tyi
    dent
    if
    yingwit
    hthei
    rphenot
    ypi
    cgender
    ,
    percei
    vi
    ngthemsel
    vestobeoftheopposit
    egender
    ,thecondi
    ti
    onister
    medwhichoft
    he
    fol
    lowi
    ng?
    Genderdy
    sphor
    ia
    119.A7-
    year
    -ol
    dgi
    rlhasexper
    iencedv
    ulv
    ari
    rr
    it
    ati
    onwi
    thext
    ernal
    itchi
    ngandbur
    ning
    duri
    ngurinat
    ionorsever almonths.Sympt omshav epersi
    steddespit
    eat t
    emptsto
    el
    iminat
    epot ent
    iali
    rr
    itantsandcont actall
    ergensfr
    om thebathandl aundrypr
    oducts
    usedbythef ami
    ly.Exami nat
    ion,asshownher e,
    reveal
    ssymmet r
    icalhypopigmentat
    ion
    andapar chment-l
    i
    kethinningoft hevulvarandperi
    analski
    n.Whati sthemostlikel
    y
    di
    agnosis?
    Li
    chenscl
    erosus
    120.A4-
    year
    -ol
    dgi
    rli
    sbr
    oughti
    nbyherpar
    entwi
    tht
    heconcer
    nthat“
    thel
    i
    psofher
    vaginahavest
    uckt
    ogether
    .”I
    nit
    ialmanagementoflabi
    aladhesi
    onoraggl
    uti
    nat
    ioni
    na
    chil
    d,asshownher
    e,doesNOTi ncl
    udewhichofthefol
    lowingopt
    ions?
    Sur
    ger
    y
    121.Pr
    ecoci
    ouspuber
    tyassoci
    atedwi
    thbonydy
    spl
    asi
    aandcaf
    éaul
    aitspot
    sonski
    nis
    notedi
    n:
    McCune-
    Albr
    ightsy
    ndr
    ome
    122.Af
    etal
    ovar
    ianmassi
    snot
    edasani
    nci
    dent
    alf
    indi
    ngdur
    ingt
    hir
    d-t
    ri
    mest
    er
    sonographicassessmentoffetalgr
    owth.Thefemalei
    nfanti
    sdeli
    ver
    edatt er
    m wit
    hout
    i
    ncident.Lowerabdominalf
    ullnessispal
    pateddur
    ingneonat
    alexaminat
    ion,and
    tr
    ansabdomi
    nal
    sonographyshowsa4.
    2-cm si
    mplerightov
    ari
    ancyst
    .Theinf
    anti
    s
    afebr
    il
    eandi
    nnodist
    ress.Whatist
    hemostappropr
    iatemanagementoft
    hisovar
    ian
    mass?
    Obser
    vat
    ionwi
    thr
    epeatsonogr
    aphyi
    n6weeks
    123.A6-
    year
    -ol
    dgi
    rli
    snot
    edt
    ohav
    ebr
    eastdev
    elopmentandv
    agi
    nal
    spot
    ti
    ng.No
    abnor
    malhai
    rgrowt
    hisnoted.A10-
    cm ov
    ari
    anmassi
    spal
    pat
    edonr
    ect
    alexami
    nat
    ion.
    Whichoft
    hefol
    l
    owingist
    hemostl i
    kel
    ydi
    agnosi
    s?
    Gr
    anul
    osa-
    thecacel
    ltumor
    124.An8-
    year
    -ol
    dgi
    rli
    sbr
    oughti
    norev
    aluat
    ionof4day
    sofi
    nter
    mit
    tentv
    agi
    nal
    bleedi
    ngandf oul
    discharge.Sheshowsnosi gnsofpubertaldevelopment.Thecauseof
    thebleedi
    ngisnotapparentduringphy
    sicalexaminat
    ion,andt hedecisi
    onismadet o
    proceedwithexaminati
    onunderanesthesiaandsali
    nev aginoscopy.Whatisthemost
    l
    ikelyfi
    ndi
    ng?
    For
    eignobj
    ect
    125.A16-y ear-
    oldadolescentfemaleisbroughtint
    ot hepediat
    rici
    an’soffi
    ceduet ono
    breastdevelopment.Thepat i
    ent’
    smot hernotesthatbothofpat i
    ent’
    ssistershadonset
    ofbreastdev el
    opmentatage10, andalsoallofherfri
    endshav ealr
    eadybegun
    menst r
    uati
    ng.Exami nati
    onrevealsTannerstageIbr eastandpubic/axil
    laryhai
    r,andi
    s
    otherwi
    seunr emarkable.Whichoft hefol
    lowi
    ngi sthemostl i
    kelydi
    agnosis?
    Del
    ayedpuber
    ty
    126.A5-year
    -oldfemal
    echil
    disbroughti
    ntothephysici
    an’
    soffi
    ceforbr
    east
    devel
    opmentandmenses.Onexami nati
    on,thechil
    disfoundtohaveTannerIVbr
    east
    devel
    opmentandTannerI Vpubi
    candaxil
    laryhai
    r.Whichofthefol
    l
    owingisthemost
    l
    ikel
    yther
    apyf ort
    hispat
    ient
    ?
    Gonadot
    ropi
    n-r
    eleasi
    nghor
    mone(
    GnRH)agoni
    st
    127.I
    nanadolescentwit
    hanot herwi
    senor
    mal
    breastandchestwal
    lexami
    nat
    ion,
    what
    i
    sthebestapproachtobreastasymmetr
    y?
    Reassur
    ethatmostcasesofbr
    eastasy
    mmet
    ryr
    esol
    vebycompl
    eti
    onofbr
    eastdev
    elopment
    128.Whyi
    scar
    eful
    preoper
    ati
    vepl
    anni
    ngwar
    rant
    edwi
    thcongeni
    tal
    vagi
    nal
    cyst
    s,as
    showni
    nsonogr
    am bel
    ow?
    Somemayext
    endupt ot
    hebr
    oadl
    i
    gamentandanat
    omi
    cal
    l
    yappr
    oxi
    mat
    ethedi
    stal
    cour
    seoft
    heuret
    er.
    129.A22- year-
    oldG3P0womanpr esentsasanewpat ientforconsultationregarding
    herhistor
    yofmul tipl
    emiscarri
    ages.Hergynecologichistoryisotherwiseunr emarkable.
    Duringphysicalexaminati
    on,younotethattheuterusismar kedl
    ydev i
    atedt otheleft.
    Transvagi
    nal sonographyisperf
    ormed,and3Di magesr eveal aut
    erust hatisdeviated
    andhasabanana- shapedcavity
    ,asshownbel ow.Whati syourdiagnosi s?
    Uni
    cor
    nuat
    eut
    erus
    130.Whi
    choft
    hef
    oll
    owi
    ngar
    eseeni
    nof
    fspr
    ingofwomenwhot
    ookdi
    ethy
    lst
    il
    best
    rol
    (
    DES)dur
    ingt
    heassoci
    atedpr
    egnancy
    ?
    Al
    loft
    hement
    ioned
    131.Whenshoul
    dsurgical
    reconst
    ruct
    ionofabi
    cor
    nuat
    eut
    erus(
    Str
    assman
    metropl
    ast
    y)beper
    formed?
    Withr
    ecurr
    entpr
    egnancyl
    ossandnoot
    heri
    dent
    if
    iabl
    ecauseexceptt
    heut
    eri
    ne
    anomaly
    132.Oneofy ourpati
    ent sbr
    ingsher13- year -
    olddaught
    erf orconsul
    tationr egardingthe
    gi
    rl’
    scompl ai
    ntsofpelvicpain.Thedaught erhasexper
    iencednor mal puber tal
    developmentt odatebuthasnoty etexperiencedmenarche.Shebeganhav ingmont hly
    pelv
    icpai nabout1y earago, andt hepainhasbeenpr ogressivel
    ywor sening.Dur ing
    physicalexaminati
    on,herext ernalgenit
    alia,incl
    udi
    nghymeneal ri
    ng,appearnor mal .
    Howev er
    ,proxi
    mal t
    ot hehymen, onlyav aginaldi
    mplei
    sf ound.Rectov aginal
    exami nati
    onconfir
    mst hepresenceofaut erusandcervix.Whatisyourdi agnosi s?
    Vagi
    nal
    atr
    esi
    a
    133.Inapregnantpopul
    ation,
    whatisthemostcommoncauseoft
    hecondi
    ti
    on
    port
    rayedi
    nt hechestx-
    rayimagebelow?
    (
    enl
    argedpul
    monar
    yhi
    l
    arar
    ter
    iesandat
    tenuat
    edper
    ipher
    almar
    kings)

    134.TheWor l
    dHeal t
    hOrgani
    zat
    ioni
    dent
    if
    ieswhi
    choft
    hef
    oll
    owi
    ngcondi
    ti
    onsas
    prohi
    bit
    iveofpregnancy
    ?

    Pul
    monar
    yar
    ter
    yhy
    per
    tensi
    on
    135.A32- year-ol
    dG2P1pr esentstoy ouroff
    iceat17weeks’ gestat
    ion.Shereport
    sa
    hist
    oryoftetralogyofFal
    lot,whichwasr epairedini nf
    ancy .Sheappearscomf or
    tabl
    eon
    theexam tablewi t
    hahear tr
    ateof92beat spermi nuteandabl oodpressureof96/62
    mm Hg.Howev er,
    shedoesr eportsigni
    fi
    cantpal pitat
    ionsanddy spneawhencl i
    mbing
    thetwofli
    ght sofstai
    rstoherapar tmentont het hirdfl
    oor.WhichNewYor kHeart
    Associat
    ioncl assbestdescri
    besherf uncti
    onal disabili
    ty?
    Cl
    assI
    I
    136.A30-year
    -ol
    dG2P0A1pr esent
    sat11weeks’gestati
    ont oestabli
    shcare.Shehasa
    hi
    storyofr
    heumat i
    chear
    tdi seaseandhadamechani cal
    valvereplacementatage20.
    Shewasprev i
    ousl
    yonwarf ari
    n7.5mgdaily
    ,butstoppedtakinghermedi cati
    onwhen
    shefoundoutshewaspregnant1weekago.Whati sherriskforwarfari
    nembr yopat
    hy
    basedonherwar f
    ari
    ndosing?
    8%
    137.Forwhi
    choft
    hef
    oll
    owi
    ngcar
    diaccondi
    ti
    onsi
    sconduct
    ionanal
    gesi
    ahi
    ghl
    y
    recommended?
    Repai
    redhy
    popl
    ast
    icl
    efthear
    tsy
    ndr
    ome
    138.Regar
    dingdi
    agnost
    icst
    udi
    es,
    whi
    choft
    hef
    oll
    owi
    ngcor
    rect
    lydescr
    ibesanor
    mal
    changet
    hati
    schar
    act
    eri
    sti
    cofpr
    egnancy
    ?
    Anav
    erage15-
    degr
    eel
    eftaxi
    sdev
    iat
    iononel
    ect
    rocar
    diogr
    am
    139.Aschemat
    icofEi
    senmengersy
    ndr
    omeduet
    oav
    ent
    ri
    cul
    arsept
    aldef
    ecti
    s
    depi
    cted.Whati
    sthemostcommoncauseofdeat
    hinpr
    egnantwomenwi
    tht
    his
    condi
    tion?
    Ri
    ghtVent
    ri
    cul
    arf
    ail
    ure
    140.Whi
    chofthef
    oll
    owi
    ngt
    her
    api
    esi
    ssaf
    einpr
    egnancyt
    otr
    eatacut
    esupr
    avent
    ri
    cul
    ar
    tachy
    car
    dia?
    Al
    loft
    heabov
    e
    141.Youar
    ecaringf
    ora24-year
    -oldG1wi t
    hsevereaort
    icst
    enosi
    s.Wheni
    npr
    egnancy
    areyoumostconcer
    nedaboutcardiacdecompensati
    on?
    Per
    ipar
    tum
    142.Youarecari
    ngforcompl ainsofshor t
    nessofbreathandchestpainwi thminimal
    exer
    ti
    onanuncomplicatedprimi gravidaat32weeks’ gestat
    ion.Anechocar di
    ogram
    demonstrat
    esami t
    ralvalvesur facear eaof2.1cm2, adil
    atedlef
    tat
    rium, anaortic
    val
    veareaof3.7cm2,ar i
    ghtv ent r
    icularsyst
    oli
    cpressureof20mm Hg, andanej ecti
    on
    fr
    acti
    onof55%.Youalsoobt ainachestx- ray,whi
    chisshown.Whati sthel i
    kel
    y
    underl
    yi
    ngcauseofhersy mptoms?
    Mi
    tr
    alSt
    enosi
    s
    143.Whichoft
    hef
    oll
    owi
    ngpat
    ient
    sdonothav
    eani
    ndi
    cat
    ionf
    orendocar
    dit
    is
    prophy
    laxi
    s?
    Apat
    ientwi
    thav
    ent
    ri
    cul
    arsept
    aldef
    ectr
    epai
    redwi
    thasy
    nthet
    icpat
    chwi
    thoutacur
    rentdef
    ect
    144.Youar
    ecar
    ingf
    orapat
    ientwi
    thanunr
    epai
    redv
    ent
    ri
    cul
    arsept
    aldef
    ectwhoi
    s
    consi
    deri
    ngpregnancy.Youper
    form anechocar
    diogr
    am toassessherfut
    urer
    isks.
    Whichofthefol
    lowingparamet
    erswouldindi
    cat
    eanextremelyelev
    atedmater
    nal and
    fet
    alr
    iskduri
    ngpregnancy?
    Ar
    ightv
    ent
    ri
    cul
    arsy
    stol
    i
    cpr
    essur
    eof75mm Hg
    145.Whi choft hef
    oll
    owingmethodsofant
    enat
    alf
    etal
    survei
    ll
    ancehasbeen
    conclusi
    v elyshowntobeofbenefi
    tint
    hemanagementofpregnanci
    escompl
    icat
    edby
    chronichy pert
    ensi
    on?
    Ser
    ial
    sonogr
    aphi
    cev
    aluat
    ionsoff
    etal
    growt
    h
    146.I
    naddi
    ti
    ont
    ochr
    oni
    chy
    per
    tensi
    on,
    whi
    choft
    hef
    oll
    owi
    ngcondi
    ti
    onsar
    e
    consi
    der
    edhi
    gh-
    ri
    skf
    ordev
    elopi
    ngpr
    eecl
    ampsi
    a?
    Sy
    stemi
    clupuser
    ythemat
    osus
    147.Forwomenwi
    thchr
    oni
    chy
    per
    tensi
    on,
    whi
    chmodi
    fi
    abl
    efact
    orf
    urt
    heri
    ncr
    easest
    he
    r
    iskf
    ort
    hepl
    acent
    alabr
    upt
    ion?
    Smoki
    ng
    148.Antihy
    per
    tensi
    vet
    her
    apyi
    smandat
    oryf
    orwhi
    choft
    hef
    oll
    owi
    ngwomendur
    ing
    pregnancy?

    30-
    year
    -ol
    dG3P2wi
    thabl
    oodpr
    essur
    eof160/
    110mm Hgandahi
    stor
    yofast
    hma
    149.Allexceptwhi
    choft
    hef
    oll
    owi
    ngsuppor
    tthedi
    agnosi
    sofsuper
    imposed
    preecl
    ampsi a?

    Decr
    easedser
    um al
    kal
    i
    nephosphat
    asel
    evel

    150.Whi
    choft
    hef
    oll
    owi
    ngi
    samaj
    orf
    act
    orcont
    ri
    but
    ingt
    othei
    nci
    denceofper
    inat
    al
    mor
    tal
    i
    tynot
    edi
    npr
    egnanci
    escompl
    i
    cat
    edbychr
    oni
    chy
    per
    tensi
    on?

    Al
    loft
    heabov
    e

    151.A33-
    year
    -ol
    dG1at32weeks’
    gest
    ati
    onhasbeendi
    agnosedwi
    thchr
    oni
    c
    hypert
    ensi
    onwi thsuperi
    mposedpr eeclampsiavi
    awor seninghy pert
    ension.Sheis
    asymptomaticwithnormallabsandnor malfetal
    gr owth.Anincreaseinthedoseofher
    anti
    hyper
    tensiv
    emedi cati
    onhasr esul
    tedinnonsev er
    ebl oodpressures.Sheasksy ou
    aboutexpect
    antmanagementofsuper imposedpr eecl
    ampsi a.Whichoft hefol
    l
    owingis
    themostappropriat
    e,evi
    dence-basedresponse?

    I
    tisreasonabl
    e,wi
    thcl
    oseinpat
    ientsur
    vei
    l
    lance,
    topur
    sueexpect
    antmanagement
    ,butt
    her
    ear
    e
    st
    il
    lri
    sksforadver
    seoutcomes.

    152.A37-
    year
    -ol
    dG2P2wi
    thnomedi
    cal
    diagnosesandanor
    mal
    bodymassi
    ndexon
    annualwell
    womanex am f
    oundtohav eBP142/ 92mm Hg, andaft
    ercheckingsev
    eral
    ti
    mesov erthenextweekathome, shecall
    swithabloodpressurel
    ogthatrangesfr
    om
    140–154/90–100mm Hg.Accor dingtotherecommendati
    onsoft heEi
    ghthJoint
    Nati
    onalCommi tt
    ee,whatisyourgoalbl
    oodpr essur
    ewit
    ht her
    apy?

    &l
    t;
    140/
    90mm Hg

    153.Ms.Thomaspr
    esent
    sforapr
    econcept
    ioncounsel
    i
    ngv
    isi
    t.Shei
    sa37-
    year
    -ol
    dG0
    wit
    habodymassi ndexof38kg/ m2, 4-
    yearhistor
    yofchroni
    chy per
    tensi
    ontreat
    edwit
    h
    amlodi
    pine5mgperday ,anda2- y
    earhistoryofdi
    abeteswhichshemanageswi thdi
    et
    andexercise.Herbloodpressurerangeis128–144/ 80–94mm Hgf rom theweekpri
    or.
    Whatwor kupwouldy ouli
    ket opursuereferentt
    oherdiagnosisofchroni
    chypert
    ensi
    on
    andprepregnancyriskst
    rati
    ficat
    ion?

    Serum creati
    nine,
    uri
    nepr
    otei
    n-t
    o-cr
    eat
    ini
    ner
    ati
    o,el
    ect
    rocar
    diogr
    am,
    andmat
    ernal
    echocardiogr
    am

    154.Youar
    eseei
    ngMs.Bl
    anchef
    orpr
    enat
    alcar
    e.Shei
    sa37-
    year
    -ol
    dG1at8weeks’
    gestati
    on.Shehasbeeny ourpat
    ientf
    orsever
    alyear
    s,andchar
    trevi
    ewshowsf ormer
    bl
    oodpr essurereadi
    ngshav ebeen110–120/70–80mm Hgatpr i
    orvisi
    ts.Theblood
    pressurenotedatherfi
    rstobstet
    ricvi
    siti
    s150/96mm Hg.Whichofthef ol
    lowi
    ngisthe
    mostappr opri
    atenextstep?

    Requestt
    hatshehav
    eherbl
    oodpr
    essur
    emeasur
    edaf
    ewt
    imesov
    ert
    henex
    t2weeksand
    r
    etur
    nwi
    thherl
    ogf
    orr
    evi
    ew.

    155.A36-
    year
    -ol
    dmul
    ti
    grav
    idawi
    thchr
    oni
    chy
    per
    tensi
    onpr
    esent
    sforagr
    owt
    h
    ult
    rasoundat36weeks’ gestat
    ion.Theult
    rasoundreportshowsy outhatesti
    matedf
    etal
    weightcorrespondto33weeks’ ,headsize-to34weeks’ ,
    whileabdominal
    cir
    cumf er
    enceandf emurlengt
    h–t o32weeks’ gestat
    ion.Whichofthef ol
    l
    owingist
    rue
    regardi
    ngthedi agnosismadeont hegrowthultr
    asound?

    Fetal
    -growt
    hdysfuncti
    oni
    smorel
    i
    kel
    yinchr
    oni
    cal
    l
    yhy
    per
    tensi
    vewomenwhodev
    elop
    superimposedpr
    eeclampsi
    a.

    156.Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    sregar
    dingacut
    evi
    ral
    hepat
    it
    isi
    scor
    rect
    ?

    Low-
    gradef
    everi
    smor
    ecommonwi
    thhepat
    it
    isA.

    157.Af
    terdel
    i
    ver
    y,t
    hel
    i
    verf
    unct
    iondet
    eri
    orat
    ionofacut
    efat
    tyl
    i
    verofpr
    egnancyhal
    ted.
    Nonethel
    ess,
    yourecommendcontinuedi
    ntensi
    vemater
    nalsur
    v ei
    l
    lanceduetothe
    appr
    ox i
    matel
    y20%riskofdev
    elopi
    ngwhichofthefol
    l
    owingintheday saf
    terdel
    i
    very
    ?

    Acut
    epancr
    eat
    it
    is

    158.Al
    lEXCEPTwhi
    choft
    hef
    oll
    owi
    ngl
    i
    ver
    -r
    elat
    edchangesar
    ephy
    siol
    ogi
    cal
    in
    pr
    egnancy
    ?

    Hy
    pol
    i
    pidemi
    a

    159.Thi
    simageshowst
    het
    ypi
    cal
    nodul
    ar,
    fibr
    oti
    cappear
    anceofaci
    rr
    hot
    icl
    i
    ver
    .What
    i
    sthemostcommoncauseoft
    hiscondi
    ti
    oni
    nthegener
    alpopul
    ati
    on?

    Al
    cohol
    exposur
    e

    160.Fr
    om anet
    iopat
    hogenesi
    sper
    spect
    ive,
    thepr
    egnancyf
    att
    yli
    verpi
    ctur
    edher
    eis
    anal
    ogoust
    owhi
    chchi
    l
    dhoodi
    l
    lness?

    Rey
    e-l
    i
    kesy
    ndr
    omes

    161.Whi
    choft
    hefol
    lowingisnotar
    ecommendedr
    equi
    sit
    eforr
    enal
    transpl
    antpat
    ient
    s
    whowanttoat
    temptpregnancy
    ?

    Pr
    otei
    nur
    ia&l
    t;
    300mg/
    day

    162.Thecl
    ini
    cal
    present
    ati
    onofawhatcondi
    ti
    onusual
    l
    yincl
    udeshy
    per
    tensi
    on,
    hematur
    ia,r
    ed-
    cel
    lcast
    s,py
    uri
    a,pr
    otei
    nur
    ia,
    edema,
    hyper
    tensi
    on,
    andci
    rcul
    ator
    y
    congest
    ion?
    Gl
    omer
    ulonephr
    it
    is

    163.Youngpr
    egnantpat
    ientwi
    thpy
    elonephr
    it
    isandl
    aborcont
    ract
    ionst
    ransf
    err
    edt
    o
    l
    abordepart
    mentformonitori
    ng.Sheisgi
    venint
    ravenous( I
    V)anti
    bioti
    cs,
    IVfl
    uids,
    acet
    aminophen,
    andaβ- agoni
    stbecauseofthecontract
    ions.Whatcomplicat
    ionis
    moreli
    kel
    yinthesett
    ingofβ-agoni
    stuseinpati
    ent
    swi thpyelonephri
    ti
    s?

    Pumonar
    yedema

    164.Whati
    sthecut
    offf
    oraur
    inar
    ypr
    otei
    n-t
    o-cr
    eat
    ini
    ner
    ati
    oonaspotur
    inesampl
    ein
    pr
    egnantpat
    ient
    ?

    0.
    3

    165.Whi
    choft
    hef
    oll
    owi
    ngi
    snotcommonl
    yfoundi
    npat
    ient
    swi
    thaur
    ethr
    al
    di
    ver
    ti
    cul
    um?

    Ur
    inar
    yRet
    ent
    ion

    166.Whi
    choft
    hef
    oll
    owi
    ngi
    sthemostcommonf
    orm ofacut
    egl
    omer
    ulonephr
    it
    is
    wor
    ldwi
    de?

    Ber
    gerdi
    sease

    167.A28-
    year
    -ol
    dat19weeks’
    gest
    ati
    onpr
    esent
    stot
    heemer
    gencyr
    oom wi
    th
    complaint
    sofr i
    ghtupperquadr
    antpai
    n,fev
    er,andvomiti
    ng.Exam r
    eveal
    sri
    ghtupper
    quadranttender
    ness,andshehasatemperatureof38.
    7°C.Onediagnost
    ici
    mageis
    shownher e.Commonbi l
    eductobstr
    uct
    ionisnotsuspected.Whati
    sthenextmost
    appropri
    atestepinhermanagement?

    Lapar
    oscopi
    cchol
    ecy
    stect
    omy

    168.Yousendaper
    ipher
    albl
    oodsmearoft
    hepat
    ientat34weeks’
    gest
    ati
    onwi
    than
    acutefat
    tyl
    iver
    ,andarepr
    esent
    ati
    vesl
    i
    dei
    sshownbel
    ow.Whati
    stheunder
    lyi
    ng
    eti
    ologyoft
    hebloodsmearfi
    ndi
    ngs?

    Decr
    easedchol
    est
    erol
    product
    ion

    169.Whi
    chcombi
    nat
    ionofl
    abor
    ator
    yfi
    ndi
    ngsbel
    owwoul
    dbemostconcer
    ningf
    or
    acut
    efat
    tyl
    i
    verofpr
    egnancy
    ?

    Hematocri
    t32%, cr
    eat
    ini
    ne2.
    0mg/
    dL,
    plat
    elet
    s90/
    L,AST400U/
    L,f
    ibr
    inogen130
    mg/dL,andglucose65mg/dL
    170.A26-year-ol
    dprimi
    grav
    idapresentsat34weeks’ gestat
    ionwithnauseaand
    vomiti
    ng,f
    atigue,andepi
    gastr
    icpain.Allexceptwhichofthef ol
    lowingar
    ecli
    nical
    charact
    eri
    sti
    cst hati
    ncr
    easeherri
    skf oracutefatt
    yliverofpregnancyastheunderl
    yi
    ng
    cause?

    Femal
    efet
    us

    171.A36- y
    ear -
    oldmul ti
    grav
    idapresentsforpr econcept i
    oncounsel ing.Herobst etri
    c
    historyi ncl
    udest wof ull
    -t
    ermv agi
    nal del
    iveri
    esaf t
    erpr egnanci escompl icatedby
    gest ationaldiabetesandaf ir
    st-t
    ri
    mest erpregnancyl oss.Shecomest oy outodi scuss
    herr ecentdi agnosisofnonalcohol i
    cfatt
    yl i
    verdisease( NAFLD)byherpr i
    mar ycare
    physi cian.Diagnosiswasbasedoni magingper formedf oranepi sodeofabdomi nal pai
    n.
    Herl iverfunctiontestsarenormal .Hermedi calhistoryisot herwisenot ablefor
    longst andingobesi t
    y( bodymassi ndex34kg/ m2)anddi abet es(hemogl obinA1c8. 2%)
    diagnosed2y earsago.Whi choft hefoll
    owingshoul dbei ncludedi nyourcounsel i
    ng?

    Thebestint
    erv
    enti
    onstoreducet
    her
    iskt
    oaf
    utur
    epr
    egnancyar
    ewei
    ghtl
    ossand
    opt
    imizi
    ngherglucosecont
    rol
    .

    172.A25-year-
    oldG1P0at16weeks’gest
    ati
    onpr esent
    sf orpr
    enat al
    care.Shehasa
    hi
    stor
    yofaki dneytr
    anspl
    ant3year
    sago.Shei sstabl
    eonpr ednisoneandazat hi
    opr
    ine.
    Thepati
    enthasnotexperi
    encedanyrej
    ect
    ion,andherbloodpr essureiswellcont
    rol
    l
    ed.
    Whichofthefoll
    owingobst
    etr
    iccompli
    cat
    ionsisnotincreasedinher?
    Per
    ipar
    tum car
    diomy
    opat
    hy
    173.Fort
    hepati
    entwit
    hseverepreecl
    ampsia,whi
    chofthefol
    l
    owi
    ngi
    sani
    ndi
    cat
    ionf
    or
    pri
    marycesar
    eandeli
    verywi
    thoutanattemptati
    nduct
    ion?

    Mal
    present
    ati
    on

    174.A42-y ear-ol
    dwomanpresentsf orprenat
    al car
    e.Shehasademandingprofessi
    onal
    careerandr eport
    ssheisunwil
    li
    ngt oattendfrequentprenat
    alvi
    sit
    satt
    heendof
    pregnancy.Youdi scour
    aget
    his,explai
    ningthesev i
    sit
    sarerecommendedforwhichof
    thefoll
    owingr easons?

    Al
    loft
    hement
    ioned

    175.Amongf
    oll
    owi
    ngchoosecor
    rectst
    atementconcer
    ningpr
    otei
    nur
    iai
    npr
    eecl
    ampt
    ic
    pati
    ent

    r
    efl
    ect
    sthesy
    stem-
    wideendot
    hel
    i
    all
    eak

    176.Amulti
    parouswomanwit
    hnoprenat
    alcar
    epresent
    sinacti
    velaborwi
    thablood
    pressur
    eof156/92mm Hgandpr
    otei
    nuri
    a.Herneonat
    eisbornvaginal
    l
    yaf
    teran
    uncomplicat
    edlaborcourse,witht
    hesecondstageoflaborlast
    ingonly15mi nut
    es.The
    i
    nfanti
    snot edtohavepet echi
    aeonthescal
    pandchest ,andoozingatthesit
    eofhis
    heelst
    ick.Anini
    ti
    alplat
    eletcounti
    s32,000/
    μL.Whichoft hefol
    lowingdisor
    dersisleast
    l
    ikel
    ytobet hecauseofthei nf
    ant’
    sthr
    ombocytopeni
    a?

    Mat
    ernal
    Preecl
    ampsi
    a

    177.AG3P2at16weeks’ gest
    ati
    onpr esentst ot
    heemergencydepart
    mentcomplai
    ning
    ofvagi
    nalbl
    eeding.Herbloodpressureis148/ 96mm Hgandshehas3+pr otei
    nuri
    aon
    aspeci
    menobt aineddur
    ingbladdercatheterizat
    ion.Whi
    chofthefol
    l
    owingmayexplain
    thedev
    elopmentofpreeclampsiainthispatient?

    I
    ncr
    easedv
    olumeofchor
    ioni
    cvi
    l
    li

    178.Al
    loft
    hef
    oll
    owi
    ngcanpr
    edi
    sposet
    ocoagul
    opat
    hyEXCEPT

    Pl
    acent
    apr
    evi
    a

    179.Al
    loft
    hefoll
    owingareindi
    cat
    ionsf
    ort
    ermi
    nat
    ionofpr
    egnancyi
    nAPH(
    ant
    epar
    tum
    haemorr
    hage)pat
    ientexcept

    Tr
    ansv
    ersel
    i
    e

    180.Theuseofwhol
    ebl
    oodf
    ormassi
    vehemor
    rhagei
    ssuppor
    tedbywhi
    choft
    he
    fol
    lowi
    ng?

    Al
    loft
    hement
    ioned

    181.A34-year-ol
    dG3P3beginshavingbri
    skbrightredbleedi
    ngf
    oll
    owi
    ngcomplet
    ionof
    av agi
    naldeli
    very
    .Yougivehercar
    boprosttr
    omet hamineandperf
    ormthemaneuv
    er
    pictur
    edbelow.Whatelseshouldbeimmediatelyconsi
    dered?

    Al
    loft
    hement
    ioned

    182.Al
    lar
    etr
    ueaboutpl
    acent
    apr
    evi
    aexcept
    :

    I
    ncr
    easedut
    eri
    net
    one

    183.Rxofchoi
    cei
    npl
    acent
    aaccr
    etai
    nmul
    ti
    par
    ousf
    emal
    e

    Hy
    ster
    ect
    omy

    184.DI
    Ciscommonwi
    th:
    .
    Abr
    upt
    iopl
    acent
    a

    185.Pl
    acent
    aaccr
    etai
    sassoci
    atedwi
    th:

    Pl
    acent
    apr
    evi
    ainpr
    esentpr
    egnancy
    Mul
    ti
    par
    a
    Ut
    eri
    nescar
    186.Duri
    ngev
    aluat
    ionofpost
    part
    um hemorrhagef
    oll
    owingav
    agi
    nal
    del
    i
    ver
    y,whi
    choft
    he
    fol
    l
    owingmaneuver
    sormedicati
    onsmightbeused?
    Bi
    manual
    uter
    inecompr
    essi
    on
    187.Whati
    srepr
    esent
    edi
    nthef
    oll
    owi
    ngi
    mage?
    Fol
    eycat
    het
    er
    188.A28- year-ol
    dwomanat32weeks’ gestat
    ionisseeni nt
    heobstetr
    icaltri
    ageareafor
    vaginalbleedi
    ngdescri
    bedassigni
    fi
    cantwithclots.Shedeni
    escrampi ngorpain.An
    ult
    rasoundi sper
    formedreveal
    i
    ngthattheplacentaiscoveri
    ngtheinternalosofthe
    cervix.Whichofthefol
    l
    owingisari
    skfactorforthispati
    ent
    ’scondi
    tion?
    Mul
    ti
    plegest
    ati
    ons
    189.A33- year-ol
    dwomanG3P2whohadt wopriorcesareansiscurr
    entl
    yat38weeks’
    gestation.Sheisnotedtohaveaposteriorpl
    acenta.
    Onul t
    rasound,t
    hereisevi
    denceof
    possibleplacentaaccr
    eta.Thepat
    ientiscounseledaboutthepossibl
    eriskofneedfor
    hyst
    er ectomy.Whichofthefoll
    owi
    ngi sthemostaccur atestat
    ement?
    Thepost
    eri
    orpl
    acent
    aisassoci
    atedwi
    thl
    essofar
    iskf
    oraccr
    etat
    hananant
    eri
    orpl
    acent
    a
    190.A29-
    year
    -ol
    dG1P0womanat39weeks’
    gest
    ati
    ondel
    i
    ver
    edv
    agi
    nal
    l
    y.Herpl
    acent
    a
    doesnotdel i
    vereasi
    l
    y.Amanual extract
    ionoft heplacentaisatt
    empt edandt he
    placentaseemst obeadherentt
    ot heuterus.Ahysterectomyiscontempl at
    ed,butthe
    patientref
    usesduetost r
    ongl
    ydesiri
    ngmor echil
    dren.Thecordisl i
    gatedwithsutureas
    highaspossible.
    Thepat i
    enti
    sgiventheopt i
    onofmet hotr
    exatetherapy.Whichofthe
    foll
    owingisthemostlikel
    ycomplicati
    onaf t
    erthisint
    erventi
    on?
    Coagul
    opat
    hicbl
    eedi
    ng

    191.A33- y
    ear-ol
    dwomanat37weeks’gest
    ati
    on,confi
    rmedbyfir
    st-
    tr
    imester
    sonography,pr
    esent
    swit
    hmoderat
    elysever
    evaginalbl
    eedi
    ng.Sheisnotedon
    sonographytohaveapl
    acent
    aprev
    ia.Whichofthefol
    lowi
    ngisthebestmanagement
    fort
    hispatient
    ?

    Caesar
    eandel
    i
    ver
    y

    192.A26-year
    -ol
    dG2P1womanunder wentanormalvaginaldel
    iver
    y.Av
    iabl
    e3.9kg
    maleinf
    antwasdeli
    ver
    ed.Thepl
    acent
    adeliv
    eredspontaneously
    .Theobstet
    ri
    ciannot
    ed
    signi
    ficantbl
    oodlossfrom t
    hev agina,tot
    ali
    ngapproximatel
    y700mL.Theuter
    ine
    fundusappear edtobewellcontracted.Whichoft
    hef oll
    owingi
    sthemostcommon
    etiol
    ogyf ort
    hebleedi
    nginthispatient?

    Geni
    tal
    tractl
    acer
    ati
    on

    193.A32- year-
    oldG1P0womanat40weeks’ gest
    ati
    onundergoesanormal vaginal
    del
    ivery.Deli
    veryoft
    heplacentai
    scomplicatedbyaninvert
    eduter
    us,wit
    hsubsequent
    hemor r
    hagel eadi
    ngto1500mLofbl oodloss.Sheismanagedwi t
    hatransfusionof
    ery
    throcytes.Whichoft
    hef ol
    lowi
    ngisthebestexplanat
    ionofthemechanism of
    hemor r
    hage?

    I
    nver
    tedut
    erusl
    eadst
    oinabi
    l
    ityf
    oranadequat
    emy
    omet
    ri
    alcont
    ract
    ionef
    fect
    .

    194.Allst
    atesi
    ntheUnit
    edStat
    eslegal
    l
    yall
    owami norwomant
    oconsenttomedical
    examinati
    onandtreat
    mentonherownbehal
    final
    lofthefol
    l
    owi
    ngsi
    tuat
    ionsEXCEPT:

    Request
    ingaschool
    -sponsor
    edspor
    ts’
    phy
    sical
    exami
    nat
    ion

    195.Accor
    dingtotheU.
    S.FDAvaccinestar
    geti
    nghumanpapi
    l
    lomav
    irusi
    nfect
    ionar
    e
    approv
    edfrom whatage(i
    nyear
    s)forfemalesormal
    es?

    196.Wit
    hprepuber
    tal
    v ul
    vov
    agini
    ti
    s,whatappr
    oximateper
    cent
    ageofbact
    eri
    alcul
    tur
    es
    obtai
    nedfr
    om vagi
    nalswabsshowonlynormalgeni
    talf
    lor
    a?

    75per
    cent

    197.Asmoot h,fi
    rm,mobil
    e,nont
    enderri
    ght-
    breastmassispal
    pabl
    eduri
    ngexami
    nati
    on
    ofa12-year-oldgir
    l.I
    tis1cm ini
    tsgreat
    estdimensi
    onandappearssol
    i
    d
    sonogr
    aphi call
    y,asshownhere.Shehashadnomaj orheal
    thprobl
    emstodat
    e.Whati
    s
    themostlikelydiagnosi
    s?

    Fi
    broadenoma

    198.A14- y
    ear-
    oldwomanpr esentswithincreasingl
    ypainf
    ul,cy
    clicmensessince
    menar che,9mont hsago.Menstrual
    flowi snor mali
    namountanddur at
    ion.Or
    al
    analgesicsandnonsteroi
    dalanti
    -i
    nfl
    ammat orymedicati
    onsnol ongeradequat
    elycontr
    ol
    hersev eredysmenorr
    hea.Whichofthef oll
    owi ngcongenit
    alanomaliesismostli
    kely
    present?

    I
    mper
    for
    atehy
    men
    199.Medi
    cat
    ionusedi
    nthet
    reat
    mentofi
    diopat
    hiccent
    ral
    precoci
    ouspuber
    tyi
    ncl
    ude:

    GnRHagoni
    sts

    200.Mül
    l
    eri
    ananomal
    i
    esar
    eassoci
    atedwi
    thanomal
    i
    esofal
    loft
    hef
    oll
    owi
    ngsy
    stems
    EXCEPT:

    Hepat
    ic

    201.A16-year-
    oldnul l
    i
    gravidapresentst ot
    heemer gencydepar t
    mentwi t
    hcompl aints
    ofabdominalandv aginalpain,
    wor seningduringthepastsev eralmonths.Shedescr i
    bes
    thepainasbeingmost l
    yonherr i
    ghtsi deandmuchwor seduringmenstruati
    on.Dur i
    ng
    yourphysi
    calexami nati
    on,apatentv aginaandcer vi
    xarenot ed,butal
    ateralvagi
    nal and
    pelv
    icmassi spalpated.Transvagi
    nal sonographydemonst ratesasingleuterusand
    cervi
    xbutalsoal ar
    gepel vi
    cmassf i
    ll
    edwi t
    hcompl exf l
    uid,asshownbel ow,andt he
    absenceoftherightkidney.Whatist hemostl ikel
    ydiagnosis?

    OHVI
    RAsy
    ndr
    ome

    202.Thepat
    hogenesi
    sofpoorpr
    egnancyoutcomeswi
    thauni
    cor
    nuat
    eut
    erusi
    s
    thoughtt
    oberel
    atedt
    owhichofthefol
    lowi
    ngactor
    s?

    Al
    loft
    hement
    ioned

    203.Septateut
    erus,asshowninthesonogram bel
    ow,hasasigni
    fi
    cant
    lyhi
    gher
    spontaneousabort
    ionrat
    eandear l
    ypregnancyl
    ossrat
    ethanbicor
    nuateut
    erus.Whatis
    theprimarymechanism t
    houghtt
    ober esponsi
    blef
    orthi
    sextr
    aordi
    nari
    l
    yhighpregnancy
    wastage?

    Par
    ti
    alorcompl
    etei
    mpl
    ant
    ati
    onont
    hel
    argel
    yav
    ascul
    arsy
    stem

    204.Comparedwi
    thot
    hermül
    ler
    ianductdef
    ect
    s,atransv
    ersev
    agi
    nal
    sept
    um i
    s
    associ
    atedwit
    hal
    owerrat
    eofwhichofthef
    oll
    owing?

    Ur
    ologi
    cabnor
    mal
    i
    ties

    205.Thepat
    hogenesi
    sofpoorpr
    egnancyoutcomeswi
    thauni
    cor
    nuat
    eut
    erusi
    s
    thoughtt
    oberel
    atedt
    owhichofthefol
    lowi
    ngactor
    s?

    Al
    loft
    hement
    ioned

    206.Whichoft
    hef
    oll
    owi
    nganat
    omi
    cst
    ruct
    uresi
    scor
    rect
    lypai
    redwi
    thi
    tsembr
    yol
    ogi
    c
    ori
    gin?
    Al
    loft
    hement
    ioned

    207.Whenshoul
    dsurgical
    reconst
    ruct
    ionofabi
    cor
    nuat
    eut
    erus(
    Str
    assman
    metropl
    ast
    y)beper
    formed?

    Withr
    ecurr
    entpr
    egnancyl
    ossandnoot
    heri
    dent
    if
    iabl
    ecauseexceptt
    heut
    eri
    ne
    anomaly

    208.Whi
    chofthefol
    l
    owingstat
    ement sist
    rueregar
    dingt
    her
    oleoft
    hesex-
    det
    ermi
    ning
    regi
    onY(SRY)i
    nthesexual
    diff
    erent
    iati
    onofhumans?

    TheSRYact
    sast
    het
    est
    is-
    det
    ermi
    ningf
    act
    or.

    209.Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    sregar
    dingbl
    adderexst
    rophyi
    sNOTt
    rue?

    Ext
    ernal
    geni
    tal
    i
    aar
    ety
    pical
    l
    ynor
    mal
    exceptf
    oroccasi
    onal
    def
    ect
    s.

    210.Whatper
    cent
    ageofpregnancy-
    rel
    ateddeat
    hsi
    ntheUni
    tedSt
    ateswer
    eat
    tri
    but
    abl
    e
    tocar
    diov
    ascul
    ardi
    seasesbetween2011and2013?

    10-
    15%

    211.Youar ecari
    ngforapri
    migravidawithknownhy pert
    rophi
    ccardi
    omyopat
    hy.She
    tel
    l
    sy ouhermot heral
    sosuff
    eredf rom t
    hecondit
    ionandpassedawayatanear l
    yage.
    Thepatientisconcer
    nedaboutherchi l
    d’sf
    utur
    eriskfordevel
    opingt
    hesameconditi
    on.
    Whatdoy outel
    lheri
    sthemostlikelyri
    skforpassingthecondi
    ti
    ontoherchi
    l
    d?

    50%

    212.Agraphicofpulmonar ycapil
    l
    arywedgepr essur
    e( r
    edline)isshownf orawoman
    withmitr
    alstenosi
    s.“A”represent
    sthefir
    ststageoflabor,“B”mar ksthesecondst
    age
    oflabor
    ,“C”demonstratestheimmedi at
    epostpartum peri
    od,and“ D”showstheperi
    od
    4–6hour spostdel
    i
    very.Whataccount sf
    orther i
    seinpulmonar ycapil
    l
    arywedge
    pressur
    eimmedi at
    elyfoll
    owingdeliv
    ery?

    Pl
    acent
    alaut
    otr
    ansf
    usi
    on

    213.Basedonthediagnosi
    sofaperi
    part
    um cardiomyopat
    hyandassumingarecov
    ery
    ofsyst
    oli
    cfunct
    ionby6mont hspost
    part
    um, whatisthepat
    ient
    ’sr
    iskf
    orsuf
    feri
    nga
    rel
    apseofthesameconditi
    oninafut
    urepregnancy?

    30%
    214.Thebenefi
    tsandsafet
    yofi
    nsti
    tut
    inganti
    hyper
    tensi
    vet
    her
    apyi
    nwomenwi
    th
    chroni
    chyper
    tensi
    onplanni
    ngordur
    ingpregnancyare:

    Notcl
    ear

    215.Indi
    cat
    ionsf
    oraspi
    ri
    nprophylaxistoreducether
    iskfordevel
    opi
    ngpr
    eecl
    ampsi
    ain
    pregnantwomenwit
    hchroni
    chy pertensi
    onincludeahist
    oryof:

    Al
    loft
    hement
    ioned

    216.Whichoft
    hef
    oll
    owi
    ngisNOTtr
    ueregar
    dingt
    hecompl
    i
    cat
    ionshownher
    e,i
    nthe
    computeri
    zedt
    omogr
    aphyscani
    mage?

    Theri
    skisnoti
    ncr
    easedamongwomenwi
    thchr
    oni
    chy
    per
    tensi
    oni
    ntheabsenceof
    super
    imposedpr
    eecl
    ampsi
    a

    217.Whyet
    hni
    cit
    yisi
    mpor
    tanti
    nrecommendat
    ionst
    oini
    ti
    ateanant
    ihy
    per
    tensi
    veagent
    ?
    Amongf
    oll
    owi
    ngchoosecor
    rectst
    atement
    s

    a.Angi
    otensi
    n-conv
    ert
    ingenzymeinhi
    bit
    orsandangiot
    ensi
    n-r
    ecept
    orbl
    ocker
    sar
    e
    r
    ecommendedasi nit
    ial
    ther
    apyintheblackpopul
    ati
    on.
    b.Bet
    abl
    ocker
    sar
    enotr
    ecommendedasi
    nit
    ial
    ther
    apyi
    nthenonbl
    ackpopul
    ati
    on.
    c.Bet
    abl
    ocker
    sar
    erecommendedasi
    nit
    ial
    ther
    apyi
    ntheAsi
    anpopul
    ati
    on.
    d.Angi
    otensi
    n-conv
    ert
    ingenzymeinhi
    bit
    orsandangi
    otensi
    n-r
    ecept
    orbl
    ocker
    sar
    e
    r
    ecommendedasi nit
    ial
    ther
    apyinthenonbl
    ackpopulat
    ion
    218.Antihy
    pert
    ensi
    vet
    her
    apyi
    smandat
    oryf
    orwhi
    choft
    hef
    oll
    owi
    ngwomendur
    ing
    pregnancy
    ?
    30-
    year
    -ol
    dG3P2wi
    thabl
    oodpr
    essur
    eof160/
    110mm Hgandahi
    stor
    yofast
    hma
    219.Whi
    choft
    hef
    oll
    owi
    ngi
    samaj
    orf
    act
    orcont
    ri
    but
    ingt
    othei
    nci
    denceofper
    inat
    al
    mor
    tal
    i
    tynot
    edi
    npr
    egnanci
    escompl
    i
    cat
    edbychr
    oni
    chy
    per
    tensi
    on?
    Al
    loft
    hement
    ioned
    220.Whi
    chant
    ihy
    pert
    ensi
    vedrugcommonl
    yusedt
    otr
    eathy
    per
    tensi
    oni
    spr
    oper
    lymat
    ched
    wi
    thi
    tsmostnot
    ablesi
    deeff
    ect?
    Hy
    dral
    azi
    ne—mat
    ernal
    tachy
    car
    dia
    221.Ms.Al doisa30-year-ol
    dG3P2whopr esent
    sforestabl
    i
    shmentofpr enat
    alcareat
    9weeks’ gestat
    ion.Herpriorpregnancieshavebothbeencompl i
    catedbygestat
    ional
    hypert
    ensionneart er
    m.Herbl oodpr essur
    ewas146/ 88mm Hg, whi chshest
    atesis
    concordantwithotherrecentmeasur ements.Whichofthefoll
    owingi st
    hemost
    appropri
    atenextstepinhermanagement ?

    Recommendt
    hatshekeepal
    ogofherbl
    oodpr
    essur
    esandbr
    ingt
    hem t
    oher
    appoi
    ntment
    s
    222.A28- year-oldG3P1102at9weeks’ gestati
    onpr esentsforestabli
    shmentof
    prenatalcare.Herf i
    rstpregnancywascompl icat
    edbygest ati
    onalhypert
    ensi
    onatt erm,
    andhersecondwascompl i
    cat edbyi at
    rogenicpreterm deli
    veryat36weeks’ gest
    ation
    forpreeclampsi a.Herbl oodpr essur ewasnor mal atherpost par
    tum visi
    t2yearsago
    buthasnotbeenassessedsi nce.Todayherbodymassi ndexis46kg/ m2andherbl ood
    pressureis158/ 96mm Hg.Asi nstruct
    ed,shecallsback2day safterhervi
    sittor
    epor t
    thatbloodpr essur eshav ebeeni nthe146–160/ 94–100mm Hgr angeathome.I n
    additi
    ont oinit
    iationofanant ihypertensi
    veagent ,whatisthenextst epinmanagement
    ofherbloodpr essurei nthi
    spr egnancy?
    Basel
    i
    neser
    um cr
    eat
    ini
    ne
    223.Whichofthefoll
    owingf
    indi
    ngsmakei
    ncaseofel
    evat
    edl
    i
    verenzy
    mesexcl
    ude
    int
    rahepat
    icchol
    estasi
    sofpregnancy
    ?
    AST800U/
    L
    224.Whichimagingmodali
    tyi
    srecommendedindiscr
    imi
    nati
    ngacut
    efat
    tyl
    i
    verof
    pregnancyf
    rom otheret
    iol
    ogi
    esofel
    evat
    edli
    verenzymes?
    Noneoft
    heabov
    e
    225.Whichofthefoll
    owingfeatur
    esarecr
    it
    eri
    aforsev
    eredi
    seaset
    hatshoul
    dpr
    ompt
    hospi
    tal
    i
    z at
    ionforacutevi
    ralhepat
    it
    is?
    Hy
    per
    bil
    i
    rubi
    nemi
    a
    226.Dur
    ingt
    hehospi
    talcareofapat
    ientwi
    thacut
    evi
    ral
    hepat
    it
    is,
    whichoft
    he
    fol
    lowi
    ngper
    sonalpr
    otecti
    veequi
    pmentshoul
    dbeusedatal
    lti
    mes?
    Gl
    oves
    227.A27-year
    -ol
    dat32weeks’
    gest
    ati
    onisbr
    oughttotheemer
    gencyr
    oom by
    ambulanceaft
    erconsumi
    ng6gramsofacet
    aminophen.Whi
    chofthef
    oll
    owi
    ngist
    rue?
    Thi
    sist
    hemostcommoncauseofacut
    eli
    verf
    ail
    urei
    ntheUni
    tedSt
    ates.
    228.Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    sregar
    dingphy
    siol
    ogi
    cal
    changesi
    npr
    egnancyi
    s
    tr
    ue?
    Ef
    fect
    iver
    enal
    plasmaf
    lowi
    ncr
    eases
    229.Whatper
    centageofpregnantwomenexperi
    encear
    ecur
    rentur
    inar
    ytr
    acti
    nfect
    ion
    aft
    ercomplet
    ionoftr
    eatmentforpyel
    onephr
    it
    is?
    30-
    40%
    230.Whatpercentageofpr
    egnantwomenwi
    thasy
    mpt
    omat
    icbact
    eri
    uri
    adev
    elopa
    symptomati
    cinfecti
    onifl
    eftunt
    reat
    ed?
    25%
    231.Thepregnantpati
    entwi
    thakidneystoneaskshowmanypregnantwomenactual
    l
    y
    passthei
    rstonewiththemanagementplanofanalgesi
    aandi
    ntr
    avenoushy
    drat
    ion.
    Whatisyourresponse?
    65-
    80%
    232.Mostwomenwit
    hnephr
    oti
    csy
    ndr
    omeswi
    l
    lhav
    esuccessf
    ulpr
    egnancyout
    comes
    incasei
    ftheyhav
    e
    pr
    otei
    nexcr
    eti
    ont
    hatex
    ceeded3g/
    d
    233.A27-
    year
    -ol
    dnul
    l
    igr
    avi
    daandherhusbandpr
    esentf
    orpr
    econcept
    ioncounsel
    i
    ng.
    ShehasWi
    lsondiseasethati
    sbeingtr
    eat
    edwi
    thzi
    ncsul
    fat
    e.Whi
    choft
    hef
    oll
    owi
    ng
    shoul
    dbei
    ncludedinyourcounsel
    ing?
    Herhusbandshoul
    dconsi
    dercar
    ri
    ert
    est
    ing
    234.A32-
    year
    -ol
    dnul
    l
    igr
    avi
    dapr
    esent
    sforpr
    econcept
    ioncounsel
    i
    ngduet
    oci
    rr
    hosi
    s
    wi
    thesophageal
    var
    ices.Whi
    choft
    hef
    oll
    owi
    ngshoul
    dbei
    ncl
    udedi
    nyourcounsel
    i
    ng?
    Al
    loft
    heabov
    e
    235.Yourpat
    ienti
    sadmi
    tt
    edt
    othehospi
    tal
    forev
    aluat
    ionofnew-
    onsethy
    per
    tensi
    onat
    30weeks’
    gest
    ati
    on.Whi
    choft
    hef
    oll
    owi
    ngt
    est
    sorev
    aluat
    ionsi
    sleastappr
    opr
    iat
    e?
    Cel
    l
    -fr
    eeDNAt
    est
    ingf
    oraneupl
    oidy
    236.Whi
    choft
    hef
    oll
    owi
    ngmedi
    cal
    ther
    api
    eshasbeenassoci
    atedwi
    thamodest
    decr
    easei
    nthei
    nci
    denceofpr
    eecl
    ampsi
    ainwomenati
    ncr
    easedr
    isk?
    Aspi
    ri
    n
    237.Apr
    egnantl
    adypr
    esent
    swi
    thv
    agi
    nal
    bleedi
    ngi
    n1stt
    ri
    mest
    er,
    onexami
    nat
    ionOs
    i
    scl
    osedandut
    eri
    nesi
    zecor
    respondst
    othePOG(
    Per
    iodofGest
    ati
    on)
    Thr
    eat
    enedabor
    ti
    on
    238.Vi
    ral
    inf
    ect
    ionr
    isksf
    rom t
    ransf
    usi
    onar
    eaccur
    atel
    ydepi
    ctedi
    nwhi
    choft
    he
    f
    oll
    owi
    ngst
    atement
    s?
    Al
    loft
    heabov
    e
    239.Whi
    chhemost
    ati
    csur
    gical
    procedur
    eisdemonst
    rat
    edi
    nthepi
    ctur
    ebel
    ow?
    Ut
    eri
    near
    ter
    yli
    gat
    ion
    240.Thefoll
    owingpict
    ureunfor
    tunat
    elydepi
    ctsamaternaldeat
    haf
    terpost
    par
    tum
    hemorrhage.Whichofthefol
    l
    owingarepossibl
    econt
    ributor
    s?
    Ut
    eri
    nei
    nver
    sion
    241.Whi
    choft
    hebact
    eri
    abel
    owar
    eassoci
    atedwi
    thconsumpt
    ivecoagul
    opat
    hy?
    Gr
    oupASt
    rept
    ococcus
    242.Ligat
    ionatwhi
    choft hef
    oll
    owinglabel
    edvessel
    poi
    ntsi
    nther
    etr
    oper
    it
    oneum wi
    l
    l
    decreasethepul
    sepressurei
    ntheuter
    ineart
    ery?
    I
    nter
    nal
    il
    iacar
    ter
    y
    243.Regar
    dingt
    hepati
    entwi
    thdi
    l
    uti
    onal
    coagulopat
    hy,
    whichoft
    hef
    oll
    owi
    ng
    i
    nterv
    enti
    onsmighthav
    eavoi
    dedoramel
    ior
    atedthi
    scondi
    ti
    on?
    Tr
    ansf
    usi
    onofwhol
    ebl
    ood
    244.Whichofthef
    oll
    owingmaneuv
    ersshouldbeperf
    ormedi
    ntheset
    ti
    ngof
    postpar
    tum hemor
    rhagefol
    l
    owi
    ngav agi
    naldel
    iv
    ery?
    Al
    loft
    hement
    ioned
    245.A32- year-
    oldwomanunder goesmy omectomyforsympt
    omati
    cuter
    inefi
    broi
    ds,
    all
    ofwhi charesubserosal(outsi
    desur f
    aceoft heuter
    us)
    .Theendomet
    ri
    alcavi
    tywasnot
    enteredduringtheprocedure.Whichoft hefoll
    owingstat
    ement
    sismostli
    kel
    ytobe
    correctregardi
    ngtheriskofplacentalaccret
    a?
    Herr
    iskofaccr
    etai
    smostl
    i
    kel
    ynotaf
    fect
    edbyt
    hemy
    omect
    omy
    246.A21-
    year
    -ol
    dpat
    ientat28weeks’
    gest
    ati
    onhasv
    agi
    nal
    bleedi
    ngandi
    sdi
    agnosed
    wi
    thpl
    acent
    apr
    evi
    a.Whi
    choft
    hef
    oll
    owi
    ngi
    sat
    ypi
    cal
    feat
    ureoft
    hiscondi
    ti
    on?
    Associ
    atedwi
    thpost
    coi
    tal
    spot
    ti
    ng
    247.A35- year
    -ol
    dwomanpr esentswit
    hbr i
    ghtr
    edvaginalbl
    eedingat30weeks’
    gestati
    on.Herurinedr
    ugscreenisposi
    tiv
    e.Whichofthefoll
    owingismostl
    ikel
    ytobe
    presentinherdrugscr
    een?
    Cocai
    ne
    248.Whi
    choft
    hefoll
    owingstat
    ementsisFALSEregardi
    ngt
    hedevelopmentoft
    he
    hypot
    hal
    ami
    c–pit
    uit
    ary-
    ovar
    ianaxi
    sinthefemal
    ef et
    usandneonat
    e?
    Thegonadot
    ropi
    n-r
    eleasi
    nghormone(GnRH)“
    pul
    segener
    ator
    ”remai
    nsf
    unct
    ional
    l
    y
    dor
    mantunti
    lsever
    al monthsaf
    terbi
    rt
    h.
    249.Pubarche,
    withdevel
    opmentofaxil
    l
    aryandpubi
    chair,
    isst
    imul
    atedbyt
    he
    androgensderi
    vedpri
    maril
    yfr
    om whichofthef
    oll
    owing?
    Adr
    enal
    glands
    250.Pri
    marytherapyorcent
    ral
    (gonadot
    ropi
    n-dependent
    )pr
    ecoci
    ouspuber
    tyconsi
    sts
    ofwhichofthefoll
    owing?
    Gonadot
    ropi
    n-r
    eleasi
    nghor
    mone(
    GnRH)agoni
    st
    251.A6-y
    ear
    -ol
    dCaucasi
    angi
    rli
    snotedtohaveTanner3br
    eastdev
    elopmentand
    menses.Whi
    choft
    hefoll
    owi
    ngistheprobabl
    etr
    eatmentf
    orthi
    spati
    ent?
    GnRHagoni
    stt
    her
    apy
    252.Lackofbreastdevelopmentisassoci
    atedwi
    thl
    owest
    rogenl
    evel
    sandmaybe
    causedbywhichoft hefoll
    owing?
    Al
    loft
    hement
    ioned
    253.Whichmüll
    eri
    ananomal
    yresul
    tsf
    rom complet
    efail
    ureoft
    hepairedmüll
    eri
    an
    ductst
    ouse?Thisanomalyi
    sshowninthi
    ssonogram,andagestat
    ionalsaci
    sseenon
    thei
    mage’sl
    eftsi
    de.
    Ut
    eri
    nedi
    del
    phy
    s
    254.Causesofnewbor
    ncl
    i
    tor
    omegal
    yincl
    udewhi
    choft
    hef
    oll
    owi
    ng?
    Al
    loft
    hement
    ioned
    255.Whi
    choft
    hef
    oll
    owi
    ngi
    sNOTt
    rueofKl
    i
    nef
    elt
    ersy
    ndr
    ome?
    Af
    fect
    edmenar
    etal
    landex
    cessi
    vel
    yvi
    ri
    li
    zed.
    256.Thev
    agi
    naf
    ormsi
    npar
    tfr
    om bot
    hthemül
    l
    eri
    anduct
    sandwhi
    chot
    herst
    ruct
    ure?
    Ur
    ogeni
    tal
    sinus
    257.Oneofy ourpati
    ent sbr
    ingsher13- year -
    olddaught
    erf orconsul
    tationr egardingthe
    gi
    rl’
    scompl ai
    ntsofpelvicpain.Thedaught erhasexper
    iencednor mal puber tal
    developmentt odatebuthasnoty etexperiencedmenarche.Shebeganhav ingmont hly
    pelv
    icpai nabout1y earago, andt hepainhasbeenpr ogressivel
    ywor sening.Dur ing
    physicalexaminati
    on,herext ernalgenit
    alia,incl
    udi
    nghymeneal ri
    ng,appearnor mal .
    Howev er
    ,proxi
    mal t
    ot hehymen, onlyav aginaldi
    mplei
    sf ound.Rectov aginal
    exami nati
    onconfir
    mst hepresenceofaut erusandcervix.Whatisyourdi agnosi s?
    Vagi
    nal
    atr
    esi
    a
    258.Post
    coi
    tal
    testi
    susedt
    oassess:
    Cer
    vical
    fact
    or
    259.Art
    ifici
    alinsemi
    nat
    ionwi
    thhusband’
    ssemeni
    sindi
    cat
    edi
    nal
    lthef
    oll
    owi
    ng
    si
    tuat
    ions,except
    Azoosper
    mia
    260.A34-year-
    oldi
    nfer
    ti
    lewomani
    snotedtohaveevi
    denceofblockedfal
    lopi
    antubes
    byhyst
    erosalpi
    ngogr
    am.Whichoft
    hefoll
    owingi
    sthebestnextstepfort
    hispati
    ent
    ?
    Lapar
    oscopy
    261.Whi
    choft
    hef
    oll
    owi
    ngi
    str
    ueoft
    hepr
    ocessofsper
    m capi
    tat
    ion?
    Al
    loft
    hement
    ioned
    262.Congeni
    tal
    bil
    ater
    alabsenceoft
    hev
    asdef
    erensi
    sgenet
    ical
    l
    yrel
    atedt
    owhi
    chof
    thefol
    l
    owing?
    Cy
    sti
    cfi
    brosi
    s
    263.Howl
    ongdoessper
    mat
    ogenesi
    stake,
    star
    ti
    ngf
    rom st
    em cel
    ltomat
    uresper
    m?
    90day
    s
    264.I
    nrepr
    oduct
    ive-
    agedwomen,
    whi
    choft
    hef
    oll
    owi
    ngi
    ncr
    easeswi
    tht
    hepassageof
    ti
    me?
    Ri
    skofspont
    aneousabor
    ti
    on
    265.Whi
    choft
    hef
    oll
    owi
    ngi
    sNOTt
    ruer
    egar
    dingcl
    omi
    pheneci
    tr
    atet
    her
    apy
    ?

    Thet
    ypi
    cal
    star
    ti
    ngdosei
    s200mgor
    all
    y.

    266.A38-year-
    oldwomanwi t
    hinfert
    il
    it
    ysecondaryt
    odistalt
    ubalblockageundergoes
    invi
    tr
    of er
    ti
    li
    zati
    on.Herpeakestr
    adioli
    s4500pg/ mL.Subsequentl
    y,17oocytesare
    ret
    ri
    eved,and2embr yosaret
    ransfer
    red.Sheconcei
    vesasinglet
    ongest at
    ionbut
    devel
    opsovari
    anhyper
    sti
    mulat
    ionsyndr
    ome(OHSS).Asonogr
    am ofherovar
    iesi
    s
    shownhere.Whichoft
    hefol
    l
    owi ngi
    sapredi
    sposi
    ngact
    ororherdevel
    opingOHSS?

    Hi
    ghest
    radi
    oll
    evel

    267.Whi
    chofthefol
    l
    owi
    nghormonesist
    houghtt
    opl
    ayacont
    ri
    but
    ingr
    oleear
    lyi
    nthe
    devel
    opmentofov
    ari
    anhyper
    sti
    mul
    ati
    onsyndr
    ome?

    Humanchor
    ioni
    cgonadot
    ropi
    n

    268.A22-
    year-ol
    dG0P0womancompl ai
    nsofirr
    egul
    armensesevery30t
    o65days.The
    semenanalysisi
    snormal
    .Thehyster
    osalpi
    ngogram i
    snor
    mal.Whichoft
    hef
    oll
    owingis
    themostl
    ikelytr
    eat
    mentfort
    hispati
    ent?

    Cl
    omi
    pheneci
    tr
    ate

    269.Awomancompl ai
    ningofinfer
    ti
    li
    tyrepor
    tsthatherhusbandhasalr
    eadyundergone
    eval
    uati
    onbyaurologi
    sttoexcludemaleactors.Thi
    sleadstothesurgi
    calr
    epairofa
    unil
    ater
    alv
    ari
    cocel
    e.Withregar
    dt ovari
    cocel
    esandi nf
    erti
    l
    ity
    ,whichofthef
    oll
    owingis
    tr
    ue?
    Av
    ari
    cocel
    eispr
    esenti
    nnear
    ly20per
    centoft
    headul
    tmal
    egener
    alpopul
    ati
    on.
    270.Whati
    stheexpect
    edpercy
    clef
    ecundabi
    l
    ityr
    ate?
    25per
    cent
    271.Asshownhere,sonographyi
    scli
    nical
    lymostusefulf
    orthediagnosi
    sofwhichof
    thefol
    l
    owingcondi
    ti
    onst hatcont
    ri
    but
    est oasi
    gnifi
    cantpercent
    ageofinfer
    ti
    li
    tycases?
    Pol
    ycy
    sti
    cov
    ari
    ansy
    ndr
    ome
    272.Whichoft
    hef
    oll
    owi
    ngst
    atement
    sist
    ruer
    egar
    dingt
    hyr
    oiddy
    sfunct
    ionand
    i
    nfert
    il
    it
    y?
    Ini
    nfer
    ti
    lewomenseeki
    ngpr
    egnancy
    ,tr
    eat
    mentofanydegr
    eeofhy
    pot
    hyr
    oidi
    sm i
    s
    advi
    sabl
    e.
    273.Averyhealth-consci
    ouspat
    ientisseekingpregnancyandasksaboutthebestdi
    et
    tofol
    lowatthi
    st ime.Sheisover
    whel medbyal ltheadvi
    ceavail
    abl
    efr
    om f r
    iends,
    books,
    andmagazines.Whi chofthefol
    l
    owi ngnutri
    tionalst
    rat
    egiesi
    smoststrongly
    recommendedf orwomenat t
    emptingpregnancy ?
    Fol
    i
    caci
    dsuppl
    ement
    ati
    on
    274. CV PATHOLOHY
    1
    I
    napregnantpopul
    ati
    on,
    whati
    sthemostcommoncauseoft
    hecondi
    ti
    onpor
    tray
    ed
    i
    nthechestx-
    rayi
    magebelow?
    (
    enl
    argedpul
    monar
    yhi
    l
    arar
    ter
    iesandat
    tenuat
    edper
    ipher
    almar
    kings)
    Ansmet
    abol
    i
    cdi
    sor
    der

    2Whati
    sthemostcommoncauseofhear
    tfai
    l
    urei
    npr
    egnancy
    ?
    Ans Chr
    oni
    chy
    per
    tensi
    onwi
    thsuper
    imposedpr
    eecl
    ampsi
    a

    3Youarecari
    ngfora24-
    year-
    oldG1withsev
    ereaort
    icst
    enosi
    s.Wheni
    npr
    egnancyar
    e
    youmostconcer
    nedaboutcardi
    acdecompensat
    ion?
    Ansper
    ipar
    tum
    4Forwhi
    chofthef
    oll
    owi
    ngcar
    diaccondi
    ti
    onsi
    sconduct
    ionanal
    gesi
    ahi
    ghl
    y
    r
    ecommended?
    Ans
    5Aschemati
    cofEisenmengersy
    ndr
    omeduet
    oav ent
    ri
    cul
    arseptaldef
    ectisdepi
    cted.
    Whati
    sthemostcommoncauseofdeat
    hinpr
    egnantwomenwiththiscondi
    ti
    on?
    Ans
    6diagnosti
    cstudi
    es,whichoft
    hef
    oll
    owi
    ngcor
    rect
    lydescr
    ibesanor
    mal
    changet
    hati
    s
    char
    acter
    ist
    icofpregnancy?
    Ans
    7A32- year-ol
    dG2P1pr esentstoy ouroffi
    ceat17weeks’ gestati
    on.Shereport
    sa
    hist
    oryoft etr
    alogyofFall
    ot,
    whi chwasr epair
    edini nf
    ancy .Sheappearscomfortabl
    eon
    theexam t abl
    ewi t
    hahear tr
    ateof92beat spermi nuteandabl oodpressureof96/62
    mm Hg.Howev er,
    shedoesr eportsigni
    fi
    cantpalpitat
    ionsanddy spneawhenclimbing
    thetwof l
    ightsofstai
    rstoherapar tmentont hethirdfl
    oor.WhichNewYor kHeart
    Associati
    oncl assbestdescri
    besherf uncti
    onaldisabili
    ty?
    Ans
    8Agr aphicofpulmonarycapil
    lar
    ywedgepr essure(redli
    ne)i
    sshownf orawomanwi t
    h
    mitr
    alstenosi
    s.“A”repr
    esentsthefirstst
    ageofl abor,“
    B”marksthesecondstageof
    l
    abor“C”demonst r
    atestheimmedi atepostpartum peri
    od,and“D”showstheperi
    od4–6
    hourspostdel
    iv
    ery.Whataccountsf ortheri
    seinpul monarycapil
    l
    arywedgepressur
    e
    i
    mmedi atel
    yfoll
    owingdeli
    very?
    Ans 50%
    9Inapr
    egnantwomanwhohaspr evi
    ousl
    yundergoneahearttr
    ansplant
    ati
    on,
    whati
    s
    t
    heappr
    oxi
    materi
    skforsuf
    fer
    ingarej
    ecti
    onepisodedur
    ingpregnancy?
    Ans
    10Whati
    sthegol
    dst
    andar
    dfordi
    agnosi
    soft
    hecondi
    ti
    oni
    nQuest
    ion49–24?
    AnsRi
    ghthear
    tcat
    het
    eri
    zat
    ion

    11TheWorldHeal
    thOrgani
    zat
    ioni
    dent
    if
    ieswhi
    choft
    hef
    oll
    owi
    ngcondi
    ti
    onsas
    pr
    ohibi
    ti
    veofpr
    egnancy?
    Ans
    12Whi choft
    hef
    oll
    owi
    ngt
    her
    api
    esi
    ssaf
    einpr
    egnancyt
    otr
    eatacut
    esupr
    avent
    ri
    cul
    ar
    tachy
    cardi
    a?
    Ans
    13Whi
    chofthefol
    lowi
    ngbestdescr
    ibest
    her
    emodel
    i
    ngoft
    hehear
    tthatoccur
    sin
    nor
    malpr
    egnancy?
    AnsEccent
    ri
    clef
    tvent
    ri
    cul
    armassexpansi
    onwi
    thspher
    ical
    remodel
    i
    ng

    14Youar ecar i
    ngforapregnantpati
    entwithmi t
    ral
    stenosis.Shei
    sablet oper
    for
    m
    mostact i
    viti
    esofdail
    yli
    vingwit
    houtsignif
    icantl
    imit
    ati
    on.Onechocardiogram,her
    eject
    ionfracti
    onis50%andhermi tralval
    veareameasur es1.8cm2.Whi chofthe
    foll
    owingv ar
    iabl
    esismostpredict
    iveofahi ghri
    skforcardiaccompl
    i
    cat i
    onsduri
    ngthi
    s
    pregnancy?
    Ans.Herdegr
    eeofl
    eft
    -si
    dedobst
    ruct
    ion

    15Thepat i
    entwhoseheartisshownint hisi
    magehassy st
    emiclupuseryt
    hemat osus
    andhasahi st
    oryofapriorstr
    oke.Theleftatr
    ium (
    LA)andl ef
    tventr
    icl
    e(LV)ar e
    identi
    fi
    ed,
    andthearrowspointtononinfecti
    ousvegetat
    ionsonthemi t
    rall
    eaflets.
    Whi choft
    hefoll
    owingistheli
    kel
    yconditionassoci
    atedwi t
    hhermi t
    rali
    nsuff
    iciency?
    Ans
    16Whichofthefol
    l
    owingcondi
    ti
    onsusual
    l
    yimpr
    ovesdur
    ingpr
    egnancyduet
    o
    pr
    egnancy
    -i
    nducedhyper
    vol
    emia?
    AnsAl
    loft
    heabov
    e

    17A30- y
    ear-oldG2P0A1pr esentsat11weeks’
    gestat
    iontoestabl
    ishcare.Shehasa
    hi
    storyofrheumat i
    chear
    tdi seaseandhadamechanicalv
    alverepl
    acementatage20.
    Shewaspr eviousl
    yonwarf ari
    n7.5mgdaily
    ,butst
    oppedtakinghermedi cat
    ionwhen
    shefoundoutshewaspr egnant1weekago.Whati sherriskforwarfar
    inembr y
    opat
    hy
    basedonherwar f
    ari
    ndosing?
    Ans.8%
    18Whatpercentageofpregnancy
    -rel
    ateddeat
    hsi
    ntheUni
    tedSt
    ateswer
    eat
    tri
    but
    abl
    e
    tocar
    diov
    asculardi
    seasesbetween2011and2013?
    Ans15–20%
    19Whi choft
    hefol
    lowi
    ngdoesnotcont
    ri
    but
    etot
    he40%i
    ncr
    easei
    ncar
    diacout
    put
    seenduri
    ngnormal
    pregnancy
    ?
    Ans I
    ncr
    easedl
    eftv
    ent
    ri
    cul
    arcont
    ract
    il
    it
    y

    20I
    ntheUni
    tedSt
    ates,
    whati
    sthemostcommoncauseofaor
    ti
    cst
    enosi
    s?
    AnsBi
    cuspi
    daor
    ti
    cval
    ve

    21A32- y
    ear-ol
    dG2P1pr esentst oyouroffi
    ceat17weeks’ gestati
    on.Shereport
    sa
    hist
    oryoftetr
    alogyofFal
    lot,
    whi chwasr epair
    edininf
    ancy.Sheappear scomfortabl
    eon
    theexam tabl
    ewi t
    hahear tr
    ateof92beat spermi nuteandabl oodpressureof96/62
    mm Hg.Howev er,
    shedoesr eportsigni
    fi
    cantpal
    pitat
    ionsanddy spneawhenclimbing
    thetwofli
    ghtsofstai
    rstoherapar tmentont het
    hirdfl
    oor.WhichNewYor kHeart
    Associ
    ati
    oncl
    assbestdescr
    ibesherf
    unct
    ional
    disabi
    l
    ity
    ?
    AnsCl
    assI
    I

    22Youar
    ecari
    ngfora24-
    year-
    oldG1withsev
    ereaorti
    cstenosi
    s.Wheni
    npr
    egnancy
    ar
    eyoumostconcer
    nedaboutcardi
    acdecompensat
    ion?
    Ans.Per
    ipar
    tum

    23Whatpercentageofpregnancy
    -rel
    ateddeat
    hsi
    ntheUni
    tedSt
    ateswer
    eat
    tri
    but
    abl
    e
    tocar
    diov
    asculardi
    seasesbetween2011and2013?
    Ans
    24Whichofthefoll
    owingcondi
    ti
    onsusual
    l
    yimpr
    ovesdur
    ingpr
    egnancyduet
    o
    pr
    egnancy-
    inducedhyperv
    olemi
    a?
    Ans Al
    loft
    heabov
    e

    25Youar ecar i
    ngforapregnantpati
    entwithmi t
    ral
    stenosis.Shei
    sablet oper
    for
    m
    mostact i
    viti
    esofdail
    yli
    vingwit
    houtsignif
    icantl
    imit
    ati
    on.Onechocardiogram,her
    eject
    ionfracti
    onis50%andhermi tralval
    veareameasur es1.8cm2.Whi chofthe
    foll
    owingv ar
    iabl
    esismostpredict
    iveofahi ghri
    skforcardiaccompl
    i
    cat i
    onsduri
    ngthi
    s
    pregnancy?
    Ans.Herdegr
    eeofl
    eft
    -si
    dedobst
    ruct
    ion

    26Whichoft
    hefol
    l
    owingdoesnotcont
    ri
    but
    etot
    he40%i
    ncr
    easei
    ncar
    diacout
    putseen
    dur
    ingnor
    malpr
    egnancy
    ?
    Ans.I
    ncr
    easedl
    eftv
    ent
    ri
    cul
    arcont
    ract
    il
    it
    y

    27Whi
    chofthefol
    lowi
    ngbestdescr
    ibest
    her
    emodel
    i
    ngoft
    hehear
    tthatoccur
    sin
    nor
    malpr
    egnancy?
    Ans.Eccent
    ri
    clef
    tvent
    ri
    cul
    armassexpansi
    onwi
    thspher
    ical
    remodel
    i
    ng

    28Forwhichoft
    hef
    oll
    owi
    ngcar
    diaccondi
    ti
    onsi
    sconduct
    ionanal
    gesi
    ahi
    ghl
    y
    recommended?
    Ans
    29I
    napr egnantpopul
    ati
    on,whati
    sthemostcommoncauseoft
    hecondi
    ti
    onpor
    tray
    ed
    i
    nthechestx-r
    ayimagebelow?
    (
    enl
    argedpul
    monar
    yhi
    l
    arar
    ter
    iesandat
    tenuat
    edper
    ipher
    almar
    kings)
    Ans

    t
    estf
    orCV-
    pat
    hol
    ogy-cl
    i
    nical
    cases

    30A32-
    year
    -ol
    dG2P1t
    ransf
    erst
    oyourcar
    eat18weeks’
    gest
    ati
    on.Shehasa
    hist
    oryofNYHAclass2hear
    tdisease.Whatamongf
    oll
    owi
    ngar
    ecommon
    recommendati
    onstothi
    spat
    ient?

    Anstoavoidcontactwi
    thpersonswhohav erespi
    rat
    oryi
    nfect
    ions,
    incl
    udi
    ngt
    hecommon
    col
    d,
    andtoreportatonceanyevi
    dencefori
    nfecti
    on

    31Youar et
    heon- cal
    lhospit
    ali
    stwheny ourecei
    veanurgentcal l
    from t
    he
    post
    part um f
    looraboutapat i
    entwhoi scompl ai
    ningofchestpainandshor t
    ness
    ofbreath.Shehadanuncompl icatedvaginaldel
    i
    verythepreviousdayandhasno
    si
    gnifi
    cantpastmedi calorsurgicalhi
    story.Youobtai
    nast atchestx-
    ray,whichi
    s
    shown.Basedont hefindi
    ngs,whatar eyoumostconcer nedfor?

    Ans

    32Youar ecaringf
    orcompl ainsofshort
    nessofbreathandchestpai nwith
    minimalexer
    tionanuncompl i
    cat
    edprimigr
    avi
    daat32weeks’ gestat
    ion.An
    echocardi
    ogram demonst r
    at esamitr
    alval
    vesurf
    acear eaof2.1cm2, adil
    ated
    lef
    tatr
    ium,anaor t
    icval
    vear eaof3.7cm2,ari
    ghtv ent
    ri
    cularsystoli
    cpressureof
    20mm Hg, andanej ecti
    onfracti
    onof55%.Youalsoobt ai
    nachestx- r
    ay,which
    isshown.Whati stheli
    kel
    yunder l
    yi
    ngcauseofhersy mptoms?

    AnsMi
    tr
    alst
    enosi
    s

    33At24weeks’ gest
    ati
    onthepat
    ientwit
    hahistor
    yofpulmonaryhypert
    ension
    duetochroni
    cthromboemboli
    cdiseasei
    nherpastbeginstodevel
    oporthopnea
    anddyspneaonex er
    ti
    on.Whattr
    eatmentwouldyouconsidert
    odecreaseher
    symptoms?

    Ans Al
    loft
    heabov
    e

    34Apr egnantwomanpr esentstotheemer gencyroom inanobt undedstate.She


    hasafev erto102.6°
    F.Onexam, a4/ 6mur murisnoted,shewithdrawsfrom pain
    duri
    ngherabdomi nalexam,andtrackmar ksarenotedonherar msandl egs.Her
    fundalheighti
    sapproxi
    mately32cm.Anemer gentechocar
    diogram isobtained,
    whichdemonst rat
    esami t
    ralval
    vev eget
    ation.Whatisthemostl ikel
    yorganism
    underl
    yingherdiagnosi
    s?

    Ans

    t
    estf
    orChr
    oni
    chy
    per
    tensi
    on–t
    heor
    y

    35Whichintr
    avenousanti
    hyper
    tensi
    vedr
    ugcommonl
    yusedtotr
    eatintr
    apart
    um
    sev
    ererangehyper
    tensi
    onisproperl
    ymat
    chedwi
    thi
    tsmostnot
    ablesideeff
    ect?

    Ans.Labet
    alol
    —neonat
    alhy
    pot
    ensi
    onandbr
    ady
    car
    dia

    36Forwomenwi
    thchr
    oni
    chy
    per
    tensi
    on,
    whi
    chmodi
    fi
    abl
    efact
    orf
    urt
    her
    i
    ncr
    easest
    her
    iskf
    ort
    hepl
    acent
    alabr
    upt
    ion?

    Anssmoki
    ng

    37Amongwomenwhohav epersi
    stent
    lywor
    ri
    somehyper
    tensi
    ondespi
    teusual
    ther
    apywhatant
    agoni
    zi
    ngsubst
    ancesmaybeused:

    AnsChr
    oni
    cingest
    ionofnonst
    eroi
    dal
    ant
    ii
    nfl
    ammat
    orydr
    ugs

    38Antihyper
    tensi
    vet
    her
    apyi
    smandat
    oryf
    orwhi
    choft
    hef
    oll
    owi
    ngwomen
    dur
    ingpregnancy?

    Ans.30-
    year
    -ol
    dG3P2wi
    thabl
    oodpr
    essur
    eof160/
    110mm Hgandahi
    stor
    yof
    ast
    hma

    39Al
    lexceptwhi
    choft
    hef
    oll
    owi
    ngsuppor
    tthedi
    agnosi
    sofsuper
    imposed
    pr
    eecl
    ampsia?

    AnsDecr
    easedser
    um al
    kal
    i
    nephosphat
    asel
    evel

    40Whyethni
    cit
    yisimport
    antinr
    ecommendat i
    onstoi
    nit
    iat
    eanant
    ihy
    per
    tensi
    ve
    agent
    ?Amongfoll
    owingchoosecor
    rectst
    atements

    Ans.Angi
    otensi
    n-conv
    ert
    ingenzy
    mei nhi
    bit
    orsandangi
    otensi
    n-r
    ecept
    or
    bl
    ocker
    sarerecommendedasi ni
    ti
    alt
    herapyint
    heblackpopul
    ati
    on.

    Bet
    abl
    ocker
    sar
    erecommendedasi
    nit
    ial
    ther
    apyi
    ntheAsi
    anpopul
    ati
    on.

    Angiot
    ensi
    n-conv
    erti
    ngenzy
    meinhi
    bit
    orsandangiotensi
    n-r
    ecept
    orbl
    ocker
    sar
    e
    recommendedasi ni
    ti
    alt
    her
    apyi
    nthenonblackpopulat
    ion.

    41Whichofthef
    oll
    owi
    ngst
    atementsisnott
    rueregar
    dingint
    rapar
    tum
    managementofawomanwit
    hchronichyper
    tensi
    onwithsuperi
    mposed
    pr
    eecl
    ampsia?

    AnsPostpar
    tum anal
    gesi
    ashouldincl
    udeschedul
    ednonster
    oidal
    ant
    ii
    nfl
    ammat or
    ydrugsforatl
    east72hourstoreducenar
    coti
    cuse.

    42Riskfort
    heplacent
    alabr
    upt
    ioni
    sincr
    easedinpregnanci
    escompl
    i
    cat
    edby
    chr
    onichypert
    ensi
    on.Howwouldyoubestchar
    acteri
    zetheri
    sk?

    Ans2-
    3-f
    oldi
    ncr
    easeov
    ert
    hegener
    alobst
    etr
    icpopul
    ati
    on

    43Whichoft
    hefol
    l
    owingappr
    oximatestheri
    skf orper
    inat
    almor
    tal
    i
    tyi
    n
    pr
    egnanci
    escompl
    icat
    edbychr
    onichypert
    ension?

    AnsAl
    loft
    hement
    ioned

    44Thet
    hreshol
    dof140/90mm Hgast
    heupperl
    i
    mitofnor
    mal
    isbasedon
    whi
    chofthefol
    l
    owing?
    AnsAct
    uar
    ial
    tabl
    esbasedondat
    afr
    om whi
    teadul
    tmal
    es

    t
    estf
    orChr
    oni
    chy
    per
    tensi
    oni
    nPr
    egnancy-cl
    i
    nical
    cases

    45A36- y
    ear-ol
    dmul t
    igr
    avidawithchronichypert
    ensionpresentsforagr owth
    ult
    rasoundat36weeks’ gestat
    ion.Theul t
    rasoundreportshowsy outhatestimatedf
    etal
    weightcorrespondto33weeks’ ,headsi ze-to34weeks’ ,
    whileabdominal
    cir
    cumf er
    enceandf emurlengt
    h–t o32weeks’ gestati
    on.Whichofthef oll
    owingist
    rue
    regardi
    ngthedi agnosismadeont hegrowthultr
    asound?

    AnsFetal-
    growthdysf
    uncti
    onismor
    eli
    kel
    yinchr
    oni
    cal
    l
    yhy
    per
    tensi
    vewomenwho
    dev
    elopsuperi
    mposedpreecl
    ampsi
    a

    46A28- year-ol
    dG3P1102at9weeks’ gestati
    onpr esentsforestabli
    shmentofpr enatal
    care.Herfir
    stpregnancywascompl icatedbygest at
    ionalhypert
    ensionatterm, andher
    secondwascompl icat
    edbyiatrogenicpr et
    erm deliv
    eryat36weeks’ gest
    ationfor
    preecl
    ampsi a.Herbloodpr
    essur ewasnor malatherpost part
    um v i
    sit2yearsagobut
    hasnotbeenassessedsi nce.Todayherbodymassi ndexis46kg/ m2andherbl ood
    pressureis158/96mm Hg.Asi nstructed,shecallsback2day saf t
    erhervisitt
    or eport
    thatbloodpressureshavebeeni nthe146–160/ 94–100mm Hgr angeathome.I n
    additi
    ontoiniti
    ati
    onofanantihypertensiveagent ,
    whati sthenextstepinmanagement
    ofherbloodpr essurei
    nthi
    spr egnancy ?

    AnsBasel
    i
    neser
    um cr
    eat
    ini
    ne

    47Ms.Edwar dsisa26- year-


    oldG2P2, now3day spostpar
    tum f
    rom av aginaldeli
    very
    .
    Shehaschroni chy per
    tensionanddev elopedsuper i
    mposedseverepreeclampsi aat36
    weeks’gestation.Shedidwel li
    nitiall
    y,butinthelast12hoursherbloodpr essur
    ehas
    beentrendi
    ngup.Mostr ecentbloodpr essurewas156/ 90mm Hg.Thenur sehascall
    ed
    youbecauseMs.Edwar dsisfeelingshor tofbreath.Arepr
    esentat
    ivechestr adi
    ograph
    isshownher e.Whati stheappr opriatetreat
    mentf orthi
    scondi
    ti
    on?

    AnsI
    ntr
    avenousf
    urosemi
    de

    48Whi
    chant
    ihyper
    tensi
    vedrugcommonlyusedt
    otr
    eathy
    per
    tensi
    oni
    spr
    oper
    ly
    mat
    chedwi
    thit
    smostnot abl
    esideef
    fect
    ?

    AnsHy
    dral
    azi
    ne—mat
    ernal
    tachy
    car
    dia

    49Forthepati
    entwit
    hmoderat
    echroni
    chyper
    tensi
    on,
    whichoft
    hefol
    lowi
    ng
    compl
    icat
    ionsi
    sreducedwi
    thuseofant
    ihy
    pert
    ensiv
    ether
    apydur
    ingpr
    egnancy
    ?

    AnsDev
    elopmentofsev
    erehy
    per
    tensi
    on
    Li
    ver
    ,ki
    dneyandendocr
    inal
    pat
    hol
    ogyi
    nPr
    egnancy

    50From anet
    iopat
    hogenesisperspect
    ive,
    thepr
    egnancyf
    att
    yli
    verpi
    ctur
    edher
    eis
    anal
    ogoustowhichchi
    ldhoodil
    lness?

    Ans

    51.Whi
    choft
    hef
    oll
    owi
    nghepat
    icenzy
    mesi
    sincr
    easedi
    nnor
    mal
    pregnancy
    ?

    Ans

    52Whi chofthef
    oll
    owi
    ngfi
    ndingsmakei
    ncaseofel
    evat
    edl
    i
    verenzy
    mesexcl
    ude
    int
    rahepat
    icchol
    est
    asi
    sofpregnancy
    ?

    Ans

    53Ri
    skofmat
    ernal
    deat
    hwi
    thacut
    efat
    tyl
    i
    veri
    srel
    atedt
    owhi
    choft
    hef
    oll
    owi
    ng?

    Ans.Al
    loft
    heabov
    e

    54Whati
    sthei
    nci
    denceandr
    ecur
    rencer
    iskofacut
    efat
    tyl
    i
    verofpr
    egnancy
    ?

    Ans

    55Lact
    ati
    oni
    scont
    rai
    ndi
    cat
    edf
    orwomeni
    nfect
    edwi
    thwhi
    choft
    hef
    oll
    owi
    ng?

    Ans HI
    V

    56Whi
    choft
    hef
    oll
    owi
    ngi
    str
    uer
    egar
    dingpancr
    eat
    it
    isi
    npr
    egnancy
    ?

    AnsThepr
    imar
    ypr
    edi
    sposi
    ngcondi
    ti
    oni
    npr
    egnancyi
    schol
    eli
    thi
    asi
    s.

    57.AllEXCEPTwhi
    choft
    hef
    oll
    owi
    ngl
    i
    ver
    -r
    elat
    edchangesar
    ephy
    siol
    ogi
    cal
    in
    pregnancy?

    Ans

    58Whichofthef
    oll
    owi
    nghav
    ethebestdat
    afort
    reat
    mentofi
    ntr
    ahepat
    icchol
    est
    asi
    sof
    pr
    egnancy?

    Ans

    59Thecy
    tochr
    omeP450sy
    stem i
    sal
    ter
    edbywhi
    choft
    hef
    oll
    owi
    ngdur
    ingpr
    egnancy
    ?

    Ans

    60Whichimagi
    ngmodali
    tyi
    srecommendedi
    ndiscri
    minat
    ingacut
    efat
    tyl
    i
    verof
    pr
    egnancyfr
    om ot
    heret
    iol
    ogi
    esofel
    evat
    edli
    verenzymes?

    Ans
    61A27-year-
    oldat32weeks’
    gest
    ati
    onisbroughttot
    heemergencyr
    oom byambul
    ance
    af
    terconsuming6gramsofacet
    aminophen.Whichofthef
    oll
    owingi
    str
    ue?

    Ans Thi
    sist
    hemostcommoncauseofacut
    eli
    verf
    ail
    urei
    ntheUni
    tedSt
    ates

    62TheSociet
    yforMat
    ernal
    -Fet
    alMedi
    cinerecommendedwhichoft
    hef
    oll
    owi
    ng
    agent
    sforwomenwit
    hhighhepati
    ti
    sBviral
    loadsi
    npregnancy?

    Ans

    63Duri
    ngthehospit
    alcar
    eofapatientwi
    thacut
    evir
    alhepat
    it
    is,
    whi
    choft
    hef
    oll
    owi
    ng
    per
    sonalpr
    otect
    iveequi
    pmentshouldbeusedatal
    lti
    mes?

    Ans.Gl
    oves

    64Whi chofthefoll
    owi
    ngfeatur
    esarecri
    ter
    iaf
    orsev
    eredi
    seaset
    hatshoul
    dpr
    ompt
    hospi
    tali
    zat
    ionforacut
    evi
    ralhepat
    it
    is?

    Ans

    65Whichofthefol
    lowingpr egnancy-r
    elatedcompl
    i
    cat
    ionshasthecapaci
    tyto
    demonstr
    atethemostpr omi nental
    terati
    onsofnor
    malhepat
    ic,
    renal
    ,hematol
    ogi
    cal
    ,
    andcoagul
    ati
    onlaboratorystudies?

    Ans

    66Chroni
    chepat
    iti
    sBinf
    ect
    ioni
    smostl
    i
    kel
    ytodev
    elopaf
    teracqui
    sit
    ionbywhi
    chof
    thef
    oll
    owingpat
    ient
    s?

    Ans

    67Duri
    ngnormalpregnancy
    ,whi
    choft
    hef
    oll
    owi
    ngi
    str
    uer
    egar
    dinggal
    l
    bladder
    phy
    siol
    ogyandfuncti
    on?

    Ans

    68Thi
    simageshowsthety
    picalnodul
    ar,
    fibr
    oti
    cappearanceofacir
    rhot
    icl
    i
    ver
    .Whati
    s
    themostcommoncauseofthi
    scondit
    ioninthegener
    al popul
    ati
    on?

    Ans

    69Afterdel
    iv
    ery,t
    hel i
    verf
    uncti
    ondeter
    iorati
    onofacutefat
    tyli
    verofpr egnancyhal
    ted.
    Nonethel
    ess,yourecommendcontinuedintensi
    vematernalsur
    v ei
    l
    lanceduet othe
    appr
    ox i
    matel
    y20%r iskofdevel
    opi
    ngwhi chofthefol
    lowingintheday safterdel
    i
    very?

    Ans Acut
    epancr
    eat
    it
    is

    70Mat
    ernalacut
    efat
    tyli
    verofpr
    egnancyisassoci
    atedwit
    hallexceptwi
    thofthe
    fol
    l
    owi
    ngrecessi
    vel
    yinher
    it
    edabnormali
    ti
    esofmi t
    ochondr
    ial
    fattyaci
    doxidat
    ion?
    Ans

    71Whichofthefol
    lowingvi
    ral
    infect
    ionshasbeenassoci
    atedwi
    thamar
    kedi
    ncr
    easei
    n
    ther
    iskf
    orintr
    ahepati
    cchol
    estasisofpregnancy
    ?

    AnsHepat
    it
    isC

    72I
    mmuni
    zat
    ioni
    snotav
    ail
    abl
    eforwhi
    choft
    hef
    oll
    owi
    ng?

    Ans.Hepat
    it
    isB

    73Concer
    ningt
    hegast
    roi
    ntest
    inal
    tractdur
    ingpr
    egnancy
    ,whi
    choft
    hef
    oll
    owi
    ngi
    s
    cor
    rect
    ?

    Ans

    74Whichofthef
    oll
    owi
    ngcombi
    nat
    ionsr
    epr
    esent
    sappr
    opr
    iat
    escr
    eeni
    ngf
    orhepat
    it
    isC
    inpr
    egnancy
    ?

    Ans 15-year
    -ol
    dwomanwhosemotherwasachroni
    cintr
    avenousdr
    uguseranddi
    edof
    l
    iverf
    ail
    urewhenthepat
    ientwas4y
    earsol
    dscr
    eenedv i
    ahepati
    ti
    sCRNA

    75Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    sregar
    dingacut
    evi
    ral
    hepat
    it
    isi
    scor
    rect
    ?

    Ans Low-
    gradef
    everi
    smor
    ecommonwi
    thhepat
    it
    isA.

    76Al
    lEXCEPTwhi
    choft
    hef
    oll
    owi
    ngl
    i
    ver
    -r
    elat
    edchangesar
    ephy
    siol
    ogi
    cal
    in
    pr
    egnancy
    ?

    AnsHy
    pol
    i
    pidemi
    a

    77Whichofthefol
    lowi
    ngf
    eatur
    esarecri
    ter
    iaf
    orsev
    eredi
    seaset
    hatshoul
    dpr
    ompt
    hospi
    tal
    i
    zat
    ionforacut
    evi
    ral
    hepat
    it
    is?

    Ans Hyper
    bil
    i
    rubi
    nemi
    a

    78A27-year-
    oldat32weeks’
    gest
    ati
    onisbroughttot
    heemergencyr
    oom byambul
    ance
    af
    terconsuming6gramsofacet
    aminophen.Whichofthef
    oll
    owingi
    str
    ue?

    AnsThi
    sist
    hemostcommoncauseofacut
    eli
    verf
    ail
    urei
    ntheUni
    tedSt
    ates

    79Whi
    choft
    hef
    oll
    owi
    nghepat
    icenzy
    mesi
    sincr
    easedi
    nnor
    mal
    pregnancy
    ?

    Ans

    ki
    dneypat
    hol
    ogyt
    heor
    y

    80Thecl
    i
    nical
    present
    ati
    onofawhatcondi
    ti
    onusual
    l
    yincl
    udeshy
    per
    tensi
    on,
    hematur
    ia,r
    ed-
    cel
    lcast
    s,py
    uri
    a,pr
    otei
    nur
    ia,
    edema,
    hyper
    tensi
    on,
    andci
    rcul
    ator
    y
    congest
    ion

    Ans.Gl
    omer
    ulonephr
    it
    is

    81Whatisthecut
    offf
    oraur
    inar
    ypr
    otei
    n-t
    o-cr
    eat
    ini
    ner
    ati
    oonaspotur
    inesampl
    ein
    pr
    egnantpati
    ent
    ?

    Ans

    82Whichofthef
    oll
    owi
    ngi
    sthemostcommonf
    orm ofacut
    egl
    omer
    ulonephr
    it
    is
    wor
    ldwide?

    Ans

    83Apregnantpat
    ientwhopr
    evi
    ouslydonat
    edakidneyandnowhasonl
    yoneheal
    thy
    ki
    dneyi
    satri
    skforwhichoft
    hefol
    lowingobst
    etr
    iccompli
    cat
    ions?

    Ans

    84Thepr
    egnantpatientwi
    thaki
    dneystoneaskshowmanypregnantwomenactual
    l
    y
    passt
    hei
    rstonewiththemanagementplanofanal
    gesi
    aandi
    ntrav
    enoushydr
    ati
    on.
    Whati
    syourresponse?

    Ans

    85Whatper
    centageofpregnantwomenexper i
    encear
    ecur
    rentur
    inar
    ytr
    acti
    nfect
    ion
    af
    tercompl
    eti
    onoftreat
    mentf orpy
    elonephr
    it
    is?

    Ans

    86Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    saboutpol
    ycy
    sti
    cki
    dneydi
    seasei
    str
    ue?

    Ans

    87Whichofthef
    oll
    owi
    ngst
    atement
    sconcer
    ningpr
    egnancyaf
    terki
    dneyt
    ranspl
    anti
    s
    notcor
    rect
    ?

    Ans

    88Whi
    choft
    hef
    oll
    owi
    ngi
    sNOTaphy
    siol
    ogi
    cal
    changei
    npr
    egnancy
    ?

    Ans

    89Whi
    chofthefol
    l
    owingisanacceptabl
    etr
    eat
    mentr
    egi
    menf
    ornewl
    ydi
    agnosed
    asy
    mptomat
    icbact
    eri
    uri
    ainpregnancy?

    Ans

    90Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    sregar
    dingphy
    siol
    ogi
    cal
    changesi
    npr
    egnancyi
    s
    t
    rue?

    Ans

    91Whati
    sthel
    eadi
    ngcauseofsept
    icshockdur
    ingpr
    egnancy
    ?

    AnsPyel
    onephr
    it
    is

    92Youngpr egnantpat i
    entwit
    hpy elonephr
    iti
    sandlaborcontract
    ionstransfer
    redto
    labordepart
    mentf ormonitori
    ng.Shei sgiv
    enintr
    avenous( I
    V)antibi
    oti
    cs,IVfl
    uids,
    acetaminophen,andaβ- agoni
    stbecauseoft hecontract
    ions.Whatcompl icat
    ionis
    mor eli
    kel
    yintheset t
    ingofβ-agonistuseinpati
    entswithpyelonephri
    ti
    s?

    Ans

    93Whi
    choft
    hef
    oll
    owi
    ngi
    snotcommonl
    yfoundi
    npat
    ient
    swi
    thaur
    ethr
    aldi
    ver
    ti
    cul
    um?

    AnsUr
    inar
    yret
    ent
    ion

    94Whichofthef
    oll
    owi
    ngi
    sthemostf
    requentbact
    eri
    ali
    nfect
    ionscompl
    i
    cat
    ing
    pr
    egnancy?

    Ansasy
    mpt
    omat
    icbact
    eri
    uri
    a

    95Oncey ouhav
    etreat
    edapregnantpat
    ientf
    orpyelonephr
    it
    isasani
    npat
    ient
    ,forhow
    longshoul
    dyouconti
    nueor
    alther
    apyasanout pat
    ient?

    Ans

    96Whenmanagingapatientwit
    hpostpar
    tum acut
    ekidneyi
    njur
    y,whi
    choft
    hef
    oll
    owi
    ng
    medi
    cat
    ionsdoesnotneedt ohavei
    tsdoseadjust
    ed?

    Ans

    97Whichofthefol
    l
    owingcompl
    i
    cat
    ionsi
    snoti
    ncr
    easedi
    npr
    egnantpat
    ient
    swi
    th
    nephr
    oti
    csyndrome?

    AnsPost
    ter
    m pr
    egnancy

    98Whati
    sthel
    eadi
    ngcauseofacut
    epy
    elonephr
    it
    isdur
    ingpr
    egnancy
    ?

    AnsEscher
    ichi
    acol
    i

    99Bywhatcr
    eatini
    nedoesonedef
    inemoder
    ater
    enal
    impai
    rmenti
    npat
    ient
    swi
    th
    chr
    oni
    crenal
    disease?

    Ans

    Whatper
    centageofpregnantwomenwit
    hasy
    mpt
    omat
    icbact
    eri
    uri
    adev
    elopa
    sy
    mptomaticinf
    ect
    ioniflef
    tuntr
    eat
    ed?
    Ans.25%

    Whi
    choft
    hef
    oll
    owi
    ngi
    smostl
    i
    kel
    ytol
    eadt
    oend-
    stager
    enal
    disease?

    Ans Di
    abet
    es

    Loweruri
    nar
    ytractsy
    mpt
    omswi
    thpy
    uri
    abutast
    eri
    l
    eur
    inecul
    tur
    ear
    eli
    kel
    yduet
    o
    whichpat
    hogen?

    Ans Chl
    amy
    diat
    rachomat
    is

    Whichofthefol
    lowi
    ngist
    het
    hreshol
    dforpr
    otei
    nur
    iai
    npr
    egnancy
    ,abov
    ewhi
    chl
    evel
    s
    ar
    econsideredabnor
    mal?

    Ans.300mg/
    d

    Ans.Pr
    otei
    nur
    ia&l
    t;
    300mg/
    day

    I
    ncaseofur
    inar
    ytr
    actobst
    ruct
    ionwhatdi
    agnost
    icopt
    ioni
    sthemet
    hodofaf
    ir
    stchoi
    ce?

    Ans.Renal
    sonogr
    aphy

    I
    nt hesetti
    ngofaggressi
    vefl
    uidhydr
    ation,whatper
    cent
    ageofpr
    egnantwomenwi
    th
    pyelonephri
    ti
    sdevel
    opacutekidneyi
    njury?

    Ans.5%

    Whi
    choft
    hef
    oll
    owi
    ngdoesnotchar
    act
    eri
    zenephr
    oti
    csy
    ndr
    omes?

    Ans

    Whi
    choft
    hef
    oll
    owi
    ngv
    aluesi
    snotanor
    mal
    ser
    um cr
    eat
    ini
    nei
    npr
    egnancy
    ?

    Ans

    Whati
    sthemostcommonr
    easonf
    oracut
    eki
    dneyi
    njur
    yinobst
    etr
    ics?

    Ans

    Testf
    orl
    i
    verpat
    hol
    ogf
    ycl
    i
    nical
    case

    A32-year
    -ol
    dat26weeks’gestat
    ionhasa3.4-
    cm l
    i
    vermassnotedinci
    dent
    all
    yona
    ri
    ghtupperquadr
    antul
    tr
    asound.Sheunder
    goesmagneti
    cresonanceimagi
    ngforf
    urt
    her
    cl
    ari
    fi
    cati
    on.Whichoft
    hefoll
    owingistr
    ue?

    Ans
    Whi
    chcombinati
    onoflabor
    ator
    yfi
    ndi
    ngsbel
    owwoul
    dbemostconcer
    ningf
    oracut
    e
    f
    att
    yli
    verofpr
    egnancy
    ?

    Ans

    Howdoy oucounsel
    theear
    lypostdel
    i
    ver
    ypat
    ientr
    egar
    dingherf
    oll
    owi
    ngv
    iral
    ser
    ologi
    es?

     I
    gAAnti-
    Hepat
    it
    isBcoreanti
    body+
     Hepat
    it
    isBsur
    faceant
    ibody–
     Hepat
    it
    isBeanti
    gen+

    Ans Shehasanact
    ivev
    irust
    hatcanl
    eadt
    oci
    rr
    hosi
    sanddeat
    h,andy
    ouwi
    l
    lref
    erhert
    o
    ahepat
    ologi
    stf
    orl
    ong-
    ter
    m managementr
    ecommendat
    ions.

    Yousendaperi
    pheral bl
    oodsmearoft
    hepat
    ientat34weeks’
    gest
    ati
    onwithanacute
    fat
    tyl
    iver
    ,andarepresentat
    ivesl
    i
    dei
    sshownbelow.Whatist
    heunder
    lyi
    ngeti
    ologyof
    thebl
    oodsmearfindings?

    Ans

    A36- y
    ear -
    oldmulti
    gravi
    dapr esent sforpr econceptioncounseli
    ng.Herobst etri
    chi st
    ory
    i
    ncludest wofull
    -t
    ermv aginaldeliveri
    esaf t
    erpregnanciescompl i
    catedbygest ati
    onal
    diabetesandaf i
    rst-
    tri
    mest erpregnancyl oss.Shecomest oyoutodi scussherrecent
    diagnosisofnonalcoholi
    cf att
    yliverdisease( NAFLD)byherpr i
    mar ycarephy si
    cian.
    Diagnosiswasbasedoni magi ngper formedf oranepisodeofabdomi nalpai
    n.Herl i
    ver
    functi
    ont est
    sarenor mal.Hermedi calhistoryisotherwisenotabl
    ef orlongst
    andi ng
    obesity(bodymassi ndex34kg/ m2)anddi abetes(hemoglobinA1c8. 2%)diagnosed2
    yearsago.Whi chofthefollowingshoul dbei ncludedinyourcounseling?

    Ans

    Thef
    oll
    owi
    ngar
    evi
    ral
    ser
    ologi
    esoft
    hepr
    egnantpat
    ient
    .Whati
    sherdi
    agnosi
    s?

    1.I
    gAAnti-
    Hepat
    it
    isBcor
    eantibody+
    2.Hepat
    it
    isBsurf
    aceant
    ibody–
    3.Hepat
    it
    isBeanti
    gen+

    Ans.Chr
    oni
    chepat
    it
    isBi
    nfect
    ion,
    sti
    l
    lact
    ive

    A19-year
    -ol
    dnulli
    gravi
    dawithSjögrensyndromepr esentsat26weeks’ gestati
    onwith
    nausea,f
    ati
    gue,andvagueabdomi nalpain.Onexam shehasabl oodpr essureof94/58
    mmHgandy ounoticemildjaundi
    ce.Laborator
    yassessmentshowssev erelyel
    evated
    tr
    ansaminasesandanti-
    nuclearandanti
    -smoot hmuscleant i
    bodi
    es.Basedony our
    pri
    marydiagnost
    icsuspici
    on,howdoy oucounsel herregardi
    ngcomplicationsof
    pr
    egnancy
    ?

    Ans

    A32-y
    ear-ol
    dG1at32weeks’gest
    ati
    onisdi
    agnosedwithintr
    ahepaticchol
    estasi
    sof
    pr
    egnancy.Dur
    ingt
    hevisi
    tshei
    nquir
    esaboutwhethert
    hisdiagnosi
    swi l
    lal
    terher
    pr
    enatal
    careordel
    iv
    erypl
    ans.Whatist
    hebestevi
    dence-basedadviceyoucanpr ov
    ide?

    Ans

    A28- year
    -ol
    dat19weeks’ gestati
    onpresent
    stotheemer gencyroom wi
    thcompl ai
    nts
    ofrightupperquadrantpai
    n,fever
    ,andvomiti
    ng.Exam r
    ev eal
    sri
    ghtupperquadrant
    tenderness,andshehasat emperatur
    eof38.7°C.Onediagnosti
    cimageisshownher e.
    Commonbi leductobstr
    ucti
    onisnotsuspected.Whati
    st henextmostappropri
    atestep
    i
    nhermanagement ?

    Ans.Lapar
    oscopi
    cchol
    ecy
    stect
    omy

    A27-year-
    oldnull
    igr
    avidaandherhusbandpresentforpreconcept
    ioncounsel
    i
    ng.She
    hasWilsondiseasethatisbeingt
    reat
    edwit
    hzi ncsulf
    ate.Whichofthefoll
    owi
    ngshould
    beincl
    udediny ourcounsel
    ing?

    Ans

    A32-year-
    oldnull
    igr
    avi
    dapr
    esent
    sforpr
    econcept
    ioncounsel
    i
    ngduetocir
    rhosiswi
    th
    esophagealvar
    ices.Whi
    choft
    hefol
    lowi
    ngshouldbeincl
    udediny
    ourcounsel
    ing?

    Ans Al
    loft
    heabov
    e

    A27-year-
    oldmult
    igr
    avi
    dacomest
    oyouf orherpost
    partum vi
    sit
    .Bothofher
    pregnanci
    eswerecompli
    cat
    edbyi
    ntr
    ahepaticchol
    estasi
    sofpregnancy.Shedesi
    res
    anotherchi
    ldi
    nabout2year
    s.Whi
    chofthefoll
    owingmet hodsofcontr
    acepti
    ondoyou
    recommend?

    Ans

    A26-year-ol
    dpri
    migravi
    dapresentsat34weeks’gestati
    onwithnauseaandvomiti
    ng,
    f
    ati
    gue, andepi
    gastri
    cpain.Al
    lexceptwhichoft
    hef oll
    owingarecl
    ini
    calchar
    act
    eri
    sti
    cs
    t
    hatincreaseherri
    skforacutefat
    tyli
    verofpr
    egnancyast heunderl
    yi
    ngcause?

    Ans

    A29-year-
    oldpr
    imi
    grav
    idapresentstoy ouforprenatalcare.Sheisknownt ohave
    hepati
    tisCwit
    hnoknownr i
    skf act
    ors,andyourpr enat
    allabsconfir
    m presenceof
    hepati
    ti
    sCRNAandant i-
    hepati
    tisCant i
    body.Compar edtoawomanwi t
    hant i
    -hepati
    ti
    s
    Cant i
    bodywhoisRNA-negat
    ive,whichofthefollowingismor eli
    kel
    ytocompl icateher
    pregnancy?

    AnsVer
    ti
    cal
    transmi
    ssi
    onofhepat
    it
    isC
    Howdoy oucounsel
    theear
    lypostdel
    i
    ver
    ypat
    ientr
    egar
    dingherf
    oll
    owi
    ngv
    iral
    ser
    ologi
    es?

     I
    gAAnti-
    Hepat
    it
    isBcoreanti
    body+
     Hepat
    it
    isBsur
    faceant
    ibody–
     Hepat
    it
    isBeanti
    gen+

    AnsShehasanact
    ivev
    irust
    hatcanl
    eadt
    oci
    rr
    hosi
    sanddeat
    h,andy
    ouwi
    l
    lref
    erhert
    o
    ahepat
    ologi
    stf
    orl
    ong-
    ter
    m managementr
    ecommendat
    ions.

    Testf
    orki
    dneypat
    hol
    ogf
    ycl
    i
    nical
    case

    Youareconsult
    edabouta19- year-
    oldpr i
    migravidaat18weeks’ gest
    ation.Thepati
    ent
    wasdiagnosedatherf i
    rstprenatalcarev i
    sitwit
    hasympt omat icbacteri
    uri
    a.Her
    provi
    dertr
    eatedherwithnitr
    ofurantoin100mgt wicedai l
    yf or7days.Thepat i
    entwas
    seenamont haft
    ert r
    eatment ,
    andherr epeaturi
    neculturewasnegat ive.Butnow,a
    uri
    necult
    uresentinerrorispositi
    vef or>100,000colony-formingunit
    s/ mLgram-
    negati
    verodsagain.Sheremai nsasy mpt omati
    c.Herpr ovideri
    snotsur ewhatt odo.
    Whatisthebestresponset othisconsul t
    ?

    Ans.Recur
    renceofasy
    mpt
    omat
    icbact
    eri
    uri
    ais30%r
    egar
    dlessofant
    ibi
    oti
    cregi
    menandi
    tmay
    i
    ndicatecover
    tuppertr
    acti
    nfect
    ion,
    sot
    reatt
    hepat
    ientwi
    thni
    tr
    ofur
    ant
    oin100mgbymout
    hat
    bedti
    mef or21days.

    A32- year
    -oldG2P0pr esentsat19weeks’ gestati
    oncompl ai
    ningofbackpai nthat
    radi
    atesfor war
    d.Sher epor
    tsthatthepai
    ni sintense,andshel ooksv eryuncomf ort
    able.
    Shehasnotbeenf ebril
    e.Aurinal
    ysisi
    ssignifi
    cantonlyforredbl oodcells.Animage
    from herrenalul
    trasoundi sprovi
    dedbelow.Youdi agnosethepat ientwithakidney
    stone.Whi chofthef oll
    owingisthebestmanagementopt ionfort hepat i
    entatthisti
    me?

    AnsAnal
    gesi
    aandi
    ntr
    avenoushy
    drat
    ion

    Aseriesofant
    eri
    or-
    poster
    iorproj
    ect
    ionchestr
    adiogr
    aphsi
    nasecond-
    tr
    imest
    er
    pregnantwomanwithseverepyel
    onephri
    ti
    sincaseofaggr
    essi
    vef
    lui
    dhydr
    ati
    on
    showingwhatofthefol
    l
    owi ng:

    Ans.Respi
    rat
    orydi
    str
    esssy
    ndr
    ome

    A25-year-
    oldG1P0at16weeks’ gestat
    ionpr esent
    sf orprenatal
    care.Shehasahi st
    ory
    ofakidneytranspl
    ant3y earsago.Shei sstabl
    eonpr ednisoneandazat hiopr
    ine.The
    pat
    ienthasnotex peri
    encedanyr ej
    ecti
    on,andherbl oodpr essur
    eiswell cont
    roll
    ed.
    Whichofthef ol
    lowingobstetr
    iccomplicati
    onsisnoti ncr
    easedinher?

    Ans
    Apregnantwomanpr esentswit
    hflankpai
    n.Sheisafebri
    l
    ebuttachycardi
    cfrom pai
    n.
    Herserum cr
    eat
    ini
    neiselevatedto5mg/ dL.Imagesfr
    om hermagneticresonance
    i
    magingarepresent
    edbel ow-hydronephr
    osis.Whichofthef
    oll
    owingisthebestplanof
    car
    e?

    AnsPer
    cut
    aneousnephr
    ost
    omyt
    ube

    1. Regardi
    ngdiagnost
    icst
    udies,
    whi
    chofthefol
    l
    owi
    ngcor
    rect
    lydescr
    ibesanor
    mal
    changethati
    scharact
    eri
    sti
    cofpr
    egnancy
    ?

    Anav
    erage15-
    degr
    eel
    eftaxi
    sdev
    iat
    iononel
    ect
    rocar
    diogr
    am

    2. Thepatientwhosehear ti
    sshowni nt
    hisimagehassy stemi clupus
    eryt
    hemat osusandhasahi stor
    yofapri
    orstroke.Theleftatri
    um (LA)andlef
    t
    ventr
    icl
    e( LV)arei dent
    if
    ied,andthear
    rowspoi nttononinfecti
    ousv eget
    ati
    onson
    themi t
    ralleafl
    ets.Whichoft hefol
    l
    owingisthelikel
    ycondi t
    ionassociat
    edwith
    hermi t
    ralinsuff
    iciency
    ?
    Ant
    iphosphol
    i
    pidant
    ibodi
    es
    3. Agr aphi
    cofpul monarycapi
    ll
    arywedgepressure(r
    edl i
    ne)isshownf orawoman
    withmi t
    ralstenosi
    s.“
    A”repr
    esentsthefi
    rstst
    ageofl abor
    , “
    B”mar ksthesecond
    stageoflabor ,“
    C”demonstr
    atestheimmediatepostpart
    um period,and“D”
    showst heper i
    od4–6hourspostdeli
    ver
    y.Whataccount sfortheri
    sein
    pulmonar ycapil
    lar
    ywedgepressureimmediat
    elyfol
    lowingdeliver
    y?
    Pl
    acent
    alaut
    otr
    ansf
    usi
    on
    4. Whati
    sthemostcommoncauseofhear
    tfai
    l
    urei
    npr
    egnancy
    ?

    Chr
    oni
    chy
    per
    tensi
    onwi
    thsuper
    imposedpr
    eecl
    ampsi
    a

    5. Youarecari
    ngforapri
    migravi
    dawi t
    hknownhy pert
    rophiccardi
    omy opathy.She
    tel
    l
    sy ouhermotheral
    sosuff
    eredfrom t
    heconditi
    onandpassedawayatan
    earl
    yage.Thepati
    enti
    sconcernedaboutherchil
    d’sfut
    ureriskfordevelopingt
    he
    sameconditi
    on.Whatdoyoutellheri
    sthemostl i
    kel
    yriskforpassingthe
    condit
    iont
    oherchil
    d?

    50%

    6. Youar ecari
    ngf orapregnantpati
    entwit
    hmi tralstenosis.Sheisablet
    oper form
    mostact i
    vit
    iesofdail
    ylivi
    ngwithoutsi
    gnif
    icantlimitat
    ion.Onechocardiogram,
    herejecti
    onf r
    acti
    onis50%andhermi t
    ralvalv
    ear eameasur es1.8cm2.Whi chof
    thefoll
    owingv ari
    abl
    esismostpr edi
    cti
    veofahi ghr i
    skf orcardi
    accompl i
    cations
    dur
    ingt
    hispr
    egnancy
    ?

    Herdegr
    eeofl
    eft
    -si
    dedobst
    ruct
    ion

    7. Whati
    sthegol
    dst
    andar
    dfordi
    agnosi
    soft
    hecondi
    ti
    oni
    nQuest
    ion49–24?
    Ri
    ghthear
    tcat
    het
    eri
    zat
    ion

    8. TheWor
    ldHeal
    thOr
    gani
    zat
    ioni
    dent
    if
    ieswhi
    choft
    hef
    oll
    owi
    ngcondi
    ti
    onsas
    pr
    ohi
    bit
    iveofpr
    egnancy
    ?

    Pul
    monar
    yar
    ter
    yhy
    per
    tensi
    on

    1.Apr egnantwomanpr esent


    st otheemer gencyr oom i
    nanobt undedstat
    e.She
    hasaf everto102.6°
    F.Onexam, a4/ 6mur murisnoted,shewithdr
    awsfrom pain
    duri
    ngherabdomi nalexam, andtrackmar ksarenotedonherar msandl egs.Her
    fundalheighti
    sapproximately32cm.Anemer gentechocar
    diogram i
    sobtained,
    whichdemonst rat
    esami tr
    al val
    vev eget
    ation.Whatisthemostl i
    kel
    yorganism
    underlyi
    ngherdiagnosi
    s?

    St
    aphy
    lococcusaur
    eus

    2.Youar ecar
    ingforcomplainsofshortnessofbreathandchestpainwi t
    hmi ni
    mal
    exert
    ionanuncompl i
    catedpr i
    migr
    avidaat32weeks’ gestati
    on.An
    echocardi
    ogram demonst ratesamitral
    val
    vesur f
    aceareaof2. 1cm2, adil
    ated
    l
    eftatri
    um,anaorti
    cv al
    vear eaof3.7cm2,arightventr
    icularsyst
    oli
    cpressureof
    20mm Hg, andanej ecti
    onf r
    acti
    onof55%.Youal soobtainachestx- r
    ay,which
    i
    sshown.Whati sthel i
    kel
    yunder l
    yi
    ngcauseofhersy mpt oms?

    Mi
    tr
    alst
    enosi
    s

    3.Youar ecari
    ngforapat i
    entwithanunr epai
    redv
    entri
    cularsept
    aldefectwhois
    consider
    ingpregnancy.Youperform anechocardi
    ogram toassessherfutur
    e
    ri
    sks.Whichoft hefol
    lowingparameterswouldindi
    cateanextremelyelev
    ated
    maternalandfetalr
    iskduringpregnancy?

    Ar
    ightv
    ent
    ri
    cul
    arsy
    stol
    i
    cpr
    essur
    eof75mm Hg
    1.Whichoft
    hefol
    lowi
    ngappr
    oxi
    matestheri
    skf orper
    inat
    almor
    tal
    i
    tyi
    n
    pr
    egnanci
    escompli
    cat
    edbychr
    onichyper
    tension?

    Al
    loft
    hement
    ioned

    2.Forawomanwhodoesnotent erpregnancywit
    haknowndiagnosi
    s,t
    he
    di
    agnosi
    sofchr
    onichypert
    ensi
    onissuppor t
    edwhenhyper
    tensi
    onispresent
    pri
    ort
    owhatgestat
    ional
    agethreshold?

    20weeks’
    gest
    ati
    on

    3.Whichofthef
    oll
    owingchar
    acter
    izest herel
    ationshi
    pbet
    weenchr
    oni
    c
    hy
    pertensi
    onandsuper
    imposedpr eeclampsia?

    Approx
    imatel
    y80%ofthosewhoal
    sohav
    eatl
    east300mg/
    dayofpr
    otei
    nur
    iaatbasel
    i
    ne
    wil
    ldevel
    opsever
    epr
    eeclampsi
    a

    4.Amongwomenwithchroni
    chyper
    tensi
    on,
    whichoft
    hef
    oll
    owi
    ngi
    str
    uer
    egar
    ding
    ri
    skf
    oradv
    ersemater
    nalandperi
    natal
    out
    come?

    Compli
    cat
    ionsar
    emor eli
    kel
    ywit
    hsev
    erer
    angehy
    per
    tensi
    onatbasel
    i
    neandt
    he
    pr
    esenceofend-
    organdamage.

    5.Riskfort
    hepl
    acentalabr
    upt
    ioni
    sincr
    easedinpregnanci
    escompli
    cat
    edby
    chroni
    chyper
    tensi
    on.Howwouldyoubestchar
    acteri
    zetheri
    sk?

    2-
    3-f
    oldi
    ncr
    easeov
    ert
    hegener
    alobst
    etr
    icpopul
    ati
    on

    6.Inaddi
    ti
    ontochr
    onichyper
    tensi
    on,
    whichoft
    hefol
    lowi
    ngcondi
    ti
    onsar
    e
    consi
    deredhi
    gh-
    ri
    skfordevel
    opi
    ngpreecl
    ampsi
    a?

    Sy
    stemi
    clupuser
    ythemat
    osus

    7.Ant
    ihy
    pert
    ensi
    vet
    her
    apyi
    smandat
    oryf
    orwhi
    choft
    hef
    oll
    owi
    ngwomendur
    ing
    pr
    egnancy
    ?
    30-
    year
    -ol
    dG3P2wi
    thabl
    oodpr
    essur
    eof160/
    110mm Hgandahi
    stor
    yofast
    hma

    1. Ms.Edwar
    dsi
    sa26-
    year
    -ol
    dG2P2,
    now3day
    spost
    par
    tum f
    rom av
    agi
    nal
    deli
    very.Shehaschr oni
    chy pert
    ensionanddev el
    opedsuper imposedsev er
    e
    preecl
    ampsi aat36weeks’ gestati
    on.Shedi dwelli
    nit
    ial
    l
    y, butinthelast12hours
    herbloodpr essurehasbeent r
    endingup.Mostr ecentbl
    oodpr essur
    ewas
    156/90mm Hg.Thenur sehascalledy oubecauseMs.Edwar dsisfeel
    ingshor
    t
    ofbreath.Ar epresentat
    ivechestradiographisshownher e.Whati sthe
    appropriat
    et r
    eatmentf orthisconditi
    on?

    I
    ntr
    avenousf
    urosemi
    de

    2. Fort
    hepat
    ientwi
    thmoder
    atechr
    oni
    chy
    per
    tensi
    on,
    whi
    choft
    hef
    oll
    owi
    ng
    compl
    i
    cat
    ionsi
    sreducedwi
    thuseofant
    ihy
    per
    tensi
    vet
    her
    apydur
    ingpr
    egnancy
    ?

    Dev
    elopmentofsev
    erehy
    per
    tensi
    on

    3. A33-
    year
    -ol
    dG1at32weeks’
    gest
    ati
    onhasbeendi
    agnosedwi
    thchr
    oni
    c
    hypertensionwit
    hsuper i
    mposedpr eeclampsi
    aviaworseninghy pertension.She
    i
    sasy mpt omati
    cwi t
    hnor mall
    absandnor malf
    etalgr
    owth.Ani ncreasei nthe
    doseofherant i
    hypertensi
    vemedicat i
    onhasresult
    edinnonsever ebl ood
    pressures.Sheasksy ouaboutexpectantmanagementofsuper imposed
    preecl
    ampsi a.Whichofthefol
    lowingist hemostappropr
    iate,
    ev idence-based
    response?

    I
    tisreasonabl
    e,wit
    hcloseinpat
    ientsur
    vei
    l
    lance,
    topur
    sueexpect
    antmanagement
    ,but
    t
    herearestil
    lri
    sksforadv
    erseoutcomes.

    1. Whi
    choft
    hef
    oll
    owi
    ngv
    iral
    inf
    ect
    ionshasbeenassoci
    atedwi
    thamar
    ked
    i
    ncr
    easei
    nther
    iskf
    ori
    ntr
    ahepat
    icchol
    est
    asi
    sofpr
    egnancy
    ?

    Hepat
    it
    isC

    2. Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    sregar
    dingacut
    evi
    ral
    hepat
    it
    isi
    scor
    rect
    ?

    Low-
    gradef
    everi
    smor
    ecommonwi
    thhepat
    it
    isA.
    3. Whi
    choft
    hef
    oll
    owi
    ngcombi
    nat
    ionsr
    epr
    esent
    sappr
    opr
    iat
    escr
    eeni
    ngf
    or
    hepat
    it
    isCi
    npr
    egnancy
    ?

    15-
    year-
    oldwomanwhosemot herwasachroni
    cintr
    avenousdr
    uguseranddi
    ed
    ofl
    iverf
    ail
    urewhent
    hepat
    ientwas4y ear
    soldscreenedvi
    ahepat
    it
    isCRNA

    4. Al
    lEXCEPTwhi
    choft
    hef
    oll
    owi
    ngl
    i
    ver
    -r
    elat
    edchangesar
    ephy
    siol
    ogi
    cal
    in
    pr
    egnancy
    ?

    Hy
    pol
    i
    pidemi
    a

    5. Mat
    ernal
    acut
    efat
    tyl
    i
    verofpr
    egnancyi
    sassoci
    atedwi
    thal
    lexceptwi
    thof
    thefol
    lowingr
    ecessi
    vel
    yinher
    it
    edabnor
    mal
    i
    tiesofmi
    tochondr
    ial
    fat
    tyaci
    d
    oxidat
    ion?

    Di
    hydr
    oli
    poami
    dedehy
    drogenase

    6. Whi
    choft
    hef
    oll
    owi
    ngf
    eat
    uresar
    ecr
    it
    eri
    aforsev
    eredi
    seaset
    hatshoul
    d
    pr
    ompthospi
    tal
    i
    zat
    ionf
    oracut
    evi
    ral
    hepat
    it
    is?
    Hy
    per
    bil
    i
    rubi
    nemi
    a
    7. Whi
    choft
    hef
    oll
    owi
    ngpr
    egnancy
    -rel
    atedcompl
    i
    cat
    ionshast
    hecapaci
    tyt
    o
    demonstr
    atethemostprominental
    terati
    onsofnor
    mal
    hepat
    ic,
    renal
    ,
    hematol
    ogical
    ,andcoagul
    ati
    onlaborator
    ystudi
    es?

    Acut
    efat
    tyl
    i
    verofpr
    egnancy

    8. Whati
    sthei
    nci
    denceandr
    ecur
    rencer
    iskofacut
    efat
    tyl
    i
    verofpr
    egnancy
    ?

    1i
    n10,
    000pr
    egnanci
    es,
    andr
    ecur
    rencei
    srar
    e

    9. Lact
    ati
    oni
    scont
    rai
    ndi
    cat
    edf
    orwomeni
    nfect
    edwi
    thwhi
    choft
    hef
    oll
    owi
    ng?

    HI
    V
    1.Whatpercentageofpr
    egnantwomenexper
    iencear ecur
    rentur
    inar
    ytr
    act
    i
    nfect
    ionaftercompl
    eti
    onoftr
    eatmentf
    orpyelonephri
    ti
    s?

    30–40%

    2.Whichoft
    hef
    oll
    owi
    ngi
    snotarecommendedr
    equi
    sit
    eforr
    enal
    transpl
    ant
    pat
    ient
    swhowantt
    oat
    temptpr
    egnancy
    ?

    Pr
    otei
    nur
    ia&l
    t;
    300mg/
    day

    3.Whi
    chofthefol
    l
    owingcompl
    i
    cat
    ionsi
    snoti
    ncr
    easedi
    npr
    egnantpat
    ient
    s
    wi
    thnephr
    oti
    csyndr
    ome?

    Post
    ter
    m pr
    egnancy

    4.Whichofthef
    oll
    owingi
    sanacceptabl
    etr
    eat
    mentregi
    menf
    ornewl
    y
    di
    agnosedasymptomat
    icbact
    eri
    uri
    ainpr
    egnancy
    ?

    Ni
    tr
    ofur
    ant
    oin100mgbymout
    hatbedt
    imef
    or10day
    s

    5.Whi
    choft
    hef
    oll
    owi
    ngst
    atement
    saboutpol
    ycy
    sti
    cki
    dneydi
    seasei
    str
    ue?

    10%oft
    hosewi
    tht
    hisdi
    seasedi
    efr
    om r
    upt
    ureofani
    ntr
    acr
    ani
    alber
    ryaneur
    ysm.

    6.Whichoft
    hefoll
    owi
    ngval
    uesi
    snotanor
    mal
    ser
    um cr
    eat
    ini
    nei
    n
    pr
    egnancy
    ? 1.0mg/
    dL

    7.Whati
    sthel
    eadi
    ngcauseofacut
    epy
    elonephr
    it
    isdur
    ingpr
    egnancy
    ?

    Escher
    ichi
    acol
    i

    8.Whi
    chofthefoll
    owingi
    sthet
    hreshol
    dforpr
    otei
    nur
    iai
    npr
    egnancy
    ,abov
    e
    whi
    chl
    evelsareconsi
    der
    edabnormal
    ?
    300mg/
    d

    9.Whichoft
    hefoll
    owingst
    atement
    sregar
    dingphy
    siol
    ogi
    cal
    changesi
    n
    pr
    egnancyi
    strue?

    Ef
    fect
    iver
    enal
    plasmaf
    lowi
    ncr
    eases.

    1. Whi
    chcombi
    nat
    ionofl
    abor
    ator
    yfi
    ndi
    ngsbel
    owwoul
    dbemostconcer
    ning
    f
    oracut
    efat
    tyl
    i
    verofpr
    egnancy
    ?

    Hematocri
    t32%, cr
    eat
    ini
    ne2.
    0mg/
    dL,
    plat
    elet
    s90/
    L,AST400U/
    L,f
    ibr
    inogen130
    mg/dL,andglucose65mg/dL

    2. A28-
    year
    -ol
    dat19weeks’
    gest
    ati
    onpr
    esent
    stot
    heemer
    gencyr
    oom wi
    th
    compl ai
    ntsofr
    ightupperquadrantpai
    n,f
    ever,
    andvomiti
    ng.Exam r
    eveals
    ri
    ghtupperquadranttender
    ness,andshehasat emper
    atur
    eof38.7°C.One
    diagnosti
    cimageisshownher e.Commonbi l
    eductobst
    ruct
    ionisnot
    suspected.Whatisthenextmostappropri
    atestepi
    nhermanagement ?

    Lapar
    oscopi
    cchol
    ecy
    stect
    omy

    3. A19-
    year
    -ol
    dnul
    l
    igr
    avi
    dawi
    thSj
    ögr
    ensy
    ndr
    omepr
    esent
    sat26weeks’
    gestati
    onwi t
    hnausea, f
    ati
    gue,
    andvagueabdomi nalpain.Onexam she
    hasabl oodpressureof94/58mmHgandy ounot i
    cemildj aundi
    ce.
    Laboratoryassessmentshowssever
    elyelevat
    edt r
    ansami nasesandanti
    -
    nuclearandanti-
    smoot hmuscl
    eanti
    bodies.Basedony ourpr i
    mary
    di
    agnost i
    csuspicion,
    howdoy oucounselherregardi
    ngcompl i
    cat
    ionsof
    pregnancy?

    Shei
    sati
    ncr
    easedr
    iskf
    orpr
    eter
    m del
    i
    ver
    y.

    4.Thefol
    lowingar
    evi
    ral
    ser
    ologi
    esoft
    hepr
    egnantpat
    ient
    .Whati
    sher
    di
    agnosis?
    1.I
    gAAnti-
    Hepat
    it
    isBcor
    eantibody+
    2.Hepat
    it
    isBsurf
    aceant
    ibody–
    3.Hepat
    it
    isBeanti
    gen+

    -Chr
    Ansr: oni
    chepat
    it
    isBi
    nfect
    ion,
    sti
    l
    lact
    ive

    5. Howdoy oucounsel
    theear
    lypostdel
    i
    ver
    ypat
    ientr
    egar
    dingherf
    oll
    owi
    ng
    vir
    alser
    ologi
    es?

     I
    gAAnti-
    Hepat
    it
    isBcoreanti
    body+
     Hepat
    it
    isBsur
    faceant
    ibody–
     Hepat
    it
    isBeanti
    gen+

    Ansr-Shehasanac
    : ti
    vevi
    rusthatcanleadtoci
    rr
    hosisanddeat
    h,andyouwi
    l
    l
    r
    eferhert
    oahepat
    ologi
    stf
    orlong-t
    erm managementrecommendati
    ons.

    1.Youar econsul tedabouta19- year-oldpri


    mi gravi
    daat18weeks’ gestat
    ion.
    Thepat ientwasdi agnosedatherf i
    rstprenatalcarevi
    sitwith
    asympt omat icbact er
    iur
    ia.Herprovidertreatedherwithnitr
    ofurantoi
    n100
    mgt wicedai lyfor7day s.Thepat i
    entwasseenamont haf t
    ertreatment,
    andherr epeaturineculturewasnegat i
    ve.Butnow, auri
    neculturesentin
    err
    orisposi t
    ivefor>100,000colony -
    formi ngunit
    s/mLgr am-negativerods
    again.Sher emai nsasy mptomatic.Herpr ovideri
    snotsur ewhatt odo.
    Whati st hebestr esponset ot
    hisconsult?

    Recurr
    enceofasymptomati
    cbacter
    iur
    iais30%regardlessofantibi
    oti
    cregi
    men
    anditmayindi
    catecover
    tuppert
    racti
    nfect
    ion,
    sotreatt hepat
    ientwit
    h
    ni
    trof
    urant
    oin100mgbymout hatbedtimefor21day s.

    2.An18-year
    -oldG1P0pr esent
    sat30weeks’gestati
    onwi thfeverof39oC,
    chil
    l
    s,vomit
    ing,dy
    suri
    a, andfr
    equentur
    inat
    ionfor3day s.Sheisalso
    experi
    enci
    ngcontract
    ions.Whatishermostli
    kelydiagnosis?

    Py
    elonephr
    it
    is

    4.Aser
    iesofant
    eri
    or-
    post
    eri
    orpr
    oject
    ionchestr
    adi
    ogr
    aphsi
    nasecond-
    tr
    imest
    er
    pregnantwomanwit
    hsever
    epyel
    onephr
    it
    isi
    ncaseofaggr
    essi
    vef
    lui
    dhy
    drat
    ion
    showingwhatoft
    hefol
    l
    owing:

    Respi
    rat
    orydi
    str
    esssy
    ndr
    ome

    5.Apr egnantwomanpresent
    swithfl
    ankpai
    n.Sheisafebr
    il
    ebuttachy
    cardicfr
    om
    pain.Herserum cr
    eat
    ini
    neisel
    evat
    edto5mg/ dL.I
    magesf r
    om hermagnetic
    resonanceimagingar
    epresent
    edbelow-hydr
    onephrosi
    s.Whichofthefol
    lowing
    i
    st hebestplanofcar
    e?

    Per
    cut
    aneousnephr
    ost
    omyt
    ube

    1.Whichoft
    hefol
    l
    owi
    ngi
    sthoughtt
    opl
    ayasi
    gni
    fi
    cantr
    olei
    nthedev
    elopmentof
    preecl
    ampsi
    a?
    Al
    loft
    hement
    ioned
    2.Ant
    ihy
    per
    tensi
    vecont
    rai
    ndi
    cat
    edi
    npr
    egnancy
    ACEi
    nhi
    bit
    ors
    3.Al
    lar
    efeat
    uresofHELLPsy
    ndr
    omeexcept
    Eosi
    nophi
    l
    li
    a
    4.Whatpropor
    ti
    onofmat
    ernal
    deat
    hscanbeat
    tri
    but
    edt
    ohy
    per
    tensi
    vedi
    sor
    der
    sin
    pregnancy
    ?
    1i
    n6
    5.Whi
    chst
    atementbestdescr
    ibesr
    enal
    per
    fusi
    onandgl
    omer
    ularf
    il
    tr
    ati
    onr
    atesi
    n
    womenwi
    thpr
    eecl
    ampsi
    athathasnoty
    etpr
    ogr
    essedt
    osev
    eredi
    sease?
    Si
    mil
    arcompar
    edt
    onor
    mal
    nonpr
    egnantv
    alues

    6.Bestr
    egi
    menf
    orecl
    ampsi
    ais
    MgSo4

    1.A19-year
    -ol
    dG1P0womanat39weeks’ gestat
    ionisdi agnosedwi t
    hpr eeclampsia
    basedonbloodpr essur
    eof150/90mm Hgand2+pr oteinuriaonur i
    nedi pstick.The
    pati
    entispl
    acedonmagnesi um sul
    fat
    e,anddevel
    opsf l
    ushi ngandf at
    igue.Sheasks
    abouttheneedforthemagnesium sul
    fat
    e.Youexplai
    nt hatitist opr
    eventt hesei zur
    es
    thatmaycomplicatepreecl
    ampsiaandmayevencausedeat h.Thepatientaskshow
    seizur
    esassoci
    atedwi t
    hpreecl
    ampsiacancausemor t
    al i
    ty.Whi chofthef oll
    owi ngis
    t
    hemostcommonmechani
    sm?

    I
    ntr
    acer
    ebr
    alhemor
    rhage

    2.Yourpati
    enti
    sadmi
    ttedt
    othehospit
    alforeval
    uati
    onofnew-onsethy
    pertensionat30
    weeks’gest
    ati
    on.Whi
    chofthef
    oll
    owingtestsoreval
    uat
    ionsi
    sleastappropri
    ate?

    Cel
    l
    -fr
    eeDNAt
    est
    ingf
    oraneupl
    oidy

    3.A19-
    year
    -ol
    dG1P0womanat39weeks’
    gest
    ati
    oni
    sdi
    agnosedwi
    thpr
    eecl
    ampsi
    a
    basedonbloodpr essur
    eof150/90mm Hgand2+pr oteinuriaonur i
    nedi psti
    ck.The
    pati
    entispl
    acedonmagnesi um sul
    fat
    e,anddevel
    opsflushi ngandf at
    igue.Sheasks
    abouttheneedforthemagnesium sul
    fat
    e.Youexplai
    nt hatitist opr
    eventt heseizur
    es
    thatmaycomplicatepreecl
    ampsiaandmayevencausedeat h.Thepatientaskshow
    seizur
    esassoci
    atedwi t
    hpreecl
    ampsiacancausemor t
    al i
    ty.Whi chofthef oll
    owingis
    themostcommonmechani sm?

    I
    ntr
    acer
    ebr
    alhemor
    rhage

    4.A23-
    year
    -ol
    dpr
    imi
    grav
    idapr
    esent
    swi
    thabl
    oodpr
    essur
    eof160/
    104mm Hg,
    3+
    prot
    einuri
    a,andrightupperquadrantdiscomf or
    t.Shehasav aginaldel
    i
    verycompli
    cated
    bybilat
    eralsul
    caltearsandanest i
    matedbl oodlossof1500mL.Shepr oduces110mL
    ofurineinthefi
    rst4hour spost
    par t
    um andherser um creat
    ininerisesfr
    om 0.98mg/dL
    to1.42mg/ dL.Whatist hemostlikel
    yexplanati
    onf orthi
    sfinding?
    Post
    par
    tum hemor
    rhage

    5.A24-
    year
    -ol
    dpr
    imi
    grav
    idapr
    esent
    sat37weeks’
    gest
    ati
    onwi
    thheadache,
    abl
    ood
    pressur
    eof170/ 102mm Hg, andsever
    eri
    ghtupperquadrantpai
    n.Sheisdiagnosed
    withHELLPsy ndromeandundergoesanuncompli
    catedinducti
    onoflabor
    .Herright
    upperquadrantpainper
    sists,
    andacomputedtomographyscanofherabdomen/ pel
    vi
    s
    i
    scompl et
    edwi ththefi
    ndingsasshownbel
    ow.Whati sdenotedbytheasteri
    sk(*)?
    Subcapsul
    arhemat
    oma

    6.A21-y
    ear-ol
    dG1at36weeks’ gestati
    onpr esentsforhercli
    nicvi
    sitandi snotedto
    haveabloodpressureof148/88mm Hg.Ar epeatbloodpressure30mi nutesl
    ateri
    s
    146/92mm Hg.Herbl oodpressuresthroughoutpr egnancyhavebeenbel ow140/ 90
    mm Hg.Shedeni esanycomplaint
    s,andur i
    nalysisisnegativ
    eforproteinuri
    a.Whatis
    themostli
    kelydi
    agnosis?
    Gest
    ati
    onal
    hyper
    tensi
    on
    7.A29-
    year
    -ol
    dG1P0womanat28weeks’
    gest
    ati
    oni
    sadmi
    tt
    edt
    othehospi
    tal
    for
    preecl
    ampsia.Herbl
    oodpressureis150/100mm Hgandherpr oteinexcret
    ionis500
    mgi n24hours.Onhospi
    talday7,sheisdiagnosedwithseverepreeclampsiaandthe
    decisi
    onismadet oadmi
    nistermagnesium sul
    fat
    eanddel i
    verthebaby .Whichofthe
    fol
    lowingfi
    ndingsi
    smostlikel
    ypresentint
    hispati
    entascrit
    eri
    af orsevere
    preecl
    ampsia?
    5gofpr
    otei
    nur
    iaexcr
    etedi
    na24-
    hourper
    iod
    8.A21-
    year-
    oldpri
    mi gr
    avidapresentsat36weeks’gestat
    ionwi
    thnew-onsetheadache.
    Herbl
    oodpressureis150/ 90mm Hg, herser
    um cr
    eatini
    neis0.
    8mg/ mL,ASTi s32U/ L,
    andpl
    atel
    etcountis28,000/μL.Whichofthefol
    l
    owi ngcri
    ter
    iaf
    orsever
    epr eecl
    ampsia
    ismet
    ?
    Thr
    ombocy
    topeni
    a
    9.Whi
    choft
    hef
    oll
    owi
    ngi
    sthebestmanagementofan18-
    year
    -ol
    dG1P0womanat28
    weeks’
    gestati
    onwithabloodpressur
    eof160/
    110mm Hg,
    elev
    atedl
    i
    verf
    unct
    iont
    est
    s,
    andaplat
    eletcountof60,
    000/
    uL?

    Magnesi
    um sul
    fat
    ether
    apyandi
    nduct
    ionofl
    abor

    1.A25-year
    -ol
    dwomanat34weeks’ gestati
    onisnotedt
    ohav eaplacentapr
    evia,
    after
    shepresent
    edwithvagi
    nalbleedi
    ngandhasunder gonesonography.At37weeks,she
    hasascheduledcesar
    ean.Uponcesar eansect
    ion,
    blui
    shti
    ssuedenselyadherent
    betweentheuter
    usandmat ernal
    bladderisnot
    ed.Whichofthefoll
    owingist
    hemost
    li
    kel
    ydiagnosi
    s?

    Pl
    acent
    aper
    cret
    a

    2.A24-
    year
    -ol
    dG1P0womanat39weeks’
    gest
    ati
    onhadi
    nduct
    ionofl
    aborduet
    o
    gestati
    onal hyper t
    ension.Shewaspl acedonmagnesi um sulfat
    eforseizureprophyl
    axi
    s.
    Shewaspl acedonoxy tocinfor15hoursandr eachedacervicaldi
    lat
    ionof6cm.Af t
    er
    beingat6cm di lati
    onf or3hoursdespiteadequat euteri
    necontracti
    onsasj udgedby
    240Mont ev ideouni t
    s,sheunder wentacesar eandeli
    v er
    y.Thebabywasdel iv
    ered
    withoutdi
    ff i
    cul t
    ythroughal ow-tr
    ansverseincisi
    on.Upondeliver
    yoft heplacenta,
    profusebleedi ngwasnot edfrom t
    heuterus,reaching1500mL.Whi choft hefoll
    owi
    ng
    i
    st hemostl ikelycauseofhemor rhageinthispatient
    ?
    Ut
    eri
    neat
    ony
    3.A23-
    year
    -ol
    dG1P0womanat38weeks’
    gest
    ati
    ondel
    i
    ver
    eda4.
    3kgbabyboy
    vaginal
    l
    y.Upondeli
    veryoftheplacent
    a,t
    her ewasnotedtobeaninvert
    eduter
    us,whi
    ch
    wassuccessful
    lymanagedi ncl
    udingr
    eplacementoftheuter
    us.Whichoft
    hef ol
    l
    owing
    placent
    ali
    mplantat
    ionsit
    eswoul dmostlikel
    ypredi
    sposetoaninv
    ertedut
    erus?
    Fundal

    1.Abnor
    mal
    breastdev
    elopmentmaybeduet
    oei
    therf
    asci
    aladher
    encet
    othe
    underl
    yi
    ngmusclel
    ay erorduetohi
    gh-
    doseexogenoushormoneexposureduri
    ng
    pubert
    y.I
    nsuchcases,breast
    shaveexcessiv
    eforwar
    dbutli
    mitedl
    ater
    al gr
    owth,
    whi
    ch
    causesanabnor
    mal shape.Thi
    scondi
    ti
    oni sref
    err
    edtoaswhichoft
    hef oll
    owi
    ng?
    Tuber
    ousbr
    east
    s
    2.Whi
    choft
    hef
    oll
    owi
    ngi
    str
    uer
    egar
    dingi
    sol
    atedpr
    emat
    uret
    hel
    arche?
    I
    tismostcommoni
    ngi
    rl
    syoungert
    han2y
    ear
    s.
    3.Whichofthefol
    l
    owi
    nggener
    all
    yoccur
    sfi
    rstamongt
    hemaj
    ordev
    elopment
    alev
    ent
    s
    offemalepuber
    ty?
    Thel
    arche
    4.I
    ntheUni
    tedSt
    ates,
    adol
    escent
    scanobt
    ainmedi
    cal
    car
    ewi
    thoutpar
    ent
    alknowl
    edge
    orconsentorwhi
    choft
    hef
    oll
    owi
    ng“
    medi
    cal
    l
    yemanci
    pat
    ed”condi
    ti
    ons?
    Al
    loft
    hement
    ioned
    5.HowdoBMIcor
    rel
    atewi
    thpuber
    tal
    dev
    elopment
    ?
    hi
    gherBMIcor
    rel
    atewi
    thear
    lydev
    elopment
    6.Pubar
    che,
    wit
    hdev
    elopmentofaxi
    l
    lar
    yandpubi
    chai
    r,i
    sst
    imul
    atedbyt
    heandr
    ogens
    der
    ivedpr
    imar
    il
    yfr
    om whi
    choft
    hef
    oll
    owi
    ng?
    Adr
    enal
    glands
    7.Whi
    choft
    hef
    oll
    owi
    ngor
    gani
    smsi
    smostl
    i
    kel
    ytocausepr
    epuber
    tal
    vul
    vi
    ti
    s?
    Gr
    oupAβ-
    hemol
    yti
    cst
    rept
    ococcus
    8.Mast
    it
    isi
    sunusual
    inchi
    l
    drenandadol
    escent
    s.Whati
    sthemostcommonpat
    hogen
    i
    sol
    atedf
    rom br
    eastabscessesi
    nthepedi
    atr
    icpopul
    ati
    on?
    St
    aphy
    lococcusaur
    eus

    1.Apat
    ientpr
    esent
    stot
    heEmer
    gencyDepar
    tmentwi
    tha1-
    dayhi
    stor
    yofheav
    yvagi
    nal
    bleedi
    ng.Sheistachy cardicbutnothy potensive,andpost ur
    alvit
    alsi
    gnsarestablewith
    changef r
    om asupinet osit
    ti
    ngposi t
    ion.Physical examinati
    ondemonst r
    atesbleedi
    ng
    fr
    om abov et
    heext ernal cer
    vicalosandcont inuedpool i
    ngofbl oodinthevagi
    na.
    Laborator
    ystudi
    esr ev ealsheisanemi c.Whichoft hefoll
    owingisthemostappr opr
    iat
    e
    fi
    rst-
    li
    neagenttoat t
    emptcont rolofheracuteut erinebleedi
    ng?
    I
    ntr
    avenousest
    rogen
    2.Cont
    rol
    ofbl
    oodl
    ossdur
    ingmensesi
    nvol
    veswhi
    choft
    hef
    oll
    owi
    ngmechani
    sms?
    Al
    loft
    hement
    ioned
    3.Thel
    esi
    onwi
    thasi
    ngl
    efeederv
    essel
    (bycol
    orDoppl
    er)i
    sseenhy
    ster
    oscopi
    cal
    l
    y.
    Ri
    skact
    orsormal
    i
    gnantt
    ransf
    ormat
    ionoft
    hisl
    esi
    oni
    ncl
    udewhi
    choft
    hef
    oll
    owi
    ng?
    Al
    loft
    hement
    ioned
    4.Whi
    choft
    hel
    abor
    ator
    ycr
    it
    eri
    ali
    stedbel
    owi
    sconsi
    stentwi
    thi
    ron-
    def
    ici
    encyanemi
    a?
    Lowser
    um f
    err
    it
    inl
    evel
    5.Suggest
    edet
    iol
    ogi
    esorabnor
    mal
    uter
    inebl
    eedi
    ngassoci
    atedwi
    thuseoft
    hedev
    ice
    shownbel
    owi
    nthi
    sthr
    ee-
    dimensi
    onal
    (3-
    D)sonogr
    am i
    ncl
    udewhi
    choft
    hef
    oll
    owi
    ng?
    Al
    loft
    hement
    ioned
    6.Whencounsel
    i
    ngapat
    ientf
    orendomet
    ri
    alabl
    ati
    on,
    whi
    choft
    hef
    oll
    owi
    ngpoi
    ntsar
    e
    di
    scussed?
    Al
    loft
    hement
    ioned
    7.I
    npremenarchi
    algi
    rl
    s,whi
    choft
    hef
    oll
    owi
    ngi
    sthemostcommonsour
    ceof
    abnor
    malbleedi
    ng?
    Vagi
    na
    8.Whi
    choft
    hef
    oll
    owi
    ngi
    sal
    i
    mit
    ati
    onofPi
    pel
    l
    esampl
    ersusedf
    orendomet
    ri
    albi
    opsy
    t
    oev
    aluat
    eabnor
    mal
    uter
    inebl
    eedi
    ng?
    Lowsensi
    ti
    vi
    tyandhi
    ghf
    alse-
    negat
    iver
    ateorf
    ocal
    endomet
    ri
    alpat
    hol
    ogy

    9.Fort
    het
    reat
    mentofdy
    sfunct
    ional
    uter
    inebl
    eedi
    ng,
    evi
    dencesuppor
    tswhi
    choft
    he
    fol
    lowi
    ngstat
    ementsregardi
    ngt
    heef
    fi
    cacyoft
    hedev
    iceshowni
    nthi
    sthr
    ee-
    dimensi
    onal(
    3-D)sonogr
    am?
    Al
    loft
    hement
    ioned
    10.Anadv
    ant
    ageoft
    ransv
    agi
    nal
    sonogr
    aphyf
    ort
    heev
    aluat
    ionofabnor
    mal
    uter
    ine
    bl
    eedi
    ngi
    ncl
    udeswhi
    choft
    hef
    oll
    owi
    ng?
    Al
    loft
    hement
    ioned

    1.Whatdef
    ini
    ti
    vet
    reat
    menti
    sthemostpr
    efer
    abl
    eina48-
    year
    -ol
    dpar
    ous,
    signi
    fi
    cant
    ly
    obese,
    diabet
    icandhy
    per
    toni
    cpat
    ientwi
    thr
    ecur
    rentDUB?
    endomet
    ri
    um abl
    ati
    on
    2.A32-
    year
    -ol
    dpat
    ientcompl
    ainsofbl
    eedi
    ngbet
    weenherper
    iodsandi
    ncr
    easi
    ngl
    y
    heavymenses.Ov erthepast9mont hs,shehashadtwodilati
    onandcurett
    ages(D&Cs)
    ,
    whichhavefail
    edtor esol
    vehersy
    mpt oms,andcont
    racept
    ivesandanti
    prostagl
    andi
    ns
    havenotdecreasedtheabnormalbleeding.Ofthef
    oll
    owingoptions,
    whichisthemost
    appropr
    iat
    eatt hi
    stime?
    Per
    for
    m hy
    ster
    oscopy

    1.Mostcommoncauseofpost
    menopausal
    bleedi
    ngi
    nIndi
    ais:
    Car
    cinomacer
    vix
    2.Apat
    ientpr
    esent
    swi
    thCacer
    vixwi
    thst
    ageI
    II
    b.Tr
    eat
    mentofchoi
    cei
    s:
    I
    ntr
    acav
    itat
    orybr
    achy
    ther
    apyf
    oll
    owedbyext
    ernal
    beam r
    adi
    other
    apy
    3.Cy
    togenet
    icsi
    sdi
    fficul
    tinsol
    i
    dtumor
    s,t
    hatt
    ooespeci
    all
    yincar
    cinomacer
    vix,
    duet
    o:
    Of
    tencont
    ami
    nat
    edandi
    nfeсt
    edwi
    thmi
    croor
    gani
    sms
    4.An18-y
    ear-oldadolescentfemaleisbeingseenforahealthmai nt
    enanceappoi
    ntment.
    ShehasnothadaPapsmearpr evi
    ously
    .Shecur r
    entl
    ytakesoralcontr
    acept
    ivepi
    l
    ls.She
    begansexualint
    ercourse1y earprevi
    ously.Whichofthefol
    lowingstat
    ementsismost
    accur
    ateregardi
    ngheal t
    hmai ntenanceforthi
    sindiv
    idual
    ?
    APapsmearshoul
    dnotbeper
    for
    medi
    nthi
    spat
    ientatt
    hist
    ime

    1.I
    nci
    denceofchor
    iocar
    cinomai
    sseenmor
    eaf
    ter
    Spont
    aneousabor
    ti
    on
    2.Al
    loft
    hef
    oll
    owi
    ngar
    eindi
    cat
    ionsf
    orpost
    oper
    ati
    ver
    adi
    other
    apyi
    nacaseof
    car
    cinomaendomet
    ri
    um,
    except
    :
    Tumorposi
    ti
    vef
    orest
    rogenr
    ecept
    ors
    3.A35-
    year
    -ol
    dG0P0pr
    esent
    stoherdoct
    orf
    ori
    nfer
    ti
    li
    ty.Sheal
    sohasheav
    yvagi
    nal
    bl
    eedingt
    hatpersi
    stedfor3weeks.Shehasalonghist
    oryofol
    igomenor
    rhea.An
    endometr
    ial
    biopsyshowsGr ade1endometr
    ial
    carci
    noma.Whichofthefol
    lowingi
    sthe
    bestt
    reat
    mentforthispati
    ent?
    Pr
    ogest
    int
    her
    apy
    4.Apat
    ienti
    srecei
    vi
    ngext
    ernal
    beam r
    adi
    ati
    onf
    ort
    het
    reat
    mentofmet
    ast
    ati
    c
    endometr
    ialcancer
    .Thetr
    eat
    mentfieldi
    ncl
    udestheenti
    repel
    vi
    s.Whi
    choft
    hef
    oll
    owi
    ng
    ti
    ssueswit
    hinthisr
    adi
    ati
    onfiel
    disthemostradi
    osensi
    ti
    ve?
    Ov
    ary
    5.Choi
    ceofadj
    uvantt
    reat
    mentf
    orendomet
    ri
    alcar
    cinomast
    ageI
    A,gr
    adeIi
    s:
    Not
    reat
    ment

    1.Thecutsur
    faceofov
    aryhas4l
    ayer
    s.Whi
    chl
    ayeri
    sthenextf
    rom t
    hev
    erysuper
    fi
    cial
    ?
    connect
    ivet
    issue
    2.Whi
    chhi
    stol
    ogi
    cal
    groupofov
    ari
    ant
    umour
    sist
    hemostcommon(
    ≈70%ofal
    l
    t
    umor
    s)?
    epi
    thel
    i
    alt
    umour
    s
    3.A16-
    year
    -ol
    dgi
    rlpr
    esent
    swi
    th6×6cm r
    ightov
    ari
    anmasswi
    thabsentAFP,
    negat
    ive
    CA125,
    andi
    ncr
    easedal
    kal
    i
    nephosphat
    ase.Di
    agnosi
    sis:
    Dy
    sger
    minoma
    4.Al
    lthef
    oll
    owi
    ngar
    etr
    ueaboutKr
    ukenber
    g’st
    umor
    ,except
    :
    Noneoft
    heabov
    e
    5.Thepr
    esent
    ati
    onwi
    tht
    hedi
    ff
    erentt
    ypesofbeni
    gnov
    ari
    ant
    umour
    svar
    ieswi
    thage.
    Mar
    kthei
    ncor
    rectst
    atement
    .
    ger
    m cel
    ltumour
    soccurmor
    ecommonl
    yinol
    derwomen
    6.A5-
    year
    -ol
    dgi
    rli
    snot
    edt
    ohav
    ebr
    eastenl
    argement
    ,vagi
    nal
    bleedi
    ng,
    andan8-
    cm
    pel
    vi
    cmass.Whi
    choft
    hef
    oll
    owi
    ngi
    sthemostl
    i
    kel
    yet
    iol
    ogy
    ?
    Gr
    anul
    osa-
    thecacel
    ltumor
    7.Mei
    gs'
    syndr
    omei
    sdi
    agnosedbasedonat
    ri
    adoft
    hef
    oll
    owi
    ngsi
    gns,
    except
    :
    oedema
    8.A55- y
    ear-
    oldwomani snotedt
    ohav eanabdominalmassandi
    ncr
    easedabdominal
    gir
    th.Onexami nat
    ion,
    ther
    eisshi
    fti
    ngdull
    nessandaf l
    uidwav
    e.Whi
    chofthefol
    l
    owing
    malignanci
    esismostlikel
    ytobefoundinthi
    spati
    ent?
    Ov
    ari
    ancancer
    9.Whi
    chbi
    ochemi
    cal
    tumourmar
    keri
    suseddur
    ingt
    reat
    mentandf
    oll
    ow-
    upofov
    ari
    an
    dy
    sger
    minoma?
    bet
    a-hCG
    10.Condi
    ti
    onsdi
    agnosedasapel
    vi
    cmassi
    nwomenofr
    epr
    oduct
    iveagear
    ethe
    f
    oll
    owi
    ngex
    cept
    :
    Pr
    olact
    inoma
    CONTENTS

    Preface ix

    SECTION 1
    BENIGN GENERAL GYNECOLOGY

    1 Well Woman Care 2 8 Abnormal Uterine Bleeding 51


    2 Techniques Used for Imaging in 9 Pelvic Mass 58
    Gynecology 7 10 Endometriosis 67
    3 Gynecologic Infection 14 11 Pelvic Pain 74
    4 Benign Disorders of the Lower 12 Breast Disease 81
    Genital Tract 23
    13 Psychosocial Issues and
    5 Contraception and Sterilization 30 Female Sexuality 90
    6 First-Trimester Abortion 37 14 Pediatric Gynecology 95
    7 Ectopic Pregnancy 44

    SECTION 2
    REPRODUCTIVE ENDOCRINOLOGY,
    INFERTILITY, AND THE MENOPAUSE

    15 Reproductive Endocrinology 104 19 Evaluation of the Infertile Couple 127


    16 Amenorrhea 110 20 Treatment of the Infertile Couple 133
    17 Polycystic Ovarian Syndrome 21 Menopausal Transition 140
    and Hyperandrogenism 116 22 The Mature Woman 146
    18 Anatomic Disorders 121

    vii
    viii Contents

    SECTION 3
    FEMALE PELVIC MEDICINE AND
    RECONSTRUCTIVE SURGERY

    23 Urinary Incontinence 154 26 Genitourinary Fistula


    and Urethral Diverticulum 173
    24 Pelvic Organ Prolapse 161
    25 Anal Incontinence and Functional
    Anorectal Disorders 168

    SECTION 4
    GYNECOLOGIC ONCOLOGY

    27 Principles of Chemotherapy 180 33 Endometrial Cancer 217


    28 Principles of Radiation Therapy 187 34 Uterine Sarcoma 223
    29 Preinvasive Lesions of the Lower 35 Epithelial Ovarian Cancer 230
    Genital Tract 193 36 Ovarian Germ Cell and
    30 Cervical Cancer 200 Sex Cord-Stromal Tumors 236
    31 Vulvar Cancer 205 37 Gestational Trophoblastic Disease 242
    32 Vaginal Cancer 211

    SECTION 5
    ASPECTS OF GYNECOLOGIC SURGERY

    38 Anatomy 250 41 Minimally Invasive Surgery


    Fundamentals 269
    39 Preoperative Considerations 257
    42 Postoperative Considerations 274
    40 Intraoperative Considerations 263

    SECTION 6
    ATLAS OF GYNECOLOGIC SURGERY

    43 Surgeries for Benign 45 Surgeries for Pelvic Floor Disorders 303


    Gynecologic Disorders 282 46 Surgeries for Gynecologic Malignancies 315
    44 Minimally Invasive Surgery 293

    Index 325
    30

    CHAPTER 5

    Contraception and Sterilization

    5–1. Which o the ollowing poses the highest risk o death 5–5. Your patient delivered a healthy in ant 2 weeks ago
    in ertile women aged 35 to 44 years? and wishes to initiate use o a contraceptive method
    a. Pregnancy during the next ew weeks. She is breast eeding
    exclusively. For which o the ollowing is there strong
    b. Oral contraceptive use
    evidence that use decreases the quantity and quality o
    c. Intrauterine device (IUD) use breast milk?
    d. Surgical tubal sterilization procedure a. Progestin-only pills
    b. Depot medroxyprogesterone acetate
    5–2. Which o the ollowing is a rst-tier contraceptive
    method with an expected ailure rate o 2 pregnancies c. Combination hormonal contraceptives
    per 100 women during the rst year? d. None o the above
    a. Spermicide
    5–6. A 16-year-old nulligravida is requesting a contracep-
    b. Male condom
    tive method. She plans to become sexually active with
    c. Intrauterine device (IUD) her boy riend soon. Which o the ollowing is legally
    d. Depot medroxyprogesterone acetate (DMPA) required in most states prior to prescribing hormonal
    contraception or adolescents below the age o consent?
    5–3. Which o the ollowing is a second-tier contracep- a. Parental consent
    tive method with an expected ailure rate o 3 to
    b. Pelvic examination
    9 pregnancies per 100 users during the rst year?
    c. Cervical cancer screening
    a. Spermicide
    d. None o the above
    b. Withdrawal
    c. Intrauterine device 5–7. Which o the ollowing statements is NOT a proges-
    d. Oral contraceptive pills tin-mediated mechanism by which a levonorgestrel-
    releasing intrauterine system (LNG-IUS) may prevent
    5–4. A 35-year-old woman presents to your o ce as a new pregnancy?
    amily planning patient or initiation o contracep- a. Endometrial atrophy
    tion. Her medical history is notable or migraines
    b. Decrease in tubal motility
    with aura. She wishes to use combination oral con-
    traceptive pills (COCs). You re er to the United States c. T ickening o cervical mucus
    Medical Eligibility Criteria (US MEC) guidelines d. Lysosomal activation and in ammation
    and see that this method is rated a “4.” Which o the
    ollowing corresponds to this score and describes the
    sa ety pro le or COC use in this particular patient?
    a. Use is not restricted.
    b. Method advantages outweigh risks.
    c. Method risks outweigh advantages.
    d. Method poses an unacceptable high health risk.
    Contraception and Sterilization 31

    5–8. Which o the ollowing conditions is NOT listed by 5–9. Your patient is a 26-year-old multipara who presents
    the manu acturer as a contraindication o this contra- or a well-woman examination. She has no complaints.
    ceptive method? She is satis ed with her current method o contracep-
    tion (shown here). It was inserted 2 years ago, and she

    C
    H
    wishes to continue with this contraceptive method.

    A
    Her pelvic examination is normal. Cervical cytology

    P
    T
    (Pap test) is obtained and is negative or malignancy,

    E
    but lamentous organisms consistent with Actinomyces

    R
    5
    species are identi ed on the smear. Which o the
    ollowing is NOT a reasonable treatment option or
    managing this incidental nding according to current
    recommendations rom the American College o
    Obstetricians and Gynecologists (2011)?

    a. Acute liver disease


    b. Heavy menses due to coagulation disorder
    c. Increased susceptibility to pelvic in ection
    d. Uterine anomaly with distortion o the uterine
    cavity

    a. Hysterectomy
    b. Expectant management (no intervention)
    c. Extended course o antibiotics with intrauterine
    device (IUD) le t in place
    d. Intrauterine device removal and initiation o an
    alternative contraceptive method

    5–10. For which o the ollowing is intrauterine device use


    contraindicated due to an increased complication
    rate?
    a. Adolescence
    b. Human immunode ciency in ection
    c. Insertion immediately a ter spontaneous or in-
    duced abortion
    d. None o the above

    5–11. What is the spontaneous expulsion rate or the intra-


    uterine device during the rst year a ter placement?
    a. 0.05 percent
    b. 0.5 percent
    c. 5 percent
    d. 15 percent
    32 Benign General Gynecology

    5–12. What is the approximate risk o the complication 5–13. A 34-year-old multipara with a copper-containing
    shown here per intrauterine device insertion? intrauterine device (IUD) in place presents or IUD
    removal because she plans to become pregnant soon.
    Her last menstrual period was 8 weeks ago. Her urine
    S
    E
    pregnancy test is positive, and transvaginal sonog-
    C
    raphy con rms an 8-week intrauterine gestation. She
    T
    I
    wishes to continue this pregnancy, i possible. She
    O
    N
    eels well, is a ebrile, and has no cervical discharge
    1
    or pelvic tenderness. You see the IUD tail strings
    protruding rom the external cervical os. Which o
    the ollowing management strategies is recommended
    to optimize the outcome or your patient?

    Used with permission rom Dr Kimberly Kho.

    a. 1 in 100
    b. 1 in 1000
    c. 1 in 10,000
    d. 1 in 100,000

    a. Remove the IUD and evacuate the uterine


    contents
    b. Remove the IUD and plan expectant pregnancy
    management
    c. Leave the IUD in place and plan expectant preg-
    nancy management
    d. Leave the IUD in place and administer broad-
    spectrum antibiotics or the next 4 weeks

    5–14. For which o the ollowing contraceptive methods is a


    history o previous ectopic pregnancy considered, by
    its manu acturer, to be a contraindication to its use?
    a. Depot medroxyprogesterone acetate
    b. Copper-containing intrauterine device
    c. Progestin-containing subdermal implant
    d. Levonorgestrel-releasing intrauterine system
    Contraception and Sterilization 33

    5–15. Which o the ollowing is thought to be a mechanism 5–18. Which o the ollowing statements is true regarding
    o action by which the etonogestrel implant provides the Essure permanent birth control system, which is
    contraception? shown in this sonogram.

    C
    a. Ovulation suppression

    H
    b. Endometrial atrophic changes

    A
    P
    c. Increased cervical mucus viscosity

    T
    E
    d. All o the above

    R
    5
    5–16. Which o the ollowing methods o tubal sterilization
    has the highest cumulative probability o ailure at
    5 years?
    a. Bipolar sterilization
    b. Unipolar sterilization
    c. Band or clip placement
    d. Puerperal sterilization

    5–17. Which o the ollowing statements is true regarding


    the ef ects o emale tubal sterilization?
    a. Procedure time averages more than 1 hour.
    b. Placement must be per ormed in the operating
    room.
    c. I coils are placed bilaterally and occlusion is
    documented, contraceptive success rates exceed
    95 percent.
    d. ransvaginal sonography has been approved by the
    Food and Drug Administration or con rmation
    o postprocedural tubal occlusion.

    5–19. Which o the ollowing statements regarding vasec-


    tomy is true?
    a. Semen analysis is per ormed 3 months a ter vasec-
    tomy to con rm azoospermia.
    b. T e ailure rate is 30 times less than that o emale
    Used with permission rom Dr Deana Hussamy. tubal sterilization.
    c. T e postoperative complication rate is 20 times
    a. Ovarian cancer risk is increased. less than that o emale tubal sterilization.
    b. T e incidence o menorrhagia and dysmenorrhea d. All o the above
    is increased.
    c. Approximately 10 percent o pregnancies occurring 5–20. Which o the ollowing is NOT a physiologic ef ect
    a ter the procedure are ectopic. exerted by the progestin component o combination
    d. By 5 years postprocedure, 50 percent o women hormonal contraceptives?
    aged 30 years or younger at the time o sterilization a. Lowered serum ree testosterone levels
    express regret. b. Suppressed serum levels o luteinizing hormone
    c. Elevated serum levels o ollicle-stimulating
    hormone
    d. All are physiologic ef ects.
    34 Benign General Gynecology

    5–21. Which o the ollowing is NOT an absolute contrain- 5–23. Rates o which o the ollowing are increased with use
    dication to use o this contraceptive method? o extended cycle hormonal contraception compared
    with that o traditional cyclic hormonal contracep-
    tion?
    S
    E
    a. Headaches
    C
    T
    b. Escape ovulation
    I
    O
    c. Endometrial cancer
    N
    1
    d. Unpredictable bleeding

    5–24. Use o which o the ollowing drugs most clearly


    decreases combined hormonal contraceptive e cacy?
    a. Ri ampin
    b. Penicillin
    c. Doxycycline
    d. Cipro oxacin

    5–25. Low-dose combination hormonal contraceptives most


    clearly increase the risk o developing which o the
    a. T rombotic disorders
    ollowing?
    b. Cholestatic jaundice
    a. Obesity
    c. Migraines with ocal neurologic de cits
    b. Clinically signi cant hypertension
    d. Uncomplicated systemic lupus erythematosus that
    c. Overt diabetes in women with prior gestational
    includes negative testing or antiphospholipid
    diabetes
    antibodies
    d. None o the above
    5–22. Which o the ollowing statements regarding the
    method o contraception shown here compared with 5–26. With combination hormonal contraceptive use,
    combination oral contraceptive pills (COCs) is true? stroke risk is elevated by which o the ollowing being
    coexistent?
    a. obacco use
    b. Hypertension
    c. Migraine headaches with aura
    d. All o the above

    5–27. Your patient is concerned a ter reading that the risk


    o deep-vein thrombosis and pulmonary embolism
    is tripled or quadrupled in current users o combina-
    tion hormonal contraceptives (CHCs) compared
    with that o the general population. You explain that
    this is true but that the risk is still lower than the risk
    o venous thrombosis related to pregnancy. What is
    the approximate rate o thromboembolic events per
    10,000 woman years with CHC use?
    a. 4 events
    a. otal estrogen exposure is higher with this b. 40 events
    method. c. 240 events
    b. T is method is less likely to cause breast d. 440 events
    tenderness.
    c. T is method controls dysmenorrhea in a greater
    percentage o women.
    d. T e pregnancy rate with this method is slightly
    higher than with COCs.
    Contraception and Sterilization 35

    5–28. Your patient is an 18-year-old nulligravida who is 5–32. Which o the ollowing is an advantage o lambskin
    not sexually active but takes combination oral contra- condoms compared with latex rubber condoms?
    ceptive pills (COCs) to achieve good control o her a. Fewer allergic reactions
    irregular menses and dysmenorrhea. She has grand mal

    C
    b. Lower breakage and slippage rates

    H
    epilepsy. Her seizures are well controlled on medica-

    A
    tion. Serum levels o which anticonvulsant medication c. Better protection against sexually transmitted

    P
    in ections

    T
    are decreased signi cantly by concurrent COC use?

    E
    d. All o the above

    R
    a. Phenytoin

    5
    b. Lamotrigine
    5–33. Which o the ollowing statements about spermicides
    c. Carbamazepine is NOT true?
    d. Phenobarbital a. Spermicides alone provide protection against sexu-
    ally transmitted diseases.
    5–29. Contemporary low-dose combination oral contracep-
    b. T e chemical agents, such as nonoxynol-9 or
    tive pills (COCs) are most strongly implicated as a
    octoxynol-9, are spermicidal.
    risk actor or the development o which o the
    ollowing neoplasms? c. Spermicide preparations are marketed in various
    orms, such as creams, jellies, suppositories, lm,
    a. Breast cancer
    and oams.
    b. Cervical cancer
    d. Even when inserted regularly and correctly, sper-
    c. Benign hepatic adenomas micide preparations have a ailure rate o up to
    d. Lymphoma, i human immunode ciency virus 12 pregnancies per 100 woman years o use.
    (HIV) in ection coexists
    5–34. Which o the ollowing is NOT a mechanism o ac-
    5–30. Your patient has diabetes mellitus and hyperten- tion or hormone-based emergency contraception?
    sion but pre ers to use “pills” or contraception. She a. Disruption o an implanted zygote
    declines an intrauterine device and barrier methods.
    b. Endometrial changes that prevent implantation
    She is considering a progestin-only contraceptive and
    avors progestin-only pills. You counsel her regarding c. Inter erence with sperm transport or penetration
    the advantages. You also explain which o the ollow- d. Inhibition or delay o ovulation and impaired
    ing disadvantages o progestin-only pills compared corpus luteum unction
    with combination oral contraceptive pills (COCs)?
    a. Higher ailure rate 5–35. Which o the ollowing is an advantage o progestin-
    only emergency contraception regimens compared
    b. High rate o irregular bleeding
    with estrogen–progestin combinations or this
    c. Higher relative ectopic pregnancy rate i pregnancy purpose?
    occurs
    a. More ef ective in preventing pregnancy
    d. All o the above
    b. Ef ective i taken beyond 5 days a ter exposure
    5–31. Which o the ollowing is generally increased by the c. Provides better protection against sexually trans-
    use o depot medroxyprogesterone acetate compared mitted in ections
    with other contraceptive methods? d. None o the above
    a. Acne
    b. Bone ractures Reference
    c. Hepatic neoplasms American College o Obstetricians and Gynecologists: Long-
    d. Interval to resumption o ovulation a ter method acting reversible contraception: Implants and intrauterine devices.
    Practice Bulletin No. 121, July 2011, Rea rmed 2013.
    cessation
    36 Benign General Gynecology

    Chapter 5 ANSWER KEY


    Question Letter Page Question Letter Page
    number answer cited Header cited number answer cited Header cited
    S
    E
    C
    5–1 a p. 105 Table 5-1 5–20 c p. 118 Pharmacology
    T
    I
    O
    5–2 c p. 105 Chapter 5: Contraception 5–21 d p. 119 Table 5-6
    N
    and Sterilization 5–22 a p. 122 Transdermal System
    1
    5–3 d p. 105 Chapter 5: Contraception 5–23 d p. 123 Extended Cycle
    and Sterilization Contraception
    5–4 d p. 105 Medical Eligibility Criteria 5–24 a p. 124 Table 5-9
    5–5 d p. 108 Table 5-3 5–25 d p. 124 Obese and Overweight
    5–6 d p. 107 Adolescence and Women, Diabetes
    Perimenopause Mellitus, Cardiovascular
    5–7 d p. 108 Levonorgestrel-Releasing Disease
    Intrauterine System 5–26 d p. 125 Cerebrovascular Disorders
    (LNG-IUS) 5–27 a p. 125 Venous
    5–8 b p. 109 Table 5-4 Thromboembolism
    5–9 a p. 109 Infection 5–28 b p. 125 Seizure Disorders
    5–10 d p. 110 Low Parity and 5–29 b p. 126 Neoplastic Diseases
    Adolescents 5–30 d p. 126 Progestin-Only Pills
    5–11 c p. 110 Expulsion or Perforation 5–31 d p. 127 Notable Effects
    5–12 b p. 110 Expulsion or Perforation 5–32 a p. 128 Male Condoms
    5–13 b p. 111 Marker Strings 5–33 a p. 130 Spermicides and
    5–14 d p. 111 Ectopic Pregnancy Microbicides
    5–15 d p. 112 Progestin Implants 5–34 a p. 131 Hormone-Based
    5–16 a p. 107 Figure 5-7 Emergency
    Contraception
    5–17 c p. 117 Other Effects
    5–35 a p. 132 Progestin-Only
    5–18 c p. 116 Counseling Regimens
    5–19 d p. 118 Male Sterilization
    51

    CHAPTER 8

    Abnormal Uterine Bleeding

    8–1. Which o the ollowing de nitions o abnormal uter- 8–6. Control o blood loss during menses involves which
    ine bleeding is incorrect? o the ollowing mechanisms?
    a. Intermenstrual bleeding is bleeding that occurs a. T rombus ormation
    between cycles. b. Platelet aggregation
    b. Oligomenorrhea re ers to cycles with intervals c. Vasoconstriction o endometrial arteries
    shorter than 35 days.
    d. All o the above
    c. Hypomenorrhea re ers to menses with diminished
    ow or shortened interval. 8–7. A 30-year-old patient presents to your o ce complain-
    d. Heavy menstrual bleeding is de ned as prolonged ing o heavy menstrual bleeding. With additional
    or heavy cyclic menstruation, with menses lasting questioning, she reports new onset dysmenorrhea.
    longer than 7 days or exceeding 80 mL o blood Given this additional symptom, which o the ollowing
    loss. etiologies or her abnormal bleeding is LEAST likely?
    a. In ection
    8–2. Which o the ollowing tools is NOT clinically use ul
    b. Anovulation
    to estimate menstrual blood loss?
    c. Pregnancy complication
    a. Pad counts
    d. Structural abnormality o the uterus
    b. Hemoglobin and hematocrit
    c. Pictorial blood assessment chart 8–8. All o the ollowing diagnostic tests are typically
    d. Sodium hydroxide extraction o hemoglobin obtained during the initial evaluation o abnormal
    uterine bleeding EXCEPT:
    8–3. In premenarchal girls, which o the ollowing is the a. Pap test
    most common source o abnormal bleeding?
    b. Pregnancy test
    a. Ovary
    c. Liver unction tests
    b. Uterus
    d. Complete blood count with platelets
    c. Vagina
    d. Urethra 8–9. Which o the laboratory criteria listed below is consis-
    tent with iron-de ciency anemia?
    8–4. Age groups have been correctly paired with their most a. Low serum erritin level
    common etiology o abnormal genital tract bleeding
    b. Normal hemoglobin and hematocrit
    in all o the ollowing EXCEPT:
    c. Low total iron-binding capacity ( IBC)
    a. Adolescence—anovulation
    d. Increase in mean corpuscular hemoglobin (MCV)
    b. Childhood—vulvovaginitis
    c. Perimenopause—anovulation 8–10. According to the American College o Obstetricians
    d. Menopause—endometrial carcinoma and Gynecologists (2013), endometrial sampling
    to assess abnormal uterine bleeding is NOT recom-
    8–5. Which layer o the endometrium sloughs and there- mended or a woman with which o the ollowing
    ore is responsible or observed menstrual discharge? characteristics?
    a. Spiral a. Is 35 years old
    b. Radial b. Has ailed medical management
    c. Basalis c. Has persistent abnormal uterine bleeding
    d. Functionalis d. Has history o unopposed estrogen exposure
    52 Benign General Gynecology

    8–11. Which o the ollowing is a limitation o Pipelle sam- 8–14. In the evaluation o abnormal uterine bleeding, what
    plers used or endometrial biopsy to evaluate abnor- is the primary advantage o hysteroscopy compared
    mal uterine bleeding? with saline in usion sonography?
    a. Rate o inadequate sampling that exceeds 50 percent a. Hysteroscopy is less pain ul.
    S
    E
    C
    b. Inability to be per ormed in an o ce setting b. Hysteroscopy is less expensive.
    T
    I
    c. Greater patient discom ort compared with a stif c. Hysteroscopy is more accurate in identi ying
    O
    metal curette global endometrial pathology.
    N
    1
    d. Low sensitivity and high alse-negative rate or d. Hysteroscopy permits simultaneous identi cation
    ocal endometrial pathology and removal o ocal endometrial lesions.

    8–12. An advantage o transvaginal sonography or the 8–15. A 60-year-old postmenopausal woman presents or
    evaluation o abnormal uterine bleeding includes evaluation o genital tract bleeding, which is con-
    which o the ollowing? rmed as uterine in origin by physical examination.
    a. Reduced use o endometrial biopsy Which diagnostic procedure is a logical rst step in
    b. Simultaneous assessment o myometrium and her evaluation?
    endometrium a. Colposcopy
    c. Greater patient com ort compared with endome- b. Diagnostic hysteroscopy
    trial biopsy or hysteroscopy c. ransvaginal sonography
    d. All o the above d. Saline in usion sonography
    8–13. What is the primary advantage o saline in usion 8–16. Which cause o abnormal uterine bleeding is NOT
    sonography compared with transvaginal sonography? represented in the International Federation o Gyne-
    cology and Obstetrics (FIGO) classi cation acronym
    PALM-COEIN?
    a. Leiomyoma
    b. Pregnancy
    c. Iatrogenic
    d. Coagulopathy

    a. Less patient discom ort


    b. Superior detection o intracavitary masses
    c. Ability to per orm at any time o the cycle
    d. Simultaneous assessment o myometrium and
    endometrium
    Abnormal Uterine Bleeding 53

    8–17. Pelvic sonography with applied color Doppler reveals 8–19. A 27-year-old woman who previously underwent
    an intrauterine growth with a single eeder vessel. dilatation and curettage or an incomplete abortion
    Which statement is true regarding this abnormality? presents with new-onset heavy menstrual bleeding.
    ransvaginal sonography rst reveals a hypoechoic

    C
    H
    tubular structure within the myometrium. With

    A
    application o color Doppler, large-caliber vessels are

    P
    T
    seen in the second image. What is the most appropri-

    E
    ate next step in her evaluation?

    R
    8
    a. T e main diagnostic tool is the Pap test.
    b. It is an uncommon cause o abnormal uterine
    bleeding.
    c. In ertility has been linked directly to this
    condition.
    d. Use o oral contraceptive pills appears to be
    protective.

    8–18. T e lesion in Question 8–17 is seen hysteroscopically.


    Risk actors or malignant trans ormation o this le-
    sion include which o the ollowing?

    a. Angiography
    b. Hysteroscopy
    c. Saline in usion sonography
    d. Pelvic computed tomography (C ) with contrast
    Used with permission rom Dr David Rogers.

    a. amoxi en use
    b. Postmenopausal status
    c. Size greater than 1.5 cm
    d. All o the above
    54 Benign General Gynecology

    8–20. Suggested etiologies or abnormal uterine bleeding 8–23. When should irregular spotting or bleeding be evalu-
    associated with use o the device shown below in this ated in a postmenopausal patient using hormone
    three-dimensional (3-D) sonogram include which o replacement therapy (HR )?
    the ollowing? a. History o endometrial polyps
    S
    E
    C
    b. Continued bleeding a ter 6 months o HR use
    T
    I
    c. Abnormal bleeding that develops a ter initial
    O
    amenorrhea
    N
    1
    d. All o the above

    8–24. Which o the ollowing statements regarding tamoxi-


    en is true?
    a. It acts as an estrogen agonist in the breast and
    uterus.
    b. amoxi en use has been linked to endometrial pol-
    yps, hyperplasia, and carcinoma but not to uterine
    sarcomas.
    c. Women using tamoxi en should undergo evalu-
    ation or endometrial cancer only i abnormal
    bleeding develops.
    a. Malpositioned device d. It is a selective estrogen-receptor modulator
    (SERM) used as an adjunct or treatment o
    b. Unbalanced ratio o prostaglandin to thromboxane
    estrogen-receptor-negative breast cancer.
    levels
    c. Increased endometrial vascularity, congestion, and 8–25. A 60-year-old patient with breast cancer taking oral
    degeneration anticoagulants or recent deep-vein thrombosis is ad-
    d. All o the above mitted or acute heavy menstrual bleeding. Which o
    the ollowing management options is LEAST suitable
    8–21. A patient or whom you initiated combination oral or this patient?
    contraceptive pills (COCs) 3 months ago returns to the a. Reversal o anticoagulation
    o ce or a routine COC re-evaluation. She complains o
    b. High-dose estrogen (intravenous Premarin)
    light, irregular bleeding during this time but states that it
    is diminishing. What is your diagnosis and plan o care? c. Intrauterine cavity insertion o a Foley catheter
    a. COC intolerance requiring method d. All are suitable or this woman.
    discontinuation
    8–26. Systemic causes o abnormal uterine bleeding include
    b. Breakthrough bleeding requiring counseling and
    which o the ollowing?
    reassurance
    a. Liver disease
    c. Endometrial pathology necessitating transvaginal
    sonography b. Severe renal dys unction
    d. Hormonal imbalance requiring selection o a c. Hypo- and hyperthyroidism
    dif erent COC ormulation d. All o the above

    8–22. A patient using the progestin-only implant (Nexpl- 8–27. A patient with heavy menstrual bleeding reveals a
    anon) complains o unscheduled light bleeding since personal history o requent gingival bleeding and
    her implant was placed 4 months ago. Which o the excessive bleeding during a recent tooth extraction.
    ollowing treatment options would be LEAST likely You screen her or a coagulation disorder. Which o
    to correct the bleeding? the ollowing laboratory tests is LEAST likely to be
    a. Single dose o depot medroxyprogesterone acetate in ormative?
    (DMPA) a. Bleeding time
    b. Addition o combination oral contraceptives or b. Prothrombin time (P )
    1 month c. Partial thromboplastin time (P )
    c. Use o a nonsteroidal anti-in ammatory medica- d. Complete blood count (CBC) with platelets
    tion or 1 week
    d. Use o a daily estrogen-only supplement such as
    ethinyl estradiol or conjugated equine estrogen or
    1 month
    Abnormal Uterine Bleeding 55

    8–28. Which is an ef ective rst-line treatment or women 8–32. For the treatment o dys unctional uterine bleeding,
    with heavy menstrual bleeding and von Willebrand evidence supports which o the ollowing statements
    disease? regarding the e cacy o the device shown in this
    three-dimensional (3-D) sonogram?

    C
    a. Endometrial ablation

    H
    b. Dilatation and curettage

    A
    P
    c. Nonsteroidal anti-in ammatory drugs

    T
    E
    d. Combination oral contraceptive pills

    R
    8
    8–29. Which o the ollowing statements regarding abnor-
    mal uterine bleeding-ovulatory (AUB-O) is true?
    a. Since ovulation does not occur, a secretory endo-
    metrium persists.
    b. At the cellular level, the availability o arachi-
    donic acid is increased, altering prostaglandin
    production.
    c. Women with anovulation may be amenorrheic
    or long periods o time, which are ollowed by
    irregular, prolonged, heavy bleeding episodes.
    d. At the tissue level, the endometrial vascular
    structure is altered and contains increased spiral a. It reduces menstrual loss by more than 75 percent
    arteriole density and constricted venous capillaries. a ter 3 months o use.
    b. Compared with endometrial ablation, this method
    8–30. A patient presents to the Emergency Department
    has similar therapeutic ef ects up to 2 years a ter
    with a 1-day history o heavy vaginal bleeding. She
    treatment.
    is tachycardic but not hypotensive, and postural vital
    signs are stable with change rom a supine to sitting c. It is more ef ective than nonsteroidal anti-in am-
    position. Physical examination demonstrates bleed- matory drugs or oral progestins in decreasing
    ing rom above the external cervical os and continued uterine blood loss.
    pooling o blood in the vagina. Laboratory studies d. All o the above
    reveal she is anemic. Which o the ollowing is the
    most appropriate rst-line agent to attempt control o 8–33. Which o the ollowing statements regarding
    her acute uterine bleeding? tranexamic acid is true?
    a. Intravenous estrogen a. o be most ef ective, it requires administration or
    b. Oral tranexamic acid 2 weeks be ore and during menses.
    c. Gonadotropin-releasing hormone (GnRH) agonist b. Contraindications to its use include a history or
    intrinsic risk o thromboembolic disease.
    d. Combination oral contraceptive pill taper
    c. It af ects blood coagulation parameters, such as
    8–31. Which o the ollowing medications used to treat platelet count, prothrombin time (P ), and partial
    abnormal uterine bleeding-endometrial (AUB-E) is thromboplastin time (P ).
    correctly paired with its mechanism o action? d. It is an anti brinolytic drug that permanently
    a. ranexamic acid—increases plasmin levels blocks lysine binding sites on plasminogen, thereby
    increasing plasmin levels and brinolytic activity.
    b. Nonsteroidal antiin ammatory drugs (NSAIDs)—
    stimulate cyclooxygenase (COX-1 and 2)
    production
    c. Oral progestins—inhibit endometrial growth
    and promote organized sloughing ollowing their
    withdrawal
    d. Combination oral contraceptive pills (COCs)—
    induce endometrial atrophy but promote increased
    prostaglandin synthesis and endometrial brinolysis
    56 Benign General Gynecology

    8–34. When counseling a patient or endometrial ablation, 8–35. Which o the ollowing is NOT a contraindication to
    which o the ollowing points are discussed? endometrial ablation?
    a. T ree ourths o women experience signi cantly a. Postmenopausal status
    decreased menstrual volume a ter ablation.
    S
    b. Prior classical cesarean delivery
    E
    C
    b. Approximately 25 percent o women will need a c. Anatomically normal endometrial cavity
    T
    hysterectomy by 5 years subsequent to ablation.
    I
    d. Desire to preserve ertility potential
    O
    c. Following ablation, evaluation o the endometrium
    N
    1
    or recurrent abnormal bleeding can be di cult due
    to resultant distortion o the endometrial cavity. Reference
    d. All o the above American College o Obstetricians and Gynecologists: Management
    o acute abnormal uterine bleeding in nonpregnant reproductive-
    aged women. Committee Opinion No. 557, April 2013.
    95

    CHAPTER 14

    Pediatric Gynecology

    14–1. Which o the ollowing statements is FALSE regard- 14–5. Delayed puberty is characterized by a lack o initial
    ing the development o the hypothalamic–pituitary- pubertal changes, usually thelarche, by what threshold
    ovarian axis in the emale etus and neonate? age?
    a. By 5 months’ gestation, 6 to 7 million oocytes a. 13 years
    have been created rom accelerated germ cell b. 14 years
    division.
    c. 15 years
    b. T e gonadotropin-releasing hormone (GnRH)
    d. 16 years
    “pulse generator” remains unctionally dormant
    until several months a ter birth.
    14–6. Compared with several decades ago, the age at which
    c. At birth, ollicle-stimulating hormone (FSH) and U.S. girls currently experience thelarche and men-
    luteinizing hormone (LH) concentrations rise and arche has shown which o the ollowing trends?
    remain high during the rst 3 months o li e.
    a. In general, later than in past
    d. Neonatal breast budding, minor uterine bleeding,
    b. In general, earlier than in past
    and transient ovarian cysts may occur as a normal
    response to initially high gonadotropin levels. c. For girls with a higher body mass index, later than
    in the past
    14–2. Which o the ollowing statements is true regarding d. No clear trend observed
    pelvic anatomy in the emale in ant and child?
    a. T e ovaries have obtained their normal adult size 14–7. All states in the United States legally allow a minor
    by birth. woman to consent to medical examination and treat-
    ment on her own behal in all o the ollowing situa-
    b. At birth, the uterus and cervix are approximately
    tions EXCEPT:
    equal in size.
    a. Pregnancy
    c. Presence o an endometrial stripe or uid within
    the endometrial cavity o the newborn uterus is a b. Emancipated minor status
    normal nding with sonography. c. Living permanently apart rom parents
    d. All the above are true statements. d. Requesting a school-sponsored sports’ physical
    examination
    14–3. Which o the ollowing generally occurs rst among
    the major developmental events o emale puberty? 14–8. Which o the ollowing is an indication or an
    a. Menarche internal vaginal examination o a child?
    b. Pubarche a. Possible tumor
    c. T elarche b. Vaginal bleeding
    d. Growth spurt c. Suspected oreign body
    d. All o the above
    14–4. An alarmed parent brings her 8-year-old daughter in
    or evaluation o breast budding. T e child shows no
    other signs o puberty. Precocious puberty is de ned
    as initial pubertal changes occurring prior to what
    threshold age?
    a. 6 years
    b. 7 years
    c. 8 years
    d. 9 years
    96 Benign General Gynecology

    14–9. A 4-year-old girl is brought in by her parent with 14–10. A 14-year-old woman presents with increasingly
    the concern that “the lips o her vagina have stuck pain ul, cyclic menses since menarche, 9 months ago.
    together.” Initial management o labial adhesion or Menstrual ow is normal in amount and duration.
    agglutination in a child, as shown here, does NOT Oral analgesics and nonsteroidal antiin ammatory
    S
    E
    include which o the ollowing options? medications no longer adequately control her severe
    C
    dysmenorrhea. Which o the ollowing congenital
    T
    I
    anomalies is most likely present?
    O
    N
    1
    Reproduced with permission rom Ho man BL, Schorge JO, Scha er JI, et al: Williams
    Gynecology, 2nd ed. New York, McGraw-Hill, 2012. Photo contributor: Dr. Mary Jane
    Pearson.
    Used with permission rom Dr. Ellen Wilson.

    a. Surgery
    a. Imper orate hymen
    b. Emollients
    b. Müllerian agenesis
    c. opical estrogen cream
    c. Complete transverse vaginal septum
    d. Await spontaneous resolution
    d. Obstructed hemivagina with ipsilateral renal agen-
    esis (OHVIRA) syndrome
    Pediatric Gynecology 97

    14–11. A 14-year-old woman presents with increasing 14–12. A 7-year-old girl has experienced vulvar irritation
    abdominal pain. She has begun appropriate pubertal with external itching and burning during urination
    development, although menarche has not occurred. or several months. Symptoms have persisted despite

    C
    During examination, a central abdominopelvic mass attempts to eliminate potential irritants and contact

    H
    is appreciated and is shown here. Physical examina- allergens rom the bath and laundry products used

    A
    P
    tion ndings prompt magnetic resonance imaging by the amily. Examination, as shown here, reveals

    T
    with contrast, and the results are shown below. Which symmetrical hypopigmentation and a parchment-like

    E
    R
    o the ollowing congenital anomalies is most likely thinning o the vulvar and perianal skin. What is the

    1
    present? most likely diagnosis?

    4
    Used with permission rom Dr. Mary Jane Pearson.

    a. Eczema
    b. Candidiasis
    c. Sexual abuse
    d. Lichen sclerosus

    14–13. Which o the ollowing organisms is most likely to


    cause prepubertal vulvitis?
    a. Candida albicans
    b. Group B streptococcus
    c. Staphylococcus aureus
    d. Group A β -hemolytic streptococcus

    14–14. With prepubertal vulvovaginitis, what approximate


    Used with permission rom Dr. Ellen Wilson.
    percentage o bacterial cultures obtained rom vaginal
    swabs show only normal genital ora?
    a. Imper orate hymen
    a. 25 percent
    b. Müllerian agenesis
    b. 50 percent
    c. Unicornuate uterus with cavitary communicating
    rudimentary horn c. 75 percent
    d. Obstructed hemivagina with ipsilateral renal agen- d. 90 percent
    esis (OHVIRA) syndrome
    98 Benign General Gynecology

    14–15. Which o the ollowing physiologic or anatomic char- 14–19. A unicornuate uterus and its noncavitary rudimentary
    acteristics predispose to prepubertal vulvovaginitis? horn are shown here. What is the pre erred imaging
    a. Poor vulvar hygiene modality when a congenital müllerian anomaly is
    suspected?
    S
    b. Lack o labial at pads and labial hair
    E
    C
    c. Nonestrogenized vulvovaginal epithelium
    T
    I
    d. All o the above
    O
    N
    1
    14–16. An 8-year-old girl presents with a mucopurulent and
    bloody vaginal discharge. Her parents report that,
    while traveling recently, the girl was brie y hospital-
    ized or treatment o severe diarrhea. Examinations o
    the vagina in the o ce and under anesthesia reveal no
    tumor or oreign body. What is the most likely organ-
    ism involved?
    a. Shigella spp.
    b. Salmonella spp.
    c. Candidia glabrata
    d. Enterobius vermicularis
    B = bladder.
    14–17. What approximate percentage o malignant tumors
    diagnosed in childhood are o ovarian origin? a. Computed tomography
    a. 0.1 percent b. Hysterosalpinography
    b. 1 percent c. ransabdominal sonography
    c. 10 percent d. Magnetic resonance imaging
    d. 30 percent
    14–20. Accessory nipples, when present, are located along the
    14–18. A etal ovarian mass is noted as an incidental nding embryonic milk line extending rom the axilla to the
    during third-trimester sonographic assessment o etal groin bilaterally. T eir presence is termed which o
    growth. T e emale in ant is delivered at term without the ollowing?
    incident. Lower abdominal ullness is palpated during a. Polythelia
    neonatal examination, and transabdominal sonog-
    raphy shows a 4.2-cm simple right ovarian cyst. T e b. Multimomium
    in ant is a ebrile and in no distress. What is the most c. Polymammoma
    appropriate management o this ovarian mass? d. Areola duplicata
    a. No urther surveillance
    b. Percutaneous cyst aspiration 14–21. Which o the ollowing is true regarding isolated
    premature thelarche?
    c. Surgery i unresolved within 2 months
    a. Bone age is advanced.
    d. Observation with repeat sonography in 6 weeks
    b. Gonadotropin levels are elevated.
    c. It is most common in girls younger than 2 years.
    d. None o the above
    Pediatric Gynecology 99

    14–22. A 14-year-old adolescent is brought in or examina- 14–26. A breast mass noted in an adolescent emale prompts
    tion due to her le t breast being noticeably larger than you to order breast sonography. What is the most
    her right when she is undressed. T e breasts are other- likely outcome o the lesion ound and shown here?

    C
    wise normal during examination. T elarche occurred

    H
    at the age o 11.5 years. She cannot think o any

    A
    P
    speci c trauma to the right breast or chest wall. She

    T
    has never had any surgery. Cosmetically, the dif er-

    E
    R
    ence is not obvious when she is clothed. Which o the

    1
    ollowing is the most common etiology o asymmetric

    4
    breast growth in a emale adolescent?
    a. Idiopathic
    b. Surgical trauma
    c. Physical trauma
    d. Strong right or le t handedness

    14–23. In an adolescent with an otherwise normal breast and


    chest wall examination, what is the best approach to
    breast asymmetry?
    a. Order breast sonography or diagnostic
    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al:
    mammography Williams Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Photo contributor: Dr. Stephen
    J. Seiler.
    b. Initiate combination low-dose oral contraceptive
    pills
    a. Spontaneous regression over time
    c. Re er now or plastic surgery be ore asymmetry
    worsens b. Persistence with little change in size
    d. Reassure that most cases o breast asymmetry c. With hormonal stimulation, gradual increase in size
    resolve by completion o breast development d. Development o more generalized brocystic changes

    14–24. Abnormal breast development may be due to either 14–27. A smooth, rm, mobile, nontender right-breast mass is
    ascial adherence to the underlying muscle layer palpable during examination o a 12-year-old girl. It is
    or due to high-dose exogenous hormone exposure 1 cm in its greatest dimension and appears solid sono-
    during puberty. In such cases, breasts have excessive graphically, as shown here. She has had no major health
    orward but limited lateral growth, which causes an problems to date. What is the most likely diagnosis?
    abnormal shape. T is condition is re erred to as which
    o the ollowing?
    a. Perithelia
    b. uberous breasts
    c. Aberrant breast hypertrophy
    d. Asymmetric lacti erous hyperplasia

    14–25. Lack o breast development is associated with low


    estrogen levels and may be caused by which o the
    ollowing?
    a. Chronic disease
    b. Gonadal dysgenesis
    c. High levels o athletic activity
    d. All o the above
    Used with permission rom Dr. Stephen J. Seiler.

    a. Malignancy
    b. Fibroadenoma
    c. Ductal ectasia
    d. Asymmetric breast budding
    100 Benign General Gynecology

    14–28. Mastitis is unusual in children and adolescents. What 14–34. Pubarche, with development o axillary and pubic
    is the most common pathogen isolated rom breast hair, is stimulated by the androgens derived primarily
    abscesses in the pediatric population? rom which o the ollowing?
    a. Escherichia coli a. Adrenal glands
    S
    E
    C
    b. Staphylococcus aureus b. Ovarian stroma
    T
    I
    c. Streptococcus pyogenes c. Peripheral aromatization o estrogens
    O
    N
    d. Staphylococcus epidermidis d. Physiology continues to be poorly understood.
    1
    14–29. An 8-year-old girl is brought in or evaluation o 14–35. Delayed puberty in women is de ned as the lack o
    4 days o intermittent vaginal bleeding and oul dis- secondary sexual characteristics by age 13 or lack o
    charge. She shows no signs o pubertal development. menarche by what age?
    T e cause o the bleeding is not apparent during a. 14
    physical examination, and the decision is made to
    b. 15
    proceed with examination under anesthesia and saline
    vaginoscopy. What is the most likely nding? c. 16
    a. Foreign object d. 18
    b. Atrophic vaginitis
    14–36. When an individual experiences di culty identi ying
    c. Endocervical polyp with their phenotypic gender, perceiving themselves
    d. Genital tract malignancy to be o the opposite gender, the condition is termed
    which o the ollowing?
    14–30. Which o the ollowing is the most common cause o a. Homosexuality
    central precocious puberty?
    b. Gender dysphoria
    a. Idiopathic
    c. Sexual identity con ict
    b. Head trauma
    d. Gender o rearing mismatch
    c. Hydrocephalus secondary to surgery
    d. Congenital central nervous system anomaly 14–37. Sexually active adolescents are particularly vulnerable
    to partner violence. In a study by Abma and associates
    14–31. Primary therapy or central (gonadotropin- (2010), what percentage o adolescent women who
    dependent) precocious puberty consists o experienced coitarche prior to age 20 described their
    which o the ollowing? rst sexual intercourse as nonvoluntary?
    a. Bromocriptine a. 0.1 percent
    b. Depot-medroxyprogesterone acetate b. 1 percent
    c. Combination oral contraceptive pills c. 7 percent
    d. Gonadotropin-releasing hormone (GnRH) agonist d. 17 percent

    14–32. A primary goal o therapy or central precocious 14–38. Which o the ollowing contraceptive methods is
    puberty includes prevention o which o the ollowing generally contraindicated in adolescents and women
    consequences? younger than 21 years?
    a. Short stature a. Vaginal ring
    b. Excessive breast size b. Intrauterine devices
    c. Learning disabilities c. Extended use o oral contraceptive pills
    d. None o the above d. None o the above

    14–33. A 5-year-old girl shows clinical signs o precocious 14–39. Which o the ollowing is required be ore initiating
    puberty. Gonadotropin levels are low, even ollowing a contraceptive method or a healthy, sexually active
    gonadotropin-releasing hormone (GnRH) stimula- adolescent?
    tion testing. However, estrogen levels are elevated. a. Pelvic examination
    Which o the ollowing could cause o her disorder?
    b. Cervical cancer screening
    a. Primary hypothyroidism
    c. Human papillomavirus (HPV) vaccination
    b. Ovarian granulosa cell tumor
    d. None o the above
    c. Congenital adrenal hyperplasia
    d. All o the above
    Pediatric Gynecology 101

    14–40. Vaccines targeting human papillomavirus in ection Reference


    are approved through what age (in years) or women
    according to the U.S. Food and Drug Administra- Abma JC, Martinez GM, Copen CE: eenagers in the United
    States: sexual activity, contraceptive use, and childbearing, National

    C
    tion? Survey o Family Growth 2006–2008. National Center or Health

    H
    Statistics. Vital Health Stat 23:30, 2010.

    A
    a. 12

    P
    b. 15

    T
    E
    R
    c. 21

    1
    d. 26

    4
    14–41. In the United States, adolescents can obtain medical
    care without parental knowledge or consent or which
    o the ollowing “medically emancipated” conditions?
    a. Pregnancy
    b. Contraception
    c. Substance abuse
    d. All o the above
    102 Benign General Gynecology

    Chapter 14 ANSWER KEY


    Question Letter Page Question Letter Page
    number answer cited Header cited number answer cited Header cited
    S
    E
    C
    14–1 b p. 318 Hypothalamic–Pituitary– 14–23 d p. 326 Breast Shape
    T
    I
    Ovarian (HPO) Axis
    O
    14–24 b p. 326 Breast Shape
    N
    14–2 c p. 318 Anatomy 14–25 d p. 326 Absent Breast Development
    1
    14–3 c p. 319 Pubertal Changes 14–26 a p. 326 Breast Mass or Infection
    14–4 c p. 319 Pubertal Changes 14–27 b p. 326 Breast Mass or Infection
    14–5 a p. 319 Pubertal Changes 14–28 b p. 326 Breast Mass or Infection
    14–6 b p. 319 Pubertal Changes 14–29 a p. 327 Table 14-2
    14–7 d p. 320 Gynecologic Examination 14–30 a p. 328 Central Precocious
    14–8 d p. 320 Gynecologic Examination Puberty (Gonadotropin
    14–9 a p. 321 Labial Adhesion Dependent), Table 14-3
    14–10 d p. 323 Congenital Anatomic 14–31 d p. 327 Central Precocious Puberty
    Anomalies (Gonadotropin Dependent)
    14–11 a p. 323 Congenital Anatomic 14–32 a p. 327 Central Precocious Puberty
    Anomalies (Gonadotropin Dependent)
    14–12 d p. 323 Lichen Sclerosus 14–33 d p. 328 Peripheral Precocious
    Puberty (Gonadotropin
    14–13 d p. 324 Infection Independent), Table 14-3
    14–14 c p. 324 Vulvovaginitis 14–34 a p. 329 Variations of Normal Puberty
    14–15 d p. 324 Table 14-1 14–35 c p. 329 Delayed Puberty
    14–16 a p. 324 Vulvovaginitis 14–36 b p. 329 Gender Identity
    14–17 b p. 325 Ovarian Tumors 14–37 c p. 330 Adolescent Sexuality
    14–18 d p. 325 Ovarian Tumors 14–38 d p. 330 Contraception
    14–19 d p. 325 Ovarian Tumors 14–39 d p. 330 Contraception
    14–20 a p. 325 Polythelia 14–40 d p. 330 Contraception
    14–21 c p. 326 Premature Thelarche 14–41 d p. 330 Contraception
    14–22 a p. 326 Breast Shape
    104

    CHAPTER 15

    Reproductive Endocrinology

    15–1. Which o the ollowing most accurately describes 15–4. A 48-year-old woman presents to the Emergency
    autocrine hormone communication? Department with severe upper abdominal pain and
    a. A cell secretes a hormone that acts on a neighbor- a positive pregnancy test. She has had a prior tubal
    ing cell. ligation. A computed tomography scan per ormed to
    evaluate her pain is signi cant or multiple hetero-
    b. A cell secretes a hormone that in uences its own
    geneous hepatic lesions (shown below). Her serum
    unction.
    β -human chorionic gonadotropin (β -hCG) test result
    c. T e hormone is secreted and acts upon a distant is 115 mIU/mL. ransvaginal sonography results are
    target tissue. also shown below. Chest radiographs are normal.
    d. T e hormone produced acts within the cell be ore What is the most likely source o her hCG?
    it is secreted.

    15–2. T e gure below portrays which type o hormone action?

    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al:
    Williams Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Figure 15-1B.

    a. Autocrine
    b. Endocrine
    c. Paracrine
    d. Intracrine

    15–3. Which o the ollowing statements is true regarding


    the gonadotropin luteinizing hormone (LH)?
    a. It is secreted by the posterior pituitary gland.
    b. Its unctional speci city is derived rom the
    α -subunit.
    c. It shares a common glycoprotein β -subunit with
    ollicle-stimulating hormone (FSH).
    d. Its β -subunit demonstrates approximately
    80 percent homology with that o human chorionic
    gonadotropin (hCG).
    a. Liver tumors
    b. Exogenous hCG injection
    c. Partial molar pregnancy
    d. Complete molar pregnancy
    Reproductive Endocrinology 105

    15–5. Which o the ollowing statements regarding steroido- 15–11. All o the ollowing will increase levels o sex hormone-
    genesis is FALSE? binding globulin EXCEPT:
    a. Steroid production primarily occurs in the Golgi a. Androgens

    C
    apparatus.

    H
    b. Estrogens

    A
    b. T e primary building block o sex steroid c. Pregnancy

    P
    hormones is cholesterol.

    T
    d. Hyperthyroidism

    E
    R
    c. T e enzymes involved in steroid production are

    1
    members o the cytochrome P450 super amily. 15–12. Where in the cell are unliganded estrogen receptors

    5
    d. T e placenta is the only steroid-producing tissue located?
    that cannot synthesize cholesterol rom its precur- a. Nucleus
    sor, acetate.
    b. Cytoplasm
    15–6. T e last step in estrogen synthesis requires which o c. Mitochondria
    the ollowing enzymes? d. Endoplasmic reticulum
    a. Aromatase
    15–13. Gonadotropin-releasing hormone agonists, such as
    b. 21-hydroxylase
    leuprolide acetate, reduce gonadotropin secretion by
    c. 5α -reductase what mechanisms?
    d. 11β -hydroxylase a. Receptor destruction
    b. Receptor hydroxylation
    15–7. All o the ollowing tissues express signi cant levels o
    aromatase EXCEPT: c. Receptor downregulation
    a. Skin d. Receptor phosphorylation
    b. Brain
    15–14. A 17-year-old adolescent presents with heavy vaginal
    c. Ovary bleeding or 3 days. Her previous menstrual period
    d. Muscle was 3 months ago, and she is sexually active without
    contraception. She denies vision changes, galactorrhea,
    15–8. What is the predominant estrogen during meno- or headaches. Physical examination is notable or a
    pause? so t, 14-week size uterus. Her urine β-human chorionic
    a. Estriol gonadotropin (β -hCG) level assay is negative. rans-
    vaginal sonography is obtained and a sagittal view o
    b. Estrone
    the uterus reveals the ndings below. What is the next
    c. Estradiol clinical step?
    d. None o the above

    15–9. Which o the ollowing androgens is NOT produced


    by the ovary?
    a. estosterone
    b. Androstenedione
    c. Dihydrotestosterone (DH )
    d. Dehydroepiandrosterone (DHEA)

    15–10. Approximately what percentage o androgens and


    estrogens are ound unbound, or ree, in the
    circulation?
    a. 1 percent
    b. 5 percent
    c. 10 percent
    d. 20 percent a. Endometrial biopsy
    b. Serum-based β -hCG assay
    c. Serum-based prolactin level
    d. Head magnetic resonance imaging
    106 Reproductive Endocrinology, Infertility, and the Menopause

    15–15. For the patient in Question 15–13, what is the 15–21. Prolactin release is primarily regulated by which
    mechanism by which signi cantly elevated hormone neurotransmitter?
    levels can saturate assay antibodies and create a alse- a. Dopamine
    negative reading?
    S
    b. Epinephrine
    E
    a. Hook ef ect
    C
    c. Norepinephrine
    T
    b. Werner ef ect
    i
    d. T yrotropin-releasing hormone
    o
    c. Layered ef ect
    n
    2
    d. Maryland ef ect 15–22. Cells o the anterior pituitary primarily express which
    o the ollowing dopamine receptors?
    15–16. What ef ect do endogenous opioids have on the a. D1
    release o gonadotropin-releasing hormone (GnRH)?
    b. D2
    a. No ef ect
    c. D3
    b. Variable ef ect
    d. D4
    c. Increase release o GnRH
    d. Suppress release o GnRH 15–23. Which o the ollowing statements is true regarding
    the corticotropin-releasing hormone–adrenocortico-
    15–17. Endorphin levels in the brain peak during what phase tropic hormone (CRH-AC H) pathway?
    o the menstrual cycle? a. Abnormalities in the pathway result in electrolyte
    a. Menses disturbances.
    b. Ovulation b. CRH secretion is under negative- eedback regula-
    c. Luteal phase tion by circulating cortisol.
    d. Follicular phase c. CRH binds to its receptors in the posterior pitu-
    itary to stimulate AC H secretion.
    15–18. Secretion o which anterior pituitary hormone is d. AC H stimulates glucocorticoid production by
    NOT stimulated by hypothalamic neuroendocrine the adrenal zona reticularis.
    secretion?
    a. Prolactin 15–24. All o the ollowing stimulate release o growth hor-
    mone EXCEPT:
    b. Growth hormone
    a. Sleep
    c. Luteinizing hormone
    b. Stress
    d. T yroid-stimulating hormone
    c. Adiposity
    15–19. Sustained gonadotropin secretion requires which d. Hypoglycemia
    o the ollowing patterns o gonadotropin-releasing
    hormone (GnRH) secretion? 15–25. Which o the ollowing is NOT believed to be a unc-
    a. Nocturnal release o GnRH tion o oxytocin?
    b. Pulsatile release o GnRH a. Promotes vaginal distension during coitus
    c. Continuous low levels o GnRH secretion b. Stimulates uterine contractions during labor.
    d. Continuous high levels o GnRH secretion c. Promotes expression o milk during lactation.
    d. Prompts uterine and tubal contractions to aid
    15–20. Which o the ollowing statements regarding ertilization.
    gonadotropin-releasing hormone (GnRH) pulsatility
    in animal models is FALSE?
    a. Progesterone decreases GnRH pulsatility.
    b. Higher pulse requency avors luteinizing hormone
    (LH) secretion.
    c. Lower pulse requency avors ollicle-stimulating
    hormone (FSH) secretion.
    d. Estrogen increases GnRH pulse requency such
    that FSH levels increase relative to LH levels.
    Reproductive Endocrinology 107

    15–26. What stage o olliculogenesis is shown here? 15–30. A 36-year-old woman is using a home ovulation-
    predictor kit to help achieve pregnancy. She is given
    speci c instructions by her physician to engage in sexual

    C
    intercourse a ter detecting the luteinizing hormone (LH)

    H
    surge. T is advice is based upon ovulation typically

    A
    P
    occurring how many hours a ter the onset o this surge?

    T
    E
    a. 12 to 16 hours

    R
    b. 24 to 30 hours

    1
    5
    c. 36 to 40 hours
    d. 48 to 52 hours

    15–31. T e patient in Question 15–30 returns to her physician,


    unsure i she detected a luteinizing hormone (LH)
    surge with her home ovulation predictor kit. o
    con rm ovulation, a progesterone level is drawn in
    the midluteal phase (day 21 o the menstrual cycle).
    At what minimum progesterone level can it be
    Used with permission rom Dr. Kelley Carrick.
    assumed that ovulation has occurred?
    a. Corpus luteum a. 0.3 ng/mL
    b. Antral ollicle b. 3 ng/mL
    c. Corpus albicans c. 30 ng/mL
    d. Primary ollicle d. 300 ng/mL

    15–27. When is meiosis II completed during oocyte matura- 15–32. Steroidogenesis in the corpus luteum is mainly under
    tion? the control o which hormone?
    a. A ter ertilization a. Activin
    b. A ter the luteinizing hormone (LH) surge b. Follistatin
    c. Immediately preceding the LH surge c. Luteinizing hormone (LH)
    d. During ollicular development in the preovulatory d. Follicle-stimulating hormone (FSH)
    phase
    15–33. A 28-year-old woman presents to the emergency
    15–28. All o the ollowing statements regarding estrone are room reporting acute onset o pelvic pain. Her urine
    true EXCEPT: pregnancy test result is positive; she reports her last
    menses was 8 weeks ago; and a rst-trimester intra-
    a. It is the principal serum estrogen in postmeno-
    uterine pregnancy is seen sonographically. T e patient
    pausal women.
    is taken to the operating room to evaluate or torsion
    b. T e major site or conversion o androstenedione a ter imaging demonstrates a large ovarian cyst. Ovar-
    to estrone is adipose tissue. ian torsion is con rmed, and the ovary containing
    c. Circulating levels o estrone are usually adequate a corpus luteum cyst must be removed. Until what
    to protect against bone loss. gestational age must this patient receive progesterone
    d. For a given body weight, conversion o andro- replacement?
    stenedione to estrone is higher in postmenopausal a. 10 weeks
    women than in premenopausal women. b. 14 weeks
    c. 20 weeks
    15–29. What hormone is responsible or the recruitment o
    the ollicles destined or ovulation? d. No replacement is necessary a ter 8 weeks’ gestation.
    a. Estrogen
    15–34. What days o the menstrual cycle constitute the win-
    b. Inhibin A dow o implantation or a human embryo?
    c. Inhibin B a. Days 14 to 16
    d. Follicle-stimulating hormone (FSH) b. Days 16 to 20
    c. Days 20 to 24
    d. Days 24 to 28
    108 Reproductive Endocrinology, Infertility, and the Menopause

    15–35. A 33-year-old woman has a 5-mm prolactin- 15–36. A 26-year-old woman presents with severe headaches.
    producing pituitary adenoma, which is well con- Visual eld de ects are noted during evaluation, and
    trolled on bromocriptine. She presents soon a ter a imaging con rms a pituitary adenoma. What is the
    missed menstrual period with a positive pregnancy best next step in management or this patient?
    S
    E
    test result. What is the best next step in management a. Radiation therapy
    C
    or this patient?
    T
    b. Neurosurgical evaluation
    i
    o
    a. Decreasing bromocriptine dose
    c. Somatostatin-agonist therapy
    n
    b. Increasing bromocriptine dose
    2
    d. Initiation o gonadotropin-releasing hormone
    c. Discontinuing bromocriptine therapy (GnRH) agonist therapy
    d. Visual eld testing in every trimester
    15–37. Which o the ollowing progestins is NOT derived
    rom 19-nortestosterone?
    a. Drospirenone
    b. Norgestimate
    c. Norethindrone
    d. Levonorgestrel
    Reproductive Endocrinology 109

    Chapter 15 ANSWER KEY


    Question Letter Page Question Letter Page

    C
    number answer cited Header cited number answer cited Header cited

    H
    A
    15–1 b p. 334 Reproductive Endocrinology 15–20 d p. 344 Pulsatile Gonadotropin-

    P
    T
    15–2 c p. 334 Reproductive Endocrinology releasing Hormone

    E
    R
    Secretion
    15–3 d p. 334 Peptide Hormones: LH, FSH,

    1
    15–21 a p. 345 Dopamine and Prolactin

    5
    and hCG
    15–4 a p. 335 Human Chorionic Gonadotropin 15–22 b p. 345 Dopamine and Prolactin
    15–5 a p. 336 Steroidogenesis 15–23 b p. 345 Corticotropin-releasing
    Hormone
    15–6 a p. 337 Figure 15-5
    15–24 c p. 345 Growth Hormone-releasing
    15–7 d p. 336 Steroidogenesis Hormone
    15–8 b p. 336 Steroidogenesis 15–25 a p. 346 Posterior Pituitary Peptides
    15–9 c p. 336 Steroidogenesis 15–26 b p. 348 Figure 15-13
    15–10 a p. 338 Steroid Hormone Transport 15–27 a p. 348 Oocyte Maturation
    in the Circulation
    15–28 c p. 350 Steroidogenesis Across the
    15–11 a p. 338 Steroid Hormone Transport Life Span
    in the Circulation
    15–29 d p. 353 Follicular Phase
    15–12 a p. 339 Estrogen, Progesterone, and
    Androgen Receptors 15–30 c p. 353 Ovulation
    15–13 c p. 340 Receptor Expression and 15–31 b p. 354 Luteal Phase
    Desensitization 15–32 c p. 354 Luteal Phase
    15–14 b p. 341 Immunoassays 15–33 a p. 354 Luteal Phase
    15–15 a p. 341 Immunoassays 15–34 c p. 357 Implantation Window
    15–16 d p. 343 Endogenous Opiates 15–35 c p. 360 Pregnancy and Pituitary
    15–17 c p. 343 Endogenous Opiates Adenomas
    15–18 a p. 343 Anterior Pituitary Hormones 15–36 b p. 360 Treatment of
    Hyperprolactinemia and
    15–19 b p. 344 Pulsatile Gonadotropin- Pituitary Adenomas
    releasing Hormone
    Secretion 15–37 a p. 363 Progestogens
    121

    CHAPTER 18

    Anatomic Disorders

    18–1. Congenital anatomic disorders o the emale repro- 18–6. Which o the ollowing statements is true regarding
    ductive tract may result rom which o the ollowing the role o the sex-determining region Y (SRY) in the
    mechanisms? sexual di erentiation o humans?
    a. Genetic mutation a. T e SRY acts as the testis-determining actor.
    b. Developmental arrest b. Without the in uence o SRY, gonads develop as
    c. Abnormal hormonal exposure or exposure to envi- testes.
    ronmental insults c. T e SRY is located on the Y chromosome and is
    d. All o the above the only gene responsible or sex determination.
    d. None o the above
    18–2. Both urinary and genital systems develop rom which
    o the ollowing cell types? 18–7. Antimüllerian hormone is involved in all o the
    a. Ectoderm ollowing EXCEPT:
    b. Endoderm a. Regression o the ipsilateral paramesonephric
    system
    c. Mesoderm
    b. Peaking o testosterone production as a result o
    d. None o the above
    stimulation o the testes
    18–3. Which o the ollowing organs is correctly paired with c. Rapid gubernacular growth necessary or the trans-
    its embryologic origin? abdominal descent o testes
    a. Uterus—mesonephric duct d. Assessment o ovarian reserve in women undergo-
    ing assisted reproduction
    b. Bladder—mesonephric duct
    c. Kidney—paramesonephric duct 18–8. During emale sex development, when do the germ
    d. estes and ovaries—genital ridge cells carrying two X chromosomes (oocytes) reach
    their peak number o 5 to 7 million?
    18–4. Up to what percentage o women with uterovaginal a. At birth
    mal ormations have associated urinary tract anoma-
    b. Age 5 to 7 years
    lies?
    c. Shortly be ore menarche
    a. 5 percent
    d. In utero at 20 weeks’ gestation
    b. 25 percent
    c. 50 percent 18–9. During a rst-trimester ultrasound or pregnancy
    d. 75 percent dating, you discover that your patient has a subsep-
    tate uterus. While counseling her, you explain that
    18–5. Embryos o male or emale gender are indistinguish- this müllerian anomaly developed in utero secondary
    able rom each other until which number o weeks o to ailure o the midline uterine septum to reabsorb
    development? completely. Normally, reabsorption o the uterine
    a. 7 septum in a etus should occur by how many weeks o
    gestation?
    b. 10
    a. 20
    c. 12
    b. 28
    d. 14
    c. 32
    d. 36
    122 Reproductive Endocrinology, Infertility, and the Menopause

    18–10. T e vagina orms in part rom both the müllerian 18–16. Which o the ollowing is NOT true o Kline elter
    ducts and which other structure? syndrome?
    a. Genital ridge a. A ected men are tall and excessively virilized.
    S
    b. Urogenital sinus b. A ected men have signi cantly reduced ertility.
    E
    C
    c. Mesonephric duct c. T e syndrome occurs in 1 to 2 percent o all men.
    T
    I
    d. Paramesonephric duct d. It con ers an increased risk or germ cell tumors,
    O
    N
    osteoporosis, and breast cancer.
    2
    18–11. T e hymen is the partition that remains between
    which structures? 18–17. rue statements about pure 46,XY gonadal dysgenesis
    a. Cloacal membrane and genital tubercle include which o the ollowing?
    b. Sinovaginal bulb and urogenital sinus a. It was ormerly named Swyer syndrome.
    c. Un used cephalad portions o the two müllerian b. It results rom a mutation in sex-determining
    ducts region Y (SRY) or in another gene with testis-
    determining e ects.
    d. None o the above
    c. T e condition creates a normal prepubertal emale
    18–12. In the male etus, dihydrotestosterone (DH ) is phenotype and normal müllerian system due to
    involved in which o the ollowing? the absence o antimüllerian hormone (AMH).
    a. Enlargement o the phallus d. All o the above
    b. Lengthening o the anogenital distance
    18–18. All o the ollowing statements regarding complete
    c. Fusion o the labioscrotal olds to orm the androgen insensitivity syndrome (CAIS) are true
    scrotum EXCEPT:
    d. All o the above a. On outward examination, patients appear as phe-
    notypically normal women.
    18–13. Which o the ollowing anatomic structures is cor-
    b. T ese women develop breasts during puberty due
    rectly paired with its embryologic origin?
    to abundant androgen-to-estrogen conversion.
    a. Genital tubercle—clitoris
    c. Surgical excision o the testes is recommended
    b. Urethral olds—labia minora be ore puberty to decrease the associated risk o
    c. Labioscrotal olds—labia majora germ cell tumors.
    d. All o the above d. Estrogen replacement a ter removal o the testes is
    important to maintain bone mass and to provide
    18–14. Which o the ollowing disorders o sex development relie rom vasomotor symptoms.
    is correctly paired with its category o abnormality?
    a. Hypospadias—ambiguous genitalia 18–19. Which o the ollowing can cause virilization o a
    46,XX in ant?
    b. Streak gonad—gonadal dysgenesis
    a. Placental aromatase de ciency
    c. rue hermaphroditism–ovotesticular disorder
    b. Fetal congenital adrenal hyperplasia due to de -
    d. All o the above
    ciency o 21-hydroxylase
    18–15. rue statements regarding urner syndrome include c. Maternal virilizing ovarian tumors, such as Sertoli–
    which o the ollowing? Leydig tumor, or maternal use o androgenic
    medication
    a. T ere are no classic physical stigmata.
    d. All o the above
    b. It is the least common orm o gonadal dysgenesis
    that leads to primary ovarian ailure.
    18–20. When aced with ambiguous external genitalia o a
    c. Although the uterus and vagina are normal, streak newborn at delivery, the obstetrician should do which
    gonads are present, and patients typically present o the ollowing?
    with primary amenorrhea.
    a. Examine the mother or signs o
    d. All o the above hyperandrogenism.
    b. Re er to the newborn as “your baby” and not as “it.”
    c. Re rain rom gender assignment by explaining that
    the genitalia are incompletely ormed.
    d. All o the above
    Anatomic Disorders 123

    18–21. Which o the ollowing statements regarding bladder 18–24. Appropriate techniques or the surgical correction o
    exstrophy is NOT true? the condition diagnosed in Question 18–23 involve
    a. T is anomaly displays a predilection or women o all o the ollowing EXCEPT:

    C
    2:1. a. Hymenectomy

    H
    A
    b. It is characterized by an exposed bladder lying b. Laparoscopy to exclude endometriosis

    P
    outside the abdomen.

    T
    c. Repair in in ancy or a ter thelarche

    E
    R
    c. Surgical closure is per ormed early in li e and as a d. Needle aspiration o the hematocolpos

    1
    staged procedure.

    8
    d. It occurs rom ailure o the cloacal membrane to 18–25. Compared with other müllerian duct de ects, a trans-
    be rein orced by an ingrowth o mesoderm. verse vaginal septum is associated with a lower rate o
    which o the ollowing?
    18–22. Causes o newborn clitoromegaly include which o a. Endometriosis
    the ollowing?
    b. Urologic abnormalities
    a. Prematurity
    c. Need or surgical correction
    b. Neuro bromatosis
    d. None o the above
    c. Fetal exposure to excessive androgens
    d. All o the above 18–26. A 16-year-old nulligravida presents to the emergency
    department with complaints o abdominal and vagi-
    18–23. A 14-year-old nulligravida presents to the emergency nal pain, worsening during the past several months.
    department with complaints o worsening lower She describes the pain as being mostly on her right
    abdominal pain over the past ew days. She states side and much worse during menstruation. During
    that she has had a similar pain in the past, usually your physical examination, a patent vagina and cervix
    or a ew days each month, but then it subsides. She are noted, but a lateral vaginal and pelvic mass is pal-
    is a ebrile with stable vital signs. Although she has pated. ransvaginal sonography demonstrates a single
    breasts and axillary and pubic hair, she has never had uterus and cervix but also a large pelvic mass lled
    a period. Examination reveals a tender midline lower with complex uid, as shown below, and the absence
    abdominal mass and a bluish bulging vaginal mass, as o the right kidney. What is the most likely diagnosis?
    shown here. Based on her history and your physical
    examination, which o the ollowing conditions is
    your most likely diagnosis?

    a. OHVIRA syndrome
    b. Ovarian neoplasm
    c. Imper orate hymen
    d. ransverse vaginal septum
    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds):
    Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2014. Photo contributor:
    Dr. Ellen Wilson.

    a. Bartholin cyst
    b. Imper orate hymen
    c. Gartner duct cyst
    d. Longitudinal vaginal septum
    124 Reproductive Endocrinology, Infertility, and the Menopause

    18–27. Why is care ul preoperative planning warranted with 18–30. Appropriate techniques or surgical correction o
    congenital vaginal cysts, as shown in sonogram below? the condition diagnosed in Question 18–29 include
    which o the ollowing?
    a. Hymenectomy
    S
    E
    C
    b. Hysterectomy
    T
    I
    c. Uterine transplantation
    O
    N
    d. Surgical creation o a neovagina
    2
    18–31. A 22-year-old G3P0 woman presents as a new patient
    or consultation regarding her history o multiple
    miscarriages. Her gynecologic history is otherwise
    unremarkable. During physical examination, you
    note that the uterus is markedly deviated to the le t.
    ransvaginal sonography is per ormed, and three-
    dimensional images reveal a uterus that is deviated
    and has a banana-shaped cavity, as shown below.
    What is your diagnosis?
    a. T e recurrence rate a ter excision is high.
    b. T ey are requently large, measuring greater than
    8 cm in size.
    c. T eir typical location is in the posterior-lateral wall
    o the vagina.
    d. Some may extend up to the broad ligament and
    anatomically approximate the distal course o the
    ureter.

    18–28. Müllerian anomalies are associated with anomalies o


    all o the ollowing systems EXCEPT:
    a. Renal
    b. Hepatic
    c. Skeletal
    d. Neurological

    18–29. One o your patients brings her 13-year-old daughter a. Septate uterus
    or consultation regarding the girl’s complaints o
    b. Bicornuate uterus
    pelvic pain. T e daughter has experienced normal
    pubertal development to date but has not yet expe- c. Uterine didelphys
    rienced menarche. She began having monthly pelvic d. Unicornuate uterus
    pain about 1 year ago, and the pain has been progres-
    sively worsening. During physical examination, her 18–32. T e pathogenesis o poor pregnancy outcomes with a
    external genitalia, including hymeneal ring, appear unicornuate uterus is thought to be related to which
    normal. However, proximal to the hymen, only a o the ollowing actors?
    vaginal dimple is ound. Rectovaginal examination a. Cervical incompetence
    con rms the presence o a uterus and cervix. What is
    b. Reduced uterine capacity
    your diagnosis?
    c. Anomalous distribution o the uterine artery
    a. Vaginal atresia
    d. All o the above
    b. Cervical atresia
    c. Imper orate hymen
    d. Müllerian agenesis
    Anatomic Disorders 125

    18–33. Which müllerian anomaly results rom complete 18–35. Septate uterus, as shown in the sonogram below,
    ailure o the paired müllerian ducts to use? T is has a signi cantly higher spontaneous abortion rate
    anomaly is shown in this sonogram, and a gestational and early pregnancy loss rate than bicornuate uterus.

    C
    sac is seen on the image’s le t side. What is the primary mechanism thought to be

    H
    responsible or this extraordinarily high pregnancy

    A
    P
    wastage?

    T
    E
    R
    1
    8
    a. Associated cervical anomalies
    a. Septate uterus b. Distortion o the uterine cavity
    b. Bicornuate uterus c. Distortion o the uterine serosal contour
    c. Uterine didelphys d. Partial or complete implantation on the largely
    d. Unicornuate uterus avascular septum

    18–34. When should surgical reconstruction o a bicornuate 18–36. Which o the ollowing are seen in o spring o
    uterus (Strassman metroplasty) be per ormed? women who took diethylstilbestrol (DES) during the
    associated pregnancy?
    a. Prior to conception
    a. Impaired conception rates in emale o spring
    b. In all women with the diagnosis o bicornuate
    uterus b. Cryptorchidism, testicular hypoplasia, and mal or-
    mations o the penis in male o spring
    c. Procedure no longer per ormed or repair o bicor-
    nuate uterus c. -shaped uterus, “cockscomb” cervix, and
    increased rates o clear cell adenocarcinoma in
    d. With recurrent pregnancy loss and no other identi-
    emale o spring
    able cause except the uterine anomaly
    d. All o the above

    18–37. While staf ng labor and delivery, you are asked to


    evaluate a pelvic mass discovered during the per or-
    mance o a postpartum tubal ligation. T e mass is a
    thin-walled, translucent cystic structure measuring
    less than 1 cm in diameter. It is attached by a thin
    pedicle to the distal end o the right allopian tube.
    T e resident physician is concerned that the mass may
    be neoplastic, but you assure her that it is not. What
    is the likely diagnosis?
    a. Hydrosalpinx
    b. Accessory ovary
    c. Supernumerary ovary
    d. Paratubal cyst (hydatid o Morgagni)
    126 Reproductive Endocrinology, Infertility, and the Menopause

    Chapter 18 ANSWER KEY


    Question Letter Page Question Letter Page
    number answer cited Header cited number answer cited Header cited
    S
    E
    C
    18–1 d p. 404 Anatomic Disorders 18–19 d p. 413 Androgen Excess
    T
    I
    O
    18–2 c p. 404 Normal Embryology 18–20 d p. 413 Gender Assignment
    N
    18–3 d p. 404 Normal Embryology 18–21 a p. 414 Defects of the Bladder and
    2
    18–4 c p. 404 Normal Embryology Perineum
    18–5 a p. 406 Gonadal Determination 18–22 d p. 414 Defects of the Clitoris
    18–6 a p. 406 Gonadal Determination 18–23 b p. 415 Hymenal Defects
    18–7 b p. 406 Gonadal Determination 18–24 d p. 415 Hymenal Defects
    18–8 d p. 406 Gonadal Determination 18–25 b p. 416 Transverse Vaginal Septum
    18–9 a p. 408 Ductal System Development 18–26 a p. 416 Longitudinal Vaginal Septum
    18–10 b p. 408 Ductal System 18–27 d p. 417 Congenital Vaginal Cysts
    Development 18–28 b p. 417 Müllerian Anomalies
    18–11 b p. 408 Ductal System 18–29 a p. 419 Vaginal Atresia
    Development 18–30 d p. 420 Müllerian Agenesis
    18–12 d p. 409 External Genitalia 18–31 d p. 420 Unicornuate Uterus
    18–13 d p. 409 External Genitalia 18–32 d p. 420 Unicornuate Uterus
    18–14 d p. 409 Disorders of Sexual 18–33 c p. 420 Uterine Didelphys
    Development, Definitions
    18–34 d p. 421 Bicornuate Uterus
    18–15 c p. 412 Gonadal Dysgenesis
    18–35 d p. 422 Septate Uterus
    18–16 a p. 411 Turner and Klinefelter
    Syndromes 18–36 d p. 423 Diethylstilbesterol-Induced
    Reproductive Tract
    18–17 d p. 412 46, XYGonadal Dysgenesis Abnormalities
    18–18 c p. 412 Abnormal Androgen 18–37 d p. 423 Fallopian Tube Anomalies
    Production or Action
    127

    CHAPTER 19

    Evaluation of the Infertile Couple

    19–1. What is the expected per cycle ecundability rate? 19–6. O in ertility causes, which o the ollowing is most
    a. 0.5 percent likely encountered?
    b. 5 percent a. Unexplained
    c. 25 percent b. Male actors
    d. 85 percent c. ubal disease
    d. Ovulatory dys unction
    19–2. Regarding couples attempting pregnancy, what percent-
    age o women are expected to have conceived at 1 year? 19–7. A 30-year-old nulligravida has been trying to conceive
    a. 15 percent or the last 2 years. She has no medical problems.
    She consumes ve alcoholic drinks weekly, smokes
    b. 30 percent
    hal a pack o cigarettes daily. She describes hersel as
    c. 60 percent a heavy cof ee drinker. She works in a dry cleaning
    d. 85 percent acility. Which o the ollowing exposures is LEAST
    likely af ecting her ertility?
    19–3. A 27-year-old married nulligravid resident physician a. Alcohol
    has been married or 3 years. She is worried about
    b. Caf eine
    delaying childbearing or another ew years while she
    pursues ellowship training. She can be reassured that c. Cigarettes
    a signi cant decline in the ecundability rate does not d. Dry cleaning uid exposure
    begin until what age (years)?
    a. 26 19–8. Preconceptional carrier screening or cystic brosis is
    currently recommended or which group?
    b. 32
    a. Ashkenazi Jewish descent
    c. 38
    b. Non-Hispanic white race
    d. 44
    c. All individuals considering pregnancy
    19–4. In general, in ertility evaluation is initiated a ter a d. Family or personal history o cystic brosis
    couple ails to conceive a ter 1 year o unprotected
    intercourse o reasonable requency. When should 19–9. How long does spermatogenesis take, starting rom
    earlier evaluation be considered? stem cell to mature sperm?
    a. Woman older than 35 years a. 10 days
    b. History o chronic anovulatory cycles b. 30 days
    c. Prior severe pelvic in ammatory disease (PID) c. 60 days
    d. All o the above d. 90 days

    19–5. An in ertile couple presents or evaluation. Neither 19–10. Which o the ollowing is NOT known to impair
    partner has ever conceived a pregnancy. Both believe sperm production or quality?
    that the emale partner alone is the source o their a. ight underwear
    ailure to achieve a pregnancy. It should be explained
    b. Chronic hot tub use
    that in ertility can be attributed to the male partner in
    approximately one third o cases and to both partners c. Chemotherapy or local radiation
    in approximately what percentage o cases? d. Illness accompanied by high ever
    a. 1 percent
    b. 10 percent
    c. 33 percent
    d. 66 percent
    128 Reproductive Endocrinology, Infertility, and the Menopause

    19–11. A woman complaining o in ertility reports that her 19–17. Which o the ollowing is NOT true o basal body
    husband has already undergone evaluation by a urolo- temperature testing to identi y ovulation in adult
    gist to exclude male actors. T is leads to the surgical women?
    repair o a unilateral varicocele. With regard to varico- a. It can be an insensitive test in many women.
    S
    E
    celes and in ertility, which o the ollowing is true?
    C
    b. With ovulation, the temperature rises rom 0.4°F
    T
    a. All should be repaired. to 0.8°F.
    I
    O
    b. T ey are an established cause o male in ertility. c. It is an inexpensive and easy test or ovulation
    N
    2
    c. Repair o subclinical varicoceles leads to correction monitoring.
    o semen abnormalities. d. Once the temperature rises, a patient should
    d. A varicocele is present in nearly 20 percent o the expect ovulation during the next 48 hours.
    adult male general population.
    19–18. Regarding commercially available urinary luteinizing
    19–12. Use o which o these is most likely to damage testicu- hormone kits, when does ovulation take place in rela-
    lar unction permanently? tion to a positive result?
    a. Gentamycin a. Same day
    b. Spironolactone b. Day a ter
    c. Anabolic steroids c. Day be ore
    d. Alcohol consumption d. 48 hours a ter

    19–13. I not already up to date as a part o routine well- 19–19. Which o the ollowing midluteal progesterone level
    woman care, which o the ollowing should be com- values signi es ovulation?
    pleted during the initial in ertility evaluation? a. 0.05 ng/mL
    a. Determine rubella immunity status b. 0.1 ng/mL
    b. Screen or cervical cancer c. 1.0 ng/mL
    c. Screen or Neisseria gonorrhoeae and Chlamydia d. 5.0 ng/mL
    trachomatis
    d. All o the above 19–20. Which o the ollowing is true o luteal phase endo-
    metrial biopsy?
    19–14. Gynecomastia in a male patient may suggest the pres- a. It shows high intra- and interobserver reliability.
    ence o which o the ollowing conditions?
    b. It does not reliably distinguish ertile women rom
    a. Noonan syndrome in ertile women.
    b. Kline elter syndrome c. An out-o -phase biopsy result predicts an increased
    c. Pituitary prolactinoma risk o uture early pregnancy loss should concep-
    d. 17β -hydroxysteroid dehydrogenase de ciency tion occur.
    d. Its per ormance on day 21 o a menstrual cycle is
    19–15. Congenital bilateral absence o the vas de erens is considered a standard component o an in ertility
    genetically related to which o the ollowing? evaluation.
    a. Cystic brosis
    b. Noonan syndrome
    c. Kline elter syndrome
    d. Red–green color blindness

    19–16. Which o the ollowing suggests ovulatory cycles?


    a. Dysmenorrhea
    b. Mittelschmerz
    c. Moliminal symptoms
    d. All o the above
    Evaluation of the Infertile Couple 129

    19–21. As shown here, sonography is clinically most use ul 19–25. Which o the ollowing statements regarding anti-
    or the diagnosis o which o the ollowing conditions müllerian hormone level (AMH) is true?
    that contributes to a signi cant percentage o in ertil-

    C
    ity cases?

    H
    A
    P
    T
    E
    R
    1
    9
    Reproduced with permission Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams
    Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Photo contributor: Dr. Kelley Carrick.

    a. Anovulation a. AMH levels are increased in women with polycys-


    b. Sex cord-stromal tumors tic ovarian syndrome.
    c. Polycystic ovarian syndrome b. Compared with estradiol or ollicle-stimulating
    hormone (FSH) levels, AMH levels correlate better
    d. Periovarian adhesive disease
    with the number o ovarian primordial ollicles
    (seen in photomicrograph above).
    19–22. In reproductive-aged women, which o the ollowing
    increases with the passage o time? c. AMH expression is strong in preantral ollicles and
    weak in larger ollicles.
    a. Fertility
    d. All o the above statements are true.
    b. Ovarian reserve
    c. Risk o spontaneous abortion 19–26. A 19-year-old woman is admitted with her second
    d. Success o donor insemination bout o pelvic in ammatory disease (PID) in 18 months.
    She is counseled that she is at increased risk o in er-
    19–23. Reduced secretion o which o the ollowing hor- tility and ectopic pregnancy in the uture. Despite
    mones is most likely responsible or the rising serum this ef ort, she is likely to continue her risk-taking
    ollicle-stimulating hormone (FSH) level seen as a behaviors. What is the estimated tubal in ertility rate
    woman ages? a ter three episodes o PID?
    a. Activin a. 0.4 percent
    b. Inhibin B b. 14 percent
    c. Estradiol c. 34 percent
    d. Follistatin d. 54 percent

    19–24. For the evaluation o ovarian unction, which o the


    ollowing laboratory tests is LEAST help ul?
    a. Random inhibin B level
    b. Cycle day 3 estradiol level
    c. Random antimüllerian hormone level (AMH)
    d. Cycle day 3 ollicle-stimulating hormone (FSH)
    level
    130 Reproductive Endocrinology, Infertility, and the Menopause

    19–27. A 28-year-old woman presents with primary in er- 19–28. A 32-year-old woman undergoes in ertility evalua-
    tility. She has no current health problems or his- tion a ter trying to conceive or 5 years. She has cyclic
    tory o serious illness, including pelvic in ammatory but heavy menses. Prior to this, she experienced one
    disease (PID). She has predictable, cyclic menses pregnancy that ended in a rst-trimester spontaneous
    S
    E
    with mild dysmenorrhea, unchanged since men- abortion. What uterine abnormality is suggested by
    C
    arche. Her healthy male partner has been evaluated her hysterosalpingogram?
    T
    I
    and has a normal physical examination and semen
    O
    N
    analysis. What is your interpretation o the patient’s
    2
    hysterosalpingogram as shown below?

    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds):
    Williams Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Photo contributor:
    Dr. Diane wickler.

    a. Normal
    b. Asherman syndrome
    c. Submucous leiomyoma
    d. Bilateral hydrosalpinges

    19–29. Hysterosalpingography is LEAST help ul or detect-


    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds): ing which o the ollowing?
    Williams Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Photo contributor: Dr. Kevin
    Doody. a. ubal patency
    b. Pelvic adhesions
    a. Normal c. Asherman syndrome
    b. Uterine didelphys d. Congenital uterine anomalies
    c. Bilateral hydrosalpinges
    d. Unilateral proximal tubal blockage
    Evaluation of the Infertile Couple 131

    19–30. T e photomicrograph o an air-dried sample o cervi- 19–34. Asthenospermia re ers to which o the ollowing
    cal mucus demonstrates the ef ect o high amounts o semen abnormalities?
    which o the ollowing hormones? a. Sperm count

    C
    H
    b. Semen volume

    A
    c. Sperm motility

    P
    T
    d. Sperm morphology

    E
    R
    1
    19–35. Which o the ollowing tests can dif erentiate between

    9
    dead and alive nonmotile sperm?
    a. Zona penetration assay
    b. DNA ragmentation index
    c. Hypoosmotic swelling test
    d. Mannose uorescence assay

    19–36. Which o the ollowing tests are currently recom-


    mended components o a basic male actor in ertility
    evaluation?
    a. DNA integrity analysis
    Reproduced with permission rom Halvorson LM: Evaluation o the in ertile couple. In
    Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, b. Sperm penetration assay
    McGraw-Hill, 2016, Figure 19-10.
    c. Antisperm antibody assay
    a. Inhibin d. None o the above
    b. Estrogen
    19–37. A couple seeking pregnancy has undergone a thor-
    c. Progesterone ough in ertility evaluation. Both partners are gener-
    d. Follicle-stimulating hormone (FSH) ally healthy. T e emale partner is without apparent
    problems that would contribute to in ertility. Semen
    19–31. Which o the ollowing is true o the process o sperm analysis is per ormed. T e sperm count is 4 million/
    capitation? mL, and semen volume is less than 1 mL. In addition
    a. Involves sperm hyperactivation. to a serum testosterone level, which o the ollowing
    should be measured during the hormonal evaluation
    b. Aids sperm penetration o the ovum’s zona
    o the male partner i an endocrinopathy is suspected?
    pellucida.
    a. Prolactin
    c. Results in the sperm’s ability to release acrosomal
    enzymes important to ertilization o the ovum. b. T yroid-stimulating hormone
    d. All o the above c. Follicle-stimulating hormone (FSH)
    d. All o the above
    19–32. Lique action o the semen specimen a ter ejaculation
    is due to secretions rom which o the ollowing? 19–38. Genetic testing should be per ormed in response to
    a. Prostate which o the ollowing semen analysis results?
    b. Epididymis a. Semen volume o 2.0 mL
    c. Cowper gland b. Sperm concentration o 2 million/mL
    d. Semini erous tubules c. Presence o ructose in the semen sample
    d. 8-percent normal sperm morphology by Kruger
    19–33. When treating hypertension with β -blocking agents, criteria
    which o the ollowing semen abnormalities may be
    seen due to retrograde ejaculation? 19–39. Which o the ollowing Y-chromosome deletions car-
    a. Azoospermia ries the best prognosis or recovering sperm rom the
    testes in an azoospermic patient?
    b. Oligospermia
    a. AZFa
    c. eratospermia
    b. AZFb
    d. Low semen volume
    c. AZFc
    d. AZFd
    132 Reproductive Endocrinology, Infertility, and the Menopause

    Chapter 19 ANSWER KEY


    Question Letter Page Question Letter Page
    number answer cited Header cited number answer cited Header cited
    S
    E
    C
    19–1 c p. 427 Evaluation of the Infertile Couple 19–21 c p. 435 Sonography
    T
    I
    O
    19–2 d p. 427 Evaluation of the Infertile Couple 19–22 c p. 435 Reproductive Aging
    N
    19–3 b p. 427 Evaluation of the Infertile Couple 19–23 b p. 436 Follicle-Stimulating Hormone
    2
    19–4 d p. 427 Evaluation of the Infertile Couple and Estradiol
    19–5 c p. 428 Etiology of Infertility 19–24 a p. 436 Antimüllerian Hormone
    19–6 d p. 428 Table 19-1 19–25 d p. 436 Antimüllerian Hormone
    19–7 d p. 428 Social, Table 19-2 19–26 d p. 437 Tubal and Pelvic Factors
    19–8 c p. 430 Ethnicity and Family History 19–27 c p. 437 Tubal and Pelvic Factors
    19–9 d p. 430 Male History 19–28 c p. 438 Hysterosalpingography
    19–10 a p. 430 Male History 19–29 b p. 438 Hysterosalpingography
    19–11 d p. 430 Male History 19–30 b p. 441 Cervical Factors, Figure 19-10
    19–12 c p. 430 Male History 19–31 d p. 442 Normal Spermatogenesis
    19–13 d p. 433 Examination of the Female 19–32 a p. 442 Semen Analysis
    Patient 19–33 d p. 442 Semen Analysis Results
    19–14 b p. 433 Examination of the Male Patient 19–34 c p. 442 Semen Analysis Results
    19–15 a P. 433 Examination of the Male 19–35 c p. 442 Semen Analysis Results
    Patient 19–36 d p. 444 Additional Sperm Testing
    19–16 d p. 434 Clinical Evaluation 19–37 d p. 444 Hormonal Evaluation of the
    19–17 d p. 434 Clinical Evaluation Male
    19–18 b p. 435 Ovulation Predictor Kits 19–38 b p. 444 Genetic Testing of the Male,
    19–19 d p. 435 Serum Progesterone Table 19-8
    19–20 b p. 435 Endometrial Biopsy 19–39 c p. 444 Genetic Testing of the Male
    133

    CHAPTER 20

    Treatment of the Infertile Couple

    20–1. Which o these statements regarding in ertility is 20–5. A 27-year-old woman is diagnosed with a pituitary
    FALSE? microadenoma during evaluation o secondary amenor-
    a. Women are a ected more than twice as o ten as rhea. She subsequently begins a dopamine agonist and
    men. becomes pregnant. Which o the ollowing is the best
    management o her adenoma during this pregnancy?
    b. Around 10 to 15 percent o the reproductive-aged
    population is in ertile. a. Resect the pituitary adenoma.
    c. Early evaluation a ter only 6 months may be justi- b. Suspend dopamine agonist therapy.
    ed or certain medical conditions or or women c. Continue medical therapy with bromocriptine.
    aged 35 years or older. d. Obtain pituitary imaging every trimester and
    d. In ertility generally is de ned as the inability to continue medical therapy with cabergoline.
    achieve success ul pregnancy a ter at least
    12 months o regular, unprotected intercourse. 20–6. Which o the ollowing statements is true regarding
    thyroid dys unction and in ertility?
    20–2. A 28-year-old nullipara who has been seeking preg- a. Subclinical hypothyroidism is not associated with
    nancy is diagnosed with polycystic ovarian syndrome ovarian dys unction.
    (PCOS). She is generally healthy, but her body mass
    b. T ere is no relationship between in ertility and
    index (BMI) is in the obese range. Which o the
    overt thyroid dys unction.
    ollowing should be recommended as rst-line man-
    agement o her anovulation? c. In in ertile women seeking pregnancy, treatment o
    any degree o hypothyroidism is advisable.
    a. Gonadotropins
    d. T yroid-stimulating hormone levels are elevated in
    b. Clomiphene citrate
    more than hal o women with in ertility.
    c. Weight loss and exercise
    d. Insulin-sensitizing agents 20–7. Which o the ollowing is NOT true regarding clomi-
    phene citrate therapy?
    20–3. Obesity increases the risk o which o the ollowing a. T e typical starting dose is 200 mg orally.
    pregnancy complications?
    b. It can be initiated on the second day o the men-
    a. Birth de ects strual cycle.
    b. Cesarean delivery c. It is taken or ve consecutive days early in the
    c. Unexplained stillbirth menstrual cycle.
    d. All o the above d. It is classi ed as a category X drug by the Food and
    Drug Administration (FDA).
    20–4. A very health-conscious patient is seeking pregnancy
    and asks about the best diet to ollow at this time. 20–8. Which o the ollowing statements is true regarding
    She is overwhelmed by all the advice available rom clomiphene citrate and its use or the treatment o
    riends, books, and magazines. Which o the ollow- anovulatory in ertile women?
    ing nutritional strategies is most strongly recommend- a. It exerts its e ect as a pure estrogen agonist.
    ed or women attempting pregnancy?
    b. T e dose required to achieve ovulation shows no
    a. High protein diet correlation with body weight.
    b. Dietary antioxidants c. Failure to achieve pregnancy alone is a su cient
    c. Folic acid supplementation indication to increase the dose in subsequent
    d. Complex carbohydrate restriction cycles.
    d. Most pregnancies achieved in response to clomi-
    phene therapy will occur during the rst several
    ovulatory cycles.
    134 Reproductive Endocrinology, Infertility, and the Menopause

    20–9. A 28-year-old woman with polycystic ovarian syndrome 20–11. Which o the ollowing gonadotropins is a recombi-
    (PCOS) and in ertility asks about the potential use nant product?
    o met ormin to help achieve pregnancy. She can be a. Menopur
    counseled that current evidence LEAST supports
    S
    b. Bravelle
    E
    which o the ollowing bene ts o met ormin therapy
    C
    in women with PCOS? c. Repronex
    T
    I
    d. Follistim
    O
    a. Improved live-birth rate
    N
    b. Improved menstrual cyclicity
    2
    20–12. Which o the ollowing is present in some gonadotro-
    c. Higher requency o spontaneous ovulation pin preparations and provides the needed luteinizing
    d. Increased ovulatory response to clomiphene citrate hormone (LH) activity by virtue o its shared receptor
    therapy with LH?
    a. Inhibin
    20–10. Despite achieving ovulation in most patients,
    b. Activin
    clomiphene citrate results in pregnancy rates o 50
    percent or less. T is disappointing pregnancy rate is c. Follistatin
    attributed to which o the ollowing? d. Human chorionic gonadotropin
    a. Long drug hal -li e
    20–13. T e treatment protocol shown here is considered
    b. Changes to cervical mucus quality
    which o the ollowing?
    c. Antiestrogenic e ects on the endometrium
    d. All o the above

    hCG
    trigge r

    GnRH a gonis t P roge s te rone


    IM or va gina l
    Gona dotropin inje ctions (8–10 days )

    -hCG

    Me ns e s Embryo
    tra ns fe r
    3 follicle s 17 mm Egg
    re trieva l
    36 h
    pos t hCG
    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed.
    New York, McGraw-Hill, 2016. Figure 20-2C.

    a. Gonadotropin-releasing hormone (GnRH) f are


    protocol
    b. GnRH antagonist protocol
    c. Down-regulation GnRH agonist protocol
    d. None o the above
    Treatment of the Infertile Couple 135

    20–14. Which o the ollowing is true regarding letrozole, an 20–17. A 38-year-old woman with in ertility secondary to
    aromatase inhibitor, in the context o ovulation induc- distal tubal blockage undergoes in vitro ertilization.
    tion? Her peak estradiol is 4500 pg/mL. Subsequently, 17

    C
    a. It is Food and Drug Administration (FDA) oocytes are retrieved, and 2 embryos are trans erred.

    H
    She conceives a singleton gestation but develops ovar-

    A
    approved or this indication.

    P
    ian hyperstimulation syndrome (OHSS). A sonogram
    b. It is typically dosed daily or 4 to 6 weeks.

    T
    o her ovaries is shown here. Which o the ollowing

    E
    R
    c. Data regarding its teratogenicity are is a predisposing actor or her developing OHSS?

    2
    contradictory.

    0
    d. It has become an accepted alternative to gonado-
    tropins and clomiphene citrate.

    20–15. Which o the ollowing hormones is thought to play a


    contributing role early in the development o ovarian
    hyperstimulation syndrome?
    a. Progesterone
    b. Luteinizing hormone (LH)
    c. Human chorionic gonadotropin
    d. Follicle-stimulating hormone (FSH)

    20–16. Which o the ollowing is NOT a typical clinical


    Reproduced with permission rom Doody KJ: reatment o the in ertile couple. In
    mani estation o ovarian hyperstimulation Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed.
    syndrome? New York, McGraw-Hill, 2016, Figure 20-4A.

    a. Ascites
    a. Older maternal age
    b. Seizures
    b. High estradiol level
    c. Hemoconcentration
    c. Etiology o her in ertility
    d. Hypercoagulability
    d. Number o embryos trans erred

    20–18. Suitable treatment o ovarian hyperstimulation syn-


    drome may include all o the ollowing EXCEPT:
    a. Paracentesis
    b. Ovarian drilling
    c. Fluid resuscitation
    d. T romboembolism prophylaxis

    20–19. A patient is now undergoing exogenous gonadotro-


    pin ovulation induction. She developed mild ovarian
    hyperstimulation syndrome during a previous attempt
    at ovulation induction. Strategies to avert or minimize
    ovarian hyperstimulation syndrome include which o
    the ollowing?
    a. Provide prophylactic volume expansion
    b. Decrease ollicle-stimulating hormone (FSH) dose
    c. Withhold the human chorionic gonadotropin
    (hCG) trigger, resulting in cycle cancellation
    d. All o the above
    136 Reproductive Endocrinology, Infertility, and the Menopause

    20–20. What approximate percentage o all multi etal births 20–26. Compared with in vitro ertilization, advantages o
    in the United States, including twins, results rom in bilateral tubal reanastomosis to reverse tubal occlusion
    vitro ertilization and related procedures? rom a prior sterilization procedure do NOT include
    a. 10 percent which o the ollowing?
    S
    E
    a. Ability to conceive naturally
    C
    b. 30 percent
    T
    b. Negligible risk o ectopic pregnancy
    I
    c. 60 percent
    O
    c. Decreased risk o multi etal gestation
    N
    d. 90 percent
    2
    d. Avoidance o ovarian stimulation with exogenous
    20–21. Most adverse maternal or perinatal outcomes o hormonal therapy
    higher-order multi etal pregnancies are the result o
    which o the ollowing? 20–27. Which o the ollowing treatment options o ers the
    a. Premature delivery best chance or intrauterine pregnancy in a patient
    with the ollowing problem?
    b. Advanced maternal age
    c. Venous thromboembolic events
    d. Fetal growth restriction and discordance

    20–22. Which o the ollowing can limit most reliably


    the risk o multi etal pregnancy resulting rom
    ovulation induction and other assisted reproductive
    technologies?
    a. Monitor serum estradiol levels.
    b. Sonographically measure ollicular size and
    number.
    c. Use in vitro ertilization to control the number o
    embryos trans erred.
    d. All o these options are equally reliable.

    20–23. T e serum level o which o the ollowing hormones Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds):
    is most likely to increase a ter ovarian drilling? Williams Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Photo contributor:
    Dr. Kevin Doody.
    a. Luteinizing hormone (LH)
    b. Follicle-stimulating hormone (FSH) a. Fimbriectomy
    c. Prolactin b. Neosalpingostomy
    d. Androstenedione c. ubal reanastomosis
    20–24. Which o the ollowing is the best treatment or a d. In vitro ertilization a ter bilateral salpingectomy
    woman with a signi cant decline in ovarian reserve?
    20–28. Which o the ollowing statements regarding the
    a. Use o donor eggs management o uterine actors in in ertile women is
    b. Clomiphene citrate ovulation induction supported by evidence rom a randomized trial?
    c. Exogenous gonadotropin ovulation induction a. Endometrial polypectomy increases pregnancy rates.
    d. In vitro ertilization with intracytoplasmic sperm b. Myomectomy o intramural myomas increases
    injection pregnancy rates.
    c. Asherman syndrome can be reversed with high-
    20–25. Which o the ollowing tubal obstruction locations is dose estrogen therapy alone.
    LEAST amenable to surgical repair?
    d. None o the above
    a. Isthmic
    b. Fimbrial 20–29. Which o the ollowing is the pre erred surgical approach
    c. Ampullary or ovarian endometriomas, usually via laparoscopy?
    d. Interstitial a. Ovarian wedge resection
    b. Cyst drainage and ablation
    c. Cyst wall excision by a stripping technique
    d. Unilateral oophorectomy i the contralateral ovary
    appears normal
    Treatment of the Infertile Couple 137

    20–30. In women with inadequate cervical mucus quantity or 20–33. In cases o male hypogonadotropic hypogonadism,
    quality as a suspected contributor to in ertility, what which o the ollowing semen analysis abnormalities is
    is the most reasonable approach to achieving preg- most typically seen?

    C
    nancy? a. Aspermia

    H
    A
    a. Cryotherapy b. Oligospermia

    P
    b. Ovulation induction

    T
    c. Asthenospermia

    E
    R
    c. Intrauterine insemination d. eratozoospermia

    2
    d. Flax seed oil supplementation

    0
    20–34. When providing treatment to increase sperm counts,
    20–31. Which o the ollowing assisted reproductive technol- it should be kept in mind that the process o sper-
    ogies, typically is used to treat male actor in ertility, matogenesis takes approximately how long?
    is shown here? a. 30 days
    b. 100 days
    c. 6 months
    d. 9 months

    20–35. During in vitro ertilization, prevention o a prema-


    ture luteinizing hormone (LH) surge prior to oocyte
    retrieval is important. Which o the ollowing medica-
    tions helps achieve this goal?
    a. Estradiol
    b. Leuprolide acetate
    c. Human menopausal gonadotropins
    d. Recombinant ollicle-stimulating hormone (FSH)

    20–36. In ertility thought secondary to which o the ollowing


    Reproduced with permission rom Doody KJ: reatment o the in ertile couple. In scenarios warrants intracytoplasmic sperm injection
    Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. (ICSI)?
    New York, McGraw-Hill, 2016, Figure 20-9A.
    a. Chronic anovulation
    a. Embryo biopsy b. Severe oligospermia
    b. Assisted hatching c. Diminished ovarian reserve in an older woman
    c. Oocyte in vitro maturation d. Bilateral distal allopian tube occlusion with
    hydrosalpinges
    d. Intracytoplasmic sperm injection (ICSI)
    20–37. Which o the ollowing assisted reproductive tech-
    20–32. Oligospermia is de ned as less than which o the
    niques avoids ertilization outside o the body,
    ollowing sperm count thresholds per milliliter o
    circumventing religious or ethical concerns or some
    semen?
    patients?
    a. 15 million/mL
    a. In vitro ertilization (IVF)
    b. 50 million/mL
    b. Intracytoplasmic sperm injection (ICSI)
    c. 100 million/mL
    c. Gamete intra allopian tube trans er (GIF )
    d. 150 million/mL
    d. Zygote intra allopian tube trans er (ZIF )
    138 Reproductive Endocrinology, Infertility, and the Menopause

    20–38. Which o the ollowing assisted reproductive tech- 20–39. Which o the ollowing complication is more com-
    niques is shown here? mon in pregnancies resulting rom assisted repro-
    ductive technologies compared with spontaneously
    conceived pregnancies?
    S
    E
    a. Cesarean delivery
    C
    T
    b. Placental abruption
    I
    O
    c. Gestational diabetes
    N
    2
    d. All o the above

    Reproduced with permission rom Doody KJ: reatment o the in ertile couple. In
    Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed.
    New York, McGraw-Hill, 2016, Figure 20-13A.

    a. Embryo biopsy
    b. Assisted hatching
    c. Oocyte in vitro maturation
    d. Intracytoplasmic sperm injection (ICSI)
    Treatment of the Infertile Couple 139

    Chapter 20 ANSWER KEY


    Question Letter Page Question Letter Page

    C
    number answer cited Header cited number answer cited Header cited

    H
    A
    20–1 a p. 449 Treatment of the Infertile Couple 20–21 a p. 456 Multifetal Gestation

    P
    T
    20–2 c p. 449 Weight Optimization 20–22 c p. 456 Multifetal Gestation

    E
    R
    20–3 d p. 449 Weight Optimization 20–23 b p. 457 Ovarian Drilling

    2
    0
    20–4 c p. 450 Nutrition 20–24 a p. 458 Correction of Diminished
    20–5 b p. 450 Hyperprolactinemia Ovarian Reserve
    20–6 c p. 450 Hypothyroidism 20–25 d p. 458 Proximal Tubal Obstruction
    20–7 a p. 451 Clomiphene Citrate 20–26 b p. 458 Proximal Tubal Obstruction
    20–8 d p. 451 Clomiphene Citrate 20–27 d p. 459 Distal Tubal Obstruction
    20–9 a p. 452 Insulin-Sensitizing agents 20–28 a p. 460 Intrauterine Adhesions
    20–10 d p. 452 Gonadotropins 20–29 c p. 460 Endometriosis
    20–11 d p. 452 Gonadotropins, Table 20-1 20–30 c p. 461 Correction of Cervical
    Abnormalities
    20–12 d p. 452 Gonadotropins
    20–31 d p. 462 Correction of Male Infertility
    20–13 a p. 452 Gonadotropins, Figure 20-2
    20–32 a p. 462 Abnormal Sperm Count
    20–14 c p. 453 Aromatase Inhibitors
    20–33 b p. 462 Abnormal Sperm Count
    20–15 c p. 453 Ovarian Hyperstimulation
    Syndrome 20–34 b p. 462 Abnormal Sperm Count
    20–16 b p. 453 Ovarian Hyperstimulation 20–35 b p. 464 In Vitro Fertilization
    Syndrome 20–36 b p. 465 Intracytoplasmic Sperm
    20–17 b p. 453 Ovarian Hyperstimulation Injection
    Syndrome 20–37 c p. 465 Gamete or Zygote
    20–18 b p. 453 Ovarian Hyperstimulation Intrafallopian Transfer
    Syndrome 20–38 a p. 466 Preimplantation Genetic
    20–19 d p. 453 Ovarian Hyperstimulation Diagnosis or Screening
    Syndrome 20–39 d p. 466 Complications of Assisted
    20–20 a p. 456 Multifetal Gestation Reproductive Technology,
    Table 20-6
    140

    CHAPTER 21

    Menopausal Transition

    21–1. Most women can now expect to live at least what 21–5. During menopausal transition, erratic uctuations
    percentage o their li etime a ter menopause? in emale reproductive hormones lead to an array o
    a. 5 percent physical and psychological symptoms. T ese symp-
    toms include all o the ollowing EXCEPT:
    b. 15 percent
    a. Headache
    c. 25 percent
    b. Poor memory
    d. 33 percent
    c. Vision changes
    21–2. Characteristically, menopausal transition begins with d. Urinary incontinence
    a variable period o menstrual cycle irregularity and
    extends to 1 year a ter permanent cessation o menses. 21–6. During the reproductive li e o a woman, gonado-
    T e menopause transition typically spans how many tropin-releasing hormone is released in a pulsatile
    years? ashion rom which o the ollowing?
    a. 1 to 2 years a. Corpus lutea
    b. 2 to 4 years b. Ovarian ollicles
    c. 4 to 7 years c. Pituitary gonadotrophs
    d. 7 to 10 years d. Arcuate nucleus o the hypothalamus

    21–3. Premature ovarian ailure is associated with a persis- 21–7. During menopausal transition, which o the ollow-
    tently elevated ollicle-stimulating hormone (FSH) ing results rom cessation o ovarian steroid hormone
    level and is urther de ned as cessation o menses release?
    be ore what age? a. A rise in luteinizing hormone (LH) levels
    a. 35 years b. A rise in ollicle-stimulating hormone (FSH) levels
    b. 40 years c. A maximal increase in the requency and ampli-
    c. 45 years tude o gonadotropin-releasing hormone secretion
    d. 51 years d. All o the above

    21–4. Several actors can alter ovarian aging. Which o the 21–8. During the menopausal transition, antimüllerian
    ollowing is LEAST likely to shi t menopause to an hormone (AMH) levels do which o the ollowing?
    earlier age? a. Remain constant
    a. Smoking b. Decrease progressively
    b. Chemotherapy c. Increase progressively
    c. Pelvic radiation d. Fluctuate erratically beyond menopause
    d. Oral contraceptive pills
    Menopausal Transition 141

    21–9. T is photomicrograph illustrates which o the 21–12. Which o the ollowing transvaginal sonographic
    ollowing? images demonstrates a typical premenopausal ovary?

    C
    H
    A
    P
    T
    E
    R
    2
    1
    A
    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds):
    Williams Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Photo contributor:
    Dr. Raheela Ash aq.

    a. Corpus lutea
    b. Corpora albicantia
    c. Primordial ollicles
    d. Polycystic ovarian syndrome

    21–10. A emale etus has 6 to 7 million oocytes present dur-


    ing the 20th week o gestation. Approximately, how
    many oocytes are present at birth?
    a. 70,000
    b. 250,000
    c. 700,000
    B
    d. 3,500,000

    21–11. An average woman is expected to experience how a. A


    many ovulatory events during her reproductive b. B
    li etime?
    c. Both A and B
    a. 100
    d. Neither o them is typical.
    b. 400
    c. 700,000 21–13. With advancing age, which o the ollowing adrenal
    d. 6 to 7 million steroid levels declines?
    a. Pregnenolone
    b. Androstenedione
    c. Dehydroepiandrosterone sul ate
    d. All o the above
    142 Reproductive Endocrinology, Infertility, and the Menopause

    21–14. Anovulation is the most common cause o erratic 21–18. A tabulation o published epidemiologic studies
    bleeding during menopausal transition. However, determined that up to what percentage o menstru-
    as shown in this sonogram, endometrial cancer is ating women develop vasomotor symptoms during
    suspected during this transition in those with abnormal menopausal transition?
    S
    E
    uterine bleeding (AUB). Here, the thickened heteroge- a. 60 percent
    C
    neous endometrium measures 26 mm. T e overall risk
    T
    b. 70 percent
    I
    or endometrial cancer increases to what percentage in
    O
    c. 80 percent
    N
    women with AUB during menopausal transition?
    2
    d. 90 percent

    21–19. T ermoregulatory changes that accompany a hot


    ush have been well documented. An individual hot
    ush typically lasts how many minutes?
    a. < 1 minute
    b. 1 to 5 minutes
    c. 6 to 10 minutes
    d. 11 to 15 minutes

    21–20. Hot ushes and the concurrent increase in metabolic


    rate may be accompanied by which o the ollowing?
    a. Panic
    b. Irritability
    c. Palpitations
    d. All o the above
    a. 0.1 percent
    b. 1 percent 21–21. Physiologic increases during a hot ush include all o
    c. 10 percent the ollowing EXCEPT:
    d. 30 percent a. Heart rate
    b. Mean skin temperature
    21–15. In postmenopausal women, unopposed estrogen may
    c. Systolic blood pressure
    be derived rom which o the ollowing sources?
    d. Plasma levels o estradiol
    a. Exogenous estrogen
    b. Extragonadal endogenous estrogen production 21–22. A menstruating 48-year-old patient undergoes a total
    c. Decreased sex hormone-binding globulin levels vaginal hysterectomy and bilateral salpingo-oophorec-
    d. All o the above tomy or symptomatic uterine leiomyomas. Surgi-
    cal menopause is associated with what percentage
    21–16. A 51-year-old woman asks or relie rom an array o probability o hot ushes during the rst year a ter
    recent-onset physical and psychological symptoms. oophorectomy?
    What is the most common medical complaint o a. 40 percent
    women during menopausal transition? b. 60 percent
    a. Depression c. 90 percent
    b. Vasomotor symptoms d. 100 percent
    c. Pain ul intercourse
    d. Stress urinary incontinence 21–23. A 55-year-old postmenopausal, thin, patient who
    smokes asks or counseling regarding osteoporosis due
    21–17. Longitudinal studies show thermoregulation dys unc- to her concern or uture bone racture risk. In addi-
    tion is associated with which o the ollowing? tion to the vertebrae and emoral neck, which o the
    ollowing is most commonly ractured?
    a. Smoking
    a. Rib
    b. Low exercise levels
    b. Wrist
    c. Socioeconomic status
    c. Fibula
    d. All o the above
    d. Humerus
    Menopausal Transition 143

    21–24. Osteopenia and osteoporosis are disorders character- 21–28. Genetic in uence on osteoporosis and bone mineral
    ized by a progressive reduction in bone mass and density (BMD) is important. Heredity is estimated
    predispose patients to ractures in the spine, hips, and to account or up to what percentage o bone mineral

    C
    other sites. What is the approximate mortality rate density variability?

    H
    rom hip racture alone?

    A
    a. 20 percent

    P
    a. 10 percent b. 40 percent

    T
    E
    b. 30 percent

    R
    c. 60 percent

    2
    c. 50 percent d. 80 percent

    1
    d. 70 percent

    21–25. Bone mineral density (BMD) values or sex, age, and


    ethnicity have been determined. For diagnostic pur-
    poses, results o BMD testing are reported as T-scores.
    What -score value is associated with osteopenia?

    Reproduced with permission rom Bradshaw KD: Menopausal transition. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill,
    2016, Figure 21-8B.

    a. -score between + 2.5 and - 1.0 21–29. Modi able actors that may bene t emoral neck and
    b. -score between + 1.0 and - 1.0 lumbar vertebral bone mineral density in postmeno-
    pausal women include which o the ollowing?
    c. -score between + 1.0 and - 2.5
    a. Alcohol use
    d. -score between - 1.0 and - 2.5
    b. Low body mass
    21–26. Age and race are nonmodi able risk actors or osteo- c. Sedative drug use
    porosis. Menopausal osteoporosis is most common in d. Progressive resistance training
    which racial group?
    a. Asian 21–30. T erapy with glucocorticoids lasting more than 2 to 3
    b. White months is a major risk actor or bone loss and racture,
    particularly among postmenopausal women. O chron-
    c. A rican–American
    ic daily prednisone doses, which minimum threshold
    d. Paci c Islander should prompt assessment and clinical intervention to
    prevent or treat glucocorticoid-induced osteoporosis?
    21–27. Which o the ollowing are secondary causes o os-
    a. 5 mg
    teoporosis that should be screened or in any patient
    with osteoporosis? b. 10 mg
    a. Hypothyroidism c. 15 mg
    b. Hypoparathyroidism d. 20 mg
    c. Chronic renal disease
    d. None o the above
    144 Reproductive Endocrinology, Infertility, and the Menopause

    21–31. In women older than 50 years, what accounts or 21–36. T e North American Menopause Society term genito-
    approximately 40 percent o deaths? urinary syndrome of menopause (GSM) encompasses
    a. Stroke which o the ollowing signs and symptoms?
    a. Dyspareunia
    S
    b. Lung cancer
    E
    C
    c. Breast cancer b. Vulvar dryness
    T
    I
    d. Atherosclerotic cardiovascular disease c. Urinary urgency and dysuria
    O
    N
    d. All o the above
    2
    21–32. Be ore menopausal transition, women have a much
    lower risk or cardiovascular events compared with 21–37. Estrogen receptors have been identi ed in the vulva,
    men o their same age. Reasons or protection rom vagina, urethra, pelvic oor musculature, and en-
    cardiovascular disease in premenopausal women are dopelvic ascia. Which o the ollowing is a result o
    complex. However, a signi cant contribution can be decreased estrogen trophic in uence?
    assigned to an e ect o estrogen that results in which a. Vaginal pH greater than 4.5
    o the ollowing?
    b. Lower rates o abnormal cervical cytology
    a. Increased low-density lipoprotein levels
    c. Increased vaginal concentrations o Lactobacilli
    b. Decreased high-density lipoprotein levels
    d. Higher rates o Bartholin gland duct cyst
    c. Increased high-density lipoprotein levels ormation
    d. Increased total cholesterol and low-density lipo-
    protein levels 21–38. Symptoms o vulvovaginal atrophy include vaginal
    dryness, itching, irritation, and dyspareunia. T ese
    21–33. A 53-year-old multigravida postmenopausal patient complaints during menopausal transition have an
    reports her physical activity level is less than when estimated prevalence that reaches what percentage?
    she was younger and that she has not altered her a. 30 percent
    eating habits. T is has resulted in weight gain. You
    b. 50 percent
    counsel her that gaining weight during menopausal
    transition is associated with at deposition in the c. 70 percent
    abdomen, increasing the likelihood o developing d. 90 percent
    which o the ollowing?
    a. Diabetes mellitus 21–39. A 38-year-old nulligravida complains o no men-
    ses or the last 12 months and denies a history o
    b. Insulin resistance
    radiation or chemotherapy exposure, galactorrhea,
    c. Cardiovascular disease headache, or cigarette smoking. A markedly elevated
    d. All o the above ollicle-stimulating hormone (FSH) level is obtained
    on repeated occasions. Which o the ollowing caus-
    21–34. T e e ect o hormone de ciency on skin aging has ative categories should now be considered?
    been widely studied but its contribution toward a. In ection
    dermatologic changes is dif cult to determine. Skin
    b. Autoimmune disorders
    aging results rom the synergistic e ects o intrinsic
    aging along with which o the ollowing? c. Chromosomal abnormalities
    a. Photoaging d. All o the above
    b. High body mass index
    c. Reduced ollicle-stimulating hormone (FSH)
    levels
    d. None o the above

    21–35. Decreasing estrogen levels seen in late menopausal


    transition result in which o the ollowing dental
    changes?
    a. Increased salivation
    b. Buccal epithelium atrophy
    c. Increased oral alveolar bone osteoblasts
    d. All o the above
    Menopausal Transition 145

    Chapter 21 ANSWER KEY


    Question Letter Page Question Letter Page

    C
    number answer cited Header cited number answer cited Header cited

    H
    A
    21–1 d p. 471 Menopausal Transition 21–21 d p. 475 Pathophysiology of Vasomotor

    P
    T
    21–2 c p. 471 Definitions Symptoms

    E
    R
    21–3 b p. 471 Definitions 21–22 c p. 476 Risk Factors for Vasomotor

    2
    Symptoms

    1
    21–4 d p. 471 Influential Factors
    21–23 b p. 477 Osteopenia and Osteoporosis
    21–5 c p. 471 Table 21-1
    21–24 b p. 477 Osteopenia and Osteoporosis
    21–6 d p. 472 Hypothalamus–Pituitary–
    Ovarian Axis 21–25 d p. 479 Table 21-3
    21–7 d p. 472 Hypothalamus–Pituitary– 21–26 b p. 481 Nonmodifiable Factors
    Ovarian Axis 21–27 c p. 479 Table 21-4
    21–8 b p. 472 Hypothalamus–Pituitary– 21–28 d p. 481 Nonmodifiable Factors
    Ovarian Axis 21–29 d p. 482 Modifiable Factors
    21–9 b p. 473 Figure 21-3 21–30 a p. 482 Modifiable Factors
    21–10 c p. 473 Ovary 21–31 d p. 483 Cardiovascular Changes
    21–11 b p. 473 Ovary 21–32 c p. 483 Cardiovascular Changes
    21–12 a p. 473 Ovary 21–33 d p. 483 Weight Gain and Fat
    21–13 d p. 473 Ovary Distribution
    21–14 c p. 474 Menstrual Disturbances 21–34 a p. 484 Dermatologic Changes
    21–15 d p. 474 Menstrual Disturbances 21–35 b p. 484 Dental Changes
    21–16 b p. 474 Central Thermoregulation 21–36 d p. 486 Lower Reproductive Tract
    21–17 d p. 474 Central Thermoregulation Changes
    21–18 a p. 474 Central Thermoregulation 21–37 a p. 486 Vulvovaginal Changes
    21–19 b p. 474 Vasomotor Symptoms 21–38 b p. 486 Vulvovaginal Changes
    21–20 d p. 474 Vasomotor Symptoms 21–39 d p. 487 Patient Evaluation
    200

    CHAPTER 30

    Cervical Cancer

    30–1. Which o the ollowing statements regarding cervical 30–5. What does the human papillomavirus (HPV) onco-
    cancer is NOT true? gene E6 bind and inactivate, leading to immortalization
    a. It is the most common gynecologic cancer in o the cell?
    women worldwide. a. Rb
    b. It is the second most common cancer diagnosed in b. p16
    women worldwide. c. p53
    c. In the Unites States, Hispanic women have the d. Cyclin D1
    highest incidence rate.
    d. In the United States, A rican–American women 30–6. Which histologic subtype o cervical carcinoma is
    have the highest mortality rate. represented in this micrograph? Arrows point to
    keratin pearls.
    30–2. Which human papillomavirus (HPV) subtype is
    most strongly associated with adenocarcinoma o the
    cervix?
    a. HPV 6
    b. HPV 16
    c. HPV 18
    d. HPV 31

    30–3. Which o the ollowing is true regarding smoking and


    cervical cancer risk?
    a. Smoking may alter viral oncoprotein expression.
    b. Passive smoking increases the risk o cervical
    cancer.
    c. Women who smoke are less likely to clear high-risk
    human papillomavirus (HPV) in ection.
    a. Melanoma
    d. All o the above
    b. Adenocarcinoma
    30–4. Which o the ollowing statements regarding cervical c. Squamous cell carcinoma
    cancer risk actors is FALSE? d. Neuroendocrine carcinoma
    a. Cervical cancer is an acquired immune de ciency
    syndrome (AIDS)-de ning illness. 30–7. Which histologic subtype o cervical cancer is associ-
    ated with Peutz–Jeghers syndrome?
    b. ransplant recipients have an increased risk o
    cervical cancer. a. Adenoma malignum
    c. In general, women who have an autoimmune dis- b. Clear cell adenocarcinoma
    ease and take immunosuppressant therapy do not c. Glassy cell adenocarcinoma
    have an increased risk o cervical cancer. d. Villoglandular adenocarcinoma
    d. Combination oral contraceptives are associated
    with an increased risk o cervical cancer due to the 30–8. Which o the ollowing should NOT be used or
    higher number o sexual partners in users. hemostasis in cases o li e-threatening hemorrhage
    rom cervical cancer?
    a. Lugol solution
    b. Emergent radiation
    c. Uterine artery embolization
    d. Monsel ( erric subsul ate) solution
    Cervical Cancer 201

    30–9. In patients with stage I cervical cancer, what percent- 30–13. A 45-year-old woman has a 6-cm adenocarcinoma o
    age o Pap tests are read as consistent with cancer? the cervix. She has positive paraaortic nodes ound
    a. 5 to 10 percent during positron emission tomography (PE ) scanning

    C
    and the ollowing nding during intravenous pyelog-

    H
    b. 10 to 20 percent
    raphy. What stage is assigned to her cervical cancer?

    A
    c. 30 to 50 percent

    P
    T
    d. 60 to 80 percent

    E
    R
    3
    30–10. A woman presents or a routine health maintenance

    0
    visit. T e ollowing is visualized during speculum
    examination. What is the most appropriate next step?

    a. IB2
    b. IIB2
    c. IIIB
    d. IVB

    30–14. A 38-year-old woman with stage IIB cervical cancer


    a. Per orm a Pap test has positron emission tomography (PE ) scanning
    that shows positive pelvic lymph nodes. In response,
    b. Per orm a cervical biopsy
    she undergoes a laparoscopic extraperitoneal para-
    c. Re er to a gynecologic oncologist aortic lymph node dissection. Histologic review shows
    d. Obtain abdominopelvic computed tomography that the paraaortic nodes are positive or tumor. What
    is the most appropriate treatment?
    30–11. Which o the ollowing tests is NOT used or staging a. Chemoradiation with extended eld radiation
    cervical cancer per the International Federation o
    b. Chemotherapy alone, since this represents meta-
    Gynecology and Obstetrics (FIGO)?
    static disease
    a. Cystoscopy
    c. Chemoradiation to pelvis alone, since involved
    b. Chest radiograph nodes were removed
    c. Intravenous pyelogram d. None o the above
    d. Computed tomography scan
    30–15. Among the ollowing, which is the most signi cant
    30–12. A woman undergoes a radical hysterectomy, bilateral prognostic actor or early-stage cervical cancer?
    pelvic and paraaortic lymph node dissection or a a. Grade
    4-cm squamous cell carcinoma o the cervix. On nal
    b. Histology
    pathology report, the parametria are noted to contain
    tumor. What stage is her cervical cancer? c. Depth o invasion
    a. IB1 d. Lymph node metastasis
    b. IB2
    30–16. What is the most appropriate surgical approach or a
    c. IIA1 woman who has a stage IA1 squamous cell carcinoma
    d. IIB2 o the cervix and has completed childbearing?
    a. Cold-kni e conization
    b. Extra ascial hysterectomy
    c. ype III radical hysterectomy
    d. Modi ed ( ype II) radical hysterectomy
    217

    CHAPTER 33

    Endometrial Cancer

    33–1. O leading causes o cancer in women in the United 33–6. Which o the ollowing birth control methods does
    States, endometrial cancer is ranked in which place? NOT reduce the risk o endometrial cancer?
    a. Second a. Bilateral tubal ligation
    b. Fourth b. Copper intrauterine device
    c. Eighth c. Combination oral contraceptives
    d. Sixteenth d. Levonorgestrel-releasing intrauterine system

    33–2. Which o the ollowing does NOT increase a woman’s 33–7. Which o the ollowing patients does NOT require an
    risk o developing endometrial cancer? endometrial biopsy?
    a. Obesity a. A 27-year-old obese woman with polycystic
    b. amoxi en ovarian syndrome and a long history o irregular
    bleeding
    c. Cigarette smoking
    b. A 37-year-old obese woman with atypical glandu-
    d. Unopposed estrogen
    lar cells (AGCs) reported rom cervical cytology
    testing
    33–3. What is the primary mechanism by which obesity
    increases the risk o endometrial cancer? c. A 55-year-old postmenopausal woman with post-
    menopausal bleeding and an endometrial stripe
    a. Androstenedione is aromatized by adipose tissue to
    measuring 8 mm by transvaginal sonography
    estrone.
    d. A 52-year-old postmenopausal woman using
    b. Androstenedione is aromatized by adipose tissue to
    combination hormone replacement therapy, who
    estradiol.
    has postmenopausal bleeding and an endometrial
    c. Higher levels o insulin growth actor lead to stripe measuring 2 mm by transvaginal sonography
    anovulation, which results in unopposed estrogen.
    d. None o the above 33–8. A 60-year-old woman has abnormal uterine bleeding.
    ransvaginal sonography reveals a 15-mm endometri-
    33–4. What percentage o endometrial cancer is diagnosed al stripe and an 8-cm, solid right adnexal mass. O ce
    in women younger than 45 years? endometrial biopsy reveals grade 1 endometrioid
    a. 1 percent adenocarcinoma o the uterus arising in a background
    o complex atypical hyperplasia. What is the most
    b. 8 percent
    likely diagnosis?
    c. 15 percent
    a. Endometrial cancer metastatic to the ovary
    d. 25 percent
    b. Synchronous ovarian and endometrial cancer
    33–5. What is the most common genetic syndrome associ- c. Pedunculated leiomyoma and endometrial cancer
    ated with endometrial cancer? d. Ovarian granulosa cell tumor and endometrial
    a. Cowden syndrome cancer
    b. Li–Fraumeni syndrome
    33–9. Which o the ollowing is an appropriate treatment o
    c. Hereditary breast ovarian cancer syndrome a 35-year-old woman with the diagnosis o complex
    d. Hereditary nonpolyposis colorectal cancer endometrial hyperplasia without atypia?
    syndrome a. Medroxyprogesterone acetate
    b. Combination oral contraceptive pills
    c. Levonorgestrel-releasing intrauterine system
    d. All o the above
    218 Gynecologic Oncology

    33–10. For simple and complex endometrial hyperplasia 33–15. Which o the ollowing patients should be re erred to
    without atypia, what is the clinical success rate or a geneticist or possible hereditary nonpolyposis colon
    resolution using progestin therapy? cancer (HNPCC/Lynch syndrome) screening?
    a. 30 to 40 percent a. A 35-year-old patient with endometrial cancer
    S
    E
    whose sister was diagnosed with breast cancer at
    C
    b. 50 to 60 percent
    T
    age 50 and maternal grandmother diagnosed with
    I
    c. 70 to 80 percent
    O
    colon cancer at age 61
    N
    d. 90 to 100 percent
    b. A 39-year-old patient with endometrial cancer
    4
    whose mother was diagnosed with endometrial
    33–11. A 30-year-old nulligravida has a body mass index o
    cancer at age 50 and maternal grandmother diag-
    35 kg/m2 and desires ertility. An endometrial biopsy
    nosed with colon cancer at age 55
    per ormed or abnormal bleeding reveals complex
    atypical hyperplasia. Which o the ollowing is NOT c. A 39-year-old patient with endometrial cancer
    an acceptable treatment option? whose maternal grand ather was diagnosed with
    colon cancer at age 65 and paternal grandmother
    a. Megestrol acetate 80 mg orally twice daily
    diagnosed with endometrial cancer at age 58
    b. Levonorgestrel-releasing intrauterine system
    d. A 35-year-old patient with complex atypical
    c. Medroxyprogesterone acetate 10 mg orally daily hyperplasia whose maternal grandmother was
    d. otal laparoscopic hysterectomy with bilateral diagnosed with colon cancer at age 58 and mater-
    salpingectomy nal grand ather diagnosed with small bowel cancer
    at age 70
    33–12. What is the approximate underlying risk o endo-
    metrial cancer in a woman diagnosed with complex 33–16. Which o the ollowing patients does NOT need
    atypical hyperplasia by endometrial biopsy? preoperative abdominopelvic computed tomography
    a. 10 percent (C ) prior to surgical management?
    b. 40 percent a. A 62-year-old patient with clear cell carcinoma
    ound by o ce endometrial biopsy
    c. 60 percent
    b. A 75-year-old patient with uterine papillary serous
    d. 80 percent
    carcinoma ound during hysteroscopy plus dilation
    and curettage
    33–13. Which o the ollowing is the most appropriate surgi-
    cal approach to a 51-year-old woman with a body c. A 58-year-old patient with grade 1 endometrioid
    mass index o 35 kg/m2 and a preoperative diagnosis adenocarcinoma arising in a background o com-
    o complex atypical hyperplasia? plex atypical hyperplasia that was ound by o ce
    endometrial biopsy
    a. ransvaginal hysterectomy, bilateral
    salpingo-oophorectomy d. All o the above require C scanning prior to
    surgical management.
    b. otal abdominal hysterectomy, bilateral salpingo-
    oophorectomy, pelvic washings
    33–17. Which o the ollowing is true when a woman with
    c. otal laparoscopic hysterectomy, bilateral salpingo- endometrial cancer is managed by a gynecologic
    oophorectomy, pelvic washings oncologist compared with a general gynecologist?
    d. None o the above a. Less surgical morbidity
    b. More likely to undergo surgical staging
    33–14. Which o the ollowing women should undergo
    annual endometrial biopsy? c. Improved overall survival rate or high-risk types
    a. A 36-year-old woman with hereditary nonpolypo- d. All o the above
    sis colorectal cancer (HNPCC/Lynch syndrome)
    b. A 45-year-old woman on tamoxi en or a personal
    history o breast cancer
    c. An obese 40-year-old woman with normal menses,
    with a ather with colon cancer diagnosed at age
    60 and a paternal aunt with endometrial cancer
    ound at age 55
    d. All o the above
    Endometrial Cancer 219

    33–18. T e histologic specimen shown below demonstrates 33–20. Which o the ollowing is true regarding the type o
    < 5 percent solid growth but severe nuclear atypia. uterine cancer shown in the photomicrograph below?
    What grade is assigned to this endometrioid adeno-

    C
    carcinoma o the uterus?

    H
    A
    P
    T
    E
    R
    3
    3
    Reproduced, with permission, by Schorge JO, Scha er JI, Halvorson LM, et al (eds):
    Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008. Photo contributor:
    Dr. Raheela Ash aq.
    Used with permission rom Dr. Kelley Carrick.

    a. It is the most common cell type o endometrial


    a. Grade 1
    cancer.
    b. Grade 2
    b. It is the least common cell type o endometrial
    c. Grade 3 cancer.
    d. T is is not endometrioid adenocarcinoma, but c. Most patients with this cell type are cured with
    rather papillary serous carcinoma o the uterus. surgery alone.
    d. T is is an aggressive type II endometrial cancer,
    33–19. Which o the ollowing subtypes is NOT a type II
    managed by a combination o surgery and chemo-
    endometrial cancer?
    therapy, with or without radiation therapy.
    a. Clear cell carcinoma
    b. Papillary serous carcinoma 33–21. What is the most common way endometrioid adeno-
    c. Endometrioid adenocarcinoma with squamous carcinoma o the uterus spreads?
    di erentiation a. Lymphatic
    d. None o the above b. Hematogenous
    c. Direct extension
    d. Intraperitoneal ex oliation

    33–22. A 60-year-old woman undergoes a robotic-assisted


    hysterectomy, bilateral salpingo-oophorectomy, and
    bilateral pelvic and paraaortic lymph node dissection
    or endometrial cancer. Histologic evaluation reveals
    a grade 2 endometrioid adenocarcinoma with > 50
    percent myometrial invasion, lymphovascular space
    invasion (LVSI), and positive washings. All other
    surgical specimens are benign. What stage is she
    assigned according to 2009 International Federation
    o Gynecology and Obstetrics (FIGO) criteria?
    a. Stage IB
    b. Stage IC
    c. Stage IIIA
    d. Stage IIIC
    220 Gynecologic Oncology

    33–23. A 47-year-old woman undergoes total laparoscopic 33–25. What International Federation o Gynecology and
    hysterectomy, bilateral salpingo-oophorectomy, and Obstetrics (FIGO) 2009 stage is represented below?
    bilateral pelvic and paraaortic lymphadenectomy or
    endometrial cancer. Histologic evaluation reveals a
    S
    E
    grade 2 endometrioid adenocarcinoma arising in the
    C
    uterus, with 30 percent myometrial invasion and with
    T
    I
    endocervical gland extension. What is her Inter-
    O
    N
    national Federation o Gynecology and Obstetrics
    4
    (FIGO) stage?
    a. Stage IA
    b. Stage IB
    c. Stage II
    d. Stage IIIB

    33–24. A 52-year-old woman undergoes a robotic hysterec-


    tomy and bilateral salpingo-oophorectomy or grade
    1 endometrioid adenocarcinoma o the uterus. T e
    uterus is bisected, and one hal is shown to display Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds):
    the endocervical canal and endometrial cavity. With Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016. Figure 32-3 II.
    rozen section analysis, no myometrial invasion and
    no lymphovascular space invasion (LVSI) are ound. a. Stage IIIA
    Which o the ollowing is FALSE? b. Stage IIIB
    c. Stage IIIC1
    d. Stage IIIC2

    33–26. Which o the ollowing is NOT an advantage o lapa-


    roscopy compared with laparotomy or the surgical
    management o endometrial cancer?
    a. Shorter hospital stay
    b. Improved quality o li e
    c. Lower rate o intraoperative injuries
    d. Fewer moderate to severe complications

    33–27. Which o the ollowing women needs continued Pap


    tests o the vaginal cu a ter a hysterectomy, bilat-
    eral salpingo-oophorectomy, and bilateral pelvic and
    paraaortic lymph node dissection or a stage IB grade
    Reproduced with permission by Schorge JO, Scha er JI, Halvorson LM, et al (eds): 1 endometrioid adenocarcinoma o the uterus?
    Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008. Photo contributor:
    Dr. Raheela Ash aq. a. A 50-year-old woman with no history o abnormal
    Pap test results
    a. T e rozen section result may be inaccurate. b. A 50-year-old woman with oci o cervical
    b. I f nal histologic analysis concurs with the rozen intraepithelial neoplasia (CIN) 2 in the hysterec-
    section, the risk o lymph node metastasis in this tomy specimen
    case is 1 percent. c. A 50-year-old woman with a remote history o
    c. I f nal histologic analysis concurs with the rozen CIN 2 treated with a loop electrosurgical excision
    section, she will need postoperative radiation i a procedure (LEEP) and no abnormal Pap tests in
    lymph node dissection is not done. the last 10 years
    d. All o the above d. All o the above
    Endometrial Cancer 221

    33–28. Which o the ollowing chemotherapeutic agents 33–31. Desiring uture ertility, a 34-year-old nulligravida
    does not have def nitive activity against endometrial with polycystic ovarian syndrome has undergone a
    cancer? hysteroscopy, dilatation and curettage (D&C), and

    C
    a. Cisplatin placement o a levonorgestrel-releasing intrauterine

    H
    system (LNG-IUS) or grade 1 endometrioid adeno-

    A
    b. opotecan

    P
    carcinoma o the uterus. Findings at the time o sur-

    T
    c. Paclitaxel gery are depicted below. How should she be ollowed?

    E
    R
    d. Doxorubicin

    3
    3
    33–29. An 80-year-old woman is diagnosed with a grade 1
    endometrioid adenocarcinoma o the uterus by o ce
    endometrial biopsy. She has a body mass index o
    45 kg/m2, has uncontrolled type 2 diabetes mellitus,
    has had a prior right below-the-knee amputation, and
    is wheelchair bound. What is the most appropriate
    management?
    a. Radiation
    b. amoxi en
    c. Vaginal hysterectomy
    d. Robotic hysterectomy, bilateral salpingo-
    oophorectomy

    33–30. A 65-year-old otherwise healthy woman has an


    episode o postmenopausal bleeding. An endometrial Used with permission rom Dr. Mayra hompson.

    biopsy reveals papillary serous carcinoma. At explo-


    ration, she has carcinomatosis and an omental cake a. Remove IUD in 3 months and per orm endome-
    (shown here). In addition to total abdominal hyster- trial biopsy.
    ectomy with bilateral salpingo-oophorectomy, what b. Remove IUD in 3 months and per orm a hysteros-
    other management is most appropriate? copy, D&C.
    c. Repeat endometrial biopsy in 3 months with the
    IUD in place.
    d. None o the above

    33–32. What is the most important prognostic actor or a


    woman with endometrioid adenocarcinoma o the
    uterus?
    a. Age
    b. Grade
    c. Stage
    d. Positive peritoneal washings

    33–33. A 68-year-old woman has a history o a stage IA


    grade 1 endometrioid adenocarcinoma o the uterus,
    treated with surgery. She develops vaginal bleeding,
    Used with permission rom Dr. David Miller. and biopsy o a 1-cm mass at her vaginal apex reveals
    recurrent uterine cancer. What is the most appropri-
    a. Omentectomy, adjuvant chemotherapy ate treatment, i no metastatic disease is ound during
    urther evaluation?
    b. Omental biopsy, adjuvant chemotherapy
    a. Radiation
    c. Omentectomy, maximal e ort at tumor debulking,
    adjuvant chemotherapy b. Chemotherapy
    d. Omentectomy, maximal e ort at tumor debulking, c. Pelvic exenteration
    adjuvant chemotherapy, and tumor-directed d. Oral continuous progesterone therapy
    radiation
    222 Gynecologic Oncology

    Chapter 33 ANSWER KEY


    Question Letter Page Question Letter Page
    number answer cited Header cited number answer cited Header cited
    S
    E
    C
    33–1 b p. 702 Epidemiology and Risk Factors 33–18 b p. 709 Histologic Grade, Table 33-6
    T
    I
    O
    33–2 c p. 702 Epidemiology and Risk Factors 33–19 c p. 710 Histologic Type
    N
    33–3 a p. 702 Epidemiology and Risk Factors 33–20 d p. 710 Clear Cell Carcinoma, Figure
    4
    33–4 b p. 702 Epidemiology and Risk Factors 33-9
    33–5 d p. 702 Epidemiology and Risk Factors 33–21 c p. 712 Patterns of Spread
    33–6 a p. 702 Epidemiology and Risk Factors 33–22 a p. 713 Table 33-9
    33–7 d p. 705 Clinical Features and Diagnosis 33–23 a p. 713 Surgical Management,
    Table 33-9
    33–8 d p. 705 Clinical Features and Diagnosis
    33–24 c p. 716 Adjuvant Radiation
    33–9 d p. 706 Nonatypical Endometrial Therapy, Table 33-8
    Hyperplasia
    33–25 a p. 714 Figure 33-11
    33–10 c p. 706 Response to Progestins
    33–26 c p. 713 Treatment
    33–11 c p. 706 Atypical Endometrial
    Hyperplasia 33–27 b p. 715 Surveillance
    33–12 b p. 706 Atypical Endometrial Hyperplasia 33–28 b p. 715 Chemotherapy
    33–13 c p. 706 Atypical Endometrial 33–29 a p. 715 Radiation
    Hyperplasia 33–30 c p. 716 Uterine Papillary Serous
    33–14 a p. 707 Prevention Carcinoma Management
    33–15 b p. 707 Prevention, Table 33-4 33–31 c p. 717 Fertility-Sparing Management
    33–16 c p. 708 Imaging Studies 33–32 c p. 717 Prognostic Factors
    33–17 d p. 709 Role of the Generalist 33–33 a p. 717 Recurrent Disease
    230

    CHAPTER 35

    Epithelial Ovarian Cancer

    35–1. In what place is ovarian cancer currently ranked 35–6. Which o the ollowing statements regarding ovarian
    among causes o cancer-related death in US women? cancer screening is true?
    a. First a. Women at average risk should undergo OvaSure
    b. Fi th testing annually.
    c. enth b. Women at average risk should undergo annual
    cancer antigen 125 (CA125) and transvaginal
    d. Fi teenth
    sonography screening.
    35–2. What percentage o epithelial ovarian cancers is c. Currently, there is no approved screening test or
    hereditary? women at average risk in the United States.
    a. 0.01 percent d. Women at average risk should undergo Risk o
    Ovarian Cancer Algorithm (ROCA)-based CA125
    b. 0.3 percent
    screening and study-directed sonography.
    c. 10 percent
    d. 30 percent 35–7. A 40-year-old woman with a BRCA1 mutation
    undergoes a laparoscopic bilateral salpingo-
    35–3. Which o the ollowing is NOT a risk actor or oophorectomy or risk reduction. Subsequent to
    ovarian cancer? this surgery, her breast cancer risk is reduced by
    a. Nulliparity what percentage?
    b. Late menopause a. 25 percent
    c. Oral contraceptive pills b. 50 percent
    d. Hereditary nonpolyposis colorectal cancer c. 75 percent
    d. 90 percent
    35–4. Which o the ollowing genetic mutations is associated
    with the highest risk o developing ovarian cancer? 35–8. What is the main histologic dif erence between a
    a. PTEN low-malignant-potential tumor and epithelial ovarian
    cancer?
    b. MLH1
    a. Stromal invasion
    c. BRCA1
    b. Mitotic activity
    d. BRCA2
    c. Degree o nuclear atypia
    35–5. Which o the ollowing statements regarding BRCA d. Nuclear to cytoplasmic ratio
    variants o uncertain clinical signif cance is FALSE?
    a. Women with this test result should undergo pro-
    phylactic salpingo-oophorectomy.
    b. T ey may be normal variants and may not repre-
    sent an increased risk o ovarian and breast cancer.
    c. One third o BRCA1 test results may be classi ed
    as variant o uncertain clinical signi cance.
    d. One hal o BRCA2 test results may be classi ed as
    variant o uncertain clinical signi cance.
    Epithelial Ovarian Cancer 231

    35–9. A 35-year-old G1P1 undergoes surgical exploration 35–10. A 27-year-old nulligravida who desires uture ertility
    or a large pelvic mass, shown here. T e rozen sec- underwent a laparoscopic le t salpingo-oophorectomy
    tion analysis o her right ovary returns a diagnosis o or a persistent 7-cm cyst that was causing pressure

    C
    “mucinous tumor o low malignant potential, cannot and pain. T e cyst was removed intact, and peritoneal

    H
    exclude invasion.” Clinically, there is no other obvi- washings were negative or cancer. T e nal pathol-

    A
    P
    ous disease. In addition to pelvic washings, multiple ogy report revealed a serous low-malignant-potential

    T
    peritoneal biopsies, omentectomy, and appendectomy, tumor. What is the most appropriate management?

    E
    R
    what other surgical procedures should be per ormed?

    3
    5
    a. Close observation
    a. No other procedures b. Right salpingo-oophorectomy (RSO), omentec-
    b. Bilateral pelvic and paraaortic lymph node tomy, multiple peritoneal biopsies
    dissection c. RSO, omentectomy, multiple peritoneal biop-
    c. otal abdominal hysterectomy, bilateral salpingo- sies, bilateral pelvic and paraaortic lymph node
    oophorectomy, and bilateral pelvic and paraaortic dissection
    lymph node dissection d. Hysterectomy, RSO, omentectomy, multiple
    d. None o the above peritoneal biopsies, bilateral pelvic and paraaortic
    lymph node dissection

    35–11. Which o the ollowing is the worst prognostic eature


    associated with low-malignant-potential tumors?
    a. Advanced stage
    b. Invasive implants
    c. Mucinous histology
    d. Stromal microinvasion

    35–12. What percentage o women with recurrent low-


    malignant-potential tumors have ovarian cancer?
    a. 10 percent
    b. 30 percent
    c. 50 percent
    d. 70 percent
    232 Gynecologic Oncology

    35–13. Which o the ollowing is FALSE regarding ovarian 35–18. In this photomicrograph, what are the arrows point-
    cancer symptoms? ing to? (Hint: T is nding is pathognomonic or the
    a. Most women with ovarian cancer experience most common histologic cell type among epithelial
    persistent symptoms. ovarian cancers.)
    S
    E
    C
    b. Women with ovarian cancer do not have symp-
    T
    toms until the disease is very advanced.
    I
    O
    c. T e most requent symptoms associated with ovar-
    N
    4
    ian cancer include urinary urgency, pelvic pain,
    and bloating.
    d. None o the above

    35–14. What percentage o patients with stage I ovarian can-


    cer have a normal cancer antigen 125 (CA125) level?
    a. 0.5 percent
    b. 5 percent
    c. 25 percent
    d. 50 percent

    35–15. Which o the ollowing conditions can cause an


    Used with permission rom Dr. Kelley Carrick.
    elevated cancer antigen 125 (CA125) level?
    a. Leiomyomata
    a. Signet ring
    b. Menstruation
    b. Hobnail cell
    c. Endometriosis
    c. Keratin pearl
    d. All o the above
    d. Psammoma body
    35–16. Which o the ollowing radiologic tests is most
    35–19. Which o the ollowing cell types o ovarian cancer is
    help ul in the treatment planning or a patient with
    NOT associated with endometriosis?
    suspected advanced ovarian cancer?
    a. Clear cell
    a. ransvaginal sonography
    b. Endometrioid
    b. Positron emission tomography
    c. Papillary serous
    c. Magnetic resonance imaging o the pelvis
    d. All o the above
    d. Computed tomography o the abdomen and pelvis
    35–20. A 27-year-old woman presents to the emergency
    35–17. Which o the ollowing women does NOT need to be
    department with a complaint o increasing abdominal
    re erred to a gynecologic oncologist?
    distention, constipation, and weight loss. Abdomino-
    a. A 35-year-old woman with a complex 7-cm pelvic computed tomography reveals a 10-cm right
    adnexal mass and a cancer antigen 125 (CA125) adnexal mass and retroperitoneal lymphadenopathy.
    level o 75 U/mL Her cancer antigen 125 (CA125) level is 45 U/mL,
    b. A 60-year-old woman with a complex 7-cm beta-human chorionic gonadotropin level is < 5 IU/mL,
    adnexal mass and a CA125 level o 75 U/mL alpha- etoprotein (AFP) and lactate dehydrogenase
    c. A 35-year-old woman with a complex 7-cm adnexal (LDH) levels are normal, and her serum calcium level
    mass, ascites, and a CA125 level o 75 U/mL is 15 mg/dL. What is the most likely diagnosis?
    d. A 40-year-old with a complex 7-cm adnexal mass, a. Lymphoma
    a CA125 level o 275 U/mL, and a liver lesion seen b. Primary hyperparathyroidism
    during abdominopelvic computed tomography c. Small-cell hypercalcemic-type ovarian cancer
    d. Malignant germ cell tumor o the ovary with bone
    metastasis
    Epithelial Ovarian Cancer 233

    35–21. Which o the ollowing is NOT a characteristic o 35–24. In the dissection shown here, which arrow correctly
    Krukenberg tumors? indicates the cephalad border o paraaortic lymph
    a. T ey are almost always bilateral. node dissection typically per ormed or ovarian cancer

    C
    that is clinically con ned to the ovary?

    H
    b. T ey usually arise rom primary gastric tumors.

    A
    c. T ey are usually the only site o metastatic disease.

    P
    T
    d. T ey are composed o mucinous and signet ring

    E
    R
    adenocarcinoma cells.

    3
    5
    35–22. What is the most common method o ovarian cancer
    spread?
    a. Lymphatic
    b. Hematogenous
    c. Direct extension
    d. umor ex oliation

    35–23 A 40-year-old woman with a small right-sided pleural


    ef usion undergoes an exploratory laparotomy or a
    pelvic mass and elevated cancer antigen 125 (CA125)
    level. During abdominal exploration, the nding Used with permission rom Dr. Jaya Lea.
    below is seen. What International Federation o
    Gynecology and Obstetrics (FIGO) stage is she? a. A
    b. B
    c. C
    d. D

    35–25. Approximately what percentage o women with ovar-


    ian cancer clinically con ned to the ovaries will be
    upstaged by surgery?
    a. 1 percent
    b. 30 percent
    c. 60 percent
    d. 90 percent

    35–26. Which o the ollowing patients does NOT need


    adjuvant chemotherapy or epithelial ovarian cancer
    ollowing total abdominal hysterectomy, bilateral
    Used with permission rom Dr. John Schorge.
    salpingo-oophorectomy, omentectomy, and multiple
    peritoneal biopsies?
    a. Stage IIIA
    a. A 65-year-old woman who underwent the above
    b. Stage IIIB
    surgeries plus pelvic and paraaortic lymph node dis-
    c. Stage IIIC section or a stage IC clear cell carcinoma o the ovary
    d. Stage IV b. A 45-year-old woman who underwent the above
    surgeries plus pelvic lymph node dissection or a
    stage IA, grade 1 endometrioid adenocarcinoma o
    the ovary
    c. A 55-year-old woman who underwent the above
    surgeries plus pelvic and paraaortic lymph node
    dissection or a stage IB, grade 1 papillary serous
    carcinoma o the ovary
    d. A 70-year-old woman who underwent the above
    surgeries plus pelvic and paraaortic lymph node
    dissection or a stage IC, grade 1 papillary serous
    carcinoma o the ovary
    234 Gynecologic Oncology

    35–27. What is the goal o cytoreductive surgery or 35–31. Which o the ollowing statements regarding mainte-
    advanced ovarian cancer? nance chemotherapy or advanced ovarian cancer is
    a. Remove all tumors measuring > 1 cm FALSE?
    a. Maintenance chemotherapy has not improved
    S
    b. Remove all tumors measuring > 2 cm
    E
    overall survival rates.
    C
    c. Remove all tumors measuring > 0.5 cm
    T
    b. Improvements in progression- ree survival rates
    I
    d. Remove all gross disease
    O
    have been demonstrated.
    N
    4
    35–28. Which o the ollowing is a possible mechanism by c. Agents that have been tested include bevacizumab,
    which primary debulking surgery is elt to improve pazopanib, and paclitaxel.
    outcomes? d. Patients should undergo second-look surgery prior
    a. Enhance tumor chemosensitivity to starting maintenance treatment.
    b. Decrease risk o chemoresistance
    35–32. Which o the ollowing is NOT a positive prognostic
    c. Improve drug delivery to cancer cells a ter removal actor or ovarian cancer?
    o necrotic tissue
    a. Younger age
    d. All o the above
    b. Clear cell type
    35–29. Patients with which o the ollowing cancers do NOT c. Absence o ascites
    require lymphadenectomy? d. Debulking to no gross residual
    a. Endometrioid adenocarcinoma o the ovary
    clinically con ned to one ovary 35–33. A woman with a history o stage IIIC ovarian cancer
    who underwent optimal cytoreductive surgery
    b. Serous carcinoma o the ovary, with omental
    ollowed by six cycles o intraperitoneal (IP) cisplatin
    implants measuring > 2 cm and with bulky aortic
    and paclitaxel has a recurrence 4 months a ter comple-
    nodes
    tion o chemotherapy. She complains o bloating and
    c. Serous carcinoma o the ovary, with carcinomatosis decreased appetite. Which o the ollowing is the
    that can be debulked to < 5 mm residual disease most appropriate treatment?
    and with no grossly enlarged nodes
    a. amoxi en
    d. None o the above
    b. Carboplatin
    35–30. Which o the ollowing chemotherapy regimens is c. Gemcitabine
    associated with the longest overall survival rate or d. Pegylated liposomal doxorubicin and bevacizumab
    women with optimally debulked (< 1 cm residual
    disease) stage III epithelial ovarian cancer? 35–34. Which o the ollowing chemotherapy regimens is an
    a. Carboplatin alone appropriate treatment or a patient with platinum-
    sensitive ovarian cancer?
    b. Intraperitoneal (IP) cisplatin and paclitaxel
    a. Carboplatin with paclitaxel
    c. Intravenous (IV) carboplatin and paclitaxel
    b. Carboplatin with gemcitabine
    d. IV carboplatin, paclitaxel, and bevacizumab
    c. Carboplatin with pegylated liposomal doxorubicin
    d. Any o the above
    Epithelial Ovarian Cancer 235

    Chapter 35 ANSWER KEY


    Question Letter Page Question Letter Page

    C
    number answer cited Header cited number answer cited Header cited

    H
    A
    35–1 b p. 735 Epidemiology and Risk Factors 35–19 c p. 746 Clear Cell Adenocarcinoma

    P
    T
    35–2 c p. 735 Epidemiology and Risk Factors 35–20 c p. 746 Other Histologic Types

    E
    R
    35–3 c p. 735 Epidemiology and Risk Factors 35–21 c p. 747 Secondary Tumors

    3
    5
    35–4 c p. 736 BRCA1 and BRCA2 Genes 35–22 d p. 747 Patterns of Spread
    35–5 a p. 737 Genetic Testing 35–23 c p. 750 Table 35-5
    35–6 c p. 738 New Biomarkers and 35–24 b p. 748 Surgical Staging
    Proteomics 35–25 b p. 749 Postsurgical Management
    35–7 b p. 738 Prophylactic Surgery 35–26 c p. 749 Postsurgical Management
    35–8 a p. 739 Pathology 35–27 d p. 750 Residual Disease
    35–9 a p. 739 Treatment 35–28 d p. 750 Residual Disease
    35–10 a p. 739 Treatment 35–29 c p. 751 Surgical Approach to
    35–11 b p. 740 Prognosis Cytoreductive Surgery
    35–12 b p. 740 Prognosis 35–30 b p. 752 Intraperitoneal Chemotherapy
    35–13 b p. 741 Symptoms and Physical 35–31 d p. 752 Management of Patients in
    Findings Remission
    35–14 d p. 742 Laboratory Testing 35–32 b p. 753 Table 35-9
    35–15 d p. 742 Laboratory Testing 35–33 d p. 753 Management of Recurrent
    35–16 d p. 742 Imaging Ovarian Cancer
    35–17 a p. 742 Role of the Generalist 35–34 d p. 753 Management of Recurrent
    Ovarian Cancer
    35–18 d p. 744 Serous Tumors
    236

    CHAPTER 36

    Ovarian Germ Cell and Sex Cord-Stromal Tumors

    36–1. What approximate percentage o all ovarian cancers 36–6. An 18-year-old woman presents with severe, acute
    are germ cell and sex cord-stromal tumors? abdominal pain. She is ound to have a large pelvic
    a. 0.1 percent mass, and torsion o an enlarged ovary is suspected.
    During the ensuing surgery, rozen section reveals a
    b. 1 percent
    dysgerminoma. T ere is no gynecologic oncologist at
    c. 10 percent your hospital. What is the most appropriate next step?
    d. 30 percent

    36–2. Women with germ cell tumors are diagnosed most


    commonly during which International Federation o
    Gynecology and Obstetrics (FIGO) disease stage?
    a. I
    b. II
    c. III
    d. IV

    36–3. Which o the ollowing invasive cancers is most


    commonly diagnosed in women during their 20s
    (third decade)?
    a. Germ cell tumors
    b. Sex cord-stromal tumors
    c. Epithelial ovarian cancer
    a. Per orm a bilateral salpingo-oophorectomy and
    d. All o these occur with equal requency. close
    b. Per orm a unilateral salpingo-oophorectomy and
    36–4. What is the most common presenting symptom in a
    close
    woman with a germ cell tumor?
    c. Close her abdomen and re er her to a gynecologic
    a. Bloating
    oncologist
    b. Abdominal pain
    d. Per orm a unilateral salpingo-oophorectomy,
    c. Abdominal distention obtain peritoneal washings, care ully palpate the
    d. Menstrual abnormality abdomen or metastases, and per orm biopsies as
    indicated
    36–5. Which o the ollowing is NOT a tumor marker or
    germ cell tumors? 36–7. Which o the ollowing is the most commonly diag-
    a. Inhibin nosed ovarian malignancy during pregnancy?
    b. Alpha- etoprotein (AFP) a. Dysgerminoma
    c. Lactate dehydrogenase (LDH) b. Choriocarcinoma
    d. Human chorionic gonadotropin (hCG) c. Immature teratoma
    d. Granulosa cell tumor
    Ovarian Germ Cell and Sex Cord-Stromal Tumors 237

    36–8. A 19-year-old emale nulligravid college student is 36–12. Which o the ollowing malignant germ cell tumors
    ound to have a pelvic mass and an elevated lactate has the worst prognosis?
    dehydrogenase (LDH) level. She reports that she was a. Dysgerminoma

    C
    amenorrheic until she started taking combination oral

    H
    b. Yolk sac tumor
    contraceptive pills at age 17. She undergoes surgical

    A
    c. Immature teratoma

    P
    exploration, and rozen section analysis o the surgical

    T
    specimen reveals ovarian dysgerminoma. Which o d. Nongestational choriocarcinoma

    E
    R
    the ollowing is FALSE?

    3
    36–13. Which o the ollowing is true regarding mixed germ

    6
    a. Her karyotype is most likely 46,XX.
    cell tumors o the ovary?
    b. Regardless o stage, she has an excellent prognosis.
    a. Dysgerminoma is the most common component.
    c. Her other ovary may contain a gonadoblastoma
    and should be removed. b. reatment is based on the dysgerminoma
    component.
    d. She should undergo complete surgical staging, but
    her uterus may be preserved. c. Women with a presumed pure dysgerminoma and
    an elevated alpha- etoprotein (AFP) level are likely
    36–9. What percentage o gonadoblastomas undergoes to have a component o immature teratoma.
    malignant trans ormation? d. All o the above
    a. 0.1 percent
    36–14. What is the most common germ cell malignancy o
    b. 10 percent
    the ovary?
    c. 40 percent
    a. Dysgerminoma
    d. 80 percent
    b. Yolk sac tumor
    36–10. Which germ cell tumor is most likely to be bilateral? c. Mature teratoma
    a. Dysgerminoma d. Immature teratoma
    b. Mature teratoma
    36–15. Which o the ollowing characteristics is primarily
    c. Immature teratoma used to grade immature teratomas?
    d. Embryonal carcinoma a. Amount o solid component present
    b. Amount o immature elements present
    36–11. T e histologic structure shown in the photomicro-
    graph below, a single papilla lined by tumor cells and c. Amount o immature neural tissue present
    containing a central vessel, is pathognomonic or d. None o the above
    which germ cell tumor?
    36–16. An 18-year-old adolescent has a history o a stage IC
    grade 3 immature teratoma. She received adjuvant
    chemotherapy with bleomycin, etoposide, and cisplatin
    (BEP). At her 6-month ollow-up, she is ound to
    have a pelvic mass. Which o the ollowing is the
    most appropriate management?
    a. Chemotherapy
    b. Radiation therapy
    c. Continued observation
    d. Exploratory laparotomy with removal o masses
    ound

    36–17. What is the most common cancer ound in a mature


    teratoma?
    a. Struma ovarii
    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds):
    Williams Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Photo contributor: b. Basal cell carcinoma
    Dr. Kelley Carrick. c. Neuroectodermal tumors
    a. Dysgerminoma d. Squamous cell carcinoma
    b. Yolk sac tumor
    c. Immature teratoma
    d. Nongestational choriocarcinoma
    238 Gynecologic Oncology

    36–18. Which o the ollowing patients does NOT need 36–23. Which o the ollowing is true regarding the tumor
    adjuvant chemotherapy a ter unilateral salpingo- represented in this photomicrograph?
    oophorectomy with surgical staging?
    a. Stage IA dysgerminoma
    S
    E
    C
    b. Stage IA yolk sac tumor
    T
    I
    c. Stage IA grade 3 immature teratoma
    O
    N
    d. All o the above
    4
    36–19. What is the most common chemotherapy regimen
    used to treat malignant germ cell ovarian cancers?
    a. Carboplatin and etoposide
    b. Carboplatin and paclitaxel
    c. Bleomycin, etoposide, and cisplatin
    d. Bleomycin, etoposide, and paclitaxel

    36–20. Which o the ollowing is a prognostic actor or


    malignant ovarian germ cell cancers?
    Reproduced with permission rom Ho man BL, Schorge JO, Bradshaw KD, et al (eds):
    a. Stage Williams Gynecology, 3rd ed. New York, McGraw-Hill, 2016. Photo contributor:
    Dr. Raheela Ash aq.
    b. Histologic subtype
    c. Amount o residual tumor a. Inhibin B is o ten elevated.
    d. All o the above b. T e tumor can o ten exceed 10 cm in size.
    36–21. Which o the ollowing is NOT a protective actor c. T e characteristic microscopic eature is the
    against the development o a sex cord-stromal tumor? Call-Exner body.
    a. Smoking d. All o the above
    b. Obesity 36–24. Which o the ollowing tumors is hormonally active
    c. Multiparity and most o ten secretes estrogen?
    d. Combination oral contraceptive pills a. T ecoma
    b. Fibroma
    36–22. What is the most common presenting symptom o a
    sex cord-stromal tumor in a prepubescent girl? c. Sertoli-Leydig tumor
    a. Hirsutism d. None o the above
    b. Abdominal pain
    c. Primary amenorrhea
    d. Isosexual precocious puberty
    Ovarian Germ Cell and Sex Cord-Stromal Tumors 239

    36–25. A woman undergoes exploratory laparotomy, total 36–26. A 22-year-old woman has the vulvar f nding demon-
    abdominal hysterectomy, and bilateral salpingo- strated below and an 8-cm pelvic mass palpable dur-
    oophorectomy or a solid pelvic mass, ascites, and an ing bimanual examination. What is the most likely

    C
    elevated serum cancer antigen 125 (CA125) level. diagnosis?

    H
    Her preoperative chest radiograph is shown below.

    A
    P
    Frozen section demonstrates a benign ovarian neoplasm.

    T
    What is the most likely diagnosis?

    E
    R
    3
    6
    Reproduced with permission rom Ho man BL, Schorge JO, Scha er JI, et al (eds): Williams
    Gynecology, 2nd ed. New York, McGraw-Hill, 2012. Photo contributor: Dr. Ben Li.

    a. Sertoli tumor
    a. Meigs syndrome b. Swyer syndrome
    b. Benign ovarian neoplasm with cirrhosis c. Leydig cell tumor
    c. Metastatic cancer with a benign adnexal mass d. Sertoli-Leydig tumor
    d. Ovarian cancer with an inaccurate rozen section
    diagnosis 36–27. A 30-year-old woman with Peutz-Jeghers syndrome is
    ound to have a sex cord-stromal tumor. Which o the
    ollowing is FALSE?
    a. Her sex cord-stromal tumor is malignant.
    b. Her sex cord-stromal tumor is likely bilateral.
    c. She probably has hamartomatous polyps in her
    colon.
    d. She has a 15-percent chance o developing
    adenoma malignum.
    240 Gynecologic Oncology

    36–28. A 35-year-old nulligravida who desires uture ertility 36–31. A 52-year-old woman with a history o granulosa cell
    is ound to have a granulosa cell tumor during rozen tumor has a rising inhibin level. Computed tomogra-
    section analysis o a right salpingo-oophorectomy phy reveals an isolated pelvic mass. What is the next
    (RSO) specimen. What is the appropriate surgical most appropriate treatment?
    S
    E
    management o this patient? a. Surgical resection
    C
    T
    a. RSO alone b. Carboplatin and paclitaxel
    I
    O
    b. RSO, omentectomy, multiple peritoneal biop- c. Medroxyprogesterone acetate
    N
    sies; consider pelvic and paraaortic lymph node
    4
    d. Bleomycin-etoposide-cisplatin chemotherapy
    dissection
    c. RSO, omentectomy, multiple peritoneal biopsies; 36–32. Which o the ollowing is a prognostic actor or sex
    consider pelvic and paraaortic lymph node cord-stromal tumors?
    dissection and dilatation and curettage o endo-
    a. Age
    metrial cavity
    b. Stage
    d. otal abdominal hysterectomy, bilateral salpingo-
    oophorectomy, omentectomy, multiple peritoneal c. Amount o residual disease
    biopsies; consider pelvic and paraaortic lymph d. All o the above
    node dissection
    36–33. Which o the ollowing is NOT true o sex cord-
    36–29. Routine surveillance or malignant sex cord-stromal stromal tumors diagnosed during pregnancy?
    tumors includes all o the ollowing EXCEPT: a. Granulosa cell tumors are most common.
    a. Inhibin levels b. Chemotherapy, i indicated, should be given dur-
    b. History and physical examination at regular ing pregnancy.
    intervals c. A third o these cases are diagnosed incidentally at
    c. Routine abdominopelvic computed tomography the time o cesarean delivery.
    every 6 months d. Surgery should consist o unilateral salpingo-
    d. Imaging as clinically indicated based on physical oophorectomy, omentectomy, and peritoneal
    examination f ndings and tumor marker levels biopsies.

    36–30. Which o the ollowing is NOT an appropriate adju-


    vant treatment or a patient with a stage III granulosa
    cell tumor?
    a. Whole pelvic radiotherapy
    b. Carboplatin and paclitaxel
    c. Bleomycin-etoposide-cisplatin chemotherapy
    d. All o the above are appropriate treatment options.
    144

    CHAPTER 21

    Physiology of Labor

    21–1. Which of the following patients are in labor? 21–5. Which of the following is not a function of the
    a. A 23-year-old G1P0 at 38 weeks’ gestation with cervix during pregnancy?
    painful contractions and a cervix that remains a. Preventing infection
    closed over 2 hours b. Maintenance of competence
    b. A 33-year-old G2P1 at 38 weeks’ gestation with c. Extracellular changes for greater compliance
    nonpainful contractions and a cervix that changes
    d. All of the above
    to 3 cm dilated over 2 hours
    c. A 33-year-old G2P1 at 38 weeks’ gestation 21–6. Which of the following is a characteristic of the
    with one prior cesarean delivery with painful amnion?
    contractions and a cervix that remains closed over
    a. Provides immunological acceptance
    2 hours
    b. Enriched with enzymes that inactivate
    d. A 33-year-old G2P1 at 38 weeks’ gestation with
    uterotonins
    one prior cesarean delivery with painful contrac-
    tions and a cervix that remains 1 cm dilated over c. Provides all tensile strength to resist rupture of
    2 hours membranes
    d. All of the above
    21–2. Which of the following describes current theories of
    labor? 21–7. Which of the following supports the theory that
    a. Synthesis of factors that induce parturition progesterone inhibits parturition?
    b. Fetal source for commencement of parturition a. Progesterone withdrawal precedes labor
    c. Functional loss of pregnancy maintenance factors b. Providing progesterone to some species delays
    labor
    d. All of the above
    c. Administration of a progesterone-receptor
    21–3. All except which of the following may result from antagonist promotes labor
    abnormal parturition? d. All of the above
    a. Dystocia
    21–8. Of the four phases of parturition, phase 2 is
    b. Preterm labor
    characterized by which of the following?
    c. Postterm pregnancy
    a. Uterine activation, cervical ripening
    d. Premature rupture of membranes
    b. Uterine quiescence, cervical softening
    21–4. Which of the following qualities of smooth muscles c. Uterine contraction, cervical dilatation
    is advantageous for contractions and fetal delivery? d. Uterine involution, cervical remodeling
    a. Greater shortening with contractions
    21–9. Which phase of parturition corresponds to the
    b. Forces are not exerted in multiple directions
    clinical stages of labor?
    c. Smooth muscle is organized in the same manner
    a. Phase 1
    as striated muscle
    d. Unidirectional force generation in the fundus and b. Phase 2
    lower uterine segment c. Phase 3
    d. Phase 4
    Physiology of Labor 145

    21–10. Which of the following does not help achieve uterine 21–15. A 23-year-old primigravida presents for induction of
    quiescence? labor at 41 weeks’ gestation. Her cervix is unfavor-
    a. Uterotonin degradation able with a Bishop score of 4. You proceed with cer-

    CHAPTER 21
    vical ripening using the agent depicted below. This
    b. Increased intracellular Ca2+
    medication belongs to which class of agents?
    c. Ion channel regulation of cell membrane potential
    d. Activation of the uterine endoplasmic reticulum
    stress response

    21–11. During which stage of labor is the fetus delivered?


    a. Stage 1
    b. Stage 2
    c. Stage 3
    d. Stage 4

    21–12. Cervical softening in phase 1 of parturition results in


    part from which of the following?
    a. Stromal atrophy
    b. Increased stromal vascularity
    c. Increased collagen monomer cross-linking
    d. All of the above a. Oxytocin
    b. Beta mimetics
    21–13. Contraction-associated protein (CAP) within the
    uterine smooth muscle prepares it to contract during c. Prostaglandins
    labor. CAP concentrations increase during phase 2 d. Nonsteroidal inflammatory drugs
    of parturition and include all except which of the
    following proteins? 21–16. What is the primary source of corticotropin-releasing
    a. Connexin 43 hormone in pregnancy?
    b. Oxytocin receptor a. Placental
    c. Progesterone A receptor b. Fetal adrenal
    d. Prostaglandin F receptor c. Fetal hypothalamus
    d. Maternal hypothalamus
    21–14. Compared to the uterine body, the cervix has a
    significantly lower percentage of which of the 21–17. Which of the following are fetal contributors to the
    following? initiation of parturition?
    a. Collagen a. Surfactant protein A
    b. Proteoglycans b. Corticotropin-releasing hormone
    c. Smooth muscle c. Senescent-associated secretory phenotype
    d. Glycosaminoglycans d. All of the above
    146 Labor

    21–18. A fetus with a neural tube defect is shown below 21–21. During cesarean delivery, the hysterotomy incision
    with the fetal orbits labeled O. Which of the is ideally made in the lower uterine segment, shown
    following abnormalities of normal parturition has here prior to bladder flap creation. Which of the
    been associated with this anomaly? following aids in development of this uterine segment
    SECTION 7

    during phase 3 of parturition?

    a. Preterm labor
    b. Prolonged gestation Used with permission from Dr. Sarah White.
    c. Uterine tachysystole
    d. None of the above a. Progressive thickening of the upper uterine segment
    with labor progression
    21–19. Which of the following are plausible causes of b. Smooth muscle cell fibers of the fundus relax to
    uterine contraction pain?
    their original length after each contraction
    a. Myometrial hypoxia
    c. Smooth muscle cell fibers of the lower uterine
    b. Uterine peritoneum stretch segment relax to their original length after each
    c. Compression of nerve ganglia in the cervix contraction
    d. All of the above d. All of the above
    21–20. A 30-year-old primigravida presents to your office 21–22. After the cervix is fully dilated, what is the most
    at 39 weeks’ gestation. She is exhausted and ready important force in fetal expulsion?
    to be delivered but does not want to be induced.
    You suggest membrane stripping and inform her a. Uterine contractions
    this will lead to a rise in which of the following b. Intraabdominal pressure
    prostaglandins? c. Fetal head descending through the pelvis
    a. I2 d. None of the above
    b. E2
    c. H
    d. F2a
    Physiology of Labor 147

    21–23. As a result of contraction forces, the cervix effaces 21–26. What is the initial step that leads to placental
    and dilates by mechanisms that include all except separation following delivery of the infant?
    which of the following? a. Uterine contractions

    CHAPTER 21
    a. Contraction forces create lateral pull against the b. Tension pulls it away from the implantation site
    cervix to open its canal. c. Formation of a hematoma behind the placenta
    b. Contraction forces are transferred directly through with uterine involution
    the presenting part to the cervix to dilate its canal. d. None of the above
    c. Contraction forces pull smooth muscle fibers at
    the internal os up into the adjacent upper uterine 21–27. In which mechanism of placental delivery does the
    segment to efface the cervix. placenta leave the body before the retroplacental
    hematoma?
    d. Contraction forces are translated into hydrostatic
    pressure within the amnionic sac, which presses a. Bandl mechanism
    against the cervix to dilate the cervical canal. b. Duncan mechanism
    c. Schultze mechanism
    21–24. In which of the following women would you expect
    d. Chadwick mechanism
    rapid descent of the fetal head?
    a. A 23-year-old G1P0 at 40 weeks’ gestation 21–28. Which of the following is accurate regarding
    b. A 23-year-old G3P2 at 40 weeks’ gestation oxytocin?
    c. A 33-year-old G1P0 at 28 weeks’ gestation a. Nanopeptide
    d. A 33-year-old G1P0 at 37 weeks’ gestation b. Synthesized as a prohormone
    c. Myometrial receptor numbers increase during
    21–25. Which of the following is the most important phase 2
    component of the pelvic floor?
    d. All of the above
    a. Vaginal wall
    b. Piriformis muscle 21–29. Indomethacin, a nonsteroidal antiinflammatory drug
    c. Coccygeus muscle (NSAID), has some tocolytic actions. As a group,
    NSAIDs target which enzyme in prostaglandin
    d. Levator ani muscle production?
    a. Phospholipase A2
    b. Cyclooxygenase-1
    c. Prostaglandin isomerase
    d. Prostaglandin dehydrogenase
    148 Labor

    21–30. A 34-year-old G1P0 is undergoing induction of


    labor with misoprostol for cervical ripening. The
    nurse calls you for fetal heart rate decelerations, and
    you notice she is having prolonged contractions,
    SECTION 7

    as shown below. You administer terbutaline, a


    β2 adrenergic receptor agonist, and initiate which
    of the following cellular responses to cause uterine
    relaxation?

    a. Increased intracellular Ca2+ levels


    b. Increased extracellular Mg2+ levels
    c. Increased cyclic adenosine monophosphate levels
    d. Decreased cyclic guanosine monophosphate levels

    21–31. A 34-year-old woman is scheduled to return for her


    postpartum visit 6 weeks after delivery. Given that
    you will discuss birth control options at that visit,
    what may be the optimal timing of that visit?
    a. 6 weeks based on tradition
    b. 4 weeks if she is breastfeeding
    c. 6 weeks as long as she is breastfeeding
    d. 4 weeks because ovulation returns 4–6 weeks
    after birth

    21–32. Which of the following uterotonins plays a role in


    phase 3 of parturition?
    a. Endothelin-1
    b. Angiotensin II
    c. Prostaglandins
    d. All of the above
    150

    CHAPTER 22

    Normal Labor

    22–1. What is the most common fetal lie? 22–4. In the photo below, the neck is only partly flexed
    a. Oblique and the anterior fontanel is presenting. What is the
    fetal attitude?
    b. Unstable
    c. Transverse
    d. Longitudinal

    22–2. When the fetus lies with the long axis transversely,
    what is the presenting part?
    a. Knee
    b. Head
    c. Shoulder
    d. Buttocks

    22–3. What is the fetal attitude in the photo below?

    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): Normal
    labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 22-1B.

    a. Face
    b. Brow
    c. Occiput
    d. Sinciput

    22–5. What composes the cephalic pole?


    a. Head
    b. Head and upper extremities
    c. Head, upper extremities, and trunk
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): Normal
    labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 22-1D. d. Head, upper extremities, trunk, and lower
    extremities
    a. Face
    b. Brow
    c. Vertex
    d. Sinciput
    Normal Labor 151

    22–6. Why is there a high incidence of breech among 22–9. What is the fetal position in the drawing below?
    hydrocephalic fetuses?
    a. Increased intracranial pressure

    CHAPTER 22
    b. Podalic pole needs more room
    c. Cephalic pole needs more room
    d. Because the fetal head is small, it does not have
    the force to turn

    22–7. What is the incidence of breech at term?


    a. 1%
    b. 3%
    c. 5%
    d. 10%

    22–8. What is the fetal position in the drawing below? Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): Normal
    labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 22-2B.

    a. Left occiput anterior


    b. Left occiput posterior
    c. Right occiput anterior
    d. Right occiput posterior

    22–10. What is the fetal position in the drawing below?

    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): Normal
    labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 22-2A.

    a. Left occiput anterior (LOA)


    b. Left occiput posterior (LOP)
    c. Right occiput anterior (ROA)
    d. Right occiput posterior (ROP)

    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Normal labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure
    22-3A.

    a. Left occiput anterior


    b. Left occiput posterior
    c. Right occiput anterior
    d. Right occiput posterior
    152 Labor

    22–11. What is the fetal position in the drawing below? 22–14. What is the fetal position in the drawing below?
    SECTION 7

    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): Normal
    labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 22-3B.

    a. Left occiput anterior


    b. Right occiput anterior
    c. Left occiput transverse
    d. Right occiput transverse

    22–12. Which of the following is least detrimental to the Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    performance of Leopold maneuvers? Normal labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 22-6.
    a. Obesity
    b. Macrosomia a. Left sacrum anterior
    c. Polyhydramnios b. Left sacrum posterior
    d. Anterior placenta c. Right sacrum anterior
    d. Right sacrum posterior
    22–13. What is the fetal position in the drawing below?
    22–15. Which Leopold maneuver determines degree of fetal
    descent?
    a. 1
    b. 2
    c. 3
    d. 4

    22–16. The term engagement refers to which of the


    following?
    a. Top of the head passing through the pelvic inlet
    b. Top of the head passing through the pelvic outlet
    c. Biparietal diameter passing through the pelvic
    inlet
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): d. Biparietal diameter passing through the pelvic
    Normal labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 22-5. outlet

    a. Left mento-anterior
    b. Left mento-posterior
    c. Right mento-anterior
    d. Right mento-posterior
    Normal Labor 153

    22–17. What is the term for lateral deflection of the sagittal 22–19. Which of the following statements about the photo
    suture toward the sacral promontory as depicted in provided below is false?
    the drawing below?

    CHAPTER 22
    a. This is the product of rapid labor.
    b. This can make it difficult to assess the sutures and
    fontanels.
    c. Most of the time, these changes to the fetal head
    shape will resolve within a week of delivery.
    d. These changes to the fetal head can facilitate
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    a vaginal delivery in women with a contracted
    Normal labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure
    22-12. pelvis.

    a. Normal asynclitism 22–20. During which portion of labor does the cervix dilate
    very little but the connective tissue component
    b. Oblique asynclitism
    change considerably?
    c. Anterior asynclitism
    a. Active phase
    d. Posterior asynclitism b. Acceleration phase
    22–18. Which of the following statements about the occiput c. Dilational division
    posterior position is true? d. Preparatory division
    a. They are more commonly seen in the setting of a
    posterior placenta. 22–21. Which of the following has been associated with
    prolonging labor?
    b. Epidural anesthesia may predispose to incomplete
    rotation to the occiput anterior position. a. Maternal fear
    c. The fetus is less likely to turn to the occiput b. Maternal obesity
    anterior position if small for gestational age. c. Epidural analgesia
    d. Extension of the fetal head improves the likelihood d. All of the above
    that it will turn from occiput posterior to occiput
    anterior. 22–22. Which stage of labor is defined as the period of time
    from when the patient reaches complete cervical
    dilation through delivery of the fetus?
    a. First stage
    b. Second stage
    c. Third stage
    d. Fourth stage
    154 Labor

    22–23. Which of the following has not been associated with 22–28. A 28-year-old primigravida at term presents in labor.
    a prolonged second stage of labor? She is very uncomfortable. You go to examine the
    a. Sedation patient, and you note that the fetal head is visible at
    the introitus. What is the fetal station?
    SECTION 7

    b. Macrosomia
    a. –5
    c. Maternal obesity
    b. –2
    d. Contracted maternal pelvis
    c. +2
    22–24. What is the recommended nurse: patient ratio for a d. +5
    low-risk laboring patient?
    a. 1:1 22–29. A 39-year-old multigravida presents for induction at
    38 weeks’ gestation. The patient has a history of two
    b. 1:2
    prior vaginal deliveries, cholestasis, pregestational
    c. 1:3 diabetes, chronic hypertension requiring two
    d. 2:1 medications, and a history of prior abruption in the
    setting of preeclampsia with severe features. You
    22–25. A 25-year-old primigravida presents at 38 weeks’ place the patient on continuous fetal monitoring.
    gestation complaining of contractions every How often should the tracing be evaluated?
    5–7 minutes. On exam, she is 1 cm dilated, 50% a. Every 15 minutes in the first and second stage.
    effaced, and the fetal head is at –1 station. Her
    b. Every 15 minutes in the first stage and every
    membranes are intact and there is no vaginal bleeding
    5 minutes in the second stage.
    seen. After 2 hours of observation, the fetal tracing is
    category I. The contractions have spaced out to every c. Every 15 minutes in the first stage and every
    15 minutes. The patient’s cervix remains unchanged. 30 minutes in the second stage.
    Her vitals are within normal limits, and she has no d. Every 30 minutes in the first stage and every
    medical problems. What is the best management 15 minutes in the second stage.
    plan for this patient?
    a. Amniotomy induction 22–30. A 30-year-old multigravida presents in active labor
    at term. She progresses from 4 cm to complete in
    b. Continued monitoring
    3 hours. She has the baby spontaneously 1 hour later.
    c. Oxytocin augmentation She has a third-degree laceration that is repaired.
    d. Discharge home with labor precautions and On postpartum day 1, she is found to have urinary
    instructions to follow up with her doctor retention. What is her risk factor for urinary retention?
    a. Age
    22–26. A 17-year-old primigravida at 38 weeks’ gestation
    b. Rapid labor
    presents complaining of leakage of fluid. When
    performing nitrazine testing to assess for the presence c. Multiparity
    of amniotic fluid in the vagina, which of the following d. Perineal laceration
    would you expect to give you a false-negative result?
    a. Blood 22–31. A 22-year-old primigravida presents in active labor at
    6 cm dilation. Her membranes are intact, the fetus
    b. Semen
    is cephalic, and the fetal tracing is category I. Two
    c. Scant fluid hours later, she is still 4 cm dilated. Her contractions
    d. Bacterial vaginosis are every 7 minutes. What is the best next step in
    labor management?
    22–27. When the cervix becomes as thin as the adjacent a. Amniotomy
    lower uterine segment, what is the effacement?
    b. Continued observation
    a. 0%
    c. Amniotomy and oxytocin
    b. 25%
    d. Cesarean section for failure to progress
    c. 50%
    d. 100% 22–32. Should the patient in Question 22–31 achieve
    adequate uterine contractions, what is a reasonable
    minimum rate of cervical dilation?
    a. 1 cm in 2 hours
    b. 1–2 cm per hour
    c. 2–3 cm per hour
    d. 3–4 cm per hour
    Normal Labor 155

    CHAPTER 22 ANSWER KEY

    Question Letter Page

    CHAPTER 22
    number answer cited Header cited
    22–1 d p. 422 Fetal Lie
    22–2 c p. 422 Fetal Presentation
    22–3 a p. 422 Figure 22-1
    22–4 d p. 422 Figure 22-1
    22–5 a p. 422 Cephalic Presentation
    22–6 c p. 422 Cephalic Presentation
    22–7 b p. 422 Breech Presentation
    22–8 a p. 423 Figure 22-2
    22–9 b p. 423 Figure 22-2
    22–10 d p. 424 Figure 22-3
    22–11 d p. 424 Figure 22-3
    22–12 b p. 424 Leopold Maneuvers
    22–13 a p. 425 Figure 22-5
    22–14 b p. 425 Figure 22-6
    22–15 d p. 426 Leopold Maneuvers
    22–16 c p. 427 Engagement
    22–17 c p. 429 Figure 22-12
    22–18 b p. 431 Occiput Posterior Presentation
    22–19 a p. 431 Figure 22-16
    22–20 d p. 432 First Stage of Labor
    22–21 d p. 433 Active Phase
    22–22 b p. 434 Second Stage of Labor
    22–23 c p. 434 Second Stage of Labor
    22–24 b p. 434 Table 22-2
    22–25 d p. 435 Identification of Labor
    22–26 c p. 435 Ruptured Membranes
    22–27 d p. 435 Cervical Assessment
    22–28 d p. 436 Cervical Assessment
    22–29 b p. 436 Intrapartum Fetal Monitoring
    22–30 d p. 438 Urinary Bladder Function
    22–31 a p. 439 Labor Management Protocols
    22–32 b p. 439 Labor Management Protocols
    156

    CHAPTER 23

    Abnormal Labor

    23–1. Which of the following may be responsible for 23–6. Incoordinate uterine dysfunction refers to which of
    dystocia in labor? the following?
    a. Bony pelvis abnormalities a. The pressure gradient is distorted
    b. Inadequate expulsive forces b. Basal uterine tone is appreciably elevated
    c. Soft tissue abnormalities of the reproductive tract c. A more forceful contraction of the uterine
    d. All of the above midsegment than the fundus
    d. All of the above
    23–2. The majority of labor dystocia is due to which of the
    following? 23–7. The Montevideo group concluded that which of
    a. Asynclitism the following was the lowest contraction pressure
    necessary to cause cervical dilation?
    b. Fetal macrosomia
    a. 15 mmHg
    c. Childhood rickets
    b. 45 mmHg
    d. Premature rupture of membranes
    c. 60 mmHg
    23–3. Which of these factors influences the progress of d. 180 mmHg
    labor?
    a. Prominent coccyx 23–8. When is the latent phase considered prolonged?
    b. Pubic symphyseal separation a. 14 hours in nullipara
    c. Forward pressure by the leading fetal part b. 20 hours in mulitpara
    d. Cervical dilation at the time of rupture of c. 10 hours in multipara
    membranes d. None of the above

    23–4. Since the 1960s, what significant advancement has 23–9. Which of the following is a protraction disorder?
    been made in treating dysfunctional labor? a. Prolonged active phase
    a. Early artificial rupture of membranes b. Protracted latent phase
    b. Use of prostaglandins for cervical ripening c. Prolonged deceleration phase
    c. Movement toward vacuum-assisted delivery in d. Protracted active phase dilation
    the setting of midpelvic arrest
    d. Realization that prolonged labor may lead to 23–10. The World Health Organization has proposed a
    increased perinatal and maternal morbidity labor management partograph in which protraction
    is defined as ___ cm/hr cervical dilation for a
    23–5. Uterine contractions in normal labor are minimum of ___ hours.
    characterized by which of the following? a. 1, 3
    a. Fundal dominance b. 2, 4
    b. Contractions migrate from caudad to cephalad c. 1, 4
    c. Pressure of an average spontaneous contraction is d. 2, 3
    15 mmHg
    d. Force of contractions is greatest at the lower
    uterine segment
    Abnormal Labor 157

    23–11. What are the Montevideo units in the tracing below?

    CHAPTER 23
    a. 50
    b. 109 23–14. Which of the following statements is true comparing
    c. 142 the Zhang versus Friedman curve?
    d. 199 10
    Friedman (1955)
    Zhang (2002)
    23–12. What is the threshold for adequate uterine 8
    contractions?
    Cervical dilation (cm)

    a. 180 Montevideo units


    6
    b. 200 Montevideo units
    c. Contractions every 2 minutes
    4
    d. Five contractions in a 10-minute period

    23–13. Which of the following statements comes from the 2


    Obstetric Care Consensus Committee of 2016?
    a. The threshold for active labor is 4 cm.
    0
    b. A protraction disorder is an indication for a cesar- 1 2 3 4 5 6 7 8 9 10 11 12 13
    ean delivery. Duration of labor (hours)

    c. A prolonged latent phase is not an indication for Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Abnormal labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 23-3.
    cesarean delivery.
    d. Active phase arrest cannot be considered until
    a. The Friedman curve begins to flatten at 3–4 cm.
    the patient is 4 cm dilated and membranes are
    ruptured. b. In the Zhang curve the active phase of labor
    begins at 6 cm.
    c. In the Friedman curve the active phase of labor
    begins at 6 cm.
    d. All of the above

    23–15. Which of the following accurately compares neur-


    axial and intravenous analgesia?
    a. Time to delivery is lower with neuraxial analgesia.
    b. Oxytocin augmentation was higher in the intrave-
    nous analgesia group.
    c. Cesarean delivery rates are greater in the intrave-
    nous analgesia group.
    d. None of the above
    158 Labor

    23–16. A 26-year-old multigravida at 40 weeks’ gestation 23–21. Which of the following is false regarding premature
    presents in labor at 6 cm. On repeat exam 4 hours rupture of membranes at term?
    later, she is still 6 cm. What other piece of information a. Premature rupture of membranes complicates 8%
    would you like to help determine your next step?
    SECTION 7

    of pregnancies.
    a. If she has any analgesia b. Oxytocin induction leads to lower rates of
    b. The estimated fetal weight chorioamnionitis.
    c. If her membranes are ruptured c. Prophylactic antibiotics do not significantly lower
    d. If her contractions are adequate the rates of chorioamnionitis.
    d. The cesarean delivery rate is lower in women who
    23–17. Regarding the patient in Question 23–16, you are induced rather than managed expectantly.
    determine she has not had any analgesia, she
    is unruptured, and her contractions total 100 23–22. Precipitous labor may result from which of the
    Montevideo units. What is the next best course of following?
    action? a. Absence of painful sensations
    a. Place neuraxial anesthesia b. Abnormally strong uterine contractions
    b. Augmentation with oxytocin c. Abnormally low resistance of the soft parts of the
    c. Provide intravenous analgesia birth canal
    d. Proceed with cesarean delivery d. All of the above

    23–18. Which of the following statements regarding the 23–23. A 34-year-old multiparous woman presents in active
    second stage of labor is false? labor at 38 weeks’ gestation. She reports onset of
    a. A prolonged first stage of labor correlates with a contractions 1 hour ago and is 8 cm dilated on
    longer second stage. admission. She delivers an infant 1 hour later. What
    maternal risk is associated with precipitous labor?
    b. No adverse maternal or neonatal outcomes are
    linked to delayed pushing. a. Nerve injury
    c. The maximum length of time all women should b. Uterine atony
    spend in the second stage of labor is 4 hours. c. Retained placenta
    d. Multiparous women should be allowed to push d. Bladder dysfunction
    for 2 hours prior to diagnosing a second-stage
    labor arrest. 23–24. The infant delivered in Question 23–23 is at
    increased risk for which of the following?
    23–19. In laboring nulliparous women, fetal station above 0 a. Sepsis
    at the time of admission is associated with which of
    the following? b. Brachial plexus palsy
    a. A 25% cesarean rate c. Meconium aspiration
    b. A 50% cesarean rate d. Continuous positive airway pressure at birth
    c. An 86% cesarean rate 23–25. In obstetrics, which of the following defines a
    d. A higher cesarean rate than if the head is engaged contracted pelvic inlet?
    a. A transverse diameter <12 cm
    23–20. Which of the following statements is true concerning
    chorioamnionitis in labor? b. An obstetric conjugate <10 cm
    a. Chorioamnionitis is associated with prolonged c. A diagonal conjugate <11.5 cm
    labor. d. An anteroposterior diameter <12 cm
    b. Chorioamnionitis in early labor is a consequence
    of dysfunctional labor. 23–26. Which of the following statements is true regarding
    contraction of the midpelvis?
    c. Chorioamnionitis in the late stage of labor
    increases the risk for cesarean delivery. a. It is less common than inlet contraction.
    d. All of the above b. It causes transverse arrest of the fetal head.
    c. It is suspected when the interspinous diameter is
    <11 cm.
    d. It can be inferred when there are parallel vaginal
    sidewalls.
    Abnormal Labor 159

    23–27. Which interischial tuberous diameter measurement a. Most cesarean deliveries occurred in women with
    serves as the threshold to define pelvic outlet macrosomic infants.
    contraction? b. Fetal size appears to be the significant contributor

    CHAPTER 23
    a. 7 cm to failed forceps deliveries.
    b. 8 cm c. Malposition of the fetal head is a contributing
    c. 9 cm factor to obstruction through the birth canal.
    d. 10 cm d. None of the above

    23–28. A 29-year-old primigravida presents for prenatal 23–31. Which of the following statements is true concerning
    care at 10 weeks’ gestation. She reports a history of a face mentum posterior presentations?
    pelvic fracture 1 year ago. Which of the following is a. Most will convert to mentum anterior.
    the most likely etiology of her fracture? b. Fetal macrosomia is the biggest risk factor.
    a. Fall c. Forceps should be applied when the station is +2.
    b. Assault d. A persistent mentum posterior presentation is
    c. Gunshot wound never deliverable.
    d. Automobile collision
    23–32. This image illustrates which fetal presentation?
    23–29. The patient in Question 23–28 reports she was told
    she could never have a vaginal delivery. Which of the
    following is true?
    a. Healing requires 8–12 weeks, so she can have a
    vaginal delivery.
    b. If she has hardware in her pelvis she cannot have
    a vaginal delivery.
    c. Hyperflexion of her hips during pushing may
    re-damage her pelvis.
    d. If imaging shows any malalignment, she will have
    to undergo cesarean delivery.

    23–30. The graphic below demonstrates the prevalence


    of cesarean deliveries after a failed forceps delivery
    attempt plotted against fetal birthweight. Which of
    the following is true regarding this data?

    25

    20
    Percent

    15
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    10 Abnormal labor. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014, Figure 23-6.

    5 a. Face presentation
    b. Brow presentation
    0 c. Occiput presentation
    9

    9
    9

    d. Anteroposterior presentation
    79

    09

    99

    39

    89
    39

    69

    59
    –2

    –3

    –3

    –4

    –4
    –3

    –3

    –4
    00

    00

    00

    00
    00

    00

    00

    00
    25

    28

    37

    40
    31

    34

    43

    46

    Birthweight
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Abnormal labor. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014, Figure 23-5.
    160 Labor

    23–33. Which statement below is accurate concerning the 23–35. Which of the following are complications of labor
    following presentation? dystocia?
    a. Infection
    SECTION 7

    b. Uterine rupture
    c. Hysterotomy incision extensions
    d. All of the above

    23–36. A 24-year-old multigravida at 41 weeks’ gestation


    with a body mass index of 38 kg/m2 progresses
    through the first stage of labor and becomes
    complete at +2 station. She pushes for about 3 hours
    with neuraxial anesthesia. She delivers a 4200-gram
    infant with the assistance of forceps. The next day
    your patient reports lower extremity weakness with
    foot drop and pain. What is the most likely cause?
    a. Obesity
    b. Prolonged second stage
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Abnormal labor. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 23-10.
    c. Forceps-assisted vaginal delivery
    d. Complication of neuraxial anesthesia
    a. There is an increased risk of prolapsed cord.
    b. This malpresentation will most likely be relieved
    with classical cesarean.
    c. This represents a complication of persistent
    transverse presentation in labor.
    d. All of the above

    23–34. Which statement concerning the following labor


    complication is true?

    Used with permission from Dr. Elizabeth Mosier.

    a. This is a composite presentation.


    b. The forearm is frequently injured in this
    presentation.
    c. In most cases the infant will deliver vaginally
    without difficulty.
    d. The infant will sometimes withdraw its hand if
    “pinched” by the delivering obstetrician.
    162

    CHAPTER 24

    Intrapartum Assessment

    24–1. Which portion of the fetal electrocardiogram is most 24–5. The NICHD Workshop standardized fetal heart
    reliably detected? rate interpretation in 2008. Which of the following
    a. P wave factors makes interpreting fetal heart rate tracings
    difficult?
    b. T wave
    a. Paper speed at 3 cm/min
    c. R-wave peaks
    b. Interobserver agreement is low
    d. QRS complex
    c. Use of standardized terminology
    24–2. Which of the following is true regarding fetal heart d. Use of external monitors instead of internal
    monitoring through a fetal scalp electrode? monitors
    a. Heart rate is determined via time between R waves.
    24–6. Which of the following are descriptive characteristics
    b. The maternal heart rate is also detected, but
    of the fetal baseline heart rate?
    masked.
    a. Rate
    c. In the setting of an intrauterine fetal demise, the
    maternal heart rate will be recorded. b. Variability
    b. All of the above c. Distinct patterns
    d. All of the above
    24–3. Current fetal monitors can detect which of the
    following? 24–7. How is the fetal heart rate baseline determined?
    a. Maternal heart rate a. Is determined over a 10-minute period
    b. Maternal pulse oximetry b. Increases with advancing gestational age
    c. Separate heart rates for a twin gestation c. Is rounded to increments of 10 beats/minute
    d. All of the above d. Minimum duration needed in a 10-minute period
    is 5 minutes
    24–4. Which of the following statements is true regarding
    the fetal heart rate pattern shown below?

    a. Does not require gel to obtain


    b. Is not more difficult in obese women
    c. Can be placed anywhere on the maternal abdomen
    d. Uses ultrasound waves to detect the fetal heart rate
    Intrapartum Assessment 163

    24–8. What fetal heart rates defines fetal bradycardia and


    fetal tachycardia, respectively?
    a. <100 and >170

    CHAPTER 24
    b. <110 and >170
    c. <110 and >160
    d. <120 and >160

    24–9. A 24-year-old primigravida at 41 weeks’ gestation is


    undergoing induction of labor. She is currently on
    intravenous oxytocin and reports abdominal pain
    that is not relieved by her epidural. The nurse calls
    you for the fetal heart rate pattern seen below. What
    is the likely etiology?

    Used with permission from Dr. Travis Sims.

    a. Fetal heart block


    b. Rapid fetal descent
    c. Placental abruption
    d. Maternal hypothermia

    24–10. What is the most common cause of fetal tachycardia?


    a. Maternal pain
    b. Chorioamnionitis
    c. Maternal terbutaline
    d. Fetal supraventricular tachycardia

    24–11. What is the single most reliable sign of fetal


    compromise?
    a. Decelerations
    b. Fetal tachycardia
    c. Change in baseline
    d. Reduced variability
    164 Labor

    24–12. A 28-year-old primigravida is undergoing induction


    of labor. She experienced rupture of membranes
    20 hours ago, and her cervical exam indicates she is
    7 cm dilated. She receives intravenous butorphanol
    SECTION 7

    for pain. Which of the following is the etiology of


    the fetal heart rate variability seen below?

    a. Active labor
    b. Butorphanol
    c. Oligohydramnios
    d. Chorioamnionitis

    24–13. Which of the following statements concerning fetal 24–16. All except which of these statements is true regarding
    arrhythmias is true? fetal heart rate accelerations?
    a. Are usually tachyarrhythmias a. Represent intact neurohormonal cardiovascular
    b. Are an indication for cesarean delivery control mechanisms
    c. May hinder interpretation of the fetal heart rate b. Occur with fetal movement, scalp stimulation,
    tracings and acoustic stimulation
    d. All of the above c. Is considered prolonged if it is ≥2 minutes but
    <10 minutes in duration
    24–14. Sinusoidal fetal heart rate patterns are best described d. At all gestational ages the peak is ≥15 beats per
    by which of the following statements? minute above the baseline
    a. Can be due to fetal sucking
    24–17. A deceleration that begins after the peak of the
    b. Observed with mild fetal anemia contraction and returns to baseline after the
    c. Frequency cycle of 2–5 cycles/minute contraction ends is which of the following?
    d. Baseline heart rate must be <120 beats/minute a. Late
    b. Early
    24–15. Which of the following defines fetal heart rate
    decelerations as recurrent? c. Variable
    a. Occurring with ≥50% of contractions in a d. Prolonged
    10-minute period.
    b. Occurring with ≥50% of contractions in a
    20-minute period.
    c. Occurring with >50% of contractions in a
    10-minute period.
    d. Occurring with >50% of contractions in a
    20-minute period.
    Intrapartum Assessment 165

    24–18. Which type of deceleration is pictured below?

    CHAPTER 24
    a. Late
    b. Early
    c. Variable
    d. Prolonged

    24–19. According to the American College of Obstetricians 24–22. Which of the following statements is true regarding
    and Gynecologists, which of the following variable fetal heart rates in the second stage of labor?
    decelerations are abnormal? a. Decelerations in the second stage of labor are
    a. Deep variables ubiquitous.
    b. Variables lasting >30 seconds b. If there is absent variability for longer than
    c. Variables with absent variability 4 minutes, acidemia can be predicted.
    d. Variables that take >30 seconds to reach their nadir c. As the number of decelerations <30 beats per
    minute increases, the 5-minute Apgar score
    24–20. Which physiologic event results in initial decreases.
    compensatory rise in the fetal heart rate during d. All of the above
    a variable deceleration?
    a. Acute increase in uterine tone 24–23. What effect do admission fetal monitoring programs
    have on low-risk women?
    b. Occlusion of the umbilical vein
    a. Improve neonatal outcomes
    c. Occlusion of the umbilical artery
    b. Decrease the number of interventions
    d. Occlusion of all umbilical vessels
    c. Increase the number of cesarean deliveries
    24–21. A 25-year-old primigravida at 38 weeks’ gestation is d. Decrease the number of operative deliveries
    in the second stage of labor. Her fetal heart tracing is
    depicted below. Which of the following characteristics
    of the tracing increases her risk for fetal compromise?

    Used with permission from Dr. Noelle Zavala.

    a. Normal baseline
    b. Fetal tachycardia
    c. Absent variability
    d. All of the above
    166 Labor

    24–24. Which of the following is true for fetal scalp 24–29. Current guidelines from the American College
    stimulation? of Obstetricians and Gynecologists recommend
    a. Accelerations predict a pH >7.2 which of following regarding intrapartum neonatal
    suctioning in the presence of meconium?
    SECTION 7

    b. Cannot be used in preterm infants


    a. Should be routinely performed in all infants
    c. Lack of an acceleration predicts a pH <7.2
    b. A credentialed team in neonatal resuscitation
    d. Cannot be used as a substitute for fetal scalp should be available
    blood sampling
    c. Routine intrapartum suctioning decreases the
    incidence of meconium aspiration syndrome
    24–25. The use of fetal pulse oximetry has been shown to
    do which of the following? d. None of the above
    a. Have no effect on the cesarean delivery rate
    24–30. In which of the following scenarios does the
    b. Increase the cesarean delivery rate for dystocia American College of Obstetricians and Gynecologists
    c. Increase the cesarean delivery rate for nonreassuring endorse amnioinfusion?
    status a. Meconium
    d. Decrease the cesarean delivery rate for nonreassuring b. Oligohydramnios
    status
    c. Variable decelerations
    24–26. Why are the terms reassuring and nonreassuring d. All of the above
    imprecise and controversial?
    a. Patterns change rapidly during labor. 24–31. The American College of Obstetricians and
    Gynecologists recommends collection of umbilical
    b. The terms are subjective and without definition. cord blood gases for which of the following
    c. The terms reflect physiology rather than conditions?
    pathology. a. Low 5-minute Apgar score
    d. All of the above b. Abnormal fetal heart rate tracing
    24–27. In 2008, the National Institute of Child Health c. Severe intrauterine growth restriction
    and Human Development convened a conference d. All of the above
    and constructed a three-tiered system for fetal heart
    rate pattern classification. Which of the following 24–32. Which of the following statements are true
    accurately characterizes the different tiers? concerning new uterine contraction terminology?
    a. Category I: absence of early decelerations and a. Hyperstimulation has been abandoned.
    presence of normal baseline variability b. Tachysystole is defined as >5 contractions in
    b. Category II: presence of recurrent late 10 minutes averaged over 30 minutes.
    decelerations and absent baseline variability c. Normal uterine activity is defined as ≤5
    c. Category III: presence of recurrent variable contractions in 10 minutes averaged over a
    decelerations and normal baseline variability 30-minute period.
    d. None of the above d. All of the above

    24–28. Since the introduction of the new National


    Institute of Child Health and Human Development
    classification of fetal heart rate patterns, which of the
    following is true regarding its effect on perinatal and
    maternal morbidity?
    a. Cesarean delivery rates have declined.
    b. Identification of fetal acidosis is easier.
    c. Neonatal morbidity rates have declined.
    d. There is not a consensus on interpretation and
    management recommendations for fetal heart rate
    patterns.
    Intrapartum Assessment 167

    CHAPTER 24 ANSWER KEY

    Question Letter Page

    CHAPTER 24
    number answer cited Header cited
    24–1 c p. 458 Internal (Direct) Electronic Monitoring
    24–2 d p. 458 Internal (Direct) Electronic Monitoring
    24–3 d p. 459 Internal (Direct) Electronic Monitoring
    24–4 d p. 458 External (Indirect) Electronic Monitoring
    24–5 b p. 459 Fetal Heart Rate Patterns
    24–6 d p. 459 Baseline Fetal Heart Activity
    24–7 a p. 459 Baseline Fetal Heart Activity
    24–8 c p. 460 Table 24-1
    24–9 c p. 461 Baseline Fetal Heart Activity
    24–10 b p. 461 Baseline Fetal Heart Activity
    24–11 d p. 462 Baseline Fetal Heart Activity
    24–12 b p. 462 Baseline Fetal Heart Activity
    24–13 c p. 462 Baseline Fetal Heart Activity
    24–14 c p. 464 Baseline Fetal Heart Activity
    24–15 b p. 465 Periodic Fetal Heart Rate Changes
    24–16 d p. 465 Periodic Fetal Heart Rate Changes
    24–17 a p. 466 Periodic Fetal Heart Rate Changes
    24–18 c p. 466 Periodic Fetal Heart Rate Changes
    24–19 c p. 467 Periodic Fetal Heart Rate Changes
    24–20 b p. 467 Periodic Fetal Heart Rate Changes
    24–21 c p. 469 Fetal Heart Rate Patterns During Second-Stage Labor
    24–22 a p. 469 Fetal Heart Rate Patterns During Second-Stage Labor
    24–23 c p. 469 Admission Fetal Monitoring in Low-Risk Pregnancies
    24–24 a p. 470 Scalp Stimulation
    24–25 a p. 471 Fetal Pulse Oximetry
    24–26 d p. 472 Nonreassuring Fetal Status
    24–27 a p. 473 Table 24-2
    24–28 d p. 473 Diagnosis
    24–29 b p. 474 Meconium in Amnionic Fluid
    24–30 c p. 476 Management Options
    24–31 d p. 477 Fetal Heart Rate Patterns and Brain Injury
    24–32 d p. 480 Uterine Contraction Terminology
    214

    CHAPTER 32

    The Newborn Infant

    32–1. After delivery, clearance of the amnionic fluid that 32–4. Which of the following is true regarding neonatal
    fills the fetal lungs occurs via which of the following resuscitation?
    mechanisms? a. Approximately 1% of newborns need extensive
    a. Physical compression of the fetal thorax resuscitation after delivery.
    b. Absorption of fluid into the neonatal pulmonary b. Newborns delivered at home face risk of death
    circulation that is 5-fold that of newborns delivered in the
    c. Absorption of fluid into the neonatal pulmonary hospital.
    lymphatic system c. Approximately 30% of newborns require some
    d. All of the above degree of active resuscitation to stimulate
    breathing.
    32–2. Which of the following postnatal changes promotes d. All of the above
    closure of the ductus arteriosus in the newborn?
    a. Fall in pulmonary arterial blood pressure 32–5. How can primary and secondary apnea in the
    newborn be distinguished from each other?
    b. Fall in cardiac output from reduced preload after
    umbilical cord clamping a. Stimulation usually reverses primary apnea.
    c. Increase in pulmonary vascular compression after b. Secondary apnea is accompanied by a fall in heart
    lung aeration from neonatal inspiration rate and primary is not.
    d. All of the above c. Secondary apnea is accompanied by loss of
    neuromuscular tone and primary is not.
    32–3. Which of the following is not a benefit of delayed d. All of the above
    cord clamping, as pictured below?
    32–6. A 26-year-old multigravida presents in spontaneous
    labor at 39 weeks 3 days. She had spontaneous
    rupture of membranes with clear amnionic fluid and
    delivered spontaneously with a category I fetal heart
    rate tracing. The neonate was vigorous and crying
    immediately after delivery. What is the next best step
    in the management of this newborn?
    a. Bulb suctioning of oropharyngeal secretions
    b. Cord clamping and transfer to the radiant warmer
    c. Placement on maternal abdomen for drying and
    evaluation of tone, heart rate, and respiratory effort
    d. Hold infant in fully supported prone position
    and deliver 3 gentle back thumps to aid in initial
    secretion clearance.

    32–7. Although initially vigorous and crying, the newborn


    a. Increased iron stores in Question 32–6 became apneic with a heart rate
    b. Reduced risk of neonatal bradycardia that was 90 beats per minute at 50 seconds of life.
    c. Reduced hyperbilirubinemia and need for The following is most appropriately initiated?
    phototherapy a. Secretions are suctioned
    d. Reduced necrotizing enterocolitis in preterm b. Positive pressure ventilation is administered
    neonates c. Newborn is stimulated, and head placed in the
    sniffing position
    d. All of the above
    The Newborn Infant 215

    32–8. The newborn in Question 32–6 was given positive 32–11. Which site in the image below depicts the correct
    pressure ventilation. Nonetheless, the newborn’s location of fingers for chest compressions in the
    heart rate at 80 seconds of life is 86 beats per neonate?

    CHAPTER 32
    minute. What is the next most appropriate step?
    a. Chest compressions
    b. Placement of an endotracheal tube
    c. Placement of an umbilical vein catheter
    d. Mask adjustment and airway repositioning

    32–9. A preterm neonate born at 29 weeks’ gestation is


    undergoing resuscitation and requires endotracheal
    ventilation. Which of the following is most correct
    regarding endotracheal tube– assisted ventilation of
    this newborn?
    a. Positive pressure ventilation is delivered at a rate
    of 30 breaths per minute.
    b. Opening pressure of 30–40 cm H2O, greater than
    that for a term neonate, is typical.
    c. Methods of confirming tracheal intubation Used with permission from Dr. David Nelson.

    include detection of end-tidal CO2, increasing


    fetal heart rate, and visualization of symmetric a. A
    chest wall motion. b. B
    d. All of the above c. C
    d. None of the above
    32–10. When chest compressions are indicated for newborn
    resuscitation, which of the following best describes 32–12. If the neonate’s heart rate remains less than or equal
    the technique? to 60 beats per minute after adequate ventilation
    a. Compressions are delivered at a 2:1 ratio with and chest compressions, which of the following is a
    ventilation recommended pharmacological intervention?
    b. Two hands encircle the chest of the neonate with a. Epinephrine delivered via endotracheal tube at
    two thumbs used to deliver compressions 0.05–0.1 mg/kg
    c. Compression depth is approximately one half of b. Epinephrine delivered intravenously at
    the anterior-posterior diameter of the neonate’s 0.05–0.1 mg/kg
    chest c. Ephedrine delivered via endotracheal tube at
    d. All of the above 0.05–0.1 mg/kg
    d. Ephedrine delivered intravenously at
    0.01–0.03 mg/kg

    32–13. Which of the following statements are true regarding


    Apgar scores?
    a. Apgar score assesses 5 characteristics and either
    0 or 2 points are awarded.
    b. Apgar score effectively assesses newborn health
    and effectiveness of resuscitation.
    c. Five-minute Apgar score is predictive of neonatal
    survival in term but not preterm neonates.
    d. In term neonates, Apgar score <7 at 5 minutes
    can be used to correlate a hypoxic event as a cause
    of cerebral palsy.
    216 The Newborn

    32–14. A term newborn has a heart rate of 128 beats per 32–18. A 27-year-old primigravida at 33 weeks’ gestation
    minute, is pink except for her feet and hands, is has been on the antepartum unit for 6 days for
    crying spontaneously and loudly, and is kicking preterm rupture of membranes. An image from
    both legs. What is her Apgar score? her admission ultrasound is shown below. You
    SECTION 9

    a. 7 get a stat page from the nurse informing you the


    patient is being wheeled over emergently with cord
    b. 8
    prolapse. Emergent cesarean delivery is performed
    c. 9 with delivery approximately 24 minutes from the
    d. 10 prolapse. Umbilical artery cord blood gas results are:
    pH 6.95, pCO2 90 mmHg, HCO3- 18 mEq/L, and
    32–15. Which of the following may impact the Apgar score? base deficit 8 mEq/L. One-minute Apgar score is 3
    a. Prematurity and five-minute Apgar score is 8. After the case you
    find her family to review the events. Which of the
    b. Fetal malformation
    following is an appropriate statement?
    c. Maternal medications
    d. All of the above

    32–16. You receive an emergent consultation from the


    trauma department. Ms. Omega was brought in via
    emergency medical transport after a motor vehicle
    collision. She has a tourniquet around her left upper
    arm proximal to an apparent traumatic amputation
    at the elbow. Another individual from the accident
    is awake and alert and states that Ms. Omega is 39
    weeks pregnant and was on the way to the hospital
    for labor. You quickly perform an exam and note
    that the fetal head is at the perineum. Delivery is
    accomplished easily and on initial survey the neonate
    is pale with no respiratory effort or response to
    stimulation, and has a pulse of 80 beats per minute.
    An umbilical cord blood gas is obtained. Which of
    the following is most likely given the history? a. Findings are consistent with a metabolic acidosis
    a. Base deficit is 14 mEq/L b. Findings suggest that the low pH was related to
    an acute event
    b. Umbilical artery pH is 7.19
    c. One-minute Apgar score is 3 c. Findings suggest high likelihood of a
    hypoxic-ischemic encephalopathy
    d. Respiratory acidemia is present
    d. All of the above
    32–17. How do normal umbilical cord blood gas results
    differ between umbilical venous and umbilical
    arterial samples?
    a. HCO3- is higher in a venous sample
    b. The pCO2 is lower in a venous sample
    c. The pH is higher in an arterial sample
    d. The base excess is lower in an arterial sample
    The Newborn Infant 217

    32–19. A 23-year-old primigravida at 38 weeks’ gestation 32–21. Ms. Smith presents for her 6-week postpartum visit.
    presents to labor and delivery after a witnessed seizure She is doing well, and is excited to show you her
    at home. Her initial blood pressure is 130/80 mmHg, newborn daughter, who is doing well overall. She

    CHAPTER 32
    and pulse is 140 beats per minute. The fetal heart has noticed some eye drainage the last few days, and
    rate tracing shows a heart rate of 100 beats per you observe the findings depicted below. Which of
    minute, absent variability, and late decelerations. the following statements is true?
    She is having frequent contractions, and exam shows
    she is 3 cm dilated. She is taken back for emergent
    cesarean delivery, and bloody fluid is noted upon
    uterine entry. Placental findings are depicted below.
    Umbilical artery blood gas pH is 6.9 and base deficit
    is 14 mEq/L. Five-minute Apgar score is 2. Which
    of the following statements is evidence-based?

    Reproduced with permission from Levsky ME, DeFlorio P: Ophthalmologic complica-


    tions. In Knoop KJ, Stack LB, Storrow AB, et l (eds): The Atlas of Emergency Medicine,
    3rd ed. New York, McGraw-Hill, 2010, Figure 2-1.

    a. Prophylactic topical eye treatments given to the


    neonate do not reliably reduce the incidence of
    chlamydial conjunctivitis.
    b. 12–25% of neonates delivered vaginally of moth-
    ers with chlamydia will develop conjunctivitis,
    but this manifests within 3 weeks of delivery.
    Used with permission from Dr. Anne Ambia. c. Some form of conjunctivitis affects 1–12% of all
    neonates, but gonococcal and chlamydial infections
    a. Speed of resolution of the acidemia after birth is are among the least common.
    associated with outcome. d. All of the above
    b. There is a high likelihood of multiorgan dysfunc-
    tion in this neonate. 32–22. During her prenatal care, Ms. Oliver is noted to
    c. These initial findings are poorly predictive of be positive for both hepatitis B surface antigen and
    subsequent neurological impairment. hepatitis B e antigen. Which of the following is the
    d. All of the above are evidence-based statements most appropriate evaluation and management of her
    related to the details of this case. term newborn?
    a. Neonatal hepatitis B viral load to guide
    32–20. Ms. Cox was treated for Neisseria gonorrhoeae subsequent management
    3 weeks prior to presentation for a term vaginal b. Administration of hepatitis B immune globulin as
    delivery. She reports several episodes of unprotected passive immunization after delivery
    intercourse since then, and does not feel confident c. Administration of hepatitis B immune globulin
    that her partner sought treatment as recommended. after delivery and administration of the first dose
    Which of the following is the most appropriate of the hepatitis B vaccine series prior to discharge
    initial intervention for her neonate?
    d. Administration of hepatitis B immune globulin if
    a. Test for gonococcal and chlamydial infection mother is planning lactation, and administration
    b. Single dose ceftriaxone 100 mg/kg intramuscular of the first dose of the hepatitis B vaccine series
    injection prior to discharge
    c. Single application of 1% silver nitrate solution to
    both eyes
    d. Single application of 0.5% erythromycin
    ointment to both eyes
    218 The Newborn

    32–23. Why is the infant below receiving an injection of 32–25. During her first trimester, Ms. Harris traveled to
    vitamin K within 1 hour of birth? a country that is known to be an endemic area for
    Zika virus. Subsequently her serological testing was
    positive. Ultrasound surveillance of the fetus has
    SECTION 9

    been performed, including the 32-week assessment


    of fetal head biometrics shown here. Which of the
    following is not included in the recommended neo-
    natal evaluation?

    a. To enhance newborn bone development


    b. To prevent vitamin K–dependent hemorrhagic
    disease of the newborn
    c. To reduce the incidence of necrotizing enterocoli-
    tis in premature infants
    d. To augment the lower vitamin K levels noted in a. Newborn neurological assessment
    breast milk compared to commercially produced
    b. Neonatal Zika virus laboratory testing
    infant formula
    c. Neonatal magnetic resonance imaging
    32–24 Which of the following is the most accurate d. Standard newborn hearing screen prior to
    statement regarding newborn screening? discharge
    a. Newborn screening panels are consistent across
    the United States.
    b. The United States federal government mandates
    newborn screening.
    c. The American Academy of Pediatrics dictates the
    content of the newborn screening panel.
    d. None of the above
    The Newborn Infant 219

    32–26. Ms. Blake comes to see you on postpartum day 5 for 32–27. A 31-year-old primigravida undergoes a spontaneous
    a blood pressure check. She had a spontaneous vagi- vaginal delivery at 40 weeks’ gestation, delivering
    nal delivery at term complicated by preeclampsia and a female infant weighing 7 lb 9 oz. They are both

    CHAPTER 32
    chorioamnionitis. The neonate never had a fever and discharged home on postpartum day 2. She has been
    has been feeding, voiding, and stooling well since home for 2 days and calls your office worried that
    discharge. Ms. Blake shows you the umbilical cord the baby weighs 7 lb today. What is the most
    stump, which is depicted below. What is the appro- appropriate response?
    priate response to her concern?

    Used with permission from Kelly Yanes. Used with permission from Dr. David Nelson.

    a. Provide reassurance of the normal finding with a. If any further weight loss occurs, supplement
    no new recommendations. breastfeeding with formula until her weight
    stabilizes.
    b. Recommend covering the stump with petroleum
    jelly and a gauze pad to hasten cord separation. b. Recommend converting to a high calorie
    commercial formula and schedule a weight check
    c. Recommend she proceed to the emergency
    with the pediatrician in 3 days.
    room due to concern for necrosis and need for
    resection. c. This amount of weight loss is within expectations.
    d. Recommend she proceed to her pediatrician’s Observe wet diapers and continue breastfeeding
    office due to concern for omphalitis with need for with expectation to regain birthweight by
    antibiotics. 10 days.
    d. None of the above

    32–28. The American College of Obstetricians and Gyne-


    cologists recommend exclusive breastfeeding for how
    long?
    a. 1 month
    b. 3 months
    c. 6 months
    d. 12 months

    32–29. Passage of meconium in the delivery room is associ-


    ated with which of the following?
    a. Necrotizing enterocolitis
    b. Gastrointestinal tract patency
    c. Fetal distress and lower Apgar score
    d. Increased risk for Hirschsprung disease
    220 The Newborn

    32–30. Ms. Lewis is pregnant with a male fetus. She asks 32–32. Which of the following is true regarding hospital
    you about circumcision. Which of the following is stay after delivery?
    not true? a. Early discharge is associated with increased
    a. Newborn male circumcision rate is estimated to
    SECTION 9

    neonatal mortality.
    be approximately 55% in the latest Centers for b. Early discharge is associated with increased
    Disease Control report. neonatal readmission rates for dehydration and
    b. Circumcision lowers the incidence of human jaundice.
    papilloma virus related penile cancer in males and c. The Newborns’ and Mothers’ Health Protection
    cervical cancer in their partners. Act of 1996 prohibits insurers from restricting
    c. In their 2012 policy statement, the American hospital stays to less than 2 days for vaginal
    Academy of Pediatrics Task Force on Circumcision delivery or 4 days for cesarean delivery.
    concluded that health benefits of male circumcision d. All of the above
    outweigh risks and recommended the procedure
    for all newborns.
    d. All of the above

    32–31. You are teaching a new intern about male circumcision.


    Which of the following points is least important in
    safe surgical technique?
    a. Never use injectable local analgesia with a
    vasoactive compound such as epinephrine.
    b. The Mogen technique is associated with less
    apparent discomfort for the newborn.
    c. Newborn circumcision is an elective procedure to
    be performed only on healthy neonates with no
    family history of a bleeding disorder.
    d. Careful inspection of the external genitalia is
    imperative to rule out any congenital disorders
    that are contraindications to routine circumcision.
    The Newborn Infant 221

    CHAPTER 32 ANSWER KEY

    Question Letter Page

    CHAPTER 32
    number answer cited Header cited
    32–1 d p. 607 Transition to Air Breathing
    32–2 a p. 607 Transition to Air Breathing
    32–3 c p. 607 Transition to Air Breathing
    Umbilical Cord Clamping
    32–4 a p. 607 Newborn Resuscitation
    32–5 a p. 608 Newborn Resuscitation
    32–6 c p. 608 Resuscitation Protocol
    32–7 d p. 609 Figure 32-2
    32–8 d p. 610 Table 32-1
    32–9 c p. 608 Alternative Airway
    32–10 b p. 609 Chest Compressions
    32–11 c p. 609 Chest Compressions
    32–12 a p. 610 Epinephrine
    32–13 b p. 610 Apgar Score
    32–14 c p. 610 Apgar Score
    32–15 d p. 611 Apgar Score
    32–16 a p. 611 Fetal Acid–Base Physiology
    32–17 b p. 612 Table 32-3
    32–18 b p. 612 Figure 32-4
    p. 613 Respiratory Acidemia
    32–19 c p. 612 Clinical Significance of Acidemia
    32–20 a p. 613 Eye Infection Prophylaxis
    32–21 a p. 613 Eye Infection Prophylaxis
    32–22 c p. 614 Hepatitis B Immunization
    32–23 b p. 614 Vitamin K
    32–24 d p. 614 Newborn Screening
    32–25 c p. 614 Zika Virus
    32–26 a p. 615 Care of Skin and Umbilical Cord
    32–27 c p. 615 Feeding and Weight Loss
    32–28 c p. 615 Feeding and Weight Loss
    32–29 b p. 615 Stools and Urine
    32–30 c p. 615 Male Circumcision
    32–31 d p. 616 Male Circumcision
    32–32 d p. 616 Rooming In and Hospital Discharge
    228

    CHAPTER 34

    The Preterm Newborn

    34–1. Compared to term infants, neonates born prematurely 34–6. What is the etiology of the diffuse reticulogranular
    have higher associated rates of which of the following? infiltrate seen on the chest radiograph below?
    a. Sleep apnea
    b. Developmental delay
    c. Congenital malformations
    d. All of the above

    34–2. What is a reason for the decrease in preterm birth


    from 12% in 2007 to 10% in 2014?
    a. Liberalized use of cerclage
    b. Decrease in teen birth rate
    c. Universal cervical length screening
    d. Use of 17-alpha hydroxyprogesterone caproate

    34–3. Respiratory distress syndrome contributes to which


    of the following comorbidities?
    a. Neurological damage Used with permission from Dr. Becky Ennis.
    b. Pulmonary hypertension
    c. Necrotizing enterocolitis a. Persistent fetal circulation
    d. All of the above b. Bronchopulmonary dysplasia
    c. Respiratory distress syndrome
    34–4. What is the mechanism of action by which surfactant d. Transient tachypnea of the newborn
    prevents respiratory distress syndrome in neonatal
    lungs?
    a. Clears fluid from the lungs
    b. Dilates the pulmonary vasculature
    c. Lowers surface tension in the alveoli
    d. Aids in maturation of the terminal bronchioles

    34–5. Respiratory distress syndrome can develop in the


    term infant as surfactant can be inactivated by which
    of the following substances?
    a. Blood
    b. Vernix
    c. Meconium
    d. All of the above
    The Preterm Newborn 229

    34–7. A 32-year-old primigravida delivers a neonate at 34–10. A 37-year-old multigravida presents for a 6-week
    31 weeks’ gestation due to preeclampsia with postpartum visit after delivering her son prematurely
    severe features. She received a course of antenatal at 28 weeks’ gestation. She informs you that he

    CHAPTER 34
    corticosteroids prior to delivery, but in the delivery developed severe respiratory distress syndrome and
    room the neonate receives the intervention pictured was on a mechanical ventilator for many weeks.
    below. The neonate likely displayed all except which She is worried he will develop bronchopulmonary
    of the following clinical signs? dysplasia (BPD). Which of the following medications
    have not been shown to prevent BPD?
    a. Caffeine
    b. Vitamin A
    c. Glucocorticoids
    d. Inhaled nitric oxide

    34–11. Surfactant has been shown to reduce the rates of


    which of the following complications?
    a. Intubation
    b. Pneumothorax
    c. Childhood asthma
    d. Necrotizing enterocolitis

    34–12. In which of the following scenarios are you least


    likely to give prophylactic surfactant?
    a. Tachypnea a. A 33-week infant who did not receive antenatal
    b. Arrhythmia corticosteroids.
    c. Hypotension b. A 27-week infant who received a course of
    d. Hypertension “rescue steroids” prior to delivery.
    c. A 37-week infant with respiratory distress
    34–8. The neonate in Question 34–7 continued to show syndrome requiring intubation.
    a respiratory acidosis despite continuous positive d. A 26-week infant who received antenatal
    airway pressure (CPAP). According to the American corticosteroids and continuous positive airway
    Academy of Pediatrics, what is the next best course pressure in the delivery room.
    of action?
    a. Intubation 34–13. The American College of Obstetricians and
    b. Nitric oxide Gynecologists considers women candidates for
    antenatal corticosteroid therapy if they are at risk
    c. Glucocorticoids for preterm delivery at what gestational ages?
    d. Surfactant administration a. 22–34 weeks
    34–9. Respiratory distress syndrome can be caused by b. 23–34 weeks
    which of the following? c. 24–32 weeks
    a. Infection d. 23–36 weeks
    b. Heart failure
    34–14. Antenatal corticosteroids have been shown to reduce
    c. Meconium aspiration which of the following complications of prematurity?
    d. All of the above a. Respiratory distress syndrome and intraventricular
    hemorrhage
    b. Bronchopulmonary dysplasia and intraventricular
    hemorrhage
    c. Respiratory distress syndrome and necrotizing
    enterocolitis
    d. Bronchopulmonary dysplasia and necrotizing
    enterocolitis
    230 The Newborn

    34–15. At what gestational age does the concentration of 34–19. A 29-year-old primigravida underwent a cesarean
    lecithin relative to sphingomyelin rise? delivery of a female infant at 32 weeks’ gestation
    a. 23 weeks secondary to preeclampsia with severe features and
    fetal-growth restriction. The infant weighed 1498
    SECTION 9

    b. 29 weeks
    grams at birth. Which of the characteristics of this
    c. 30 weeks infant, pictured below, is not a risk factor for the
    d. 34 weeks development of necrotizing enterocolitis?

    34–16. Which of the following are methods to assess fetal


    lung maturity?
    a. Foam stability test
    b. Lamellar body count
    c. Fluorescence polarization test
    d. All of the above

    34–17. Which of the following methods to assess fetal lung


    maturity is considered the gold standard?
    a. Foam stability test
    b. Lamellar body count
    c. Lecithin-sphingomyelin ratio
    d. All of the above

    34–18. A 26-year-old primigravida presents for her prenatal a. Female gender


    visit at 36 weeks’ gestation and inquires about b. Very low birthweight
    scheduling an induction of labor. At her first visit
    c. Umbilical catheterization (U)
    she was unsure of her last menstrual period, and
    she was dated by a 22-week ultrasound. At what d. Supplementation of cow milk formula (G)
    gestational age does the American College of
    Obstetricians and Gynecologists (ACOG) 34–20. The neonate in Question 34–19 develops abdominal
    recommend delivery? distention, fever, and intolerance of nasogastric feeds.
    An abdominal radiograph is performed and shown
    a. 39 weeks
    below. What is thought to be the pathophysiology of
    b. 41 weeks this condition?
    c. 39 weeks after amniocentesis documenting fetal
    lung maturity
    d. 41 weeks after amniocentesis documenting fetal
    lung maturity

    Used with permission from Dr. Natalie Frost.

    a. Intestinal immaturity
    b. Exposure to enteral feeds
    c. Highly immunoreactive intestinal mucosa
    d. All of the above
    The Preterm Newborn 231

    34–21. How does hyperoxemia lead to retinopathy of 34–25. Which of the following is the preferred initial
    prematurity? modality for identifying brain abnormalities in the
    a. Causes centripetal vascularization of retina newborn?

    CHAPTER 34
    b. Causes hemorrhage from retinal vessels and a. Sonography
    subsequent aberrant neovascularization b. Computed tomography
    c. Causes severe retinal vasoconstriction, c. Magnetic resonance imaging
    vessel obliteration, and subsequent aberrant d. Positron emission tomography
    neovascularization
    d. Causes dilation of the retinal vessels, increase 34–26. Which of the following contributes to the increased
    in angiogenic factors, and subsequent aberrant risk of intraventricular hemorrhage in preterm
    neovascularization infants?
    a. Venous stasis and congestion
    34–22. The infant pictured below was born at 34 weeks’
    b. Impaired vascular autoregulation
    gestation by cesarean delivery due to preeclampsia
    with severe features. The infant’s birthweight c. Poor vessel support by the subependymal
    was 1928 grams. Even at this gestational age, low germinal matrix
    birthweight is a risk factor for which of the following d. All of the above
    complications of prematurity?
    34–27. A 34-year-old multigravida presents for her post-
    partum visit and informs you her infant, born at
    25 weeks’ gestation, has a bleed in its brain. She
    reports she was told the bleeding has extended into
    the tissue. What grade intraventricular hemorrhage
    does her infant have?
    a. Grade I
    b. Grade II
    c. Grade III
    d. Grade IV

    34–28. Which of the following medications has been shown


    to reduce neurodevelopmental impairment in the
    preterm infant?
    a. Vitamin E
    b. Indomethacin
    a. Necrotizing enterocolitis
    c. Phenobarbital
    b. Retinopathy of prematurity
    d. Magnesium sulfate
    c. Intraventricular hemorrhage
    d. Respiratory distress syndrome 34–29. Which of the following women are candidates
    for a course of antenatal corticosteroids according
    34–23. All except which of the following are cerebral lesions to the American College of Obstetricians and
    seen in the preterm infant? Gynecologists?
    a. Cerebellar hemorrhage a. 26 weeks’ gestation dilated to 3 cm contracting
    b. Middle cerebral artery stroke every 2 minutes
    c. Cystic periventricular leukomalacia c. 23 weeks’ gestation dilated to 2 cm contracting
    d. Periventricular hemorrhagic infarction every 5 minutes
    c. 33 weeks’ gestation dilated to 3 cm who received
    34–24. Which of the following is seen more typically in a a course of steroids 21 days ago on presentation
    term infant rather than a preterm infant? for preterm premature rupture of membranes
    a. Subdural hemorrhage d. All of the above
    b. Cerebellar hemorrhage
    c. Subarachnoid hemorrhage
    d. Intraventricular hemorrhage
    232 The Newborn

    34–30. All except which of the following are risk factors for 34–32. Which of the following statements about periven-
    development of cerebral palsy? tricular leukomalacia are true?
    a. Ischemia a. It is associated with cerebral palsy
    SECTION 9

    b. Chorioamnionitis b. Damage is irreversible because brain tissue does


    c. Operative vaginal delivery not regenerate
    d. Intraventricular hemorrhage c. Due to lack of gliosis the areas appear as echolu-
    cent cysts on imaging
    34–31. Which of the following types of cerebral palsy is the d. All of the above
    least common?
    a. Diplegia 34–33. All except which of the following substances have
    been shown to be toxic to brain tissue?
    b. Hemiplegia
    a. Calcium
    c. Spastic quadriplegia
    b. Glutamate
    d. Choreoathetoid types
    c. Magnesium
    d. Tumor necrosis factor
    The Preterm Newborn 233

    CHAPTER 34 ANSWER KEY

    Question Letter Page

    CHAPTER 34
    number answer cited Header cited
    34–1 c p. 636 Introduction
    34–2 b p. 636 Introduction
    34–3 d p. 636 Respiratory Distress Syndrome
    34–4 c p. 637 Etiopathogenesis
    34–5 c p. 637 Etiopathogenesis
    34–6 c p. 637 Clinical Course
    34–7 c p. 637 Treatment
    34–8 d p. 637 Treatment
    34–9 d p. 637 Clinical Course
    34–10 d p. 637 Treatment
    34–11 b p. 638 Surfactant Prophylaxis and Rescue
    34–12 d p. 638 Surfactant Prophylaxis and Rescue
    34–13 b p. 638 Prevention
    34–14 a p. 638 Prevention
    34–15 d p. 638 Prevention
    34–16 d p. 638 Prevention
    34–17 c p. 638 Prevention
    34–18 b p. 638 Prevention
    34–19 a p. 639 Necrotizing Enterocolitis
    34–20 d p. 639 Necrotizing Enterocolitis
    34–21 c p. 639 Retinopathy of Prematurity
    34–22 a p. 639 Necrotizing Enterocolitis
    34–23 b p. 639 Brain Disorders
    34–24 a p. 639 Intracranial Hemorrhage
    34–25 a p. 639 Brain Disorders
    34–26 d p. 639 Periventricular-Intraventricular Hemorrhage
    34–27 d p. 640 Periventricular-Intraventricular Hemorrhage
    34–28 d p. 640 Periventricular-Intraventricular Hemorrhage
    34–29 d p. 641 Periventricular-Intraventricular Hemorrhage
    34–30 c p. 641 Risks
    34–31 d p. 641 Cerebral Palsy
    34–32 d p. 640 Periventricular Leukomalacia
    34–33 c p. 641 Risks
    242

    CHAPTER 36

    The Puerperium

    36–1. What duration of time is encompassed in the 36–6. A 26-year-old G3P3 is postpartum day 1 following
    puerperium? an uncomplicated vaginal delivery. She reports sharp,
    a. 2–4 weeks intermittent lower abdominal pain, which is more
    severe than in her prior deliveries. Her heart rate is
    b. 4–6 weeks
    84 beats per minute, blood pressure 110/60 mmHg,
    c. 6–8 weeks and her temperature 99.3 °F. Her abdomen is soft
    d. 10–12 weeks on exam and there is no uterine tenderness. A scant
    amount of lochia is appreciated on bimanual exam.
    36–2. What are myrtiform caruncles? What is the most likely diagnosis?
    a. Vaginal rugae a. Afterpains
    b. Scarred tags of hymenal tissue b. Endometritis
    c. A sexually transmitted infection c. Bladder flap hematoma
    d. Microscopic tears in the vaginal epithelium d. Septic pelvic thrombophlebitis

    36–3. At what point in the puerperium does the 36–7. A 20-year-old G1P1 presents to the emergency room
    endocervical canal reform? 10 days after an uncomplicated vaginal delivery
    a. 1 week postpartum complaining of fever, nausea/vomiting, abdominal
    pain, and increased vaginal discharge. On arrival, she
    b. 2 weeks postpartum is febrile to 38.6 °C and she has fundal tenderness on
    c. 3 weeks postpartum exam. Which of the following tests would be least
    d. 4 weeks postpartum helpful for further evaluation?
    a. A complete blood count
    36–4. What percentage of women experience regression of b. A basic metabolic profile
    high-grade dysplasia following delivery?
    c. A transvaginal ultrasound
    a. 10%
    d. A Gram stain of her vaginal discharge
    b. 33%
    c. 35% 36–8. A 40-year-old G2P2 presents to your office 2 weeks
    d. 50% after her scheduled cesarean delivery for follow-up.
    She complains of intermittent episodes of heavy
    36–5. How long does complete uterine involution take vaginal bleeding, occurring as recently as the day
    following delivery? prior. Her temperature is 99.6°F, heart rate 98 beats
    a. 1 week per minute, and blood pressure 120/80 mmHg. On
    exam, her uterus is noted to be enlarged to 20 weeks
    b. 2 weeks in size and boggy. Her incision appears well approxi-
    c. 3 weeks mated without evidence of infection. The most
    d. 4 weeks appropriate management includes which of the
    following?
    a. A complete blood count
    b. Methergine administration
    c. Empiric antibiotic treatment
    d. All of the above
    The Puerperium 243

    36–9. Secondary postpartum hemorrhage is defined as 36–14. Your patient is postoperative day 2 following a primary
    uterine hemorrhage occurring during what time- cesarean delivery for failure to progress. She is frustrated
    frame after delivery? because she is only getting small drops of thick yellow

    CHAPTER 36
    a. 24 hours to 6 weeks liquid from her breasts. How long would you tell her
    to expect colostrum production before beginning her
    b. 48 hours to 6 weeks
    conversion to a more mature milk?
    c. 24 hours to 12 weeks
    a. 2 to 5 days
    d. 48 hours to 12 weeks
    b. 2 to 10 days
    36–10. What are common features of the urinary bladder in c. 5 to 14 days
    the postpartum period? d. 5 to 21 days
    a. Increased capacity
    b. Incomplete emptying 36–15. What vitamin is virtually absent in human breast
    milk?
    c. Insensitivity to intravesical pressures
    a. Vitamin C
    d. All of the above
    b. Vitamin A
    36–11. A 24-year-old G1P1 complains of abdominal pain c. Vitamin K
    and subjective fever 1 day following an uncomplicated d. All vitamins are equally represented in breast milk
    vaginal delivery. Which of the following physical
    exam signs or laboratory values would be most 36–16. Which hormone is most responsible for milk
    helpful to make a diagnosis of endometritis in this expression during lactation?
    postpartum patient? a. Prolactin
    a. Fundal tenderness b. Oxytocin
    b. An absolute neutrophilia c. Dopamine
    c. White blood cell count of 25,000/µL d. Progesterone
    d. All of the above
    36–17. How would you advise a patient who is exclusively
    36–12. After delivery, how long do cardiovascular parameters breastfeeding 4 weeks after delivery and develops
    including cardiac output, heart rate, and blood nipple fissures?
    pressure take to return to nonpregnant levels? a. Wash the area with mild soap and water daily.
    a. 48 hours b. Apply a steroid cream and use a nipple shield
    b. 72 hours temporarily.
    c. 7 days c. Continue exclusive breastfeeding without
    d. 10 days interruption.
    d. Do not allow infant to feed on the affected side
    36–13. You counsel your puerperal patient that most women and empty the breast regularly with a pump.
    first approach their prepregnancy weight by which
    time interval following delivery? 36–18. All except which of the following conditions are
    a. 3 months contraindications to breastfeeding?
    b. 6 months a. Infant with galactosemia
    c. 9 months b. Maternal hepatitis B infection
    d. 12 months c. Human immunodeficiency virus infection
    d. Maternal active and untreated tuberculosis
    244 The Puerperium

    36–19. A 21-year-old G1P1 presents to your office 4 days fol- 36–20. Your patient presents 5 days postpartum with
    lowing an uncomplicated vaginal delivery complaining an axillary mass. She noted it during pregnancy
    of breast pain and difficulty with breastfeeding. Her although reports it was much smaller. Yesterday, she
    temperature is 37.8oC, heart rate 102 beats per
    SECTION 10

    noticed that the mass became larger and more ten-


    minute, and respiratory rate 22 breaths per minute. der. Her face is shielded and a sagittal photograph of
    The appearance of her breasts is similar to that her breast, axilla, and arm is show below. She denies
    pictured in the image. No erythema or fluctuance is fever and has no additional complaints. Management
    appreciated on exam. What should you recommend of the patient should primarily include which of the
    to the patient? following?

    a. Initiation of dicloxacillin a. Needle aspiration


    b. Admission to the hospital b. Observation and reassurance
    c. Stop breastfeeding immediately and use a breast c. Axillary lymph node excision
    binder d. Antibiotic therapy with gram-positive coverage
    d. Oral analgesics, cool packs, and frequent feeding
    or pumping 36–21. A 34-year-old G3P3 with a history of migraine head-
    aches calls your office 1 week following an uncom-
    plicated vaginal delivery complaining of severe
    headaches. She did receive epidural anesthesia during
    her labor course, but review of her chart confirms
    that the epidural placement was easy and uncompli-
    cated. The patient reports that the headaches began
    a few days following delivery and are associated
    with nausea, but no vomiting, and are minimally
    improved with either rest or over-the-counter analge-
    sics. What is the most likely trigger of this patient’s
    postpartum headaches?
    a. Dural puncture
    b. Estrogen withdrawal
    c. Progesterone withdrawal
    d. Intracerebral hemorrhage
    The Puerperium 245

    36–22. Your patient had a 4-hour second stage of labor and 36–25. Which of the following is true regarding the postpar-
    vaginal delivery without laceration. As her epidural tum blues?
    analgesia subsides, she complains of perineal pain. Her a. May be affected by body image concerns

    CHAPTER 36
    temperature is a 37.0oC, pulse 84 beats per minute,
    b. Usually lasts for no more than 10 days after delivery
    and blood pressure 120/68 mmHg. Her first void
    yielded 300 mL of urine. Management of the patient c. Effective treatment involves recognition and
    should primarily include which of the following? reassurance
    a. Perineal cool pack d. All of the above
    b. Surgical evacuation 36–26. A 30-year-old G1P1 complains of difficulty with
    c. Diagnostic needle aspiration ambulation on postpartum day 1 following a labor
    d. Broad-spectrum intravenous antibiotic therapy and delivery course, which lasted 24 hours and
    included 3 hours of pushing in stirrups. You perform
    36–23. A 19-year-old G1P1 complains of worsening vul- an exam and note bilateral foot drop on exam.
    var pain in the recovery room 6 hours following a Injury to what nerve is the most likely cause of the
    vaginal delivery. The delivery was complicated by a patient’s ambulation difficulty?
    prolonged second stage and a third degree laceration. a. Femoral nerve
    On further evaluation, her temperature is 37.2oC, b. Ilioinguinal nerve
    heart rate 130 beats per minute, blood pressure
    86/52 mmHg, and respiratory rate 28 breaths per c. Common peroneal nerve
    minute. She appears pale and mildly diaphoretic. d. Lateral femoral cutaneous nerve
    Examination of the perineum reveals the findings
    shown in the photo below. What is the next best 36–27. Which of the following is true regarding the
    course of action? condition shown in the pelvic radiograph?

    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): The
    a. Urgent surgical evacuation Puerperium. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 36-7.

    b. Place a vaginal pack and Foley catheter


    a. Symphyseal separation >1.5 cm is diagnostic.
    c. Check a complete blood count and observe
    closely b. Surgery is usually necessary for separation >3 cm.
    d. Start intravenous antibiotics with gram-negative c. Treatment is generally conservative and consists
    coverage of rest and placement of a pelvic binder.
    d. All of the above
    36–24. A 29-year-old G2P2 with an 18-hour labor course is
    unable to void 5 hours following a vaginal delivery. 36–28. What is the mean time to ovulation resumption in a
    What is the best management option? postpartum woman who elects not to breastfeed?
    a. A single in-and-out catheterization a. 4 weeks
    b. Place a Foley catheter for 24 hours b. 5 weeks
    c. Continue close observation without intervention c. 6 weeks
    d. Encourage increased fluid intake since the bladder d. 7 weeks
    is likely empty following delivery
    246 The Puerperium

    36–29. Your patient presents for her 6-week follow-up 36–32. Approximately what percentage of postpartum
    visit after having a primary cesarean delivery for women require readmission to the hospital within
    breech presentation. She is trying to breastfeed 8 weeks of delivery?
    SECTION 10

    exclusively but reports issues with milk supply. What a. <1%


    contraceptive option would you not recommend for
    b. 3%
    this patient?
    c. 7%
    a. Progestin-only pills
    d. 10%
    b. Estrogen-progestin patch
    c. Depot medroxyprogesterone 36–33. A 29-year-old G1P1 presents for a follow-up visit
    d. A levonorgestrel intrauterine device 4 weeks postpartum following an uncomplicated
    spontaneous vaginal delivery. She is overall doing
    36–30. Following an uncomplicated vaginal delivery, when well and has returned to most of her usual activities.
    can women be advised to resume coitus based on However, she complains of low energy levels despite
    desire and comfort? the fact that her baby is sleeping for long intervals at
    a. 1 week postpartum night. What should you offer her?
    b. 2 weeks postpartum a. Reassurance only
    c. 3 weeks postpartum b. Psychiatry referral
    d. 4 weeks postpartum c. Check her thyroid hormone levels
    d. All of the above
    36–31. What treatment can be offered to the postpartum
    woman who is exclusively breastfeeding and
    complains of vaginal dryness during intercourse
    7 weeks following delivery?
    a. Topical estrogen
    b. Reassurance only
    c. Topical testosterone
    d. Intercourse is not recommended within the first
    8 weeks of delivery.
    248

    CHAPTER 37

    Puerperal Complications

    37–1. What percentage of non-breastfeeding women 37–6. What organism has been implicated in late-onset,
    develop fever from breast engorgement postpartum? indolent metritis?
    a. 15% a. Proteus
    b. 25% b. Klebsiella
    c. 35% c. Chlamydia
    d. 55% d. Peptostreptococcus

    37–2. What is the most common etiology of persistent 37–7. What is the most important criterion for the
    fevers after childbirth? diagnosis of postpartum metritis?
    a. Atelectasis a. Fever
    b. Pyelonephritis b. Leukocytosis
    c. Breast engorgement c. Foul-smelling lochia
    d. Genital tract infections d. Parametrial tenderness

    37–3. What physiological process in the postpartum period 37–8. A 20-year-old G1P1 underwent a cesarean delivery
    causes urinary tract infections to be uncommon? for failure to progress. Just prior to surgery, the
    a. Diuresis patient was diagnosed with metritis and started on
    broad-spectrum antibiotics, which were continued
    b. Passage of lochia postpartum. The patient continues to have fever on
    c. Uterine involution postoperative day 5. She does not appear septic. She
    d. Immunosuppression is frustrated that she can’t go home. Which of the
    following is the least likely diagnosis?
    37–4. Which of the following is the single most significant a. Infected hematoma
    risk factor for development of an uterine infection? b. Parametrial phlegmon
    a. Route of delivery c. Septic pelvic thrombophlebitis
    b. Use of internal monitors d. Antimicrobial-resistant bacteria
    c. Artificial rupture of membranes
    d. Group B streptococcus colonization 37–9. What is the difference in treatment for metritis in
    cases of vaginal delivery versus cesarean section?
    37–5. A 35-year-old multigravida at 39 weeks’ gestation a. Dosing of antibiotics
    undergoes an induction for elevated blood pressures b. Coverage of anaerobes
    at term. After 24 hours, placement of internal
    monitors, and 10 cervical exams, the patient c. Duration of treatment
    undergoes a cesarean delivery for failure to progress. d. Route of administration of antibiotics
    Which of the following is not a risk factor for her
    developing an uterine infection? 37–10. Which of the following regimens is the gold standard
    a. Multiparity for treatment of a pelvic infection following a cesarean
    delivery?
    b. Prolonged labor
    a. Meropenem
    c. Cesarean delivery
    b. Vancomycin
    d. Placement of internal monitors
    c. Clindamycin and aztreonam
    d. Clindamycin and gentamicin
    Puerperal Complications 249

    37–11. A 22-year-old primigravida at term is diagnosed with 37–15. A 30-year-old G2P2 presents on postoperative day
    failure to progress, and the plan is made for cesarean 6 to the emergency room complaining of drainage
    delivery. The patient has no medical problems other from her cesarean incision. The cesarean delivery was

    CHAPTER 37
    than a body mass index of 50 kg/m2. She also denies for failure to progress after a long induction. The
    any allergies. The anesthesiologist asks if you would patient is currently afebrile. Her body mass index
    like routine perioperative antimicrobial prophylaxis. is 47 kg/m2. The patient reports that she sat down
    Which antibiotic do you ask for to further reduce yesterday and felt a pop. Shortly thereafter, she
    her chance of a postoperative infection? noticed pink/light brown drainage coming from
    a. 3 grams instead of 2 grams of cefazolin her incision. She endorses chills and skin irritation
    around the incision. Lochia has been normal. On
    b. Vancomycin instead of the routine cefazolin
    your exam, her skin is erythematous near the incision.
    c. Routine 2 grams of cefazolin prior to skin There is serosanguinous drainage from the wound.
    incision Although the patient has good pain tolerance, why
    d. Ampicillin, gentamicin, and clindamycin for do you elect to take her to the operating room to
    24 hours after the surgery evaluate the incision?
    a. You plan to proceed with hysterectomy.
    37–12. Which of the following has not been shown to lower
    b. You want to open the wound, debride necrotic
    the risk for infection after cesarean delivery?
    tissue, and then close it back up using en bloc
    a. Spontaneous separation of the placenta closure.
    b. Chlorhexidine-alcohol skin preparation c. You want to place a negative-pressure wound
    c. Single-dose antibiotics prior to skin incision therapy system and that can only be done in the
    d. Surgeons changing gloves after delivery of the operating room.
    placenta d. You are concerned that the fascia may not be
    intact and if so, the fascia needs to be closed in
    37–13. In more than 90% of women, metritis responds to the operating room.
    treatment with antibiotics within what period of
    time? 37–16. Which of the following statements about necrotizing
    a. 12–24 hours fasciitis is false?
    b. 24–36 hours a. It is common with low mortality rates.
    c. 48–72 hours b. Three risk factors are diabetes, obesity, and
    hypertension.
    d. 72–96 hours
    c. Surgical debridement of infected tissue should
    37–14. Which of the following is an evidence-based statement leave wide margins of healthy bleeding tissue.
    about the use of vacuum-assisted wound closure d. Early diagnosis, surgical debridement, anti-
    devices in obstetrics? microbials, and intensive care are paramount to
    a. It prevents wound infection. successful treatment.
    b. It is superior to standard dressings.
    37–17. Which of the following statements about an ovarian
    c. Provider time is decreased substantially. abscess in the puerperium is true?
    d. It is significantly more cost effective than stan- a. Rupture is rare
    dard dressings.
    b. Usually affects both ovaries
    c. Women present 4–6 weeks after delivery
    d. It is thought to be caused by bacterial invasion of
    the ovary through a rent in the capsule.
    250 The Puerperium

    37–18. Which of the following is frequently the first sign/ 37–21. What is the overall incidence of septic pelvic
    symptom of peritonitis in a postpartum woman? thrombophlebitis?
    a. Diarrhea a. 1/100
    SECTION 10

    b. Skin erythema b. 1/200


    c. Adynamic ileus c. 1/2000–1/3000
    d. Abdominal rigidity d. 1/20,000–1/30,000

    37–19. Which of the following statements about the 37–22. A 19-year-old primigravida undergoes a cesarean
    phlegmon illustrated in the figure below is true? delivery for failure to progress. Her course is com-
    plicated by chorioamnionitis for which she receives
    broad-spectrum antibiotics. On postoperative day 5,
    the patient is still having fevers. She feels well and is
    becoming annoyed that she can not go home. Her
    incision is healing nicely with no erythema or drain-
    age. On computed tomography imaging, the patient
    is noted to have a clot that extends to the ovarian
    vein. An image is provided below. What is the next
    step in your management?

    Reproduced with permission from Worley KC: Postoperative complications. In Yeomans


    ER, Hoffman BL, Gilstrap LC III, et al (eds). Cunningham and Gilstrap’s Operative
    Obstetrics, 3rd ed. New York, McGraw Hill Education, 2017.

    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Puerperal complications. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, a. Therapeutic heparin
    Figure 37-3.
    b. Continuation of antibiotic therapy
    a. This is usually a bilateral process. c. Consult interventional radiology about removing
    the clot and/or placing a filter.
    b. Rarely is this limited to the parametrium.
    d. Stop all medications and discharge home, so she
    c. Typically fever resolves in 5–7 days with broad- can walk, reducing further clot risk.
    spectrum antibiotics.
    d. The most common route of extension is posteri-
    orly into the rectovaginal septum.

    37–20. Which of the following is least likely to occur during


    surgery for uterine incisional necrosis?
    a. Transfusion
    b. Hysterectomy
    c. Surgical debridement
    d. Bilateral salpingo-oophorectomy
    Puerperal Complications 251

    37–23. Which of the following is a risk factor for episiotomy 37–27. Which of the following is the best treatment for
    dehiscence? toxic shock syndrome?
    a. Smoking a. Supportive care

    CHAPTER 37
    b. Infection b. Supportive care and antibiotics
    c. Genital warts c. Supportive care, antibiotics, and wound
    d. All of the above debridement if necessary
    d. There is no necessary treatment as it will resolve
    37–24. A 22-year-old G1P1 presents 6 days after a on its own over time
    vaginal delivery. Her course was complicated by
    chorioamnionitis and a second-degree perineal 37–28. What is the incidence of mastitis?
    laceration. The patient is complaining of pain and a. 1%
    drainage from her vagina. On exam, her laceration
    repair is open and draining purulent material. b. 3%
    Which of the following would not be a step in your c. 10%
    management? d. 15%
    a. Intravenous antibiotics
    b. Debridement of necrotic tissue 37–29. When is mastitis most likely to occur?
    c. Establishment of adequate analgesia prior to a. Postpartum day 1
    debridement b. Postpartum day 5
    d. Intravenous antibiotics, debridement of necrotic c. 3–4 weeks postpartum
    tissue in the operating room, and then immediate d. 6–9 months postpartum
    closure of the laceration
    37–30. What percentage of women with mastitis develop an
    37–25. What is the case-fatality rate of toxic shock abscess?
    syndrome? a. 1%
    a. 1–2% b. 3%
    b. 5–6% c. 10%
    c. 10–15% d. 15%
    d. 20–25%
    37–31. Which of the following is not expected in cases of
    37–26. A 20-year-old G1P1 presents 3 days postpartum mastitis?
    after a vaginal delivery for fever, headache, nausea/ a. Fever
    vomiting, and lower abdominal pain. The patient’s
    b. Chills
    boyfriend reports that she got sick very quickly and
    is “not making sense when she talks.” On exam, the c. Breast firmness
    patient has severe abdominal pain and foul-smelling d. Symptoms in both breasts
    lochia. She is hypotensive and tachycardic. She
    appears extremely ill. Which of the following is the
    most likely diagnosis?
    a. Listeriosis
    b. Pyelonephritis
    c. Gastroenteritis
    d. Toxic shock syndrome
    252 The Puerperium

    37–32. A 32-year-old G4P2 presents 3 weeks after under-


    going a cesarean delivery for breech presentation.
    She has been exclusively breastfeeding and feeling
    SECTION 10

    well. She now complains of a 2-day history of fever,


    chills, and breast pain. She finds it difficult to feed
    the infant on the affected side. On exam, the breast
    is warm, red, and tender. You expect mastitis at the
    least, are not sure if there is an abscess. You obtain
    an ultrasound and the image is shown below. What
    is the best management plan?

    Used with permission from Dr. Emily Adhikari.

    a. Intravenous antibiotics, supportive care, suspend


    breast feeding on the affected side for 48–72
    hours
    b. Oral antibiotics, discontinuation of breast feeding
    on the affected side, follow up with OB/GYN next
    week
    c. Intravenous antibiotics, drainage of abscess,
    culture, pumping or breast feeding continued for
    both breasts
    d. Milk culture, discharge home with pain
    medication, encourage breast feeding on that
    side, antibiotics if the milk culture is positive
    Puerperal Complications 253

    CHAPTER 37 ANSWER KEY

    Question Letter Page

    CHAPTER 37
    number answer cited Header cited
    37–1 a p. 666 Puerperal Fever
    37–2 d p. 666 Puerperal Fever
    37–3 a p. 667 Puerperal Fever
    37–4 a p. 667 Uterine Infection
    37–5 a p. 667 Uterine Infection
    37–6 c p. 668 Uterine Infection
    37–7 a p. 668 Uterine Infection
    37–8 d p. 668 Uterine Infection
    37–9 b p. 668 Choice of Antimicrobials
    37–10 d p. 669 Table 37-2 Antimicrobial regimens for pelvic infections
    following cesarean delivery
    37–11 a p. 669 Perioperative Prophylaxis
    37–12 d p. 669–670 Perioperative Prophylaxis
    37–13 c p. 670 Complications of Uterine and Pelvic Infections
    37–14 c p. 670–671 Vacuum-Assisted Wound Closure
    37–15 d p. 671 Abdominal Incisional Infections
    37–16 a p. 671 Necrotizing Fasciitis
    37–17 d p. 671 Adnexal Abscesses and Peritonitis
    37–18 c p. 672 Adnexal Abscesses and Peritonitis
    37–19 c p. 672 Figure 37-3
    37–20 d p. 672 Parametrial Phlegmon
    37–21 c p. 673 Septic Pelvic Thrombophlebitis
    37–22 b p. 673 Septic Pelvic Thrombophlebitis
    37–23 d p. 674 Perineal Infections
    37–24 d p. 675 Early Repair of Infected Episiotomy
    37–25 c p. 675 Toxic Shock Syndrome
    37–26 d p. 675 Toxic Shock Syndrome
    37–27 c p. 675 Toxic Shock Syndrome
    37–28 b p. 675 Breast Infections
    37–29 c p. 675 Breast Infections
    37–30 c p. 675 Breast Infections
    37–31 d p. 675 Breast Infections
    37–32 c p. 676 Breast Abscess
    254

    CHAPTER 38

    Contraception

    38–1. According to the World Health Organization, with 38–5. Which of the following statements properly describe
    no contraceptive use, a sexually active woman has the intrauterine device?
    what risk for pregnancy over a year? a. Mirena is a levonorgestrel-eluting device, and it is
    a. 65% approved for 5 years of use following insertion.
    b. 70% b. Liletta contains 52 mg of levonorgestrel, and it is
    c. 75% approved for 5 years of use following insertion.
    d. 85% c. Skyla is the largest of the intrauterine devices, and
    it is approved for 3 years of use following insertion.
    38–2. In contrast to the answer to Question 38–1, typical d. ParaGard is not considered a “chemically active”
    use of combination oral contraceptive pills by a intrauterine device, and it is approved for 7 years
    sexually active woman has what risk for pregnancy of use following insertion.
    over the first year of use?
    a. 3% 38–6. Contraceptive efficacy with the method pictured below
    is not believed to result from which of the following
    b. 9%
    mechanisms?
    c. 13%
    d. 17%

    38–3. Which of the following is not considered a


    long-acting reversible contraceptive method?
    a. Levonorgestrel implant
    b. Copper intrauterine device
    c. Depot medroxyprogesterone acetate
    d. All of the above are long-acting reversible
    contraceptive methods

    38–4. What is the purpose of the United States Medical


    Eligibility Criteria, published by the Centers for
    Disease Control and Prevention?
    a. Provides legal criteria for contraception provision
    to minors
    b. Provides codified data for insurance submission a. Ovulation inhibition
    under the Affordable Care Act b. Decreased motility and viability of sperm
    c. Provides financial stratification criteria for c. Reduced viability of egg and sperm preventing
    Medicaid contraception eligibility fertilization
    d. Provides guidance in contraceptive choice for d. Endometrial inflammation action directed toward
    women with various comorbidities a blastocyst, if formed
    Contraception 255

    38–7. Which of the following statements properly 38–10. Ms. Thomas from Question 38–8 undergoes an
    characterizes expulsion of an intrauterine device? ultrasound with the findings shown below. Which of
    a. The cumulative expulsion rate after 3 years is 20%. the following is the next best clinical step?

    CHAPTER 38
    b. Expulsion is most common in the final years of
    approved use.
    c. If a woman is unable to palpate the trailing
    strings, she should be evaluated.
    d. All of the above

    38–8. Ms. Thomas calls complaining of dull lower abdominal


    pain for the last 2 months. You placed an intrauterine
    device (IUD) 3 months ago, and she has never
    attempted to palpate the strings. On speculum
    examination you see the picture below. Which of the
    following is the most appropriate next step?

    a. Obtain a β-hCG level


    b. Obtain a KUB radiograph
    c. Attempt IUD removal by means of an IUD hook
    or Randall stone clamp a. Hysterectomy
    d. Continue the exam by twirling a cytologic brush b. Dilation and curettage
    in her endocervical canal
    c. Diagnostic laparoscopy
    38–9. Ms. Thomas in Question 38–8 has a negative d. Operative hysteroscopy
    β-hCG. Which of the following is the next best
    management step? 38–11. You receive a phone call from an emergency medicine
    physician. She is seeing a patient who reports having
    a. Diagnostic laparoscopy a ParaGard in place. Which of the following imaging
    b. Diagnostic hysteroscopy modalities is contraindicated in this patient?
    c. Transvaginal ultrasound a. Computed tomography scan
    d. Computed tomography scan b. 3-tesla magnetic resonance imaging
    c. 1.5-tesla magnetic resonance imaging
    d. None of the above
    256 The Puerperium

    38–12. Which of the following is true regarding the intra- 38–14. Which of the following is true regarding the
    uterine device–related complication pictured here? risk for infection associated with an intrauterine
    device (IUD)?
    SECTION 10

    a. An IUD is not a safe method of contraception for


    women with human immunodeficiency virus.
    b. The risk for upper genital tract device-related
    infection increases in parallel with increasing time
    of device use.
    c. The American Heart Association recommends
    single dose antibiotic prophylaxis prior to
    IUD insertion for women at risk for bacterial
    endocarditis.
    d. An IUD may remain in situ for pelvic inflam-
    matory disease that is responding to antibiotic
    therapy, but removal is indicated in the case of a
    tuboovarian abscess.

    38–15. Ms. Cooper presents reporting 14 weeks of amenorrhea


    Used with permission from Dr. Seth Hawkins. and she is found to have a positive pregnancy test.
    Strings of her intrauterine device (IUD) are visible
    a. Is more common with insertion during lactation at the cervical os, and her ultrasound findings are
    b. Rate of occurrence is approximately 1 per 100 shown below. Which of the following is the correct
    insertions course of action in this case?
    c. Is suspected clinically when sound or insertion
    device will not travel as far as expected based on
    bimanual examination
    d. None of the above

    38–13. Which of the following best characterizes the


    relationship between intrauterine device (IUD) use
    and ectopic pregnancy?
    a. Use of an IUD increases the risk for an ectopic
    pregnancy.
    b. IUD is contraindicated in women with a history
    of an ectopic pregnancy.
    c. Use of an IUD does not impact risk for an
    ectopic pregnancy because the overall risk for
    pregnancy is decreased.
    d. Compared to pregnancy after failure of combination
    oral contraceptive pills, a higher proportion of a. IUD removal
    pregnancies after IUD failure will be ectopic b. IUD removal and laparoscopy
    pregnancies. c. IUD removal and 10-day course of doxycycline
    d. IUD remains in place, and continue routine
    prenatal care
    Contraception 257

    38–16. Which of the following is most accurate regarding 38–20. Which of the following is true regarding placement
    pregnancy with an intrauterine device (IUD) in situ? of the progestin implant?
    a. Risk for spontaneous abortion is approximately a. For women who are certain they are not pregnant,

    CHAPTER 38
    four times as high if the device is left in situ. insertion can occur at any time with no need for
    b. Retention of an IUD during pregnancy increases backup contraception.
    risk for fetal malformation and preterm delivery. b. For women transitioning from combination oral
    c. After viability has been reached, data is definitive contraceptives, it is inserted on what would be
    that the IUD should be left in place even if the first day of a new pack.
    strings are visible. c. Insertion can occur prior to discharge home
    d. Evidence of pelvic infection during a pregnancy following miscarriage, abortion, or delivery with
    with a retained IUD should be treated with no impairment of lactation.
    antibiotics and uterine evacuation. d. For women not currently using hormonal
    contraception, it is ideally inserted 5 days prior
    38–17. Which of the following is true regarding insertion of to expected menses onset with contraception
    an intrauterine device (IUD)? established within 24 hours.
    a. Implanon cannot be easily identified for removal
    with ultrasound and has lost approval by the 38–21. Which of the following is a suspected method of
    Food and Drug Administration. efficacy for all progestin-only contraceptive methods?
    b. For placement unrelated to pregnancy, the only a. Endometrial atrophy
    recommended time is near the end of menstruation b. Inhibition of ovulation
    as it is easier, and pregnancy is excluded. c. Thickening of cervical mucus
    c. With immediate postabortion or postdelivery d. All of the above
    placement, fewer women will receive and retain
    their IUD compared to those scheduled to return 38–22 Ms. Hubbard is a 28-year-old G6P5 who is seeing
    for traditionally timed placement. you for her postpartum exam. She had a repeat
    d. All of the above cesarean delivery 2 weeks ago and desires reversible
    contraception. Her pregnancy was complicated
    38–18. Which of the following is true regarding progestin by gestational diabetes requiring insulin. She also
    implants? takes medication for depression. She asks about
    a. Implanon cannot be easily identified for removal Nexplanon. Which of the following is an appropriate
    with ultrasound and has lost approval by the statement as part of her contraceptive counseling?
    Food and Drug Administration. a. Nexplanon will further increase your risk for overt
    b. Nexplanon provides 3 years of contraception by diabetes due to weight gain and increased insulin
    releasing etonogestrel, and it is implanted in the resistance.
    upper, medial surface of the arm. b. Nexplanon is a good choice, but may increase
    c. The first implantable progestin contraceptive was your depression, so I would like you to call me if
    Norplant, which released etonogestrel from six you notice changes.
    subdermal rods, but it is no longer manufactured. c. According to the United Stated Medical Eligibility
    d. All of the above Criteria, depression is a contraindication to pro-
    gestin only contraceptive methods.
    38–19. Ms. Bradley calls your office a few weeks after d. Nexplanon will reduce your breast milk
    insertion of her Nexplanon and reports that she has production, but if you choose this method
    had numbness and tingling in her arm. Which of the we should insert it today before ovulation can
    following characterizes the most likely approximate resume.
    region of her symptoms?
    a. Anterior and posterior portions of her shoulder
    b. Lateral surface of her forearm extending inferiorly
    to the base of her thumb
    c. Anterior and posterior portions of her 5th digit
    and the medial half of her 4th digit
    d. Medial aspect of her forearm extending superiorly
    to the anterior surface of her upper arm
    258 The Puerperium

    38–23. Which of the following statements most accurately 38–27. Which of the following statements is true regarding
    describes the injectable progestin contraceptive depot patient-specific factors that impact choice of
    medroxyprogesterone acetate (DMPA)? combination oral contraceptive (COC) pill?
    SECTION 10

    a. When injection is given within 5 days of the a. Ongoing irregular bleeding may improve from
    onset of menses, a backup method is needed for using a pill with a higher estrogen dose.
    7 days. b. Women with significant menstrual symptoms
    b. Although irregular bleeding leads to 25% of users may benefit from an extended cycle formulation.
    discontinuing within the first year, amenorrhea c. Patients on heparin should have their potassium
    develops in 80% of users after 1 year. monitored in the first month of using a COC
    c. For women desiring only a brief period of with the progestin drospirenone.
    contraception, DMPA is not a good choice due d. All of the above
    to prolonged anovulation after discontinuation.
    d. All of the above 38–28. Which of the following is not true regarding the
    relationship of combination oral contraceptive
    38–24. Combination oral contraceptive (COC) pills differ (COC) pills and thrombotic events?
    from progestin-only “mini-pills” in which of the a. Etonogestrel-containing COCs are linked to
    following ways? greater risk.
    a. COC pills primarily inhibit ovulation, and progestin b. Highest risk is in women with a co-morbid
    only pills do not reliably inhibit ovulation. thrombophilia.
    b. COC pills are contraindicated in women with c. COCs are contraindicated for women over
    breast cancer, but progestin only pills are not. 35 years of age who smoke.
    c. When one COC dose is missed, a barrier method d. Thrombotic events are increased with COC use
    should be used for 7 days. Whereas, when one in the 4 weeks prior to a major operation and in
    progestin pill is taken >4 hours late, a barrier the first weeks postpartum.
    method needs to be used for 48 hours.
    d. All of the above 38–29. Relative risk is increased for which of the following
    cancers with combination oral contraceptive (COC)
    38–25. The combination oral contraceptive pill’s mechanism pill use?
    of action is best described by which of the following a. Ovarian
    statements? b. Cervical
    a. The estrogen component suppresses luteinizing c. Endometrial
    hormone. d. Hepatocellular carcinoma
    b. Overall mechanism is stimulation of the hypo-
    thalamic gonadotropin-releasing factors.
    c. Pituitary secretion of follicle-stimulating hormone
    and luteinizing hormone are blocked, and
    ovulation is inhibited
    d. All of the above

    38–26. Undesirable effects attributed to the estrogen


    component of combination oral contraceptive pills
    include all except which of the following?
    a. Headache
    b. Hirsutism
    c. Weight gain
    d. Breast tenderness
    Contraception 259

    38–30. With use of the contraceptive method pictured, how 38–32. In counseling a woman who is considering the
    frequently should it be replaced? contraceptive method pictured here, which of the
    following is not true?

    CHAPTER 38
    a. Daily
    b. Weekly a. The ring must be carefully inserted such that it
    remains in an oblique lie around the cervix.
    c. Every 9 days
    b. The ring can be removed during intercourse but
    d. Every 3 weeks
    should be replaced within 3 hours of removal.
    38–31. Ms. Adams is a 35-year-old multigravida who is c. The ring is more forgiving than combination oral
    seeing you for her annual exam. She has hypertension contraceptive pills, as it remains efficacious if left
    that is well controlled with a single agent. You are in place for a fourth week.
    encouraged that three times per week she is still d. The ring is placed within 5 days of menses onset
    doing the water aerobics you recommended last year. and stays in place for 3 weeks with removal
    Her blood pressure is 130/78 mm Hg and weight is prompting withdrawal bleeding.
    92 kg, which is down from 98 kg at last year’s visit.
    She inquires about starting the contraceptive patch 38–33. Contraceptive efficacy of the male latex condom is
    for her birth control method. Which characteristic enhanced by which of the following?
    below is not a reason she cannot use the patch? a. Reservoir tip
    a. Patient weight may reduce efficacy b. Oil-based spermicide
    b. Regular immersion in water limits patch efficacy c. Concurrent female condom use
    c. A 35-year-old with hypertension presents excess d. All of the above
    cardiac risk
    d. All of the above make this a poor choice 38–34. Ms. Burns is a 26-year-old G1P1001 with a partner
    who has a history of herpes. She desires contracep-
    tion, and advice on how she can reduce the risk for
    getting genital herpes. In addition to counseling her
    regarding symptoms and lesions, you discuss which
    of the following?
    a. The female condom is not an option if she is
    allergic to latex.
    b. The female condom has a lower contraceptive
    failure rate than the male condom.
    c. The female condom is a single-use barrier method
    that provides both contraception and protection
    against sexually transmitted diseases.
    d. All of the above should be considered.
    260 The Puerperium

    38–35. Which of the following is not true regarding spermi- 38–38. Which of the following is false regarding emergency
    cide use? contraception?
    a. Spermicide enhances the contraceptive efficacy of a. The major mechanism of action with all methods
    SECTION 10

    other barrier methods. is inhibition or delay in ovulation.


    b. Duration of maximal effectiveness is 6 hours, and b. Single dose regimen, such as Plan B One-Step is
    they must be reinserted before repeat intercourse. available over the counter to all reproductive aged
    c. Spermicides currently do not require prescription women.
    in the United States and are available in several c. Outside of an allergy, there are no health
    formats. comorbidities that contraindicate use of
    d. Spermicides function by providing a physical emergency contraception.
    barrier to sperm penetration and chemical d. The ParaGard method is most efficacious and
    spermicidal action. carries the additional benefit of 10 subsequent
    years of effective contraception.
    38–36. Which of the following is not a variation of periodic
    abstinence as a family planning method?
    a. Withdrawal method
    b. Standard days method
    c. Cervical mucus method
    d. Temperature rhythm method

    38–37. Ms. Polly is a 24-year-old recently engaged G0 who


    presents to discuss contraceptive methods in advance
    of her wedding. She and her fiancé have not been
    sexually active and do not intend to be until after the
    wedding. She has no medical comorbidities and has
    a normal body mass index. She has always had irreg-
    ular menstrual cycles ranging from 28 to 40 days.
    She is sure that they do not desire pregnancy for 1
    to 2 years, and she has a religious objection to any
    method that has prevention of implantation of a
    fertilized embryo as a major mechanism of action.
    Taking all these factors into account, what is the
    most efficacious method you can recommend for
    this patient?
    a. Male condom
    b. Intrauterine device
    c. Fertility awareness-based method
    d. Combination oral contraceptive pill
    Contraception 261

    CHAPTER 38 ANSWER KEY

    Question Letter Page

    CHAPTER 38
    number answer cited Header cited
    38–1 d p. 680 Table 38-1
    38–2 b p. 680 Table 38-1
    38–3 c p. 681 Introduction
    38–4 d p. 681 Introduction
    38–5 a p. 682 Intrauterine Devices
    38–6 a p. 683 Intrauterine Devices
    38–7 c p. 683 Intrauterine Devices
    38–8 a p. 683 Intrauterine Devices
    38–9 c p. 683 Intrauterine Devices
    38–10 c p. 683 Intrauterine Devices
    38–11 d p. 683 Intrauterine Devices
    38–12 a p. 683 Intrauterine Devices
    38–13 d p. 683 Intrauterine Devices
    38–14 d p. 684 Intrauterine Devices
    38–15 a p. 684 Intrauterine Devices
    38–16 d p. 684 Intrauterine Devices
    38–17 a p. 685 Intrauterine Devices
    38–18 b p. 687 Progestin Implants
    38–19 d p. 688 Progestin Implants
    38–20 c p. 688 Progestin Implants
    38–21 d p. 689 Progestin-Only Contraceptives
    38–22 b p. 689 Progestin-Only Contraceptives
    38–23 c p. 693 Injectable Progestin Contraceptives
    38–24 a p. 690 Combination Oral Contraceptive Pills
    p. 693 Progestin-Only Pills
    38–25 c p. 689 Combination Hormonal Contraceptives Mechanism of Action
    38–26 b p. 690 Combination Oral Contraceptive Pills
    38–27 d p. 690 Combination Oral Contraceptive Pills
    38–28 a p. 691 Combination Oral Contraceptive Pills
    38–29 b p. 692 Combination Oral Contraceptive Pills
    38–30 b p. 692 Transdermal Patch
    38–31 b p. 692 Transdermal Patch
    38–32 a p. 693 Transvaginal Ring
    38–33 a p. 694 Barrier Methods
    38–34 c p. 680 Table 38-1
    p. 694 Barrier Methods
    38–35 b p. 695 Spermicides
    38–36 a p. 695 Fertility Awareness-Based Methods
    38–37 d p. 680 Table 38-1
    p. 683 Contraceptive Action
    p. 689 Actions and Side Effects
    p. 695 Fertility Awareness-Based Methods
    38–38 c p. 696 Emergency Contraception
    262

    CHAPTER 39

    Sterilization

    39–1. Among women using contraception, what percentage 39–6. A 36-year-old G3P2 desires permanent sterilization
    use sterilization? after delivery. She has read recently that the entire
    a. 10% fallopian tube should be removed when perform-
    ing a tubal ligation. What is the rationale for this
    b. 15%
    recommendation?
    c. 20%
    a. Decrease cancer risks
    d. 33%
    b. Decrease the failure rate
    39–2. A 28-year-old G4P3 presents for prenatal care at c. Decrease bleeding complications
    8 weeks’ gestation and reports she does not want any d. Decrease the risk for an ectopic pregnancy
    more children. She asks for a postpartum bilateral
    tubal ligation. All except which of the following are 39–7. What method of tubal ligation is displayed below?
    accurate and should be included in your counseling?
    a. It is permanent
    b. There are failure rates
    c. It can be reversed without consequence
    d. An explanation of alternative options for
    contraception

    39–3. Which of the following aspects of postpartum anat-


    omy are advantageous for a puerperal sterilization?
    a. A noninvoluted uterus
    b. Laxity of the abdominal wall
    c. Fallopian tubes directly beneath the abdominal
    wall
    d. All of the above
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al
    39–4. All except which of the following aspects of the (eds): Sterilization. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    intrapartum and postpartum periods should be Figure 39-1B.
    accounted for when considering a puerperal tubal
    sterilization? a. Uchida
    a. Status of the newborn b. Pomeroy
    b. Postpartum hemorrhage c. Parkland
    c. Patient’s ability to ambulate d. Modified Pomeroy
    d. Utilization of neuraxial anesthesia placed for labor
    39–8. Sterilization in the puerperium is typically performed
    39–5. Which of the following methods of puerperal using which of the following anesthetic methods?
    sterilization carries the greatest morbidity? a. Spinal anesthesia
    a. Hysterectomy b. General anesthesia
    b. Salpingectomy c. Incision infiltration
    c. Uchida method d. Transverse abdominis plane block
    d. Parkland method
    Sterilization 263

    39–9. You are seeing a 33-year-old G3P2 for prenatal care. 39–12. Which of the following is true regarding identification
    She had two prior vaginal deliveries and desires a of the structure being ligated?
    bilateral tubal ligation after this pregnancy. She a. The distal fimbria must be seen prior to ligation.

    CHAPTER 39
    anticipates having another vaginal delivery and
    b. Common reason for failure of sterilization is
    wants to know what type of incision she will have
    ligation of the wrong structure.
    for her tubal ligation. Which of the answer choices
    below depicts the best incision for a puerperal tubal c. The midportion of the fallopian tube can be
    ligation? confused with that of the round ligament.
    d. All of the above

    39–13. What is the most common approach to the


    nonpuerperal tubal ligation?
    a. Colpotomy
    b. Laparotomy
    c. Laparoscopy
    d. Minilaparotomy

    39–14. What type of suture is typically used to complete the


    tubal ligation picture below?

    a. A
    b. B
    c. C
    d. D

    39–10. Why is an infraumbilical incision the most favorable


    for a puerperal tubal ligation?
    a. Smallest incision
    b. Yields better cosmesis
    c. Decreased risk for bleeding complications
    d. It’s the thickest portion, which improves the Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    integrity of the incision. Sterilization. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 39-2.

    39–11. Which of the following are reasonable options to a. Vicryl


    provide adequate exposure during a puerperal tubal
    b. Chromic
    ligation?
    c. Monocryl
    a. A larger incision
    d. Plain catgut
    b. Reverse Trendelenburg
    c. Elevate the abdominal wall with your fingers 39–15. Why should that particular suture be used in
    d. Tilt the table to same side as the tube being Question 39–14?
    exposed a. Quick absorption allows separation of the severed
    ends
    b. Easier to tie knots with this suture compared to
    others
    c. Quick absorption leads to decreased adhesion
    formation
    d. Delayed absorption decreases the risk for bleeding
    complications
    264 The Puerperium

    39–16. What is the cumulative failure rate for tubal 39–20. A 27-year-old multigravida tells you at her 28-week
    sterilization? prenatal care visit that she desires a tubal ligation
    a. 0.5% after delivery. For which of the following reasons do
    SECTION 10

    you counsel her on the permanence of the procedure


    b. 1%
    and encourage her to seek another method of
    c. 3% contraception?
    d. 5% a. It is associated with early menopause.
    39–17. Which of the following are reasons for failure of b. Younger women have increased risk for regret.
    tubal sterilization? c. It is associated with an increased risk for ovarian
    cancer.
    a. Spontaneous reanastomosis
    d. There is a decrease in sexual interest after tubal
    b. Transection of the round ligament
    ligation.
    c. Partial transection of the fallopian tube
    d. All of the above 39–21. Which of the following factors favor successful tubal
    reversal?
    39–18. What benefits, other than contraception, does a a. Age <35 years
    tubal ligation provide?
    b. Isthmic-isthmic repairs
    a. Decrease risk for menorrhagia
    c. 7 cm of remaining tube
    b. Decrease risk for breast cancer
    d. All of the above
    c. Decrease risk for ovarian cancer
    d. All of the above 39–22. The following form of contraception is made of
    what material?
    39–19. A 37-year-old G3P3 underwent a bilateral tubal
    ligation 2 years ago at the time of her third cesarean
    section. She now presents with amenorrhea and nau-
    sea and vomiting for the last month. You perform a
    urine pregnancy test and it is positive. You perform
    an ultrasound and discover the finding below. This
    complication affects what percentage of pregnancies
    after a tubal ligation?

    a. Zinc
    b. Copper
    c. Progesterone
    d. Nickel and titanium alloy

    39–23. How does Essure work as a form of contraception?


    a. Prevents ovulation
    b. Alters cervical mucous
    c. Tubal lumen occlusion
    d. Thinning of the endometrium

    39–24. What adverse effects are associated with Essure use?


    a. 10%
    a. Perforation
    b. 20%
    b. Allergic reactions
    c. 30%
    c. Abnormal bleeding
    d. 70%
    d. All of the above
    Sterilization 265

    39–25. When after Essure placement should confirmation 39–29. Which of the following is a reason why pregnancy
    with a hysterosalpingography be performed? after a vasectomy may occur?
    a. 3 weeks a. Recanalization

    CHAPTER 39
    b. 6 weeks b. Incomplete occlusion
    c. 12 weeks c. Unprotected intercourse too soon
    d. 16 weeks d. All of the above

    39–26. During a vasectomy, which of the following structures 39–30. Pregnancy rates after vasectomy reversal increase
    is ligated? with all except which of the following?
    a. Epididymis a. Microsurgical technique
    b. Spermatic cord b. Younger female partner age
    c. Efferent ductile c. Longer duration from vasectomy to reversal
    d. Ductus deferens d. Normal sperm quality during reversal procedure

    39–27. Compared with tubal ligation, which of the 39–31. Compared to a traditional tubal ligation, which of
    following is an advantage of vasectomy? the following is increased with a salpingectomy?
    a. Less invasive a. Risk for bleeding
    b. Easily reversed b. Risk for postoperative ileus
    c. Immediately effective c. Risk for adhesion formation
    d. Does not require confirmation d. All of the above

    39–28. How long does it take for sperm to be completely 39–32. Why should the bladder be emptied prior to a
    removed from the reproductive tract? puerperal tubal ligation?
    a. 1 week a. Avoid bladder injury
    b. 4 weeks b. Prevent postop urinary retention
    c. 12 weeks c. Prevent the fundus from dropping to the pubic
    d. 16 weeks symphysis
    d. All of the above
    266 The Puerperium

    CHAPTER 39 ANSWER KEY

    Question Letter Page


    SECTION 10

    number answer cited Header cited


    39–1 d p. 702 Introduction
    39–2 c p. 702 Introduction
    39–3 d p. 702 Timing
    39–4 c p. 702 Timing
    39–5 a p. 703 Technique
    39–6 a p. 703 Technique
    39–7 c p. 703 Figure 39-1
    39–8 a p. 703 Technique
    39–9 d p. 703 Technique
    39–10 b p. 703 Technique
    39–11 a p. 703 Technique
    39–12 d p. 703 Technique
    39–13 c p. 704 Nonpuerperal Tubal Sterilization
    39–14 d p. 704 Figure 39-2
    39–15 a p. 704 Figure 39-2
    39–16 a p. 704 Contraceptive Failure
    39–17 d p. 705 Contraceptive Failure
    39–18 c p. 705 Other Effects
    39–19 c p. 705 Contraceptive Failure
    39–20 b p. 705 Other Effects
    39–21 d p. 705 Tubal Sterilization Reversal
    39–22 d p. 705 Transcervical Sterilization
    39–23 c p. 705 Transcervical Sterilization
    39–24 d p. 705 Transcervical Sterilization
    39–25 c p. 705 Transcervical Sterilization
    39–26 d p. 706 Vasectomy
    39–27 a p. 706 Vasectomy
    39–28 c p. 706 Vasectomy
    39–29 d p. 706 Vasectomy
    39–30 c p. 706 Vasectomy
    39–31 a p. 704 Technique
    39–32 a p. 703 Technique
    268

    CHAPTER 40

    Hypertensive Disorders

    40–1. What percentage of pregnancies are complicated by 40–5. A 28-year-old G1 at 38 weeks’ gestation presents
    hypertension? with complaint of contractions. Her blood pressure
    a. 2–3% is noted to be 148/90 mm Hg and 152/96 mm Hg.
    She has a urine protein:creatinine ratio of 0.4, a
    b. 4–5%
    creatinine of 1.04 mg/dL (baseline 0.48 mg/dL),
    c. 5–10% normal AST and ALT, and platelet count of
    d. 10–20% 110,000/µL. She denies any symptoms. What criteria
    for severe preeclampsia does this patient meet?
    40–2. What percentage of eclamptic seizures occur in a. Proteinuria
    women without significant proteinuria?
    b. Low platelets
    a. 5–9%
    c. Elevated creatinine
    b. 10–17%
    d. She does not meet criteria for severe preeclampsia.
    c. 20–25%
    d. 30–33% 40–6. Many conditions and factors are associated with
    an increased risk for preeclampsia. Which of the
    40–3. A 21-year-old G1 at 36 weeks’ gestation presents for following factors results in the greatest relative risk for
    her clinic visit and is noted to have a blood pressure of a diagnosis of preeclampsia in the current pregnancy?
    148/88 mm Hg. A repeat blood pressure 30 minutes a. Primigravida
    later is 146/92 mm Hg. Her blood pressures through-
    b. Advanced maternal age
    out pregnancy have been below 140/90 mm Hg.
    She denies any complaints, and urinalysis is negative c. Systemic lupus erythematous
    for proteinuria. What is the most likely diagnosis? d. History of preeclampsia in a prior pregnancy
    a. Delta hypertension
    40–7. Which of the following is thought to play a
    b. Chronic hypertension
    significant role in the development of preeclampsia?
    c. Preeclampsia syndrome
    a. Genetic factors
    d. Gestational hypertension
    b. Immunological factors
    40–4. What percentage of eclamptic seizures occur more c. Abnormal trophoblastic invasion
    than 48 hours after delivery? d. All of the above
    a. 2%
    40–8. Which of the following angiogenic factors are
    b. 5%
    elevated in women who proceed to develop
    c. 10% preeclampsia?
    d. 20% a. sFlt-1
    b. PIGF
    c. VEGF
    d. TGF-β
    Hypertensive Disorders 269

    40–9. Which of the following is not a pathophysiologi- 40–11. The patient Question 40–10 has a prolonged
    cal change to the cardiovascular system seen in the induction receiving over 5 liters of intravenous fluids.
    setting of preeclampsia? She requires 4 liters supplemental oxygen via nasal

    CHAPTER 40
    a. Increased preload cannula. On the below schematic, which position best
    describes her hemodynamic state at this time?
    b. Decreased preload
    c. Increased afterload 120

    d. Endothelial activation 110 Hyperdynamic

    100
    40–10. A 25-year-old primigravida at 36 weeks’ gestation D
    presents with scotomata and headache, a blood 90
    pressure of 168/102 mm Hg, and proteinuria. A

    LVSWI (g·m·m–2)
    diagnosis of severe preeclampsia is made. On the 80 Normal
    below schematic, which position best describes her 70
    hemodynamic state?
    60
    120 C
    50 A
    110 Hyperdynamic B
    40 Depressed
    100
    D 30
    90
    LVSWI (g·m·m–2)

    0
    80 Normal 0 5 10 15 20 25 30
    PCWP (mm Hg)
    70
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    60 Hypertensive disorders. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    C Figure 40-5.
    50 A
    B
    40 Depressed a. A
    b. B
    30
    c. C
    0
    0 5 10 15 20 25 30
    d. D
    PCWP (mm Hg)
    40–12. A 21-year-old primigravida presents at 36 weeks’
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    gestation with new-onset headache. Her blood
    Hypertensive disorders. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    Figure 40-5. pressure is 150/90 mm Hg, her serum creatinine is
    0.8 mg/mL, AST is 32 U/L, and platelet count is
    a. A 28,000/µL. Which of the following criteria for severe
    preeclampsia is met?
    b. B
    a. Hypertension
    c. C
    b. Liver dysfunction
    d. D
    c. Thrombocytopenia
    d. Elevated serum creatinine
    270 Obstetrical Complications

    40–13. For the patient Question 40–12, which of the following 40–16. What proportion of maternal deaths can be attrib-
    is an indication for primary cesarean delivery without uted to hypertensive disorders in pregnancy?
    an attempt at induction? a. 1 in 2
    SECTION 11

    a. Malpresentation b. 1 in 6
    b. Unfavorable cervix c. 1 in 10
    c. Possible fetal thrombocytopenia d. 1 in 20
    d. None of the above
    40–17. A G3P2 at 16 weeks’ gestation presents to the emer-
    40–14. Which statement best describes renal perfusion and gency department complaining of vaginal bleeding.
    glomerular filtration rates in women with preeclampsia Her blood pressure is 148/96 mm Hg and she has
    that has not yet progressed to severe disease? 3+ proteinuria on a specimen obtained during
    a. Similar compared to normal pregnant values bladder catheterization. Which of the following may
    explain the development of preeclampsia in this
    b. Increased compared to normal pregnant values
    patient?
    c. Similar compared to normal nonpregnant values
    d. Decreased compared to normal nonpregnant
    values

    40–15. A 24-year-old primigravida presents at 37 weeks’


    gestation with headache, a blood pressure of
    170/102 mm Hg, and severe right upper quadrant
    pain. She is diagnosed with HELLP syndrome and
    undergoes an uncomplicated induction of labor.
    Her right upper quadrant pain persists, and a
    computed tomography scan of her abdomen/pelvis is
    completed with the findings as shown below. What
    is denoted by the asterisk (*)?

    a. Increased volume of chorionic villi


    b. Extensive remodeling of the spiral arterioles
    c. Increased invasion of extravillous trophoblastic
    tissue
    d. None of the above

    40–18. What is the underlying etiology of the proteinuria


    seen with preeclampsia?
    a. Increased capillary permeability
    b. Increased renal artery resistance
    c. Increased glomerular filtration rate
    a. Splenic infarction d. Increased systemic vascular resistance
    b. Intrahepatic infarction
    c. Subcapsular hematoma
    d. Periportal hemorrhagic necrosis
    Hypertensive Disorders 271

    40–19. A 39-year-old G3P2 presents at 30 weeks’ gestation 40–23. A multiparous woman with no prenatal care presents
    with hypertension, proteinuria, and headache. She is in active labor with a blood pressure of 156/92 mm Hg
    diagnosed with severe preeclampsia, and induction and proteinuria. Her neonate is born vaginally after

    CHAPTER 40
    of labor is indicated. Her pregnancy is complicated an uncomplicated labor course, with the second
    by the fetal karyotype shown below. What is the stage of labor lasting only 15 minutes. The infant
    possible explanation for her increased risk for is noted to have petechiae on the scalp and chest,
    preeclampsia with the below fetal karyotype? and oozing at the site of his heel stick. An initial
    platelet count is 32,000/µL. Which of the following
    disorders is least likely to be the cause of the infant’s
    thrombocytopenia?
    a. Aneuploidy
    b. Maternal preeclampsia
    c. Maternal autoimmune disorder
    d. Alloimmune thrombocytopenia

    40–24. A 23-year-old primigravida presents with a blood


    pressure of 160/104 mm Hg, 3+ proteinuria, and
    right upper quadrant discomfort. She has a vaginal
    delivery complicated by bilateral sulcal tears and an
    estimated blood loss of 1500 mL. She produces
    110 mL of urine in the first 4 hours postpartum
    and her serum creatinine rises from 0.98 mg/dL to
    a. Increased antiangiogenic factor levels 1.42 mg/dL. What is the most likely explanation for
    this finding?
    b. Increased frequency of placenta mosaicism
    c. Higher frequency of spiral arteriole atherosis
    a. Postpartum hemorrhage
    d. Increased levels of oxidative products in the b. Subcapsular liver hematoma
    placenta c. Ureteral injury during laceration repair
    d. Dehydration due to prolonged induction of labor
    40–20. Which of the following nutritional supplements has
    been shown to reduce the incidence of preeclampsia? 40–25. The following computed tomography image shows
    a. Calcium cerebral edema in a postpartum patient with
    b. Vitamin E hypertension, vision changes, and confusion. What
    associated morbidity is the patient at risk for?
    c. Ascorbic acid
    d. None of the above

    40–21. Which of the following physiological responses is


    typically seen in preeclamptic patients?
    a. Increased production of nitric acid
    b. Increased sensitivity to angiotensin II
    c. Decreased reactivity to norepinephrine
    d. All of the above

    40–22. The typical blood volume of a gravida at term is


    4500 mL. In patients with preeclampsia, which of
    the following would be the expected blood volume?
    a. 2500 mL
    b. 3200 mL
    c. 4500 mL a. Hemiplegia
    d. 5000 mL b. Cystic leukomalacia
    c. Retinal artery occlusion
    d. Transtentorial herniation
    272 Obstetrical Complications

    40–26. Which of the following interventions is least 40–30. A 42-year-old woman presents for prenatal care.
    indicated for the patient in Question 40–25? She has a demanding professional career and reports
    a. Mannitol she is unwilling to attend frequent prenatal visits at the
    SECTION 11

    end of pregnancy. You discourage this, explaining these


    b. Dexamethasone
    visits are recommended for which of the following
    c. Antihypertensive medication reasons?
    d. Intravenous immune globulin a. To aid in the early detection of preeclampsia
    b. To detect possible malpresentation and discuss
    40–27. Your patient is admitted to the hospital for evalua-
    delivery planning
    tion of new-onset hypertension at 30 weeks’ gesta-
    tion. Which of the following tests or evaluations is c. To aid in the timely detection of fetal com-
    least appropriate? plications such as growth restriction or
    oligohydramnios
    a. Maternal weight
    d. All of the above
    b. Protein:creatinine ratio
    c. Cell-free DNA testing for aneuploidy 40–31. The patient in Question 40–30 presents to labor and
    d. Sonographic evaluation of fetal growth delivery at 38 weeks’ gestation with contractions,
    vaginal bleeding, and hypertension. She has a rapid
    40–28. What is the sensitivity and specificity, respectively, of labor with recurrent late fetal heart rate decelerations and
    hyperuricemia for the detection of preeclampsia? delivers a depressed infant within an hour of arrival.
    a. 0–55%, 17–30% What is the most likely finding on pathological
    examination of the placenta?
    b. 0–55%, 77–95%
    a. No abnormality
    c. 65–90%, 20–55%
    b. Chronic chorioamnionitis
    d. 77–95%, 85–97%
    c. Retroplacental clot and diffuse infarction
    40–29. Which of the following medical therapies has been d. Small for gestational age with villous infarction
    associated with a modest decrease in the incidence of
    preeclampsia in women at increased risk? 40–32. A 21-year-old primigravida at 32 weeks’ gestation
    a. Aspirin has new-onset hypertension and proteinuria. She
    inquires as to whether or not initiation of an anti-
    b. Metformin
    hypertensive agent may be helpful. Which of the
    c. Enoxaparin following complications is more likely when labetalol
    d. Heparin sulfate is initiated for preeclampsia?
    a. Preterm birth
    b. Hypertensive urgency
    c. Fetal growth restriction
    d. None of the above
    Hypertensive Disorders 273

    40–33. A 24-year-old G4P2 at 26 weeks’ gestation presents


    via emergency medical services after being found
    unconscious at home by her 6-year-old child. She

    CHAPTER 40
    is oriented on arrival and found to have a blood
    pressure of 180/110 mm Hg and 4+ proteinuria.
    Upon questioning she reports a history of eclampsia
    in her prior pregnancy at 34 weeks’ gestation. She
    then has a 5-minute-long tonic-clonic seizure which
    resolves with magnesium sulfate administration.
    Once the patient is stabilized, she undergoes cesarean
    delivery for malpresentation. The below magnetic
    resonance imaging was performed postpartum. What
    is the most likely finding on imaging?

    Used with permission from Dr. Emily Calasanz.

    a. Subdural hematoma
    b. Parenchymal hemorrhage
    c. Subarachnoid hemorrhage
    d. Posterior reversible encephalopathy syndrome
    274 Obstetrical Complications

    CHAPTER 40 ANSWER KEY

    Question Letter Page


    SECTION 11

    number answer cited Header cited


    40–1 c p. 710 Introduction
    40–2 b p. 711 Terminology and Diagnosis
    40–3 d p. 711 Terminology and Diagnosis
    40–4 c p. 712 Terminology and Diagnosis
    40–5 c p. 712 Terminology and Diagnosis
    40–6 d p. 714 Incidence and Risk Factors
    40–7 d p. 715 Etiology
    40–8 a p. 717 Pathogenesis
    40–9 a p. 718 Pathophysiology
    40–10 a p. 719 Pathophysiology
    40–11 d p. 719 Pathophysiology
    40–12 c p. 720 Pathophysiology
    40–13 a p. 720 Pathophysiology
    40–14 c p. 721 Pathophysiology
    40–15 c p. 722 Pathophysiology
    40–16 b p. 724 Incidence and Risk Factors
    40–17 a p. 715 Etiology
    40–18 a p. 721 Pathophysiology
    40–19 a p. 716 Etiology
    40–20 d p. 728 Prevention
    40–21 b p. 717 Pathogenesis
    40–22 b p. 719 Pathophysiology
    40–23 b p. 720 Pathophysiology
    40–24 a p. 721 Pathophysiology
    40–25 d p. 725 Pathophysiology
    40–26 d p. 725 Pathophysiology
    40–27 c p. 727 Prediction
    40–28 b p. 727 Prediction
    40–29 a p. 729 Prevention
    40–30 d p. 729 Preeclampsia
    40–31 c p. 729 Preeclampsia
    40–32 c p. 731 Preeclampsia
    40–33 d p. 724 Pathophysiology
    275

    CHAPTER 41

    Obstetrical Hemorrhage

    41–1. What is the most important cause of maternal 41–4. For a woman measuring 5!0" and 120 lb, what is her
    mortality worldwide? expected pregravid blood volume?
    a. Infection a. 3000 mL
    b. Hemorrhage b. 3250 mL
    c. Pulmonary embolism c. 3500 mL
    d. None of the above d. 3800 mL

    41–2. Which of the following statements is accurate 41–5. Assuming a 50% increase in the blood volume of
    concerning postpartum hemorrhage? a woman during pregnancy, what would the blood
    a. The blood loss at delivery approaches the volume volume of a 5!2" woman who weighed 140 lb
    of blood added during pregnancy. pregravid be at term?
    b. Studies show that estimated blood loss reported is a. 4000 mL
    often less than the actual blood loss. b. 4340 mL
    c. The American College of Obstetricians and c. 4700 mL
    Gynecologists defines postpartum hemorrhage as d. 4930 mL
    cumulative blood loss of >100 mL accompanied
    by symptoms and signs of hypovolemia. 41–6. Causes of uterine atony include which of the
    d. None of the above following?
    a. Obesity
    41–3. Given the diagram below, which of the following
    b. Placenta previa
    statements is true?
    c. Multiple fetuses
    70
    <500 mL d. Placental abruption
    60
    500–1000 mL
    50 1000–1500 mL 41–7. A 33-year-old G4P3 at 35 weeks’ gestation presents
    Percent of cases

    >2500 mL to labor and delivery with a small amount of vaginal


    40
    bleeding. When you place her on the fetal monitor
    30 there is a category III fetal heart rate tracing.
    An emergent cesarean delivery is performed.
    20
    The 1-minute and 5-minute Apgars are 0 and 3,
    10 respectively. Which of the following is the etiology?
    0 a. Vasa previa
    Vaginal Repeat cesarean Repeat cesarean
    delivery delivery with hysterectomy b. Placenta previa
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): c. Placental abruption
    Obstetrical hemorrhage. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, d. All of the above
    Figure 41-1.

    a. Very few vaginal deliveries have blood loss less


    than 500 mL.
    b. All cesarean hysterectomies have blood loss
    greater than 1000 mL.
    c. A smaller percentage of vaginal deliveries have
    blood loss greater than 1000 mL than cesarean
    hysterectomies have blood loss less than 500 mL.
    d. None of the above
    276 Obstetrical Complications

    41–8. Which of the following maneuvers should be 41–11. The patient in Question 41–10 continues bleeding
    performed in the setting of postpartum hemorrhage after the interventions mentioned above. Which of
    following a vaginal delivery? the following maneuvers might be employed?
    SECTION 11

    a. Evaluate birth canal for lacerations a. Hysterectomy


    b. Evaluate the placenta for possible retained b. Bakri balloon placement
    fragments c. Uterine compression sutures
    c. The uterus should be manually explored, and d. All of the above
    placental fragments removed
    d. All of the above 41–12. The patient in Question 41–10 undergoes a
    hysterectomy and 5 units of packed red blood cells
    41–9. During evaluation of postpartum hemorrhage are given, but bleeding continues. What is the most
    following a vaginal delivery, which of the following likely etiology of the bleeding?
    maneuvers or medications might be used? a. Vaginal cuff bleeding
    a. Bimanual uterine compression b. Dilutional coagulopathy
    b. Ergot alkaloids for patients with hypertension c. Lacerated internal iliac artery
    c. Carboprost tromethamine in patients with mild d. Placental implantation on the omentum
    asthma
    d. All of the above 41–13. Regarding the patient in Question 41–10, which of
    the following interventions might have avoided or
    41–10. A 34-year-old G3P3 begins having brisk bright red ameliorated this condition?
    bleeding following completion of a vaginal delivery. a. Transfusion of platelets
    You give her carboprost tromethamine and perform
    b. Transfusion of whole blood
    the maneuver pictured below. What else should be
    immediately considered? c. Infusion of 5% albumin for initial resuscitation
    d. All of the above

    41–14. What is represented in the following image?

    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Obstetrical hemorrhage. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    Figure 41-4.
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Obstetrical hemorrhage. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    a. Call for help Figure 41-5.

    b. Ask for urgent help from anesthesia


    a. Bakri balloon
    c. Place large-bore intravenous lines, order blood,
    and begin volume resuscitation b. Foley catheter
    d. All of the above c. Blakemore tube
    d. Jackson-Pratt drain
    Obstetrical Hemorrhage 277

    41–15. The following picture unfortunately depicts a maternal 41–19. The hematoma in the following picture is in which
    death after postpartum hemorrhage. Which of the location?
    following are possible contributors?

    CHAPTER 41
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    a. Ischiorectal hematoma
    Obstetrical hemorrhage. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, b. Periurethral hematoma
    Figure 41-7.
    c. Supralevator hematoma
    a. Placenta previa d. Left-sided anterior perineal triangle
    b. Uterine rupture
    41–20. The following picture represents which of the
    c. Uterine inversion following?
    d. Chorioamnionitis

    41–16. What percentage of women have lacerations at the


    time of vaginal delivery?
    a. 50%
    b. 90%
    c. 80%
    d. 65%

    41–17. Which maneuvers below should be performed when


    repairing a cervical laceration?
    a. Operator grasps lips of cervix with ring forceps.
    b. Second assistant can provide better exposure with
    vaginal wall retractors.
    c. Assistant place downward pressure on the uterus
    to expose the cervix better for the operator. Used with permission from Dr. Ed Wells.

    d. All of the above a. Molar gestation


    41–18. What is the appropriate management of vulvovaginal b. Placenta accreta
    hematomas? c. Acute abruption
    a. Surgical exploration in all cases d. Partial abruption
    b. To prevent infection they should all undergo
    ultrasound guided drainage. 41–21. Which of the following are risk factors for recurrent
    abruption?
    c. In a small hematoma, if pain is severe then ice
    packs and analgesia are appropriate. a. Prior abruption
    d. If bleeding ceases, small to moderate-sized b. Low birthweight
    hematomas can be treated expectantly. c. Preterm rupture of membranes
    d. None of the above
    278 Obstetrical Complications

    41–22. Your patient is a 22-year-old G2P1 at 36 weeks’ 41–26. How is a low-lying placenta defined?
    gestation with a history of prior abruption during a a. The placenta is implanted in the lower uterine
    spontaneous vaginal delivery. Which of the following segment.
    SECTION 11

    might be effective for preventing recurrence during


    b. The placental edge covers the internal os, but not
    this pregnancy?
    completely.
    a. Antepartum testing
    c. The placental edge does not cover the internal os
    b. Delivery at 38 weeks but lies within a 1-cm wide perimeter.
    c. Cesarean delivery at 38 weeks d. The placental edge does not cover the internal os
    d. Cesarean delivery at 39 weeks but lies within a 2-cm wide perimeter.

    41–23. Which of the following is true concerning placental 41–27. What percentage of women who have a primary
    abruption? cesarean with a placenta previa have hysterectomies
    a. It may lead to a dilutional coagulopathy. performed?
    b. Concealed abruption forces thromboplastin into a. 1%
    large veins draining the implantation site. b. 2%
    c. In most women with abruption severe enough to c. 6%
    kill the fetus, the plasma fibrinogen level will be d. 10%
    less than 150 mg/dL.
    d. All of the above 41–28. Which of the following statements are true concern-
    ing morbidly adherent placentas?
    41–24. What is depicted in the following picture? a. Cesarean-scar pregnancies are a precursor to a
    morbidly adherent placenta.
    b. Placenta villi attach to smooth muscle fibers
    rather than to decidual cells.
    c. Abnormal placental adherence is in part due to
    partial or total absence of Nitabuch layer.
    d. All of the above

    41–29. The picture below represents which of the following


    placental pathologies?

    a. Placenta previa
    b. Placenta accreta
    c. Couvelaire uterus
    d. None of the above

    41–25. A 22-year-old G2P1 at 28 weeks’ gestation presents


    with rupture of membranes about 2 hours ago. What
    is true about this patient concerning abruption?
    a. She has a 5% risk for abruption. Used with permission from Dr. Ed Wells.
    b. She has a 17% risk for abruption.
    c. Her risk for abruption is not increased. a. Placenta increta
    d. None of the above b. Placenta accreta
    c. Placenta percreta
    d. Placental abruption
    Obstetrical Hemorrhage 279

    41–30. From the following graph, which of the following 41–31. Which of the following can be seen in the ultra-
    statements concerning morbidly adherent placenta sound picture below?
    (MAP) is accurate?

    CHAPTER 41
    75
    67
    61
    Accrete syndromes (percent)

    50
    40

    25

    11

    3
    a. Lacunae
    0
    0 1 2 3 4 5
    b. Bridging vessels
    Number of prior CDs in women c. Intraabdominal placental implantation
    with current placenta previa d. None of the above
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Obstetrical hemorrhage. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, 41–32. Which of the statements below accurately depicts the
    Figure 41-26. difference between consumptive coagulopathy and
    disseminated intravascular coagulation?
    a. The highest risk for placenta previa is with your a. Abruption best represents a consumptive
    5th pregnancy. coagulopathy.
    b. Most women with MAP have had more than b. Loss of procoagulants with massive hemorrhage is
    3 previous cesareans. the basis of dilutional coagulopathy.
    c. With placenta previa, the more cesareans a c. A concealed abruption forces thromboplastin into
    woman has had, the higher her risk for MAP. the circulation and leads to the consumption of
    d. All of the above procoagulants.
    d. All of the above
    280 Obstetrical Complications

    41–33. The slide pictured below is consistent with a fatal 41–37. Which hemostatic surgical procedure is to be per-
    syndrome. Which of the following proposed diag- formed in the picture below?
    nostic criteria are required to make the diagnosis?
    SECTION 11

    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Obstetrical hemorrhage. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    Figure 41-31a.
    a. B-Lynch procedure
    a. Clinical onset during labor or within 30 minutes b. Uterine artery ligation
    of placental delivery. c. Vaginal artery ligation
    b. Abrupt onset of cardiorespiratory arrest, or both d. Ovarian artery ligation
    hypotension and respiratory compromise.
    c. Documentation of overt disseminated intra- 41–38. Which hemostatic surgical procedure is
    vascular coagulopathy must be detected prior demonstrated in the picture below?
    to enough blood loss to cause dilutional
    coagulopathy.
    d. All of the above

    41–34. Which of the bacteria below are associated with


    consumptive coagulopathy?
    a. Escherichia coli
    b. Klebsiella pneumoniae
    c. Group A streptococcus 2
    5
    d. Group B streptococcus 3
    4

    1 6
    41–35. The use of whole blood for massive hemorrhage is
    supported by which of the following?
    a. Less renal failure
    b. Less pulmonary edema
    c. Fewer intensive care unit admissions
    d. All of the above
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    41–36. Viral infection risks from transfusion are accurately Obstetrical hemorrhage. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    depicted in which of the following statements? Figure 41-34b.

    a. Hepatitis B risk is <1 per 100,000 units


    a. B-Lynch procedure
    b. Hepatitis C risk is 1 per 1–2 million units
    b. Uterine artery ligation
    c. Human immunodeficiency virus risk is 1 per
    1–2 million units c. Vaginal artery ligation
    d. All of the above d. Ovarian artery ligation
    Obstetrical Hemorrhage 281

    41–39. Ligation at which of the following labeled vessel


    points in the retroperitoneum will decrease the pulse
    pressure in the uterine artery?

    CHAPTER 41
    A

    C
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Obstetrical hemorrhage. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    Figure 41-35.

    a. Posterior division
    b. Internal iliac vein
    c. Internal iliac artery
    d. External iliac artery
    283

    CHAPTER 42

    Preterm Birth

    42–1. What is the definition of very low birthweight? 42–6. At what gestational age does the Obstetric Care
    a. <500 grams Consensus document recommend consideration of
    neonatal resuscitation?
    b. 500 to 1000 grams
    a. 21 weeks’ gestation
    c. 1000 to 1500 grams
    b. 22 weeks’ gestation
    d. 1500 to 2500 grams
    c. 23 weeks’ gestation
    42–2. What is the approximate preterm birth rate in the d. 24 weeks’ gestation
    United States based on the most recently available
    data (2015)? 42–7. A 25-year-old G2P1 presents at 23 weeks and 3 days’
    a. 9.5% gestation with painful contractions. Her cervix is
    dilated to 3 cm. Which interventions should be con-
    b. 10.0% sidered based on her presentation?
    c. 10.5% a. Magnesium sulfate
    d. 11.0% b. Corticosteroid therapy
    42–3. You deliver a 17-year-old G1 at 28 weeks’ gestation c. Cesarean delivery for fetal indications
    following preterm labor. She gives birth to a female d. All of the above
    infant weighing 1090 grams who is immediately taken
    to the neonatal intensive care unit for evaluation. 42–8. Approximately what percentage of all preterm births
    What would you tell her is the approximate survival in the United States occurs after 34 weeks’ gestation?
    rate for her infant? a. 30%
    a. 85% b. 50%
    b. 90% c. 70%
    c. 95% d. 90%
    d. 99%
    42–9. Of the responses listed below, which complication is
    42–4. An infant born at 25 weeks’ gestation is at risk for all least commonly associated with preterm delivery?
    except which of the following complications? a. Hypertension
    a. Asthma b. Fetal complications
    b. Blindness c. Placental abruption
    c. Blood cancers d. None of the above
    d. Pulmonary hypertension

    42–5. What percentage of infants born at 22 weeks’


    gestation is expected to survive without neuro-
    developmental impairment?
    a. 0.5%
    b. 1.0%
    c. 1.5%
    d. 2.0%
    284 Obstetrical Complications

    42–10. A 26-year-old G3P2 presents for pregnancy 42–14. Which of the following bacteria is frequently detected
    confirmation at 10 weeks’ gestation. She is noted to in the amnionic fluid of women with preterm labor?
    have the ultrasound findings pictured. What is her a. Mycoplasma hominis
    SECTION 11

    risk for preterm birth based on the findings?


    b. Gardnerella vaginalis
    c. Ureaplasma urealyticum
    d. All of the above

    42–15. Which of the following lifestyle factors is not


    associated with preterm birth?
    a. Poverty
    b. Short stature
    c. Vitamin D deficiency
    d. Advanced maternal age

    42–16. A 32-year-old G2P1 presents at 16 weeks’ gestation


    for prenatal care. She describes a history of preterm
    premature rupture of membranes in her last pregnancy
    with delivery at 31 weeks’ gestation. How significantly
    increased is her preterm birth risk in her current
    pregnancy based on this history?
    a. 30%
    a. 2-fold increase
    b. 50%
    b. 3-fold increase
    c. 70%
    c. 4-fold increase
    d. 90%
    d. Her recurrent preterm birth risk is not increased
    42–11. Which of the following placental hormones may
    42–17. A 22-year-old G2P1 at 14 weeks’ gestation complains
    play a role in preterm birth caused by maternal–fetal
    of malodorous vaginal discharge. A saline preparation
    stress?
    of the discharge is performed, and the findings are
    a. Estrogen illustrated in the image below. What do you tell her
    b. Human placental lactogen regarding her diagnosis?
    c. Insulin-like growth hormone
    d. Corticotropin-releasing hormone

    42–12. Which of the following bacteria may enhance the


    risk for preterm birth by secretion of hyaluronidase?
    a. Escherichia coli
    b. Peptostreptococcus
    c. Bacterial vaginosis
    d. Group B streptococcus

    42–13. Which of the following enzymes is not involved in


    the inflammatory cascade by which infection induces
    preterm labor?
    a. IL-4
    b. IL-8
    c. Tumor-necrosis factor alpha a. The condition is associated with frequent douching.
    d. All of the above are involved b. There is an association with preeclampsia and
    placental abruption.
    c. Women with this diagnosis and a susceptible
    genotype have a 6-fold increased risk for preterm
    birth.
    d. All of the above
    Preterm Birth 285

    42–18. You perform a routine cervical exam on a 39-year-old 42–21. The Food and Drug Administration approved
    G3P2 at 30 weeks’ gestation. You find her cervix 17-hydroxyprogesterone caproate for the prevention
    to be 2 to 3 cm dilated. She denies having any of recurrent preterm birth based on a 2003 Maternal-

    CHAPTER 42
    contractions, discharge, pelvic pain or pressure. Fetal Medicine Units (MFMU) Network study
    What is her chance of a preterm delivery before performed by Meis et al. What was one of the major
    34 weeks’ gestation? criticisms of this study?
    a. 5% a. It was underpowered
    b. 15% b. Injections were not initiated until 16 weeks’
    c. 25% gestation
    d. 35% c. There was an unexpectedly high preterm delivery
    rate in the placebo arm
    42–19. Which of the following is true regarding transvaginal d. All of the above
    sonographic evaluation of the cervix as a part of the
    assessment for preterm labor? 42–22. A recent study by Nelson et al showed that which of
    a. It can be performed any time after 14 weeks’ the following complications might be increased in
    gestation. pregnant women using 17-hydroxyprogesterone
    caproate to prevent recurrent preterm birth?
    b. It is not affected by maternal obesity, cervix
    position, or shadowing. a. Depression
    c. The American College of Obstetricians and b. Hypertension
    Gynecologists recommends it for all women with c. Gestational diabetes
    a history of a spontaneous preterm birth. d. Urinary tract infections
    d. All of the above
    42–23. A 23-year-old G1 is incidentally noted to have a
    42–20. Your patient is found to have the sonographic cervical length of 18 mm at 21 weeks’ gestation.
    finding shown below during her anatomy ultra- According to available research, which of the
    sound at 22 weeks’ gestation. Her last pregnancy following therapies could be offered to potentially
    was complicated by spontaneous preterm birth decrease her chance of preterm birth?
    at 33 weeks’ gestation. Which of the following a. Cerclage
    interventions could be recommended based on her
    b. Vaginal progesterone
    history and current findings?
    c. 17-hydroxyprogesterone caproate
    d. None of the above

    42–24. In women who experience preterm premature


    rupture of membranes between 24 and 34 weeks’
    gestation, what percentage might be expected to still
    be pregnant 48 hours after rupture?
    a. 5–10%
    b. 10–15%
    c. 15–20%
    d. 20–25%

    42–25. A pregnant woman presents at 32 weeks and 5 days’


    gestation complaining of mild contractions and
    heavy discharge. You perform a speculum exam,
    which demonstrates pooling in the posterior fornix.
    Which of the following interventions would not be
    a. Cerclage placement
    considered based on the clinical presentation?
    b. Aspirin 81 mg daily
    a. Antimicrobials
    c. Vaginal progesterone
    b. Corticosteroids
    d. None of the above
    c. Magnesium sulfate
    d. Expectant management
    286 Obstetrical Complications

    42–26. What appears to be the gestational age threshold 42–31. Which of the following is a potential consequence of
    for lung hypoplasia in women with early membrane bed rest for suspected preterm labor?
    rupture? a. Bone loss
    SECTION 11

    a. 19 weeks’ gestation b. Venous thromboembolism


    b. 21 weeks’ gestation c. Increased risk for preterm delivery
    c. 23 weeks’ gestation d. All of the above
    d. 25 weeks’ gestation
    42–32. An 18-year-old G1 African American female presents
    42–27. Which of the following neonatal outcomes was to the emergency department at 19 weeks’ gestation
    potentially improved following antimicrobial therapy complaining of pelvic pressure. She is found to be
    for pregnant woman with premature rupture of 2 cm dilated with membranes prolapsing beyond
    membranes before 35 weeks’ gestation? the os. No contractions are noted after extended
    a. Improved survival monitoring. You perform a rescue cerclage as pictured
    in the image below. Which of the following factors is
    b. Decreased risk for sepsis
    not associated with a decreased chance of pregnancy
    c. Decreased risk for intracranial hemorrhage continuation after cerclage placement?
    d. Decreased risk for respiratory distress syndrome

    42–28. Which of the following drugs would not be


    recommended either alone or in combination
    for treatment of preterm premature rupture of
    membranes?
    a. Amoxicillin
    b. Erythromycin
    c. Ampicillin-sulbactam
    d. None of the above

    42–29. A pregnant patient is transferred to your facility


    because of concerns for preterm labor at 35 weeks’
    gestation. She received a single course of corticosteroids
    prior to transfer. What neonatal complication is her
    infant potentially at greater risk for?
    a. Sepsis
    a. Nulligravida
    b. Hypothermia
    b. African American race
    c. Hypoglycemia
    c. Membrane prolapse beyond the external os
    d. Transient tachypnea of the newborn
    d. Cerclage placement before 22 weeks’ gestation
    42–30. Treatment with magnesium sulfate is often used
    for neuroprotection for women at risk for delivery
    prior to 32 weeks’ gestation. Approximately how
    many women need to be treated with magnesium to
    prevent one case of cerebral palsy?
    a. 65
    b. 70
    c. 75
    d. 80
    Preterm Birth 287

    42–33. A 28-week pregnant woman presents to labor and 42–34. Which of the following is true regarding
    delivery with preterm contractions and is treated indomethacin use in pregnancy?
    with terbutaline. Two days after the initiation of a. It can only be administered orally

    CHAPTER 42
    therapy, she begins complaining of shortness of
    b. It can lead to reversible oligohydramnios
    breath and cough. A chest radiograph is obtained
    and shown in the image below. Which of the c. It lowers the risk for necrotizing enterocolitis
    following risk factors is associated with development d. All of the above
    of this complication?
    42–35. Cesarean delivery would be expected to decrease
    the risk for intracranial hemorrhage in which of the
    following scenarios?
    a. Estimated fetal weight <1000 grams
    b. Estimated fetal weight <1500 grams
    c. Estimated fetal weight <2000 grams
    d. None of the above

    a. Asthma
    b. Gestational diabetes
    c. Concurrent corticosteroid therapy
    d. All of the above
    289

    CHAPTER 43

    Postterm Pregnancy

    43–1. A pregnancy is considered prolonged after how many 43–7. Maternal risks of postterm pregnancy include all
    completed weeks? except which of the following?
    a. 39 weeks a. Preeclampsia
    b. 40 weeks b. Perineal lacerations
    c. 41 weeks c. Postpartum hemorrhage
    d. 42 weeks d. Morbidly adherent placenta

    43–2. What is the most accurate way of dating a pregnancy? 43–8. What are the best estimates for the frequency of
    a. Last menstrual period postmaturity syndrome in gestations that have
    completed 42 weeks?
    b. 1st-trimester ultrasound
    a. 1%
    c. 2nd-trimester ultrasound
    b. 5%
    d. Last menstrual period and a 2nd-trimester
    ultrasound c. 10–20%
    d. 25%
    43–3. In the United States in 2013, what percentage of
    pregnancies were considered postterm? 43–9. Which of the following is true the syndrome afflicting
    a. 3% this infant?
    b. 5%
    c. 8%
    d. 10%

    43–4. Rare fetal–placental factors associated with postterm


    pregnancy include which of the following?
    a. Anencephaly
    b. Wilms tumor
    c. Adrenal hyperplasia
    d. Autosomal-recessive placental sulfatase deficiency

    43–5. What is a major cause of perinatal mortality associated


    with pregnancy duration beyond 41 weeks?
    a. Birth injuries
    b. Gestational hypertension
    c. Hypoxic-ischemic encephalopathy
    d. All of the above

    43–6. Which of the following have been found to be Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    increased in the setting of postterm pregnancies? Postterm pregnancy. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    Figure 43-2.
    a. Neonatal seizures and deaths
    b. Neonatal intensive care admissions a. Neurological deficits are found in 33%
    c. Cesarean delivery for fetal distress b. Majority have birthweights <10th percentile
    d. All of the above c. Features include simian crease and low-set ears
    d. Oligohydramnios increases its likelihood at 42 weeks
    290 Obstetrical Complications

    43–10. Which of the following characterizes the placenta in


    a postterm pregnancy?
    a. Decreased rate of apoptosis
    SECTION 11

    b. Increased rates of placental separation


    c. Downregulation of the kisspeptin gene
    d. Increased levels of cord erythropoietin levels

    43–11. A 33-year-old multigravida presents in labor


    at 43 weeks’ gestation. She is 3 cm dilated and
    approximately 2 hours after arrival undergoes an
    emergent cesarean delivery due to fetal heart rate
    abnormalities. Which of the following was most
    likely her tracing prior to delivery?

    a. c.

    b. d.
    Postterm Pregnancy 291

    43–12. At the time of cesarean delivery in Question 43–11, 43–16. A 24-year-old primigravida presents to clinic at
    which of the following was likely present? 42 weeks’ gestation after missing several clinic visits.
    a. Meconium An ultrasound image of the deepest vertical pocket

    CHAPTER 43
    is displayed below. She is at risk for having which of
    b. Polyhydramnios the following outcomes?
    c. Short umbilical cord
    d. Bloody amnionic fluid

    43–13. When does the volume of amnionic fluid begin to


    decline?
    a. After 36 weeks
    b. After 37 weeks
    c. After 38 weeks
    d. After 39 weeks

    43–14. In which of the following conditions in pregnancy is


    it generally recommended to be delivered at less than
    42 weeks?
    a. Diabetes
    b. Gestational hypertension
    a. Meconium
    c. Previous cesarean delivery
    b. Macrosomia
    d. All of the above
    c. Shoulder dystocia
    43–15. Most stillbirths in prolonged pregnancies are associ- d. 5-minute Apgar ≤6
    ated with which of the following?
    43–17. Which of the following statements concerning
    a. Oligohydramnios decreased amnionic fluid is false?
    b. Late prenatal care a. Associated with fetal distress during labor
    c. Fetal growth restriction b. Amnionic fluid index <5 cm is associated with
    d. Shortened pregnancy interval more adverse outcomes than largest vertical
    pocket <2 cm.
    c. Amnionic fluid index is the best method
    by which to estimate the occurrence of
    oligohydramnios.
    d. All of the above

    43–18. According to the American College of Obstetricians


    and Gynecologists, at what estimated fetal weight is
    it reasonable to offer cesarean delivery to a nondia-
    betic gravida at term?
    a. 4250 grams
    b. 4500 grams
    c. 4750 grams
    d. 5000 grams
    292 Obstetrical Complications

    43–19. Routine membrane sweeping on cervical exam at 43–25. With thick meconium early in the labor process,
    38–40 weeks’ gestation has been shown to be which of the following is true?
    associated with which of the following? a. Cesarean delivery is likely
    SECTION 11

    a. Increased pain b. Chances for vaginal delivery are diminished


    b. Increased bleeding c. If delivery is remote, some obstetricians elect to
    c. Lower rate of postterm pregnancies perform cesarean delivery
    d. All of the above d. All of the above

    43–20. In primigravidas undergoing induction of labor at 43–26. The American College of Obstetricians and
    41 weeks’ gestation, what beginning fetal station Gynecologists recommends which of the following
    was associated with the highest rate of cesarean in the setting of meconium-stained amnionic fluid?
    section? a. Intubation if the baby is depressed
    a. 0 b. Amnioinfusion only during active labor
    b. –1 c. The pediatrician should immediately perform
    c. –2 bulb suction on the warmer.
    d. –4 d. The obstetrician should perform bulb suction
    after delivery of the baby.
    43–21. Which of the following is predictive of a successful
    induction of labor? 43–27. A 44-year-old primigravida presents to clinic at
    a. Cervical length <3 cm 40 weeks’ gestation. She wants to go into labor
    naturally, and therefore wants to wait as long as
    b. Cervical length <2.5 cm possible to be induced. Based on the American
    c. Cervical dilation prior to induction College of Obstetricians and Gynecologists, when
    d. All of the above should she be induced?
    a. 40 weeks’ gestation
    43–22. Comparing induction of labor at 41 weeks’ gestation b. 41 weeks’ gestation
    to prolonging pregnancies with fetal testing, research
    supports which of the following statements? c. 42 weeks’ gestation
    a. Induction increases the rate of cesarean delivery. d. When the patient is ready
    b. Induction increases the rate of postpartum
    43–28. The patient in Question 43–27 inquires about the
    hemorrhage.
    risks of going past 41 weeks’ gestation. What are the
    c. Induction increases the rate of anesthesia risks she is concerned about?
    complications.
    a. Macrosomia
    d. Induction decreases the rate of meconium
    b. Cesarean delivery
    aspiration syndrome.
    c. Postmaturity syndrome
    43–23. What are considerations when considering d. Anesthesia complications
    amniotomy during a postterm induction?
    a. Increase risk for cord compression 43–29. The patient in Question 43–27 agrees to induction
    of labor at 41 weeks’ gestation. How will you man-
    b. Allows more precise fetal heart rate monitoring
    age her pregnancy during this week?
    c. Aids in identification of thick meconium in
    amnionic fluid a. Fetal surveillance
    d. All of the above b. Anesthesia consult
    c. Weekly prenatal care visit only, as usual
    43–24. When used during labor, amnioinfusion does which d. Cancel her clinic visit and see her on the day of
    of the following? her induction
    a. Prevents placental abruption
    b. Decreases the occurrence of variable decelerations
    c. Decreases the incidence of meconium aspiration
    syndrome
    d. None of the above
    Postterm Pregnancy 293

    43–30. The patient in Question 43–27 presents for her 43–32. The patient in Question 43–31 delivers a male
    nonstress test, and her tracing is pictured below. Given infant, and the neonatologist at delivery suspects
    the fetal heart rate tracing, what are you worried about? postmaturity syndrome. Her suspicion is based on

    CHAPTER 43
    which of the findings below?
    a. Peeling skin
    b. Long, thin body
    c. Unusually old in appearance
    d. All of the above

    a. Meconium
    b. Fetal acidemia
    c. Oligohydramnios
    d. Placental insufficiency

    43–31. A 27-year-old primigravida presents to labor and


    delivery reporting contractions. She reports scant
    prenatal care, and based on her last menstrual period
    she is 41 weeks pregnant. Bedside ultrasound is
    consistent with her last menstrual period. She is not
    in labor, but 1 cm dilated, and she would like to be
    induced. What is the next best step?
    a. Delivery
    b. Follow-up in clinic in 1 week
    c. Amniocentesis for fetal lung maturity
    d. Schedule for induction at 42 weeks’ gestation
    294 Obstetrical Complications

    CHAPTER 43 ANSWER KEY

    Question Letter Page


    SECTION 11

    number answer cited Header cited


    43–1 d p. 835 Introduction
    43–2 b p. 835 Estimated Gestational Age
    43–3 c p. 836 Incidence
    43–4 a p. 836 Incidence
    43–5 d p. 836 Perinatal Morbidity and Mortality
    43–6 d p. 836 Perinatal Morbidity and Mortality
    43–7 d p. 836 Perinatal Morbidity and Mortality
    43–8 c p. 837 Postmaturity Syndrome
    43–9 d p. 837 Postmaturity Syndrome
    43–10 d p. 837 Placental Dysfunction
    43–11 b p. 838 Fetal Distress and Oligohydramnios
    43–12 a p. 838 Fetal Distress and Oligohydramnios
    43–13 c p. 838 Fetal Distress and Oligohydramnios
    43–14 d p. 839 Complications
    43–15 c p. 839 Fetal Growth Restriction
    43–16 d p. 839 Figure 43-5
    43–17 d p. 839 Oligohydramnios
    43–18 d p. 839 Macrosomia
    43–19 d p. 840 Induction Factors
    43–20 d p. 840 Induction Factors
    43–21 d p. 840 Induction Factors
    43–22 d p. 840 Induction versus Fetal Testing
    43–23 d p. 841 Intrapartum Management
    43–24 b p. 841 Intrapartum Management
    43–25 d p. 841 Intrapartum Management
    43–26 a p. 842 Intrapartum Management
    43–27 c p. 840 Induction versus Fetal Testing
    43–28 b p. 840 Induction versus Fetal Testing
    43–29 a p. 841 Figure 43-6
    43–30 c p. 838 Figure 43-4
    43–31 a p. 841 Management Strategies
    43–32 d p. 836 Postmaturity Syndrome
    324

    CHAPTER 49

    Cardiovascular Disorders

    49–1. What percentage of pregnancy-related deaths in the 49–5. Regarding diagnostic studies, which of the following
    United States were attributable to cardiovascular correctly describes a normal change that is character-
    diseases between 2011 and 2013? istic of pregnancy?
    a. 10–15% a. Improved systolic function on echocardiographic
    b. 15–20% assessment
    c. 20–25% b. A decrease in the cardiac silhouette size on chest
    radiograph
    d. 25–30%
    c. An average 15-degree left axis deviation on
    49–2. Which of the following does not contribute to the electrocardiogram
    40% increase in cardiac output seen during normal d. All of the above
    pregnancy?
    a. Increased heart rate 49–6. A 32-year-old G2P1 presents to your office at
    17 weeks’ gestation. She reports a history of tetral-
    b. Increased left ventricular contractility
    ogy of Fallot, which was repaired in infancy. She
    c. Decreased systemic vascular resistance appears comfortable on the exam table with a heart
    d. All of the above contribute to increased cardiac rate of 92 beats per minute and a blood pressure of
    output in pregnancy 96/62 mm Hg. However, she does report significant
    palpitations and dyspnea when climbing the two
    49–3. You are caring for a 24-year-old G1 with severe flights of stairs to her apartment on the third floor.
    aortic stenosis. When in pregnancy are you most Which New York Heart Association class best
    concerned about cardiac decompensation? describes her functional disability?
    a. Peripartum a. Class I
    b. During the first trimester b. Class II
    c. During the second trimester c. Class III
    d. During the third trimester d. Class IV

    49–4. Which of the following best describes the remodel- 49–7. You are caring for a pregnant patient with mitral
    ing of the heart that occurs in normal pregnancy? stenosis. She is able to perform most activities of
    a. Eccentric left ventricular mass expansion with daily living without significant limitation. On
    spherical remodeling echocardiogram, her ejection fraction is 50% and
    her mitral valve area measures 1.8 cm2. Which of
    b. Concentric left ventricular mass expansion with
    the following variables is most predictive of a
    spherical remodeling
    high risk for cardiac complications during this
    c. Eccentric left ventricular mass expansion with pregnancy?
    longitudinal remodeling
    a. Her ejection fraction
    d. Concentric left ventricular mass expansion with
    longitudinal remodeling b. Her functional capacity
    c. Her degree of left-sided obstruction
    d. None of the above
    Cardiovascular Disorders 325

    49–8. The World Health Organization identifies which of 49–12. You obtain a chest radiograph for the patient in
    the following conditions as prohibitive of pregnancy? Question 49–11 at 14 weeks’ gestation because of
    a. Heart transplantation a persistent cough and shortness of breath. Her

    CHAPTER 49
    chest x-ray is shown. What is her mortality risk in
    b. Cyanotic heart disease
    pregnancy based on her history of mechanical valve
    c. Pulmonary artery hypertension replacement?
    d. Systemic ventricular dysfunction with left
    ventricular ejection fraction of 35%

    49–9. For which of the following cardiac conditions is


    conduction analgesia highly recommended?
    a. Severe aortic stenosis
    b. Pulmonary artery hypertension
    c. Repaired hypoplastic left heart syndrome
    d. All of the above

    49–10. You are caring for a 28-year-old G1 with a history


    of moderate mitral stenosis who presented in active
    labor and is now 8 cm dilated. She desires a natural
    labor and declines pain medications during labor.
    As her contractions get closer together, she reports
    increasing pain, is visibly uncomfortable, and inter-
    mittently becomes tachycardic to 130 beats per
    a. 0.1–0.5%
    minute. She suddenly begins complaining of short-
    ness of breath and her oxygen saturation declines b. 1–2%
    to 90% on room air. What is your best course of c. 3–4%
    action? d. 5–6%
    a. Administer metoprolol
    b. Administer intravenous Lasix 49–13. In a pregnant woman who has previously
    undergone a heart transplantation, what is the
    c. Request immediate anesthesia assessment
    approximate risk for suffering a rejection episode
    d. All of the above during pregnancy?
    a. 10%
    49–11. A 30-year-old G2P0A1 presents at 11 weeks’ gesta-
    tion to establish care. She has a history of rheumatic b. 20%
    heart disease and had a mechanical valve replacement c. 30%
    at age 20. She was previously on warfarin 7.5 mg d. 40%
    daily, but stopped taking her medication when she
    found out she was pregnant 1 week ago. What is her
    risk for warfarin embryopathy based on her warfarin
    dosing?
    a. 1%
    b. 3%
    c. 5%
    d. 8%
    326 Medical and Surgical Complications

    49–14. At 32 weeks’ gestation, an uncomplicated primi- 49–16. A graphic of pulmonary capillary wedge pressure
    gravida you are caring for complains of shortness of (red line) is shown for a woman with mitral stenosis.
    breath and chest pain with minimal exertion. You “A” represents the first stage of labor, “B” marks the
    SECTION 12

    obtain an echocardiogram, which demonstrates a second stage of labor, “C” demonstrates the immedi-
    mitral valve surface area of 2.1 cm2, a dilated left ate postpartum period, and “D” shows the period
    atrium, an aortic valve area of 3.7 cm2, a right 4–6 hours postdelivery. What accounts for the rise
    ventricular systolic pressure of 20 mm Hg, and an in pulmonary capillary wedge pressure immediately
    ejection fraction of 55%. You also obtain a chest following delivery?
    x-ray, which is shown. What is the likely underlying

    Pulmonary capillary wedge pressure


    cause of her symptoms? 25

    20

    15

    (mm Hg)
    10
    A B C
    D E
    5

    0
    A B C D E
    Time-arbitrary units
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Cardiovascular disorders. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    Figure 49-3.

    a. Aortic stenosis a. Heart rate normalization


    b. Mitral stenosis b. Placental autotransfusion
    c. Left ventricular heart failure c. Increase in systemic vascular resistance
    d. Pulmonary artery hypertension d. Pitocin-induced increase in cardiac output

    49–15. How would you manage the patient in Question


    49–14?
    a. Administer diuretics
    b. Initiate anticoagulation
    c. Recommend immediate labor induction
    d. All of the above
    Cardiovascular Disorders 327

    49–17. The patient whose heart is shown in this image has 49–20. A patient with a term gestation and a history of
    systemic lupus erythematosus and has a history of a critical aortic stenosis presents in active labor. Which
    prior stroke. The left atrium (LA) and left ventricle of the following management strategies is advisable

    CHAPTER 49
    (LV) are identified, and the arrows point to nonin- while caring for her in her labor course?
    fectious vegetations on the mitral leaflets. Which of a. Assisted second stage delivery
    the following is the likely condition associated with
    b. Slow-dose epidural anesthesia
    her mitral insufficiency?
    c. Generous fluid administration
    d. All of the above
    49–21. You are caring for a patient with an unrepaired
    ventricular septal defect who is considering preg-
    nancy. You perform an echocardiogram to assess
    her future risks. Which of the following parameters
    would indicate an extremely elevated maternal and
    fetal risk during pregnancy?
    a. A septal defect measuring 0.7 cm2
    b. Presence of left ventricular hypertrophy
    c. A left ventricular ejection fraction of 50%
    d. A right ventricular systolic pressure of 75 mm Hg
    49–22. What associated condition is the patient in
    Question 49–21 at high risk for developing based
    on her history?
    a. Embolic stroke
    b. Bacterial endocarditis
    c. Venous thromboembolism
    d. None of the above
    a. Antiphospholipid antibodies
    b. Infarction of the papillary muscle 49–23. A schematic of Eisenmenger syndrome due to a
    ventricular septal defect is depicted. What is the
    c. Calcification of the mitral annulus
    most common cause of death in pregnant women
    d. None of the above with this condition?

    49–18. Which of the following conditions usually improves Initial left-to-right shunt Ultimate right-to-left shunt

    during pregnancy due to pregnancy-induced


    hypervolemia?
    a. Aortic stenosis Pulmonary
    artery
    Pulmonary
    artery
    Pulmonary
    b. Mitral stenosis Left
    arteriole
    atrium Left
    c. Mitral valve prolapse Right
    atrium
    Right
    d. All of the above atrium atrium

    Left Left
    49–19. In the United States, what is the most common ventricle
    Right ventricle
    ventricle
    Right
    cause of aortic stenosis? ventricle
    hypertrophy
    Narrowed pulmonary
    a. Idiopathic arterioles result and
    lead to pulmonary
    hypertension
    b. Bicuspid aortic valve
    c. Infectious endocarditis Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    Cardiovascular disorders. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    d. Rheumatic heart disease Figure 49–4.

    a. Sepsis
    b. Cardiac tamponade
    c. Left ventricular failure
    d. Right ventricular failure
    328 Medical and Surgical Complications

    49–24. In a pregnant population, what is the most common 49–28. You are caring for a primigravida with known hyper-
    cause of the condition portrayed in the chest x-ray trophic cardiomyopathy. She tells you her mother
    image below? also suffered from the condition and passed away
    SECTION 12

    at an early age. The patient is concerned about her


    child’s future risk for developing the same condition.
    What do you tell her is the most likely risk for
    passing the condition to her child?
    a. <1%
    b. 25%
    c. 50%
    d. 100%

    49–29. You are the on-call hospitalist when you receive


    an urgent call from the postpartum floor about a
    patient who is complaining of chest pain and short-
    ness of breath. She had an uncomplicated vaginal
    delivery the previous day and has no significant past
    medical or surgical history. You obtain a stat chest
    x-ray, which is shown. Based on the findings, what
    a. Idiopathic are you most concerned for?
    b. Left-sided heart disease
    c. Obstructive sleep apnea
    d. Connective tissue disease

    49–25. What is the gold standard for diagnosis of the condi-


    tion in Question 49–24?
    a. Echocardiography
    b. Chest radiography
    c. Electrocardiography
    d. Right heart catheterization

    49–26. A 32-year-old G2P1 transfers to your care at


    18 weeks’ gestation. She has a history of pulmo-
    nary hypertension due to chronic thromboembolic
    disease. She was told by her previous obstetrician
    Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    that pregnancy was contraindicated with her condi- Cardiovascular disorders. In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
    tion and is very concerned about her mortality risk. Figure 49-5.
    What is her approximate mortality risk in pregnancy
    based on the underlying cause of her pulmonary a. Pneumonia
    hypertension? b. Cardiomyopathy
    a. 1% c. Pulmonary edema
    b. 5% d. Pulmonary hypertension
    c. 10%
    d. 20% 49–30. You obtain an echocardiogram on the patient in
    Question 49–29. Her ejection fraction is found to be
    49–27. At 24 weeks’ gestation the patient in Question 49–26 20% with no significant structural or valvular disease
    begins to develop orthopnea and dyspnea on exer- noted. Which hormone has been implicated in the
    tion. What treatment would you consider to decrease development of this condition?
    her symptoms? a. Estrogen
    a. Diuretics b. Prolactin
    b. Supplemental oxygen c. Progesterone
    c. Pulmonary vasodilator drugs d. Human placental lactogen
    d. All of the above
    Cardiovascular Disorders 329

    49–31. Based on her diagnosis and assuming a recovery of 49–34. Which of the following patients do not have an indi-
    systolic function by 6 months postpartum, what is cation for endocarditis prophylaxis?
    the patient in Question 49–30’s risk for suffering a a. A patient with a porcine mitral valve

    CHAPTER 49
    relapse of the same condition in a future pregnancy?
    b. A patient with a history of endocarditis
    a. 5%
    c. A patient with Eisenmenger syndrome due to an
    b. 10% atrial septal defect
    c. 20% d. A patient with a ventricular septal defect repaired
    d. 30% with a synthetic patch without a current defect

    49–32. What is the most common cause of heart failure in 49–35. You are caring for a patient with Marfan syndrome
    pregnancy? who just found out she is 13 weeks pregnant. You
    a. Idiopathic obtain an echocardiogram which demonstrates an
    aortic root measurement of 4.5 cm. Based on these
    b. Severe preeclampsia
    findings, what would you recommend?
    c. Chronic hypertension
    a. Beta blocker initiation
    d. Chronic hypertension with superimposed
    b. Bimonthly echocardiograms
    preeclampsia
    c. Consideration of pregnancy termination
    49–33. A pregnant woman presents to the emergency room d. All of the above
    in an obtunded state. She has a fever to 102.6°F. On
    exam, a 4/6 murmur is noted, she withdraws from 49–36. Which of the following therapies is safe in pregnancy
    pain during her abdominal exam, and track marks to treat acute supraventricular tachycardia?
    are noted on her arms and legs. Her fundal height is a. Valsalva maneuver
    approximately 32 cm. An emergent echocardiogram b. Intravenous adenosine
    is obtained, which demonstrates a mitral valve veg-
    etation. What is the most likely organism underlying c. Synchronized cardioversion
    her diagnosis? d. All of the above
    a. Enterococcus
    b. Staphylococcus aureus
    c. Neisseria gonorrhoeae
    d. Staphylococcus epidermidis
    331

    CHAPTER 50

    Chronic Hypertension

    50–1. Which of the following factors does not impact rest- 50–4. Regarding the patient in Question 50–3, accord-
    ing blood pressure reading? ing to the recommendations of the Eighth Joint
    a. Race National Committee, what is your goal blood pres-
    sure with therapy?
    b. Gender
    a. <120/80 mm Hg
    c. Activity level
    b. <130/85 mm Hg
    d. Age and weight
    c. <140/90 mm Hg
    50–2. The threshold of 140/90 mm Hg as the upper limit d. <150/100 mm Hg
    of normal is based on which of the following?
    a. Actuarial tables based on data from white adult 50–5. Ms. Thomas presents for a preconception coun-
    males seling visit. She is a 37-year-old G0 with a body
    mass index of 38 kg/m2, 4-year history of chronic
    b. A large, widely sampled international popula-
    hypertension treated with amlodipine 5 mg per day,
    tion of men and women of various ages with no
    and a 2-year history of diabetes which she manages
    known health complications
    with diet and exercise. Her blood pressure range is
    c. The discrete point at which risk for myocardial 128–144/80–94 mm Hg from the week prior. What
    infarction, stroke, renal failure, and peripheral workup would you like to pursue referent to her
    artery disease sharply increases diagnosis of chronic hypertension and prepregnancy
    d. None of the above risk stratification?
    a. Serum creatinine and urine protein-to-creatinine
    50–3. A 37-year-old G2P2 with no medical diagnoses and ratio
    a normal body mass index saw your partner for an
    b. Serum creatinine, urine protein-to-creatinine
    annual well woman exam. Her blood pressure was
    ratio, electrocardiogram, and maternal
    142/92 mm Hg, and after checking several times
    echocardiogram
    over the next week at home, she calls with a blood
    pressure log that ranges from 140–154/90–100 mm c. Serum creatinine, 24-hour urine collection for
    Hg. Your partner is now out on maternity leave, protein and creatinine clearance, electrocardio-
    so prior to calling her back you ask your nurse to gram, and cardiac stress test
    confirm that patient’s ethnicity. Why is her ethnicity d. No further evaluation is indicated, as she has only
    important in your recommendations to initiate an had a diagnosis of hypertension for 4 years and
    antihypertensive agent? her blood pressure is well controlled on a single
    a. Beta blockers are recommended as initial therapy medication.
    in the Asian population.
    b. Beta blockers are not recommended as initial
    therapy in the Asian population.
    c. Angiotensin-converting enzyme inhibitors and
    angiotensin-receptor blockers are recommended
    as initial therapy in the black population.
    d. Angiotensin-converting enzyme inhibitors and
    angiotensin-receptor blockers are not recom-
    mended as initial therapy in the black population.
    332 Medical and Surgical Complications

    50–6. The patient in Question 50–5 has a copy of her 50–9. According to the Nationwide Patient Sample data,
    records from her primary care physician. Review of which of the following is the most frequent comor-
    the records shows a recent serum creatinine of bidity associated with chronic hypertension?
    SECTION 12

    0.9 mg/dL, urine protein-to-creatinine ratio of a. Depression


    0.22, a normal electrocardiogram, and she had a
    b. Hypothyroidism
    normal exercise stress test performed 3 months ago.
    Fasting glucose was 93 mg/dL this morning, and her c. Pregestational diabetes
    hemoglobin A1C was 6.0 last month. Which of the d. Systemic lupus erythematosus
    following is the most appropriate recommendation?
    a. You do not yet have adequate information from 50–10. Pregnancy is associated with which of the follow-
    which to make a recommendation. ing blood pressure changes in women with chronic
    hypertension?
    b. Risk for adverse outcome in pregnancy is unac-
    ceptably high, and you recommend that she a. Blood pressure decreases from baseline in early
    consider gestational surrogacy or adoption. pregnancy
    c. There is no contraindication to pregnancy, but b. Blood pressure reaches its nadir at approximately
    she can further reduce her risk with weight loss 20 weeks’ gestation
    and regular, moderate intensity aerobic exercise c. In pregnancy, women with chronic hypertension
    3–4 times per week. have persistently elevated vascular resistance
    d. There is no contraindication to pregnancy, but d. All of the above
    you recommend converting to an alternative
    antihypertensive agent in advance of pursuing 50–11. Among women with chronic hypertension, which of
    pregnancy to reduce teratogenic risk. the following is true regarding risk for adverse mater-
    nal and perinatal outcome?
    50–7. For a woman who does not enter pregnancy with a a. Chronic hypertension is associated with a twofold
    known diagnosis, the diagnosis of chronic hyperten- increased risk for maternal death.
    sion is supported when hypertension is present prior b. The risk is inversely proportional to the severity
    to what gestational age threshold? and duration of hypertension prior to pregnancy.
    a. 14 weeks’ gestation c. Complications are more likely with severe range
    b. 20 weeks’ gestation hypertension at baseline and the presence of end-
    c. 24 weeks’ gestation organ damage.
    d. 28 weeks’ gestation d. All of the above

    50–8. A 28-year-old G3P1102 at 9 weeks’ gestation presents 50–12. Ms. Clamp is a 30-year-old G1 presenting for ini-
    for establishment of prenatal care. Her first pregnancy tiation of prenatal care at 12 weeks’ gestation. Her
    was complicated by gestational hypertension at term, medical history is notable for chronic hypertension,
    and her second was complicated by iatrogenic preterm and she has been on antihypertensive therapy for
    delivery at 36 weeks’ gestation for preeclampsia. Her 3 years. Her blood pressure is 148/94 mm Hg. How
    blood pressure was normal at her postpartum visit would you best counsel her regarding the risk for
    2 years ago but has not been assessed since. Today her developing superimposed preeclampsia?
    body mass index is 46 kg/m2 and her blood pressure a. The risk for developing superimposed preeclamp-
    is 158/96 mm Hg. As instructed, she calls back 2 days sia is in the 7–9% range.
    after her visit to report that blood pressures have been b. The risk is highest if workup reveals proteinuria
    in the 146–160/94–100 mm Hg range at home. In or other end-organ impact.
    addition to initiation of an antihypertensive agent,
    what is the next step in management of her blood c. The risk for superimposed preeclampsia is
    pressure in this pregnancy? not related to the severity of her baseline
    hypertension.
    a. Baseline serum creatinine
    d. Maternal serum markers yield a high positive pre-
    b. Renal ultrasound with Doppler dictive value in discriminating who will and will
    c. Baseline 24-hour urine collection for protein, cre- not develop superimposed preeclampsia.
    atinine clearance, and urinary metanephrines
    d. All of the above
    Chronic Hypertension 333

    50–13. Which of the following is not true regarding the 50–16. Risk for the complication pictured below is increased
    complication shown here, in the computerized in pregnancies complicated by chronic hypertension.
    tomography scan image? How would you best characterize the risk?

    CHAPTER 50
    Used with permission from Dr. Patricia Santiago-Munoz.
    a. This occurs during pregnancy in approximately
    3 per 1000 women with chronic hypertension.
    a. Incidence not impacted by the severity of blood
    b. The risk is not increased among women with pressure
    chronic hypertension in the absence of superim-
    posed preeclampsia. b. 2-3-fold increase over the general obstetric
    population
    c. Systolic blood pressure ≥160 mm Hg or diastolic
    blood pressure ≥110 mm Hg can rapidly result c. 5-6-fold increase over the general obstetric
    in the finding shown here. population
    d. None of the above d. Incidence not impacted by development of
    superimposed preeclampsia
    50–14. Which of the following interventions is recom-
    mended by the American College of Obstetricians 50–17. For women with chronic hypertension, which modi-
    and Gynecologists in their 2016 Clinical Update to fiable factor further increases the risk for the compli-
    reduce risk for developing preeclampsia in women cation referenced in Question 50–16?
    with chronic hypertension? a. Obesity
    a. At least 3 months of preconception supplementa- b. Exercise
    tion with vitamins C and E. c. Smoking
    b. Initiation of low dose aspirin as early as possible d. Marijuana use
    and continuation until 28 weeks’ gestation.
    c. Initiation of low dose aspirin from 12–28 weeks’ 50–18. Which of the following approximates the risk for
    gestation with continuation until delivery. perinatal mortality in pregnancies complicated by
    d. No intervention has shown benefit over pre- chronic hypertension?
    conception and early pregnancy folic acid a. Approximately 3% of births in women with mild
    supplementation. hypertension
    b. Approximately 10% of births in women with
    50–15. In addition to chronic hypertension, which of the severe hypertension
    following conditions are considered high-risk for c. 3- to 4-fold increase over pregnancies not compli-
    developing preeclampsia by the American College of cated by chronic hypertension
    Obstetricians and Gynecologists in their 2016
    Clinical Update guidelines? d. All of the above
    a. Asthma
    b. Systemic lupus erythematosus
    c. History of gestational diabetes
    d. Elevated maternal serum alpha-fetoprotein
    334 Medical and Surgical Complications

    50–19. Which of the following is a major factor contribut- 50–22. A 43-year-old G5P3013 presents to labor and deliv-
    ing to the incidence of perinatal mortality noted in ery at 32 weeks’ gestation with contractions. She
    pregnancies complicated by chronic hypertension? only recently realized she was pregnant and has not
    SECTION 12

    a. Fetal growth restriction been able to establish prenatal care. She reports a
    history of chronic hypertension and type 2 diabetes.
    b. Iatrogenic preterm birth
    Her blood pressure is 136/80 mm Hg. She is taking
    c. Superimposed preeclampsia an unknown medication for her hypertension and
    d. All of the above manages her diabetes with diet. Her fetal heart rate
    tracing is shown below. An ultrasound is performed,
    50–20. A 36-year-old multigravida with chronic hyperten- and the amnionic fluid index is 2.4 cm. You suspect
    sion presents for a growth ultrasound at 36 weeks’ that this may be related to the antihypertensive agent
    gestation. The ultrasound report is displayed below. she is taking. Use of which of the following classes of
    Which of the following is true regarding the diagno- antihypertensive agents is contraindicated during all
    sis made on the growth ultrasound? trimesters of pregnancy?

    a. The risk is reduced with administration of the


    antioxidants, vitamin C and vitamin E. a. Those that act centrally to reduce sympathetic
    b. The risk is not modified by whether a woman outflow
    with chronic hypertension requires treatment. b. Those that interfere with binding sites on
    c. The risk is approximately 20% in women with voltage-dependent calcium channels.
    chronic hypertension, and approximately 50% if c. Those that act to inhibit the conversion of
    women with chronic hypertension develop super- angiotensin-I to angiotensin-II.
    imposed preeclampsia.
    d. Those that act peripherally to reduce sympathetic
    d. All of the above tone and decrease cardiac output
    50–21. You are seeing Ms. Blanche for prenatal care. She is a
    50–23. A 24-year-old G1 with chronic hypertension has
    37-year-old G1 at 8 weeks’ gestation. She has been your
    required medication for 2 years. She is being induced
    patient for several years, and chart review shows former
    at 29 weeks’ gestation for superimposed severe
    blood pressure readings have been 110–120/70–80 mm
    preeclampsia. Which of the following characterizes
    Hg at prior visits. The blood pressure noted at her first
    the relationship between chronic hypertension and
    obstetric visit is 150/96 mm Hg. Which of the follow-
    superimposed preeclampsia?
    ing is the most appropriate next step?
    a. Approximately 30% of women with severe
    a. Order maternal cardiac echocardiogram.
    range hypertension will develop superimposed
    b. Recommend low-sodium diet and recheck her preeclampsia.
    blood pressure in 2 weeks. b. Approximately 40% of women with severe
    c. Request that she have her blood pressure mea- range hypertension will develop superimposed
    sured a few times over the next 2 weeks and preeclampsia.
    return with her log for review. c. Approximately 80% of those who also have at
    d. Counsel regarding the risks of preexisting hyper- least 300 mg/day of proteinuria at baseline will
    tension in pregnancy and recommend initiation develop severe preeclampsia
    of a daily baby aspirin to reduce the risk for d. None of the above
    preeclampsia.
    Chronic Hypertension 335

    50–24. Ms. Aldo is a 30-year-old G3P2 who presents for 50–28. According to the American College of Obstetricians
    establishment of prenatal care at 9 weeks’ gestation. and Gynecologists, which of the following methods
    Her prior pregnancies have both been complicated of antenatal fetal surveillance has been conclusively

    CHAPTER 50
    by gestational hypertension near term. Her blood shown to be of benefit in the management of
    pressure was 146/88 mm Hg, which she states is pregnancies complicated by chronic hypertension?
    concordant with other recent measurements. Which a. Nonstress testing
    of the following is the most appropriate next step in
    b. Biophysical profile
    her management?
    c. Umbilical artery Doppler studies
    a. Continued routine observation
    d. Serial sonographic evaluations of fetal growth
    b. Initiate antihypertensive therapy
    c. Recommend that she keep a log of her blood 50–29. A 33-year-old G1 at 32 weeks’ gestation has been
    pressures and bring them to her appointments diagnosed with chronic hypertension with superim-
    d. None of the above posed preeclampsia via worsening hypertension. She
    is asymptomatic with normal labs and normal fetal
    50–25. For Ms. Aldo in Question 50–24, which of the growth. An increase in the dose of her antihyperten-
    following complications is reduced with use of sive medication has resulted in nonsevere blood
    antihypertensive therapy during pregnancy? pressures. She asks you about expectant management
    a. Preterm birth of superimposed preeclampsia. Which of the follow-
    ing is the most appropriate, evidence-based response?
    b. Fetal growth restriction
    a. Preeclampsia mandates immediate delivery, so
    c. Development of severe hypertension
    you recommend proceeding with cesarean.
    d. All of the above b. Inpatient expectant management is reasonable,
    and with close surveillance, adverse outcome
    50–26. Guidelines provided by the American College of would not be expected.
    Obstetricians and Gynecologists in 2013 and the
    Society for Maternal-Fetal Medicine in 2015 state c. It is reasonable, with very close inpatient surveil-
    lance, to pursue expectant management, but there
    that antihypertensive therapy is mandatory for which
    are risks for adverse outcomes.
    of the following women during pregnancy?
    a. 30-year-old G3P2 with a blood pressure of d. None of the above
    160/110 mm Hg and a history of asthma
    50–30. For women with chronic hypertension without
    b. 42-year-old G2P1 with a blood pressure of superimposed preeclampsia, when is delivery
    130/88 mm Hg and a history of myocardial recommended?
    infarction
    a. 37 weeks 0 days to 38 weeks 6 days
    c. 28-year-old G2P1 with a blood pressure of
    146/94 mm Hg and history of preeclampsia in b. 38 weeks 0 days to 39 weeks 6 days
    her last pregnancy c. 39 weeks 0 days to 40 weeks 0 days
    d. 38-year-old G4P3 with a blood pressure of d. There are no guidelines for a specific
    148/96 mm Hg and history of transient renal recommendation
    insufficiency 3 years ago when she had an
    obstructive nephrolithiasis 50–31. Which intravenous antihypertensive drug commonly
    used to treat intrapartum severe range hypertension
    50–27. All except which of the following support the is properly matched with its most notable side effect?
    diagnosis of superimposed preeclampsia? a. Hydralazine—fetal arrhythmia
    a. Decreased platelet count b. Labetalol—neonatal tachycardia
    b. Increased serum creatinine level c. Hydralazine—maternal tachycardia
    c. Elevated serum alkaline phosphatase level d. Labetalol—neonatal rebound hypertension
    d. Elevated serum aspartate aminotransferase level
    336 Medical and Surgical Complications

    50–32. Which of the following statements is not true 50–33. Ms. Edwards is a 26-year-old G2P2, now 3 days
    regarding intrapartum management of a woman postpartum from a vaginal delivery. She has chronic
    with chronic hypertension with superimposed hypertension and developed superimposed severe
    SECTION 12

    preeclampsia? preeclampsia at 36 weeks’ gestation. She did well


    a. Trial of labor is not contraindicated. initially, but in the last 12 hours her blood pres-
    sure has been trending up. Most recent blood pres-
    b. Magnesium sulfate is the neuroprophylactic agent
    sure was 156/90 mm Hg. The nurse has called you
    of choice to prevent eclampsia.
    because Ms. Edwards is feeling short of breath. A
    c. These women are more sensitive to the acute representative chest radiograph is shown here. What
    hypotensive effects of epidural anesthesia. is the appropriate treatment for this condition?
    d. Postpartum analgesia should include scheduled
    nonsteroidal antiinflammatory drugs for at least
    72 hours to reduce narcotic use.

    Used with permission from Dr. Barbara Hoffman.

    a. Lovenox anticoagulation
    b. Albuterol via metered dose inhaler
    c. Incentive spirometer and ambulation
    d. Intravenous furosemide administration
    343

    CHAPTER 52

    Thromboembolic Disease

    52–1. What has led to a decrease in the frequency of 52–6. A 33-year-old G4P5 presents to the hospital on
    venous thromboembolism in the puerperium? POD #15 from a cesarean delivery due to a twin ges-
    a. Anticoagulation tation complaining of right lower extremity swelling.
    She reports the swelling started 2 days ago but has
    b. Early ambulation
    not improved with leg elevation. She reports she had
    c. Decrease in cesarean deliveries a blood clot in her left leg 10 years ago. The only
    d. Sequential compression devices medication she is taking is iron because her hemo-
    globin was 8 mg/dL on discharge. Which of the fol-
    52–2. What percentage of pregnancy-related deaths are due lowing risk factors for venous thromboembolism is
    to pulmonary embolism? most important in pregnancy?
    a. 9% a. Anemia
    b. 15% b. Cesarean delivery
    c. 25% c. Multifetal gestation
    d. 30% d. Personal history of thrombosis

    52–3. Which of the following statements is accurate 52–7. The patient in Question 52–6 reports she was never
    regarding the timing of venous thrombosis? tested for a thrombophilia. What percentage of
    a. Deep-vein thrombosis is more common during women with venous thrombosis during pregnancy
    the antepartum period. have an underlying thrombophilia?
    b. An equal number occur during the antepartum a. 10%
    period and puerperium. b. 20%
    c. Pulmonary embolism is more common in the c. 50%
    first 6 weeks postpartum. d. 90%
    d. All of the above
    52–8. Which of the following is not an inherited
    52–4. All except which of the following is an aspect of thrombophilia?
    Virchow’s triad? a. Protein S deficiency
    a. Stasis b. Antiphospholipid syndrome
    b. Local trauma c. Antithrombin III deficiency
    c. Immobilization d. Activated protein C resistance
    d. Hypercoagulability
    52–9. Which of the following statements regarding
    52–5. Which of the following pregnancy-related fac- antithrombin III deficiency is accurate?
    tors contributes to an increased risk for venous a. Autosomal dominant
    thromboembolism? b. Inactivates thrombin and factor Xa
    a. Enhanced synthesis of clotting factors c. The most thrombogenic inheritable coagulopathy
    b. Endothelial cell injury during delivery d. All of the above
    c. Compression of the pelvic veins and inferior vena
    cava 52–10. What happens to protein S levels in pregnancy?
    d. All of the above a. Increase
    b. Decrease
    c. Stay the same
    d. Decrease in the first trimester and then increase
    344 Medical and Surgical Complications

    52–11. Why does the presence of a factor V Leiden 52–17. Which of the following antiphospholipid antibodies
    mutation lead to increased risk for venous is associated with the lowest live birth rate?
    thromboembolism? a. Lupus anticoagulant
    SECTION 12

    a. Increased levels of factor V are produced b. Anti-β2-glycoprotein I


    b. Decreased levels of factor V are produced c. Anticardiolipin antibody
    c. Factor V is resistant to inactivation by protein C d. All are equal
    d. Factor V is more sensitive to inactivation by
    protein C 52–18. A 32-year-old G3P0 presents for preconception
    counseling after suffering three first-trimester preg-
    52–12. How does the prothrombin G20210A mutation nancy losses. She reports her obstetrician performed
    promote clot formation? a workup and she has a genetic blood clotting disor-
    a. Leads to increased prothrombin production der. Which inherited thrombophilia has been associ-
    ated with adverse pregnancy outcomes, including
    b. Leads to decreased prothrombin production
    first-trimester loss?
    c. Accelerates prothrombin inactivation by protein S
    a. Prothrombin G20210A
    d. Yields prothrombin resistant to inactivation by
    b. Factor V Leiden mutation
    protein S
    c. 5,10-Methylene-tetrahydrofolate reductase
    52–13. Which of the following adverse pregnancy outcomes (MTHFR) mutation
    is linked to factor V Leiden mutation? d. None of the above
    a. Preeclampsia
    52–19. As you discuss her results, for which thrombophilia
    b. Fetal-growth restriction
    do you encourage the patient in Question 52–18 to
    c. First-trimester pregnancy loss undergo testing?
    d. None of the above a. Protein S deficiency
    b. Protein C deficiency
    52–14. Which of the following is an acquired thrombophilia?
    c. Antiphospholipid syndrome
    a. Cancer
    d. All of the above
    b. Antiphospholipid syndrome
    c. Heparin-induced thrombocytopenia 52–20. The American College of Obstetricians and Gyne-
    d. All of the above cologists recommends screening in which of the
    following situations?
    52–15. Which of the following is in the clinical criteria for a. Personal history of an unprovoked deep-vein
    antiphospholipid syndrome? thrombosis
    a. At least one spontaneous preterm birth b. Personal history of a deep-vein thrombosis after
    b. Three unexplained fetal losses before 12 weeks’ knee surgery
    gestation c. Family history consisting of a sister with a pulmo-
    c. At least one unexplained fetal death beyond nary embolus during pregnancy at age 25
    20 weeks’ gestation d. Family history of an aunt with a deep-vein
    d. At least 1 preterm birth before 34 weeks’ gesta- thrombosis while undergoing treatment for breast
    tion due to severe preeclampsia, eclampsia, or cancer at the age of 62
    placental insufficiency
    52–21. Which one of the following thrombophilias can
    52–16. A 34-year-old G1P1 presents for preconception be tested for while on treatment for a venous
    counseling because her last pregnancy ended in thrombosis?
    delivery at 27 weeks’ gestation due to preeclampsia a. Protein S deficiency
    with severe features. She brings documentation of b. Protein C deficiency
    lab results showing she is positive for anti-β2-
    glycoprotein I IgM. A minimum of how many weeks c. Antithrombin III deficiency
    after the initial labs are the confirmatory labs drawn? d. Prothrombin G20210A mutation
    a. 8 weeks
    b. 10 weeks
    c. 12 weeks
    d. 16 weeks
    Thromboembolic Disease 345

    52–22. Which of the following thrombophilias is tested for 52–25. The patient in Question 52–24 undergoes compres-
    using DNA analysis? sion ultrasonography with the findings shown below.
    a. Protein S deficiency What is the next best step in the management of this

    CHAPTER 52
    patient?
    b. Protein C deficiency
    c. Antithrombin III deficiency
    d. Prothrombin G20210A mutation

    52–23. In pregnancy, why is a left leg deep-vein thrombosis


    more common than a right leg deep-vein thrombosis?
    a. Natural leftward tilt of the gravid uterus
    b. Compression of the left iliac vein by the left iliac
    artery
    c. Compression of the left iliac vein by the left
    ovarian artery
    d. Compression of the left iliac vein by the right
    iliac artery

    52–24. A 29-year-old G2P1 at 29 weeks’ gestation presents


    for a routine prenatal care visit with complaints of
    lower extremity swelling. On examination her feet
    appear as pictured below. Which of the following is a. Serum d-dimer
    true regarding this condition in pregnancy? b. Initiate anticoagulation
    c. Magnetic resonance imaging
    d. Ventilation-perfusion scintigraphy

    52–26. Serum d-dimer is unreliable in pregnancy because it


    is affected by all except which of the following?
    a. Preeclampsia
    b. Cesarean delivery
    c. Multifetal gestation
    d. All of the above

    52–27. What are the advantages of low-molecular-weight


    heparin in pregnancy?
    a. Shorter half-life
    b. Easily reversible
    c. Better bioavailability
    d. Increased dosing leads to more predictable
    response

    52–28. What is the risk of pulmonary embolism in the


    setting of a treated deep-vein thrombosis?
    a. 2%
    b. 5%
    c. 10%
    d. 15%
    a. A positive Homans sign is virtually diagnostic
    b. Most cases are located in the iliofemoral veins
    c. Associated with a pulmonary embolism in
    30–60% of cases
    d. Pain more than swelling correlates with the
    degree of vessel involvement
    346 Medical and Surgical Complications

    52–29. A 33-year-old G3P2 is on prophylactic low- 52–32. Superficial venous thrombophlebitis is treated with
    molecular-weight heparin due to history of venous all except which of the following?
    thromboembolism and factor V Leiden mutation. a. Heat
    SECTION 12

    She inquires as to why she has to be switched to a


    b. Analgesia
    medication that requires injections twice daily at
    36 weeks’ gestation. What is your response? c. Elastic support
    a. Heparin has a shorter half-life and is more easily d. Anticoagulation
    reversible.
    52–33. What percentage of maternal deaths are caused by
    b. Heparin has a lower rate of heparin-induced
    pulmonary embolism?
    thrombocytopenia.
    a. 1%
    c. Heparin does not cross the placenta as low-
    molecular-weight heparin does. b. 5%
    d. Fetal exposure to low-molecular-weight heparin c. 10%
    close to delivery increases the risk for intraven- d. 20%
    tricular hemorrhage.
    52–34. What is the most common presenting symptom in
    52–30. What medication is used to reverse the effects of patients with a pulmonary embolus?
    heparin? a. Cough
    a. Calcium b. Syncope
    b. Vitamin K c. Dyspnea
    c. Protamine sulfate d. Chest pain
    d. Fresh frozen plasma
    52–35. All except which of the following is included in
    52–31. When switching from therapeutic heparin to the diagnostic algorithm of pulmonary embolus in
    warfarin, how are paradoxical thrombosis and skin pregnancy?
    necrosis from the anti–protein C effects of warfarin a. Chest radiograph
    avoided?
    b. Magnetic resonance imaging
    a. Watch the patient in the hospital for the first
    c. Ventilation-perfusion scintigraphy
    5 days.
    b. Give the patient a test dose and watch for these d. Computed-tomographic pulmonary angiography
    side effects.
    c. Overlap of heparin and warfarin for at least 3 days
    and until the INR is therapeutic for 1 day.
    d. Overlap of heparin and warfarin for at least 5 days
    and until the INR is therapeutic for 2 days.
    347

    CHAPTER 52 ANSWER KEY

    Question Letter Page

    CHAPTER 52
    number answer cited Header cited
    52–1 b p. 1004 Introduction
    52–2 a p. 1004 Introduction
    52–3 d p. 1004 Introduction
    52–4 c p. 1004 Pathophysiology
    52–5 d p. 1004 Pathophysiology
    52–6 d p. 1005 Pathophysiology
    52–7 c p. 1005 Pathophysiology
    52–8 b p. 1006 Table 52-2
    52–9 d p. 1006 Antithrombin Deficiency
    52–10 b p. 1007 Protein S Deficiency
    52–11 c p. 1007 Activated Protein C Resistance-Factor V Leiden Mutation
    52–12 a p. 1007 Prothrombin G20210A Mutation
    52–13 d p. 1007 Activated Protein C Resistance-Factor V Leiden Mutation
    52–14 d p. 1008 Acquired Thrombophilias
    52–15 d p. 1008 Antiphospholipid Syndrome
    52–16 c p. 1008 Antiphospholipid Syndrome
    52–17 b p. 1008 Antiphospholipid Syndrome
    52–18 d p. 1009 Thrombophilias and Pregnancy Complications
    52–19 c p. 1010 Thrombophilia Screening
    52–20 a p. 1010 Thrombophilia Screening
    52–21 d p. 1010 Table 52-4
    52–22 d p. 1010 Table 52-4
    52–23 d p. 1010 Clinical Presentation
    52–24 b p. 1010 Clinical Presentation
    52–25 b p. 1011 Diagnosis
    52–26 d p. 1011 D-Dimer Screening Tests
    52–27 c p. 1012 Management
    52–28 b p. 1012 Management
    52–29 a p. 1014 Labor and Delivery
    52–30 c p. 1014 Labor and Delivery
    52–31 d p. 1015 Anticoagulation with Warfarin Compounds
    52–32 d p. 1016 Superficial Venous Thrombophlebitis
    52–33 c p. 1016 Pulmonary Embolism
    52–34 c p. 1016 Clinical Presentation
    52–35 b p. 1017 Figure 52-5
    348

    CHAPTER 53

    Renal and Urinary Tract Disorders

    53–1. Which of the following is not a physiological change 53–4. Which of the following is the threshold for protein-
    in pregnancy that contributes to the findings in the uria in pregnancy, above which levels are considered
    image below? abnormal?
    a. 100 mg/d
    b. 250 mg/d
    c. 300 mg/d
    d. 1000 mg/d

    53–5. Which of the following values is not a normal serum


    creatinine in pregnancy?
    a. 0.4 mg/dL
    b. 0.6 mg/dL
    c. 0.8 mg/dL
    d. 1.0 mg/dL

    53–6. A pregnant patient who previously donated a kidney


    and now has only one healthy kidney is at risk for
    which of the following obstetric complications?
    a. Vesicoureteral reflux a. Placenta previa
    b. Glomerular hypertrophy b. Normocytic anemia
    c. Distal ureteral compression by the uterus c. Gestational hypertension
    d. Progesterone-induced relaxation of the muscularis d. Preterm premature rupture of membranes
    53–2. Which of the following statements regarding 53–7. A 28-year-old G1P0 at 20 weeks’ gestation presents
    physiological changes in pregnancy is true? to the emergency room complaining of frequency,
    a. Glomerular filtration decreases. urgency, and dysuria. She is afebrile with no costo-
    b. Effective renal plasma flow increases. vertebral angle tenderness. On review of her prenatal
    records, you see that she had a urine culture at her
    c. Serum creatinine concentration increases.
    first prenatal visit with >100,000 colony-forming
    d. The number of glomerular cells increases. units/mL gram-negative rods that was never treated.
    What percentage of pregnant women with asymp-
    53–3. A 35-year-old G5P3 presents at 24 weeks’ gestation. tomatic bacteriuria develop a symptomatic infection
    She has a history of chronic hypertension, but she is if left untreated?
    noncompliant with medication. You would like to
    do a baseline 24-hour urine collection. The patient is a. 5%
    of low health literacy, and you are concerned she will b. 10%
    not complete the collection as an outpatient, but she c. 25%
    refuses to be admitted for it. You decide to do a uri- d. 50%
    nary protein-to-creatinine ratio on a spot urine sample
    so you can gather additional information about the
    patient’s renal status. What is the cutoff for abnormal?
    a. 0.1
    b. 0.2
    c. 0.3
    d. 0.5
    Renal and Urinary Tract Disorders 349

    53–8. Which of the following is an acceptable treatment 53–12. In the setting of aggressive fluid hydration, what
    regimen for newly diagnosed asymptomatic bacteri- percentage of pregnant women with pyelonephritis
    uria in pregnancy? develop acute kidney injury?

    CHAPTER 53
    a. Nitrofurantoin 100 mg by mouth at bedtime for a. 5%
    10 days b. 10%
    b. Ampicillin 250 mg by mouth four times per day c. 15%
    for one day
    d. 20%
    c. Trimethoprim-sulfamethoxazole 160/800 mg by
    mouth one time 53–13. An 18-year-old G1P0 presents at 30 weeks’ gestation
    d. Nitrofurantoin 100 mg by mouth four times with fever, chills, vomiting, dysuria, and frequency
    daily for 21 days for 3 days. She is also experiencing contractions. You
    diagnose her with pyelonephritis based on her symp-
    53–9. You are consulted about a 19-year-old primigravida toms, fever of 39oC, and urinalysis. She is transferred
    at 18 weeks’ gestation. The patient was diagnosed at to labor and delivery for monitoring of contractions.
    her first prenatal care visit with asymptomatic bacte- The patient is given intravenous (IV) antibiotics,
    riuria. Her provider treated her with nitrofurantoin IV fluids, acetaminophen, and a β-agonist because
    100 mg twice daily for 7 days. The patient was seen of the contractions. What complication is more
    a month after treatment, and her repeat urine culture likely in the setting of β-agonist use in patients with
    was negative. But now, a urine culture sent in error pyelonephritis?
    is positive for >100,000 colony-forming units/mL a. Anemia
    gram-negative rods again. She remains asymptom-
    atic. Her provider is not sure what to do. What is b. Abruption
    the best response to this consult? c. Pulmonary edema
    a. Single-dose treatment is more successful, so give d. Acute kidney injury
    the patient nitrofurantoin 200 mg by mouth one
    time. 53–14. Once you have treated a pregnant patient for pyelo-
    b. The patient likely has a highly resistant organ- nephritis as an inpatient, for how long should you
    ism, so she should be admitted for intravenous continue oral therapy as an outpatient?
    antibiotics. a. 1–3 days
    c. The urine culture is probably a false-positive b. 3–5 days
    given it was negative after treatment, so she does c. 7–14 days
    not need any further antibiotics.
    d. 14–21 days
    d. Recurrence of asymptomatic bacteriuria is 30%
    regardless of antibiotic regimen and it may indi- 53–15. What percentage of pregnant women experience a
    cate covert upper tract infection, so treat the recurrent urinary tract infection after completion of
    patient with nitrofurantoin 100 mg by mouth at treatment for pyelonephritis?
    bedtime for 21 days.
    a. 5–10%
    53–10. Lower urinary tract symptoms with pyuria but a ster- b. 10–20%
    ile urine culture are likely due to which pathogen? c. 30–40%
    a. Escherichia coli d. 50–60%
    b. Proteus mirabilis
    c. Klebsiella pneumoniae
    d. Chlamydia trachomatis

    53–11. What is the leading cause of septic shock during


    pregnancy?
    a. Pneumonia
    b. Breast abscess
    c. Pyelonephritis
    d. Chorioamnionitis
    350 Medical and Surgical Complications

    53–16. A 24-year-old G1P0 presents at 24 weeks’ gestation 53–18. A 25-year-old G1P0 at 16 weeks’ gestation presents
    complaining of back pain that radiates forward. She for prenatal care. She has a history of a kidney trans-
    reports that the pain is intense, and she looks very plant 3 years ago. She is stable on prednisone and
    SECTION 12

    uncomfortable. She has not been febrile. A urinalysis azathioprine. The patient has not experienced any
    is significant only for red blood cells. An image from rejection, and her blood pressure is well controlled.
    her renal ultrasound is provided below. You diagnose The patient is concerned about how her pregnancy
    the patient with a kidney stone. Which of the fol- will be affected by her transplant and vice versa.
    lowing is the best management option for the patient Which of the following statements would not be
    at this time? part of your counseling?
    a. Opportunistic infections are common, so there
    must be proper surveillance for that.
    b. It is a good prognostic indicator that she has been
    stable and in good health for the past several years.
    c. She would be expected to have a better outcome
    than someone with end-stage renal disease on
    dialysis.
    d. It is unfortunate that she is on azathioprine as it
    has a much higher rate of fetal malformation than
    mycophenolate.

    53–19. Which of the following obstetric complications is


    not increased in women who have undergone a
    kidney transplant?
    a. Preeclampsia
    b. Preterm birth
    a. Analgesia c. Fetal-growth restriction
    b. Analgesia and intravenous hydration d. Peripartum cardiomyopathy
    c. Analgesia, intravenous hydration, and intravenous
    antibiotics 53–20. Which of the following is not a recommended
    d. Analgesia, intravenous hydration, intravenous requisite for renal transplant patients who want to
    antibiotics, and ureteral stenting attempt pregnancy?
    a. Proteinuria <300 mg/day
    53–17. The patient in Question 53–16 asks how many preg- b. Serum creatinine <2 mg/dL
    nant women actually pass their stone with the man-
    agement plan you selected. What is your response? c. No evidence of graft rejection for 6 months
    a. 50–60% d. No identifiable pyelocalyceal distention by
    urography
    b. 65–80%
    c. 90–95% 53–21. Which of the following statements about polycystic
    d. 95–100% kidney disease is true?
    a. It is usually X-linked inheritance.
    b. Renal complications are more common in women
    than men.
    c. The majority of cases are due to the PKD3 muta-
    tion on chromosome 4.
    d. 10% of those with this disease die from rupture
    of an intracranial berry aneurysm.

    53–22. Which of the following is a pulmonary-renal


    syndrome?
    a. Berger disease
    b. Goodpasture syndrome
    c. Minimal change disease
    d. Focal segmental glomerulosclerosis
    Renal and Urinary Tract Disorders 351

    53–23. Which of the following does not characterize 53–29. What is the most common reason for acute kidney
    nephrotic syndromes? injury in obstetrics?
    a. Edema a. Sepsis

    CHAPTER 53
    b. Heavy proteinuria b. Acute blood loss
    c. Hyperalbuminemia c. Use of loop diuretics
    d. Hypercholesterolemia d. Ureteral injury at cesarean section

    53–24. Which of the following complications is not 53–30. A pregnant woman presents with flank pain. She is
    increased in pregnant patients with nephrotic afebrile but tachycardic from pain. Her serum creati-
    syndrome? nine is elevated to 5 mg/dL. Images from her mag-
    a. Anemia netic resonance imaging are presented below. Which
    of the following is the best plan of care?
    b. Preeclampsia
    c. Renal insufficiency
    d. Postterm pregnancy

    53–25. Which of the following is most likely to lead to


    end-stage renal disease?
    a. Diabetes
    b. Hypertension
    c. Glomerulonephritis
    d. Polycystic kidney disease

    53–26. By what creatinine does one define moderate renal


    impairment in patients with chronic renal disease?
    a. 1–1.5 mg/dL
    b. 1.5–3.0 mg/dL
    c. 3.0–4.5 mg/dL Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
    d. 5–7 mg/dL Renal and urinary tract disorders. In Williams Obstetrics, 25th ed. New York, McGraw-
    Hill, 2018, Figure 53-6A and 53-6B.

    53–27. Which of the following plans in a pregnant patient


    on dialysis is correct?
    a. Renal biopsy

    a. If the patient’s creatinine is less than 7 mg/dL, b. Nephrectomy


    the dialysis can be held. c. Percutaneous nephrostomy tube
    b. Change from peritoneal dialysis to hemodialysis d. Intravenous antibiotics and aggressive fluid
    because outcomes are worse in cases of peritoneal hydration
    dialysis.
    53–31. Which of the following is not commonly found in
    c. Increase the frequency of dialysis to avoid the
    patients with a urethral diverticulum?
    abrupt volume changes which could result in
    hypotension. a. Pain
    d. Decrease the frequency of dialysis because the b. Palpable mass
    glomerular filtration rate will increase with c. Urinary retention
    increasing blood volume, making dialysis less d. Recurrent urinary infections
    necessary.
    53–32. Which of the following circumstances is most likely
    53–28. When managing a patient with postpartum acute to lead to fistula formation?
    kidney injury, which of the following medications
    a. Rupture of a posterior wall fibroid
    does not need to have its dose adjusted?
    b. Prolonged obstructed labor in a resource-poor
    a. Gentamycin
    country
    b. Clindamycin
    c. A fetus being at +1 station for the week leading
    c. Magnesium sulfate up to labor
    d. Ketorolac tromethamine d. A cesarean section done for breech presentation at
    term and complicated by a 2-cm extension
    359

    CHAPTER 55

    Hepatic, Biliary, and Pancreatic Disorders

    55–1. All except which of the following liver-related 55–6. A 27-year-old multigravida comes to you for her
    changes are physiological in pregnancy? postpartum visit. Both of her pregnancies were com-
    a. Hypolipidemia plicated by intrahepatic cholestasis of pregnancy.
    She desires another child in about 2 years. Which
    b. Spider angiomas
    of the following methods of contraception do you
    c. Palmar erythema recommend?
    d. Elevated serum alkaline phosphatase levels a. Vaginal ring
    b. Copper intrauterine device
    55–2. The cytochrome P450 system is altered by which of
    the following during pregnancy? c. Combination oral contraceptive pills
    a. Estrogen levels d. None of the above
    b. Progesterone levels
    55–7. Which of the following have the best data for treat-
    c. Placental expression ment of intrahepatic cholestasis of pregnancy?
    d. All of the above a. Cholestyramine
    b. Dexamethasone
    55–3. Which of the following pregnancy-related compli-
    cations has the capacity to demonstrate the most c. Low-cholesterol diet
    prominent alterations of normal hepatic, renal, d. Ursodeoxycholic acid
    hematological, and coagulation laboratory studies?
    a. Preeclampsia 55–8. A 32-year-old G1 at 32 weeks’ gestation is diagnosed
    with intrahepatic cholestasis of pregnancy. During
    b. Hyperemesis gravidarum
    the visit she inquires about whether this diagnosis
    c. Acute fatty liver of pregnancy will alter her prenatal care or delivery plans. What is
    d. Intrahepatic cholestasis of pregnancy the best evidence-based advice you can provide?
    a. We can avoid risk for stillbirth with weekly fetal
    55–4. Which of the following findings can narrow the dif- nonstress testing.
    ferential of elevated liver enzymes to exclude intrahe-
    b. Since your bile acid levels are <10 µmol/L,
    patic cholestasis of pregnancy?
    delivery will be recommended before 39 weeks’
    a. Jaundice gestation.
    b. AST 800 U/L c. If we pursue delivery at 38–39 weeks’ gestation,
    c. Liver biopsy showing bile plugs in the hepatocytes we will avoid neonatal sequelae of intrahepatic
    d. All of the above cholestasis of pregnancy.
    d. None of the above
    55–5. Which of the following viral infections has been
    associated with a marked increase in the risk for 55–9. What is the incidence and recurrence risk of acute
    intrahepatic cholestasis of pregnancy? fatty liver of pregnancy?
    a. Hepatitis B a. 1 in 10,000 pregnancies, and recurrence is rare
    b. Hepatitis C b. 1 in 100,000 pregnancies, and recurrence is rare
    c. Cytomegalovirus c. 1 in 100,000 pregnancies, and recurrence is
    d. Human immunodeficiency virus common
    d. 1 in 1,000,000 pregnancies, and recurrence is rare
    360 Medical and Surgical Complications

    55–10. Maternal acute fatty liver of pregnancy is associ- 55–13. You know that nausea and vomiting in the third
    ated with all except with of the following recessively trimester is not something to be dismissed, so you
    inherited abnormalities of mitochondrial fatty acid start the work-up on the patient in Question 55–12.
    SECTION 12

    oxidation? Which combination of laboratory findings below


    a. Carnitine palmitoyltransferase 1 would be most concerning for acute fatty liver of
    pregnancy?
    b. Dihydrolipoamide dehydrogenase
    a. Hematocrit 34%, creatinine 1.1 mg/dL, platelets
    c. Medium-chain acyl-CoA dehydrogenase
    190/L, AST 60 U/L, fibrinogen 450 mg/dL, and
    d. Long-chain-3-hydroxyacyl-CoA-dehydrogenase glucose 96 mg/dL
    b. Hematocrit 32%, creatinine 2.0 mg/dL, platelets
    55–11. From an etiopathogenesis perspective, the pregnancy-
    90/L, AST 400 U/L, fibrinogen 130 mg/dL, and
    related complication pictured here is analogous to
    glucose 65 mg/dL
    which childhood illness?
    c. Hematocrit 39%, creatinine 1.2 mg/dL, platelets
    90/L, AST 80 U/L, fibrinogen 450 mg/dL, and
    glucose 105 mg/dL
    d. Hematocrit 30%, creatinine 1.0 mg/dL, platelets
    200/L, AST 600 U/L, fibrinogen 420 mg/dL,
    and glucose 120 mg/dL

    55–14. You send a peripheral blood smear on the patient in


    Question 55–12, and a representative slide is shown
    below. What is the underlying etiology of the blood
    smear findings?

    Reproduced with permission from Cunningham FC, Leveno KJ, Bloom SL, et al (eds):
    Hepatic, biliary, and pancreatic disorders. In Williams Obstetrics, 25th ed. New York,
    McGraw-Hill, 2018, Figure 55-1.

    a. Biliary atresia
    b. Reye-like syndromes
    c. Autoimmune hepatitis
    d. Epstein-Barr viral hepatitis

    55–12. A 26-year-old primigravida presents at 34 weeks’


    gestation with nausea and vomiting, fatigue, and
    Reproduced with permission from Lichtman MA, Beutler E, Kipps TJ: Color Atlas III:
    epigastric pain. All except which of the following are
    Red cell morphology. In Williams Hematology, 7th ed. New York, McGraw-Hill, 2006,
    clinical characteristics that increase her risk for acute Plate III-3.
    fatty liver of pregnancy as the underlying cause?
    a. Nulliparity a. Autoimmune antibody binding
    b. Female fetus b. Decreased cholesterol production
    c. Twin gestation c. Increased destruction in the spleen
    d. Third trimester d. Thrombotic microangiopathy in microvessels

    55–15. Which imaging modality is recommended in dis-


    criminating acute fatty liver of pregnancy from other
    etiologies of elevated liver enzymes?
    a. Computed tomography
    b. Magnetic resonance imaging
    c. Ultrasound with color Doppler
    d. None of the above
    Hepatic, Biliary, and Pancreatic Disorders 361

    55–16. Risk of maternal death with acute fatty liver is 55–22. The following viral serologies are resulted for the
    related to which of the following? patient in Question 55–21. What is her diagnosis?
    a. Sepsis

    CHAPTER 55
    b. Hemorrhage IgA Anti-Hepatitis B core antibody +
    c. Renal failure Hepatitis B surface antibody –
    d. All of the above
    Hepatitis B e antigen +
    55–17. After delivery, the liver function deterioration of
    acute fatty liver of pregnancy halted. Nonethe- a. History of hepatitis B vaccination
    less, you recommend continued intensive maternal b. Chronic hepatitis B infection, still active
    surveillance due to the approximately 20% risk of c. History of hepatitis B infection, now latent
    developing which of the following in the days after
    delivery? d. It is not possible to make a diagnosis from the
    serologies presented
    a. Sepsis
    b. Hemorrhage 55–23. How do you counsel the patient in Question 55–21
    c. Diabetes mellitus regarding her lab results?
    d. Acute pancreatitis a. She has a virus that can lead to cirrhosis and
    death, and you will refer her to a hepatologist for
    55–18. Which of the following statements regarding acute discussion of ribavirin therapy.
    viral hepatitis is correct? b. She does not need to be concerned. Her results
    a. Jaundice is usually the presenting symptom. represent vaccination for Hepatitis B, and she
    b. Low-grade fever is more common with hepatitis A. should have lifelong antibodies.
    c. Bilirubin levels typically fall as transaminase levels c. She has a virus that can lead to cirrhosis and
    rise. death, but it appears dormant. You will refer her
    to a hepatologist for surveillance.
    d. Serum transaminase levels correspond with
    disease severity. d. She has an active virus that can lead to cirrhosis
    and death, and you will refer her to a hepatologist
    55–19. Which of the following features are criteria for severe for long-term management recommendations.
    disease that should prompt hospitalization for acute
    viral hepatitis? 55–24. Lactation is contraindicated for women infected with
    which of the following?
    a. Hyperglycemia
    a. Hepatitis A
    b. AST over 500 U/L
    b. Hepatitis B
    c. Hyperalbuminemia
    c. Hepatitis C
    d. Hyperbilirubinemia
    d. None of the above
    55–20. During the hospital care of a patient with acute viral
    hepatitis, which of the following personal protective 55–25. The Society for Maternal-Fetal Medicine recom-
    equipment should be used at all times? mended which of the following agents for women
    with high hepatitis B viral loads in pregnancy?
    a. Gloves
    a. Ribavirin
    b. N95 respiratory mask
    b. Tenofovir
    c. Negative-pressure ventilation hospital room
    c. Lamivudine
    d. All of the above
    d. Telbivudine
    55–21. During a cesarean delivery you sustain a needle stick.
    The patient’s prenatal record was not available at 55–26. Chronic hepatitis B infection is most likely to
    admission, so her infectious serologies are pending at develop after acquisition by which of the following
    the time of your contact. Immunization is not avail- patients?
    able for which of the following? a. 9-year-old child
    a. Hepatitis A b. Newborn infant
    b. Hepatitis B c. 28-year-old healthy woman
    c. Hepatitis C d. Risk is equivalent in all of the above
    d. It is available for all three
    362 Medical and Surgical Complications

    55–27. Which of the following combinations represents 55–31. A 36-year-old multigravida presents for preconcep-
    appropriate screening for hepatitis C in pregnancy? tion counseling. Her obstetric history includes two
    a. 27-year-old woman with human immunodefi- full-term vaginal deliveries after pregnancies com-
    SECTION 12

    ciency virus screened via anti-hepatitis C antibody plicated by gestational diabetes and a first-trimester
    pregnancy loss. She comes to you to discuss her
    b. 26-year-old woman with a history of skin abscesses
    recent diagnosis of nonalcoholic fatty liver disease
    from heroin use screened via anti-hepatitis C
    (NAFLD) by her primary care physician. Diagnosis
    antibody
    was based on imaging performed for an episode of
    c. 37-year-old woman with a history of blood trans- abdominal pain. Her liver function tests are normal.
    fusion after her last pregnancy in 2014 screened Her medical history is otherwise notable for long-
    via hepatitis C RNA standing obesity (body mass index 34 kg/m2) and
    d. 15-year-old woman whose mother was a chronic diabetes (hemoglobin A1c 8.2%) diagnosed 2 years
    intravenous drug user and died of liver failure ago. Which of the following should be included in
    when the patient was 4 years old screened via your counseling?
    hepatitis C RNA a. The best interventions to reduce the risk to a
    future pregnancy are weight loss and optimizing
    55–28. A 29-year-old primigravida presents to you for pre- her glucose control.
    natal care. She is known to have hepatitis C with no
    b. Compared to women of similar weight, because
    known risk factors, and your prenatal labs confirm
    of the NAFLD, she has a much higher risk for
    presence of hepatitis C RNA and anti-hepatitis C
    liver-related adverse pregnancy outcome.
    antibody. Compared to a woman with anti-hepatitis
    C antibody who is RNA-negative, which of the fol- c. With normal liver enzymes, you question the
    lowing is more likely to complicate her pregnancy? diagnosis of NAFLD and recommend that she
    seek a second opinion from a gastroenterologist
    a. Preterm delivery
    d. All of the above
    b. Fetal growth restriction
    c. Vertical transmission of hepatitis C 55–32. This image shows the typical nodular, fibrotic
    d. None of the above appearance of a cirrhotic liver. What is the most
    common cause of this condition in the general
    55–29. A 21-year-old nulligravida with Sjögren syndrome population?
    presents at 26 weeks’ gestation with nausea, fatigue,
    and vague abdominal pain. On exam she has a blood
    pressure of 94/58 mmHg and you notice mild jaun-
    dice. Laboratory assessment shows severely elevated
    transaminases and anti-nuclear and anti-smooth
    muscle antibodies. Based on your primary diagnostic
    suspicion, how do you counsel her regarding compli-
    cations of pregnancy?
    a. She is at increased risk for preeclampsia.
    b. She is at increased risk for preterm delivery.
    c. She is at increased risk for cesarean delivery.
    d. All of the above

    55–30. A 23-year-old nulligravida and her husband present


    for preconception counseling. She has Wilson disease
    that is being treated with zinc sulfate. Which of the
    Reproduced with permission from Geller DA, Goss JA, Tsung A: Liver. In Brunicardi FC,
    following should be included in your counseling? Anderson DK, Billiar TR, et al (eds): Schwartz’s Principles of Surgery, 9th ed. New York,
    a. Her husband should consider carrier testing. McGraw-Hill, 2010, Figure 31-16a.

    b. Upon confirmation of pregnancy, she should dis-


    continue her chelation therapy. a. Viral hepatitis
    c. Available data suggests she should convert to b. Alcohol exposure
    penicillamine prior to conception, as it is a better c. Autoimmune hepatitis
    chelating agent. d. Nonalcoholic fatty liver disease
    d. All of the above
    Hepatic, Biliary, and Pancreatic Disorders 363

    55–33. A 32-year-old nulligravida presents for preconcep- 55–36. Which of the following is true regarding pancreatitis
    tion counseling due to cirrhosis with esophageal in pregnancy?
    varices. Which of the following should be included a. Severity is correlated to the degree of enzyme

    CHAPTER 55
    in your counseling? elevation.
    a. You do not recommend that she become pregnant. b. The primary predisposing condition in pregnancy
    b. 1/3 to 1/2 of women with varices will have bleed- is cholelithiasis.
    ing in pregnancy and this carries an 18% mortal- c. The Apache II scoring system is the most appro-
    ity rate. priate for pancreatitis in pregnancy.
    c. Without variceal rupture there is high risk for d. Total parenteral nutrition is the preferred method
    liver failure, preterm delivery, fetal growth restric- of providing nutrition in severe pancreatitis.
    tion, and maternal death.
    d. All of the above 55–37. A 32-year-old at 26 weeks’ gestation has a 3.4-cm
    liver mass noted incidentally on a right upper quad-
    55–34. A 27-year-old at 32 weeks’ gestation is brought to the rant ultrasound. She undergoes magnetic resonance
    emergency room by ambulance after consuming 6 grams imaging for further clarification. Which of the fol-
    of acetaminophen. Which of the following is true? lowing is true?
    a. The fetus is not at risk, so no monitoring is necessary. a. Due to size and bleeding risk, surgical resection is
    b. N-Acetyl-p-benzoquinoneimine should be admin- indicated if it is a hepatic adenoma.
    istered promptly. b. If it is a hepatic adenoma, there is a 5% risk of
    c. This is the most common cause of acute liver fail- malignant transformation, so biopsy should be
    ure in the United States. performed next.
    d. All of the above c. If it is focal nodular hyperplasia, estrogen-
    containing birth control pills are not a good
    55–35. A 31-year-old at 20 weeks’ gestation presents to the contraceptive option postpartum.
    emergency room with complaints of right upper d. None of the above
    quadrant pain, fever, and vomiting. Exam reveals right
    upper quadrant tenderness, and she has a temperature
    of 38.7°C. One diagnostic image is shown here. Com-
    mon bile duct obstruction is not suspected. What is
    the next most appropriate step in her management?

    Used with permission from Dr. Barbara Hoffman.

    a. Laparoscopic cholecystectomy
    b. Endoscopic retrograde cholangiopancreatography
    c. Admit for serial abdominal examinations and
    intravenous antibiotics
    d. Discharge home with oral antibiotics, pain medi-
    cation, and antiemetics
    CARDIOVASCULAR PATHOLOGY

    Вопрос 1
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A schematic of Eisenmenger syndrome due to a ventricular septal defect is
    depicted. What is the most common cause of death in pregnant women with
    this condition?

    Выберите один ответ:


    a. Left ventricular failure
    b. Sepsis
    c. Cardiac tamponade
    d. Right ventricular failure
    Вопрос 2
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 32-year-old G2P1 presents to your office at 17 weeks’ gestation. She
    reports a history of tetralogy of Fallot, which was repaired in infancy. She
    appears comfortable on the exam table with a heart rate of 92 beats per
    minute and a blood pressure of 96/62 mm Hg. However, she does report
    significant palpitations and dyspnea when climbing the two flights of stairs
    to her apartment on the third floor. Which New York Heart Association class
    best describes her functional disability?
    Выберите один ответ:
    a. Class II
    b. Class I
    c. Class III
    d. Class IV
    Вопрос 3
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса _
    What is the gold standard for diagnosis of the condition in Question 49–24?
    Выберите один ответ:
    a. Electrocardiography
    b. Chest radiography
    c. Right heart catheterization
    d. Echocardiography
    Вопрос 4
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following best describes the remodeling of the heart that
    occurs in normal pregnancy?
    Выберите один ответ:
    a. Concentric left ventricular mass expansion with spherical remodeling
    b. Concentric left ventricular mass expansion with longitudinal remodeling
    c. Eccentric left ventricular mass expansion with spherical remodeling
    d. Eccentric left ventricular mass expansion with longitudinal remodeling
    Вопрос 5
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following therapies is safe in pregnancy to treat acute
    supraventricular tachycardia?
    Выберите один ответ:
    a. All of the above
    b. Valsalva maneuver
    c. Synchronized cardioversion
    d. Intravenous adenosine
    Вопрос 6
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    For which of the following cardiac conditions is conduction analgesia highly
    recommended?
    Выберите один ответ:
    a. Pulmonary artery hypertension
    b. Repaired hypoplastic left heart syndrome
    c. Severe aortic stenosis
    d. All of the above
    Вопрос 7
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following conditions usually improves during pregnancy due to
    pregnancy-induced hypervolemia?
    Выберите один ответ:
    a. Aortic stenosis
    b. Mitral valve prolapse
    c. All of the above
    d. Mitral stenosis
    Вопрос 8
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    In a pregnant woman who has previously undergone a heart transplantation,
    what is the approximate risk for suffering a rejection episode during
    pregnancy?
    Выберите один ответ:
    a. 40%
    b. 10%
    c. 20%
    d. 30%
    Вопрос 9
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following does not contribute to the 40% increase in cardiac
    output seen during normal pregnancy?
    Выберите один ответ:
    a. Decreased systemic vascular resistance
    b. Increased heart rate
    c. Increased left ventricular contractility
    d. All of the above contribute to increased cardiac output in pregnancy
    Вопрос 10
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    In the United States, what is the most common cause of aortic stenosis?
    Выберите один ответ:
    a. Rheumatic heart disease
    b. Idiopathic
    c. Bicuspid aortic valve
    d. Infectious endocarditis

    Вопрос 1
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Regarding diagnostic studies, which of the following correctly describes a
    normal change that is characteristic of pregnancy?
    Выберите один ответ:
    a. An average 15-degree left axis deviation on electrocardiogram
    b. A decrease in the cardiac silhouette size on chest radiograph
    c. All of the above
    d. Improved systolic function on echocardiographic assessment
    Вопрос 2
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    You are caring for a pregnant patient with mitral stenosis. She is able to
    perform most activities of daily living without significant limitation. On
    echocardiogram, her ejection fraction is 50% and her mitral valve area
    measures 1.8 cm2. Which of the following variables is most predictive of a
    high risk for cardiac complications during this pregnancy?
    Выберите один ответ:
    a. None of the above
    b. Her ejection fraction
    c. Her degree of left-sided obstruction
    d. Her functional capacity
    Вопрос 3
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    What percentage of pregnancy-related deaths in the United States were
    attributable to cardiovascular diseases between 2011 and 2013?
    Выберите один ответ:
    a. 20–25%
    b. 15–20%
    c. 10–15%
    d. 25–30%
    Вопрос 4
    Нет ответа
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    You are caring for a 24-year-old G1 with severe aortic stenosis. When in
    pregnancy are you most concerned about cardiac decompensation?
    Выберите один ответ:
    a. During the first trimester
    b. Peripartum
    c. During the second trimester
    d. During the third trimester
    Вопрос 5
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    The patient whose heart is shown in this image has systemic lupus
    erythematosus and has a history of a prior stroke. The left atrium (LA) and
    left ventricle (LV) are identified, and the arrows point to noninfectious
    vegetations on the mitral leaflets. Which of the following is the likely
    condition associated with her mitral insufficiency?

    Выберите один ответ:


    a. Calcification of the mitral annulus
    b. Antiphospholipid antibodies
    c. Infarction of the papillary muscle
    d. None of the above
    Вопрос 6
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    The World Health Organization identifies which of the following conditions
    as prohibitive of pregnancy?
    Выберите один ответ:
    a. Pulmonary artery hypertension
    b. Cyanotic heart disease
    c. Heart transplantation
    d. Systemic ventricular dysfunction with left ventricular ejection fraction of
    35%
    Вопрос 7
    Нет ответа
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 30-year-old G2P0A1 presents at 11 weeks’ gestation to establish care.
    She has a history of rheumatic heart disease and had a mechanical valve
    replacement at age 20. She was previously on warfarin 7.5 mg daily, but
    stopped taking her medication when she found out she was pregnant 1
    week ago. What is her risk for warfarin embryopathy based on her warfarin
    dosing?
    Выберите один ответ:
    a. 1%
    b. 8%
    c. 5%
    d. 3%
    Вопрос 8
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    What is the most common cause of heart failure in pregnancy?
    Выберите один ответ:
    a. Chronic hypertension
    b. Chronic hypertension with superimposed preeclampsia
    c. Severe preeclampsia
    d. Idiopathic
    Вопрос 9
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    You are caring for a primigravida with known hypertrophic cardiomyopathy.
    She tells you her mother also suffered from the condition and passed away
    at an early age. The patient is concerned about her child’s future risk for
    developing the same condition. What do you tell her is the most likely risk
    for passing the condition to her child?
    Выберите один ответ:
    a. 100%
    b. 25%
    c. 50%
    d. &lt;1%
    Вопрос 10
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A graphic of pulmonary capillary wedge pressure (red line) is shown for a
    woman with mitral stenosis. “A” represents the first stage of labor, “B”
    marks the second stage of labor, “C” demonstrates the immediate
    postpartum period, and “D” shows the period 4–6 hours postdelivery. What
    accounts for the rise in pulmonary capillary wedge pressure immediately
    following delivery?

    Выберите один ответ:


    a. Increase in systemic vascular resistance
    b. Pitocin-induced increase in cardiac output
    c. Placental autotransfusion
    d. Heart rate normalization

    Вопрос 3
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    In a pregnant population, what is the most common cause of the condition
    portrayed in the chest x-ray image below?
    (enlarged pulmonary hilar arteries and attenuated peripheral markings)

    Выберите один ответ:


    a. Chronic renal failure
    b. Left-sided heart disease
    c. Metabolic disorders
    d. Connective tissue disease

    CASES

    Question 1
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    You are caring for a patient with Marfan syndrome who just found out she is
    13 weeks pregnant. You obtain an echocardiogram which demonstrates an
    aortic root measurement of 4.5 cm. Based on these findings, what would
    you recommend?
    Select one:
    a. Beta blocker initiation
    b. Bimonthly echocardiograms
    c. All of the above
    d. Consideration of pregnancy termination
    Question 2
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    At 24 weeks’ gestation the patient with a history of pulmonary hypertension
    due to chronic thromboembolic disease in her past begins to develop
    orthopnea and dyspnea on exertion. What treatment would you consider to
    decrease her symptoms?
    Select one:
    a. Supplemental oxygen
    b. Pulmonary vasodilator drugs
    c. All of the above
    d. Diuretics
    Question 3
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    How would you manage the patient at 32 weeks’ gestation you are caring
    for complains of shortness of breath and chest pain with minimal exertion
    with previously uncomplicated pregnancy with a new-found mitral stenosis
    and an ejection fraction of 55%?
    Select one:
    a. Administer diuretics
    b. Initiate anticoagulation
    c. All of the above
    d. Recommend immediate labor induction
    Question 4
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    What associated condition the patient with an unrepaired ventricular septal
    defect, considering pregnancy, is at high risk for developing based on her
    history?
    Select one:
    a. Bacterial endocarditis
    b. Venous thromboembolism
    c. None of the above
    d. Embolic stroke
    Question 5
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    You are the on-call hospitalist when you receive an urgent call from the
    postpartum floor about a patient who is complaining of chest pain and
    shortness of breath. She had an uncomplicated vaginal delivery the
    previous day and has no significant past medical or surgical history. You
    obtain a stat chest x-ray, which is shown. Based on the findings, what are
    you most concerned for?
    Select one:
    a. Pulmonary hypertension
    b. Cardiomyopathy
    c. Pneumonia
    d. Pulmonary edema

    Вопрос 1
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Based on the diagnosis of a peripartum cardiomyopathy and assuming a
    recovery of systolic function by 6 months postpartum, what is the patient’s
    risk for suffering a relapse of the same condition in a future pregnancy?
    Выберите один ответ:
    a. 5%
    b. 20%
    c. 10%
    d. 30%
    Вопрос 2
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    You obtain an echocardiogram on the patient in postdelivery period with
    new-onset cardiomyopathy. Her ejection fraction is found to be 20% with
    no significant structural or valvular disease noted. Which hormone has
    been implicated in the development of this condition?
    Выберите один ответ:
    a. Prolactin
    b. Estrogen
    c. Human placental lactogen
    d. Progesterone
    Вопрос 4
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    You are caring for a 28-year-old G1 with a history of moderate mitral
    stenosis who presented in active labor and is now 8 cm dilated. She desires
    a natural labor and declines pain medications during labor. As her
    contractions get closer together, she reports increasing pain, is visibly
    uncomfortable, and intermittently becomes tachycardic to 130 beats per
    minute. She suddenly begins complaining of shortness of breath and her
    oxygen saturation declines to 90% on room air. What is your best course of
    action?
    Выберите один ответ:
    a. All of the above
    b. Request immediate anesthesia assessment
    c. Administer intravenous Lasix
    d. Administer metoprolol

    A 32-year-old G2P1 transfers to your care at 18 weeks' gestation. She has a history of NYHA class 2
    heart disease. What among following are common recommendations to this patient?
    Select one:
    a. cigarette smoking cessation is not recommended because of potential Increase in pulmonary
    hypertension X
    b. for the majority of these patients prolonged hospitalization or bed rest is necessary
    c. to avoid contact with persons who have respiratory infections, including the common cold, and to
    report at once any evidence for Infection
    d. illicit drug use may be particularly harmful, because of increased risk of liver failure
    You are caring for a patient with an unrepaired ventricular septal defect who is considering pregnancy.
    You perform an echocardiogram to assess her future risks. Which of the following parameters would
    indicate an extremely elevated maternal and fetal risk during pregnancy?
    Select one:
    a. A right ventricular systolic pressure of 75 mm Hg
    b. A septal defect measuring 0.7 cm2
    c. A left ventricular ejection fraction of 50% X
    d. Presence of left ventricular hypertrophy

    A pregnant woman presents to the emergency room in an obtunded state. She has a fever to 102.6°F.
    On exam, a 4/6 murmur is noted, she withdraws from pain during her abdominal exam, and track
    marks are noted on her arms and legs. Her fundal height is approximately 32 cm. An emergent
    echocardiogram is obtained, which demonstrates a mitrel valve vegetation. What is the most likely
    organism underlying her diagnosis?
    Select one:
    a. Neisseria gonorrhoeae
    b. Staphylococcus aureus
    c. Staphylococcus epidermidis
    d. Enterococcus

    CHRONIC HYPERTENSION

    Question 1
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Why ethnicity is important in recommendations to initiate an
    antihypertensive agent? Among following choose correct statements
    Select one or more:
    a. Angiotensin-converting enzyme inhibitors and angiotensin-
    receptor blockers are recommended as initial therapy in the black
    population.
    b. Angiotensin-converting enzyme inhibitors and angiotensin-
    receptor blockers are recommended as initial therapy in the nonblack
    population.
    c. Beta blockers are not recommended as initial therapy in the
    nonblack population.
    d. Beta blockers are recommended as initial therapy in the Asian
    population.
    Question 2
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Among women who have persistently worrisome hypertension despite usual
    therapy what antagonizing substances may be used:
    Select one:
    a. Smoking more than 20 cigarettes per day
    b. Chronic ingestion of nonsteroidal antiinflammatory drugs
    c. Everyday antacids usage
    d. Marijuana abuse
    Question 3
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    For women with chronic hypertension without superimposed preeclampsia,
    when is delivery recommended by American College of Obstetricians and
    Gynecologists?
    Select one:
    a. 37 weeks 0 days to 38 weeks 6 days
    b. There are no guidelines for a specific recommendation
    c. 38 weeks 0 days to 39 weeks 6 days
    d. 39 weeks 0 days to 40 weeks 0 days
    Question 4
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which intravenous antihypertensive drug commonly used to treat
    intrapartum severe range hypertension is properly matched with its most
    notable side effect?
    Select one:
    a. Hydralazine — neonatal tachycardia
    b. Labetalol — neonatal rebound hypertension
    c. Hydralazine — maternal arrhythmia
    d. Labetalol — neonatal hypotension and bradycardia
    Question 5
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following characterizes the relationship between chronic
    hypertension and superimposed preeclampsia?
    Select one:
    a. Approximately 80% of those who also have at least 300 mg/day of
    proteinuria at baseline will develop severe preeclampsia
    b. All women with severe hypertension have renal disease—as either cause
    or effect
    c. Women with severe chronic hypertension who did not develop
    superimposed preeclampsia have the same outcomes as those, who
    developed.
    d. None of the mentioned
    Question 6
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    The benefits and safety of instituting antihypertensive therapy in women
    with chronic hypertension planning or during pregnancy are:
    Select one:
    a. Evident
    b. Not clear
    c. Absent
    Question 7
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Ms. Clamp is a 30-year-old G1 presenting for initiation of prenatal care at 12
    weeks’ gestation. Her medical history is notable for chronic hypertension,
    and she has been on antihypertensive therapy for 3 years. Her blood
    pressure is 148/94 mm Hg. How would you best counsel her regarding the
    risk for developing superimposed preeclampsia?
    Select one:
    a. The risk for developing superimposed preeclampsia is in the 7–9% range.
    b. Maternal serum markers yield a high positive predictive value in
    discriminating who will and will not develop superimposed preeclampsia.
    c. The risk for superimposed preeclampsia is not related to the severity of
    her baseline hypertension.
    d. The risk is highest if workup reveals proteinuria or other end-organ
    impact.
    Question 8
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    The threshold of 140/90 mm Hg as the upper limit of normal is based on
    which of the following?
    Select one:
    a. A large, widely sampled international population of men and women of
    various ages with no known health complications
    b. Actuarial tables based on data from white adult males
    c. The discrete point at which risk for myocardial infarction, stroke, renal
    failure, and peripheral artery disease sharply increases
    d. None of the mentioned
    Question 9
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    According to the Nationwide Patient Sample data, which of the following is
    the most frequent comorbidity associated with chronic hypertension?
    Select one:
    a. Depression
    b. Hypothyroidism
    c. Pregestational diabetes
    d. Systemic lupus erythematosus
    Question 10
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    For women with chronic hypertension, which modifiable factor further
    increases the risk for the placental abruption?
    Select one:
    a. Exercise
    b. Smoking
    c. Obesity
    d. Marijuana use

    Question 1
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    All except which of the following support the diagnosis of superimposed
    preeclampsia?
    Select one:
    a. Decreased serum alkaline phosphatase level
    b. Increased serum creatinine level
    c. Elevated serum aspartate aminotransferase level
    d. Decreased platelet count
    Question 2
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which of the following interventions is recommended to reduce risk for
    developing preeclampsia in women with chronic hypertension?
    Select one:
    a. Initiation of low dose aspirin from 12–28 weeks’ gestation with
    continuation until delivery.
    b. Initiation of low dose aspirin as early as possible and continuation until
    28 weeks’ gestation.
    c. No intervention has shown benefit over preconception and early
    pregnancy folic acid supplementation.
    d. At least 3 months of preconception supplementation with vitamins C and
    E.
    Question 3
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which of the following methods of antenatal fetal surveillance has been
    conclusively shown to be of benefit in the management of pregnancies
    complicated by chronic hypertension?
    Select one:
    a. Umbilical artery Doppler studies
    b. Serial sonographic evaluations of fetal growth
    c. Nonstress testing
    d. Biophysical profile
    Question 4
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Risk for the placental abruption is increased in pregnancies complicated by
    chronic hypertension. How would you best characterize the risk?
    Select one:
    a. Incidence not impacted by the severity of blood pressure
    b. Incidence not impacted by development of superimposed preeclampsia
    c. 2-3-fold increase over the general obstetric population
    Question 5
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Antihypertensive therapy is mandatory for which of the following women
    during pregnancy?
    Select one:
    a. 28-year-old G2P1 with a blood pressure of 140/94 mm Hg and history of
    preeclampsia in her last pregnancy
    b. 42-year-old G2P1 with a blood pressure of 130/88 mm Hg and a history
    of myocardial infarction
    c. 30-year-old G3P2 with a blood pressure of 160/110 mm Hg and a
    history of asthma
    d. 38-year-old G4P3 with a blood pressure of 148/96 mm Hg and history of
    transient renal insufficiency 3 years ago when she had an obstructive
    nephrolithiasis
    Question 6
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following is a major factor contributing to the incidence of
    perinatal mortality noted in pregnancies complicated by chronic
    hypertension?
    Select one:
    a. All of the mentioned
    b. Fetal growth restriction
    c. Iatrogenic preterm birth
    d. Superimposed preeclampsia
    Question 7
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    For a woman who does not enter pregnancy with a known diagnosis, the
    diagnosis of chronic hypertension is supported when hypertension is
    present prior to what gestational age threshold?
    Select one:
    a. 20 weeks’ gestation
    b. 14 weeks’ gestation
    c. 28 weeks’ gestation
    d. 24 weeks’ gestation
    Question 8
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following approximates the risk for perinatal mortality in
    pregnancies complicated by chronic hypertension?
    Select one:
    a. 3- to 4-fold increase over pregnancies not complicated by chronic
    hypertension
    b. Approximately 10% of births in women with severe hypertension
    c. Approximately 3% of births in women with mild hypertension
    d. All of the mentioned
    Question 9
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following is NOT true regarding the complication shown here,
    in the computerized tomography scan image?
    Select one:
    a. None of the mentioned
    b. The risk is not increased among women with chronic hypertension
    in the absence of superimposed preeclampsia.
    c. Systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm
    Hg can rapidly result in the finding shown here.
    d. This occurs during pregnancy in approximately 3 per 1000 women with
    chronic hypertension.
    Question 10
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which of the following factors does not impact resting blood pressure
    reading?
    Select one:
    a. Race
    b. Gender
    c. Age and weight
    d. Activity level
    Вопрос 1
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following statements is not true regarding intrapartum
    management of a woman with chronic hypertension with superimposed
    preeclampsia?
    Выберите один ответ:
    a. Postpartum analgesia should include scheduled nonsteroidal
    antiinflammatory drugs for at least 72 hours to reduce narcotic use.
    b. Trial of labor is not contraindicated.
    c. These women are more sensitive to the acute hypotensive effects of
    epidural anesthesia.
    d. Magnesium sulfate is the neuroprophylactic agent of choice to prevent
    eclampsia.
    Вопрос 3
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Pregnancy is associated with which of the following blood pressure
    changes in women with chronic hypertension?
    Выберите один ответ:
    a. All of the mentioned
    b. Blood pressure decreases from baseline in early pregnancy
    c. In pregnancy, women with chronic hypertension have persistently
    elevated vascular resistance
    d. Blood pressure reaches its nadir at approximately 20 weeks’ gestation
    Вопрос 4
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    What is main concern about antihypertensive treatment during pregnancy
    for those with mild or moderate hypertension?
    Выберите один ответ:
    a. potentially diabetogenic
    b. not improving maternal morbidity
    c. potentially teratogenic
    d. diminish placental perfusion

    Indications for aspirin prophylaxis to reduce the risk for developing preeclampsia in pregnant women
    with chronic hypertension include a history of:
    Select one:
    a. Preeclampsia during previous pregnancy
    b. All of the mentioned
    c. Renal disease
    d. Multifetal gestation
    e. Autoimmune disease
    f. Diabetes

    Among women with chronic hypertension, which of the following is true regarding risk for adverse
    maternal and perinatal outcome?
    Select one:
    a. The risk Is inversely proportional to the severity and duration of hypertension prior to pregnancy.
    b. All of the mentioned X
    c. Complications are more likely with severe range hypertension at baseline and the presence of end-
    organ damage.
    d. Chronic hypertension is associated with a twofold Increased risk for maternal death.

    CASE

    Question 1
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Use of which of the following classes of antihypertensive agents is
    contraindicated during all trimesters of pregnancy?
    Select one:
    a. Those that act centrally to reduce sympathetic outflow
    b. Those that interfere with binding sites on voltage-dependent calcium
    channels.
    c. Those that act peripherally to reduce sympathetic tone and decrease
    cardiac output
    d. Those that act to inhibit the conversion of angiotensin-I to
    angiotensin-II.
    e. Those that relaxes arterial smooth muscle
    Question 2
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    A 37-year-old G2P2 with no medical diagnoses and a normal body mass
    index on annual well woman exam found to have BP 142/92 mm Hg, and
    after checking several times over the next week at home, she calls with a
    blood pressure log that ranges from 140–154/90–100 mm Hg. According to
    the recommendations of the Eighth Joint National Committee, what is your
    goal blood pressure with therapy?
    Select one:
    a. &lt;120/80 mm Hg
    b. &lt;130/85 mm Hg
    c. &lt;150/100 mm Hg
    d. &lt;140/90 mm Hg
    Question 3
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    A 33-year-old G1 at 32 weeks’ gestation has been diagnosed with chronic
    hypertension with superimposed preeclampsia via worsening hypertension.
    She is asymptomatic with normal labs and normal fetal growth. An increase
    in the dose of her antihypertensive medication has resulted in nonsevere
    blood pressures. She asks you about expectant management of
    superimposed preeclampsia. Which of the following is the most
    appropriate, evidence-based response?
    Select one:
    a. It is reasonable, with close inpatient surveillance, to pursue
    expectant management, but there are still risks for adverse
    outcomes.
    b. Inpatient expectant management is reasonable, and with close
    surveillance, adverse outcome would not be expected.
    c. None of the above
    d. Preeclampsia mandates immediate delivery, so you recommend
    proceeding with cesarean now.
    Question 4
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Ms. Edwards is a 26-year-old G2P2, now 3 days postpartum from a vaginal
    delivery. She has chronic hypertension and developed superimposed severe
    preeclampsia at 36 weeks’ gestation. She did well initially, but in the last 12
    hours her blood pressure has been trending up. Most recent blood pressure
    was 156/90 mm Hg. The nurse has called you because Ms. Edwards is
    feeling short of breath. A representative chest radiograph is shown here.
    What is the appropriate treatment for this condition?

    Select one:
    a. Intravenous furosemide
    b. Immediate blood test for anemia
    c. Broncholytic inhalation
    d. Anticoagulation
    Question 5
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    A 36-year-old multigravida with chronic hypertension presents for a growth
    ultrasound at 36 weeks’ gestation. The ultrasound report shows you that
    estimated fetal weight correspond to 33 weeks’, head size - to 34 weeks’,
    while abdominal circumference and femur length – to 32 weeks’ gestation.
    Which of the following is true regarding the diagnosis made on the growth
    ultrasound?
    Select one:
    a. The risk is not modified by whether a woman with chronic hypertension
    has got treatment
    b. All of the mentioned
    c. The risk is reduced with administration of the antioxidants, vitamin C and
    vitamin E.
    d. Fetal-growth dysfunction is more likely in chronically hypertensive
    women who develop superimposed preeclampsia.

    Question 1
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    You are seeing Ms. Blanche for prenatal care. She is a 37-year-old G1 at 8
    weeks’ gestation. She has been your patient for several years, and chart
    review shows former blood pressure readings have been 110–120/70–
    80 mm Hg at prior visits. The blood pressure noted at her first obstetric
    visit is 150/96 mm Hg. Which of the following is the most appropriate next
    step?
    Select one:
    a. Counsel regarding the risks of preexisting hypertension in pregnancy and
    recommend initiation of a daily baby aspirin to reduce the risk for
    preeclampsia.
    b. Request that she have her blood pressure measured a few times
    over the next 2 weeks and return with her log for review.
    c. Order maternal cardiac echocardiogram.
    d. Recommend low-sodium diet and recheck her blood pressure in 2 weeks.
    Question 2
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which antihypertensive drug commonly used to treat hypertension is
    properly matched with its most notable side effect?
    Select one:
    a. Thiazide—neonatal bradycardia
    b. Nifedipine — circulating volume depletion
    c. Angiotensin-receptor blockers—fetal arrhythmia
    d. Hydralazine—maternal tachycardia
    Question 3
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Ms. Thomas presents for a preconception counseling visit. She is a 37-
    year-old G0 with a body mass index of 38 kg/m2, 4-year history of chronic
    hypertension treated with amlodipine 5 mg per day, and a 2-year history of
    diabetes which she manages with diet and exercise. Her blood pressure
    range is 128–144/80–94 mm Hg from the week prior. What workup would
    you like to pursue referent to her diagnosis of chronic hypertension and
    prepregnancy risk stratification?
    Select one:
    a. Serum creatinine and urine protein-to-creatinine ratio
    b. Serum creatinine, 24-hour urine collection for protein and creatinine
    clearance, electrocardiogram, and cardiac stress test
    c. Serum creatinine, urine protein-to-creatinine ratio,
    electrocardiogram, and maternal echocardiogram
    d. No further evaluation is indicated, as she has only had a diagnosis of
    hypertension for 4 years and her blood pressure is well controlled on a
    single medication.
    Question 4
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    A 28-year-old G3P1102 at 9 weeks’ gestation presents for establishment of
    prenatal care. Her first pregnancy was complicated by gestational
    hypertension at term, and her second was complicated by iatrogenic
    preterm delivery at 36 weeks’ gestation for preeclampsia. Her blood
    pressure was normal at her postpartum visit 2 years ago but has not been
    assessed since. Today her body mass index is 46 kg/m2 and her blood
    pressure is 158/96 mm Hg. As instructed, she calls back 2 days after her
    visit to report that blood pressures have been in the 146–160/94–100mm
    Hg range at home. In addition to initiation of an antihypertensive agent,
    what is the next step in management of her blood pressure in this
    pregnancy?
    Select one:
    a. Baseline 24-hour urine collection for protein, creatinine clearance, and
    urinary metanephrines
    b. All of the mentioned
    c. Baseline serum creatinine
    d. Renal ultrasound with Doppler
    Question 5
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    The 37-year-old G0 patient with 4-year history of chronic hypertension
    treated with amlodipine 5 mg per day, and a 2-year history of diabetes
    which she manages with diet and exercise presents for a preconception
    counseling. She has a copy of her records from her primary care physician.
    Serum creatinine of 0.9 mg/dL, urine protein-to-creatinine ratio of 0.22, a
    normal electrocardiogram. Fasting glucose was 93 mg/dL (5.16 mmol/l) this
    morning, and her hemoglobin A1C was 6.0 last month. Which of the
    following is the most appropriate recommendation?
    Select one:
    a. There is no contraindication to pregnancy, but you recommend
    converting to an alternative antihypertensive agent in advance of pursuing
    pregnancy to reduce teratogenic risk.
    b. You do not yet have adequate information from which to make a
    recommendation.
    c. There is no contraindication to pregnancy, but she can further
    reduce her risk with weight loss and regular, moderate intensity
    aerobic exercise 3–4 times per week.
    d. Risk for adverse outcome in pregnancy is unacceptably high, and you
    recommend that she consider gestational surrogacy or adoption.

    KIDNEY PATHOLOGY

    Question 1
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which of the following does not characterize nephrotic syndromes?
    Select one:
    a. Hyperalbuminemia
    b. Heavy proteinuria
    c. Hypercholesterolemia
    d. Edema
    Question 2
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following statements about polycystic kidney disease is true?
    Select one:
    a. It is usually X-linked inheritance.
    b. Asymptomatic coexisting hepatic cysts are uncommon.
    c. Renal complications are more common in women than men.
    d. 10% of those with this disease die from rupture of an intracranial
    berry aneurysm.
    Question 3
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following is the threshold for proteinuria in pregnancy, above
    which levels are considered abnormal?
    Select one:
    a. 250 mg/d
    b. 300 mg/d
    c. 1000 mg/d
    d. 100 mg/d
    Question 4
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Once you have treated a pregnant patient for pyelonephritis as an inpatient,
    for how long should you continue oral therapy as an outpatient?
    Select one:
    a. 14–21 days
    b. 3–5 days
    c. 1–3 days
    d. 7–14 days
    Question 5
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following is most likely to lead to end-stage renal disease?
    Select one:
    a. Hypertension
    b. Glomerulonephritis
    c. Polycystic kidney disease
    d. Diabetes
    Question 6
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    What percentage of pregnant women with asymptomatic bacteriuria
    develop a symptomatic infection if left untreated?
    Select one:
    a. 5%
    b. 10%
    c. 25%
    d. 50%
    Question 7
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    What is the leading cause of septic shock during pregnancy?
    Select one:
    a. Breast abscess
    b. Chorioamnionitis
    c. Pneumonia
    d. Pyelonephritis
    Question 8
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    In case of urinary tract obstruction what diagnostic option is the method of
    a first choice?
    Select one:
    a. Plain abdominal radiograph
    b. One-shot intravenous pyelogram
    c. Renal sonography
    d. MR imaging
    Question 9
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following is NOT a physiological change in pregnancy?
    Select one:
    a. Progesterone-induced relaxation of the muscularis
    b. Glomerular hypertrophy
    c. Vesicoureteral reflux
    d. Distal ureteral compression by the uterus
    Question 10
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following is not commonly found in patients with a urethral
    diverticulum?
    Select one:
    a. Urinary retention
    b. Palpable mass
    c. Pain
    d. Recurrent urinary infections
    Вопрос 1
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    What percentage of pregnant women experience a recurrent urinary tract
    infection after completion of treatment for pyelonephritis?
    Выберите один ответ:
    a. 30–40%
    b. 50–60%
    c. 5–10%
    d. 10–20%
    Вопрос 4
    Выполнен
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following statements regarding physiological changes in
    pregnancy is true?
    Выберите один ответ:
    a. Effective renal plasma flow increases.
    b. The number of glomerular cells increases.
    c. Glomerular filtration decreases.
    d. Serum creatinine concentration increases.
    Вопрос 5
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    What is the cutoff for a urinary protein-to-creatinine ratio on a spot urine
    sample in pregnant patient?
    Выберите один ответ:
    a. 0.1
    b. 0.2
    c. 0.3
    d. 0.5
    Вопрос 6
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    What is the most common reason for acute kidney injury in obstetrics?
    Выберите один ответ:
    a. Acute blood loss
    b. Sepsis
    c. Ureteral injury at cesarean section
    d. Use of loop diuretics

    Вопрос 8
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    By what creatinine does one define moderate renal impairment in patients
    with chronic renal disease?
    Выберите один ответ:
    a. 5–7 mg/dL
    b. 1.5–3.0 mg/dL
    c. 3.0–4.5 mg/dL
    d. 1–1.5 mg/dL
    Вопрос 9
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following complications is not increased in pregnant patients
    with nephrotic syndrome?
    Выберите один ответ:
    a. Anemia
    b. Postterm pregnancy
    c. Preeclampsia
    d. Renal insufficiency
    Вопрос 10
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following is not a recommended requisite for renal transplant
    patients who want to attempt pregnancy?
    Выберите один ответ:
    a. Serum creatinine &lt;2 mg/dL
    b. No identifiable pyelocalyceal distention by urography
    c. Proteinuria &lt;300 mg/day
    d. No evidence of graft rejection for 6 months

    The clinical presentation of a what condition usually includes hypertension,


    hematuria, red-cell casts, pyuria, proteinuria, edema, hypertension, and
    circulatory congestion?
    Select one:
    a. Anemia
    b. Polycystic kidney disease
    c. Glomerulonephritis
    d. Preeclampsia
    e. Renal insufficiency

    Young pregnant patient with pyelonephritis and labor contractions transferred to labor department for
    monitoring. She is given intravenous (IV) antibiotics, IV fluids, acetaminophen, and a beta-agonist
    because of the contractions. What complication is more likely in the setting of p-agonist use in patients
    with pyelonephritis?
    Select one:
    a. Abruption
    b. Acute kidney injury
    c. Anemia
    d. Pulmonary edema

    The pregnant patient with a kidney stone asks how many pregnant women actually pass their stone
    with the management plan of analgesia and intravenous hydration. What is your response?
    Select one:
    a. 95-100%
    b. 50-60%
    c. 65-80%
    d. 90-95%

    When managing a patient with postpartum acute kidney injury, which of the following medications
    does not need to have its dose adjusted?
    Select one:
    a. Clindamycin
    b. Ketorolac tromethamine
    c. Gentamycin
    d. Magnesium sulfate X

    CASE

    Question 1
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    An 18-year-old G1P0 presents at 30 weeks’ gestation with fever of 39oC,
    chills, vomiting, dysuria, and frequent urination for 3 days. She is also
    experiencing contractions. What is her most likely diagnosis?
    Select one:
    a. Labor
    b. Pyelonephritis
    c. Infarcted leiomyoma
    d. Adnexal torsion
    e. Appendicitis
    Question 2
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    A 32-year-old G2P0 presents at 19 weeks’ gestation complaining of back
    pain that radiates forward. She reports that the pain is intense, and she
    looks very uncomfortable. She has not been febrile. A urinalysis is
    significant only for red blood cells. An image from her renal ultrasound is
    provided below. You diagnose the patient with a kidney stone. Which of the
    following is the best management option for the patient at this time?

    Select one:
    a. Analgesia and intravenous hydration
    b. Analgesia, intravenous hydration, intravenous antibiotics, and ureteral
    stenting
    c. Analgesia
    d. Analgesia, intravenous hydration, and intravenous antibiotics
    Question 3
    Complete
    Mark 0.00 out of 1.00
    Flag question
    Question text
    A 25-year-old G1P0 at 16 weeks’ gestation presents for prenatal care. She
    has a history of a kidney transplant 3 years ago. She is stable on prednisone
    and azathioprine. The patient has not experienced any rejection, and her
    blood pressure is well controlled. Which of the following obstetric
    complications is not increased in her?
    Select one:
    a. Preeclampsia
    b. Peripartum cardiomyopathy
    c. Preterm birth
    d. Fetal-growth restriction
    Question 4
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    A pregnant woman presents with flank pain. She is afebrile but tachycardic
    from pain. Her serum creatinine is elevated to 5 mg/dL. Images from her
    magnetic resonance imaging are presented below - hydronephrosis. Which
    of the following is the best plan of care?

    Select one:
    a. Renal biopsy
    b. Nephrectomy
    c. Intravenous antibiotics and aggressive fluid hydration
    d. Percutaneous nephrostomy tube
    Question 5
    Complete
    Mark 1.00 out of 1.00
    Flag question
    Question text
    You are consulted about a 19-year-old primigravida at 18 weeks’ gestation.
    The patient was diagnosed at her first prenatal care visit with asymptomatic
    bacteriuria. Her provider treated her with nitrofurantoin 100 mg twice daily
    for 7 days. The patient was seen a month after treatment, and her repeat
    urine culture was negative. But now, a urine culture sent in error is positive
    for >100,000 colony-forming units/mL gram-negative rods again. She
    remains asymptomatic. Her provider is not sure what to do. What is the best
    response to this consult?
    Select one:
    a. Single-dose treatment is more successful, so give the patient
    nitrofurantoin 200 mg by mouth one time.
    b. The urine culture is probably a false-positive given it was negative after
    treatment, so she does not need any further antibiotics.
    c. Recurrence of asymptomatic bacteriuria is 30% regardless of
    antibiotic regimen and it may indicate covert upper tract infection, so
    treat the patient with nitrofurantoin 100 mg by mouth at bedtime for
    21 days.
    d. The patient likely has a highly resistant organism, so she should be
    admitted for intravenous antibiotics.
    Вопрос 2
    Выполнен
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A series of anterior-posterior projection chest radiographs in a second-
    trimester pregnant woman with severe pyelonephritis in case of aggressive
    fluid hydration showing what of the following:

    Выберите один ответ:


    a. Secondary pneumonia
    b. Cardiac pulmonary edema
    c. Streptococcal sepsis
    d. Respiratory distress syndrome

    PREECLAMPSIA

    Question 1
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 42-year-old woman presents for prenatal care. She has a demanding
    professional career and reports she is unwilling to attend frequent prenatal
    visits at the end of pregnancy. You discourage this, explaining these visits
    are recommended for which of the following reasons?
    Select one:
    a. To aid in the timely detection of fetal complications such as growth
    restriction or oligohydramnios
    b. All of the mentioned
    c. To detect possible malpresentation and discuss delivery planning
    d. To aid in the early detection of preeclampsia
    Question 2
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    Among following choose correct statement concerning gestational
    hypertension
    Select one:
    a. diagnosis is made in women with new-onset hypertension and proteinuria
    after midpregnancy
    b. 30–33% of these women subsequently develop preeclampsia syndrome
    c. it is not dangerous until proteinuria has not yet developed
    d. blood pressure returns to normal by 12 weeks postpartum
    Question 3
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Among following choose correct statement concerning proteinuria in
    preeclamptic patient
    Select one:
    a. reflects the hyperalbuminemia state
    b. represent unique isolated nephphrotic syndrome
    c. reflects the system-wide endothelial leak
    d. is not clearly understood
    Question 4
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Many conditions and factors are associated with an increased risk for
    preeclampsia. Which of the following factors results in the greatest relative
    risk for a diagnosis of preeclampsia in the current pregnancy?
    Select one:
    a. Primigravida
    b. Systemic lupus erythematous
    c. History of preeclampsia in a prior pregnancy
    d. Advanced maternal age
    Question 5
    Correct
    Marked out of 1.00
    Flag question
    Question text
    All are features of HELLP syndrome except
    Select one:
    a. Increased liver enzymes
    b. Eosinophillia
    c. Thrombocytopenia
    d. Haemolytic anemia
    Question 6
    Correct
    Marked out of 1.00
    Flag question
    Question text
    What percentage of eclamptic seizures occur more than 48 hours after
    delivery?
    Select one:
    a. 10%
    b. 20%
    c. 2%
    d. 5%
    Question 7
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Antihypertensive contraindicated in pregnancy
    Select one:
    a. Hydrazaline
    b. ACE inhibitors
    c. Methyldopa
    d. Nifedipine
    Question 8
    Correct
    Marked out of 1.00
    Flag question
    Question text
    DOC for hypertension in pregnancy
    Select one:
    a. {Methyldopa
    b. Nifedipine
    c. Labetalol
    d. ACE inhibitors
    Question 9
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    What percentage of eclamptic seizures occur in women without significant
    proteinuria?
    Select one:
    a. 5–9%
    b. 10%
    c. 30–33%
    d. 20%
    Question 10
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which statement best describes renal perfusion and glomerular filtration
    rates in women with preeclampsia that has not yet progressed to severe
    disease?
    Select one:
    a. Similar compared to normal nonpregnant values
    b. Increased compared to normal pregnant values
    c. Similar compared to normal pregnant values
    d. Decreased compared to normal nonpregnant values
    Вопрос 2
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following is thought to play a significant role in the
    development of preeclampsia?
    Выберите один ответ:
    a. Immunological factors
    b. Abnormal trophoblastic invasion
    c. Genetic factors
    d. All of the mentioned
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 39-year-old G3P2 presents at 30 weeks’ gestation with hypertension,
    proteinuria, and headache. She is diagnosed with severe preeclampsia, and
    induction of labor is indicated. Her pregnancy is complicated by the fetal
    karyotype shown below. What is the possible explanation for her increased
    risk for preeclampsia with the below fetal karyotype?
    Выберите один ответ:
    a. Increased frequency of placenta mosaicism
    b. Higher frequency of spiral arteriole atherosis
    c. Increased levels of oxidative products in the placenta
    d. Increased antiangiogenic factor levels
    Вопрос 6
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    What percentage of pregnancies are complicated by hypertension?
    Выберите один ответ:
    a. 2–3%
    b. 10–20%
    c. 5–10%
    d. 4–5%
    Вопрос 7
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    The typical blood volume of a gravida at term is 4500 mL. In patients with
    preeclampsia, which of the following would be the expected blood volume?
    Выберите один ответ:
    a. 2500 mL
    b. 4500 mL
    c. 5000 mL
    d. 3200 mL
    Вопрос 9
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Cause of convulsion in eclampsia
    Выберите один ответ:
    a. Hypokalemia
    b. Shock
    c. Cerebral anoxia due to arterial spasm
    d. Hypovolemia
    Вопрос 10
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    The following computed tomography image shows cerebral edema in a
    postpartum patient with hypertension, vision changes, and confusion. What
    associated morbidity is the patient at risk for?

    Выберите один ответ:


    a. Retinal artery occlusion
    b. Hemiplegia
    c. Cystic leukomalacia
    d. Transtentorial herniation
    CASE

    Question 1
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Your patient is admitted to the hospital for evaluation of new-onset
    hypertension at 30 weeks’ gestation. Which of the following tests or
    evaluations is least appropriate?
    Select one:
    a. Maternal weight
    b. Sonographic evaluation of fetal growth
    c. Protein:creatinine ratio
    d. Cell-free DNA testing for aneuploidy
    Question 2
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which of the following is the best management of an 18-year-old G1 P0
    woman at 28 weeks’ gestation with a blood pressure of 160/110 mm Hg,
    elevated liver function tests, and a platelet count of 60,000/uL?
    Select one:
    a. Platelet transfusion
    b. Intravenous immunoglobulin therapy
    c. Magnesium sulfate therapy and induction of labor
    d. Oral antihypertensive therapy
    Question 3
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 24-year-old primigravida presents at 37 weeks’ gestation with headache,
    a blood pressure of 170/102 mm Hg, and severe right upper quadrant pain.
    She is diagnosed with HELLP syndrome and undergoes an uncomplicated
    induction of labor. Her right upper quadrant pain persists, and a computed
    tomography scan of her abdomen/pelvis is completed with the findings as
    shown below. What is denoted by the asterisk (*)?

    Select one:
    a. Periportal hemorrhagic necrosis
    b. Splenic infarction
    c. Subcapsular hematoma
    d. Intrahepatic infarction
    Question 4
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 21-year-old G1 at 36 weeks’ gestation presents for her clinic visit and is
    noted to have a blood pressure of 148/88 mm Hg. A repeat blood pressure
    30 minutes later is 146/92 mm Hg. Her blood pressures throughout
    pregnancy have been below 140/90 mm Hg. She denies any complaints, and
    urinalysis is negative for proteinuria. What is the most likely diagnosis?
    Select one:
    a. Chronic hypertension
    b. Preeclampsia syndrome
    c. Gestational hypertension
    d. Delta hypertension
    Question 5
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    Which of the following interventions is least indicated for the postpartum
    patient with hypertension, vision changes, and confusion and confirmed
    cerebral edema?
    Select one:
    a. Intravenous immune globulin
    b. Dexamethasone
    c. Antihypertensive medication
    d. Mannitol
    Question 6
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 28-year-old G1 at 38 weeks’ gestation presents with complaint of
    contractions. Her blood pressure is noted to be 148/90 mm Hg and 152/96
    mm Hg. She has a urine protein:creatinine ratio of 0.4, a creatinine of 1.04
    mg/dL (baseline 0.48 mg/dL), normal AST and ALT, and platelet count of
    110,000/µL. She denies any symptoms. What criteria for severe
    preeclampsia does this patient meet?
    Select one:
    a. Elevated creatinine
    b. She does not meet criteria for severe preeclampsia.
    c. Proteinuria
    d. Low platelets
    Question 7
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 19-year-old G1 P0 woman at 39 weeks’ gestation is diagnosed with
    preeclampsia based on blood pressure of 150/90 mm Hg and 2+ proteinuria
    on urine dipstick. The patient is placed on magnesium sulfate, and develops
    flushing and fatigue. She asks about the need for the magnesium sulfate.
    You explain that it is to prevent the seizures that may complicate
    preeclampsia and may even cause death. The patient asks how seizures
    associated with preeclampsia can cause mortality. Which of the following is
    the most common mechanism?
    Select one:
    a. Electrolyte abnormalities
    b. Myocardial infarction
    c. Aspiration
    d. Intracerebral hemorrhage
    Вопрос 1
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 23-year-old primigravida presents with a blood pressure of 160/104 mm
    Hg, 3+ proteinuria, and right upper quadrant discomfort. She has a vaginal
    delivery complicated by bilateral sulcal tears and an estimated blood loss of
    1500 mL. She produces 110 mL of urine in the first 4 hours postpartum and
    her serum creatinine rises from 0.98 mg/dL to 1.42 mg/dL. What is the most
    likely explanation for this finding?
    Выберите один ответ:
    a. Dehydration due to prolonged induction of labor
    b. Postpartum hemorrhage
    c. Subcapsular liver hematoma
    d. Ureteral injury during laceration repair
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 29-year-old G1 P0 woman at 28 weeks’ gestation is admitted to the
    hospital for preeclampsia. Her blood pressure is 150/100 mm Hg and her
    protein excretion is 500 mg in 24 hours. On hospital day 7, she is diagnosed
    with severe preeclampsia and the decision is made to administer
    magnesium sulfate and deliver the baby. Which of the following findings is
    most likely present in this patient as criteria for severe preeclampsia?
    Выберите один ответ:
    a. Platelet count of 115,000/uL
    b. Elevated uric acid levels
    c. 5 g of proteinuria excreted in a 24-hour period
    d. 4+ pedal edema
    Вопрос 7
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 24-year-old G4P2 at 26 weeks’ gestation presents via emergency
    medical services after being found unconscious at home by her 6-year-old
    child. She is oriented on arrival and found to have a blood pressure of
    180/110 mm Hg and 4+ proteinuria. Upon questioning she reports a history
    of eclampsia in her prior pregnancy at 34 weeks’ gestation. She then has a
    5-minute-long tonic-clonic seizure which resolves with magnesium sulfate
    administration. Once the patient is stabilized, she undergoes cesarean
    delivery for malpresentation. The below magnetic resonance imaging was
    performed postpartum. What is the most likely finding on imaging?

    Выберите один ответ:


    a. Subdural hematoma
    b. Parenchymal hemorrhage
    c. Subarachnoid hemorrhage
    d. Posterior reversible encephalopathy syndrome

    OBSTETRIC HEMORRHAGE

    Question 1
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Couvelaire uterus is present:
    Select one:
    a. Placenta previa
    b. Abruptio placenta
    c. Vasa previa
    d. All of the above
    Question 2
    Correct
    Marked out of 1.00
    Flag question
    Question text
    All of the following can lead to renal failure EXCEPT
    Select one:
    a. Eclampsia
    b. Septicaemia
    c. Heart disease
    d. Abruption placentae
    Question 3
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Placenta accreta is associated with:
    Select one or more:
    a. Uterine malformation
    b. Placenta previa in present pregnancy
    c. Multiple pregnancy
    d. Uterine scar
    e. Multipara
    Question 4
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A pregnant woman presents with placenta previa of major degree. The fetus
    is malformed. Which of the following will be the best line of management
    Select one:
    a. Rupture of membranes
    b. Instillation of PGE2
    c. Oxytocin drip
    d. LSCS (lower segment Caesarean section)
    Question 5
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A pregnant lady comes with 38 weeks with painless bleeding uterus is
    nontense, non-tender, Next step is
    Select one:
    a. USG (ultrasonography)
    b. Termination of Pregnancy
    c. Per speculum examination
    d. Conservative treatment
    Question 6
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which hemostatic surgical procedure is to be performed in the picture
    below?
    Select one:
    a. Vaginal artery ligation
    b. Uterine artery ligation
    c. Ovarian artery ligation
    d. B-Lynch procedure
    Question 7
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Causes of uterine atony include which of the following?
    Select one:
    a. Placenta previa
    b. Multiple fetuses
    c. Obesity
    d. Placental abruption
    Question 8
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Viral infection risks from transfusion are accurately depicted in which of the
    following statements?
    Select one:
    a. Hepatitis B risk is <1 per 100,000 units
    b. Hepatitis C risk is 1 per 1–2 million units
    c. Human immunodeficiency virus risk is 1 per 1–2 million units
    d. All of the
    Question 9
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    What is the appropriate management of vulvovaginal hematomas?
    Select one:
    a. If bleeding ceases, small to moderate-sized hematomas can be treated
    expectantly
    b. Surgical exploration in all cases
    c. In a small hematoma, if pain is severe then ice packs and analgesia are
    appropriate
    d. To prevent infection they should all undergo ultrasound guided drainage
    Question 10
    Correct
    Marked out of 1.00
    Flag question
    Question text
    During evaluation of postpartum hemorrhage following a vaginal delivery,
    which of the following maneuvers or medications might be used?
    Select one:
    a. All of the mentioned
    b. Carboprost tromethamine in patients with mild asthma
    c. Bimanual uterine compression
    d. Ergot alkaloids for patients with hypertension
    Вопрос 1
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Painless, causeless vaginal bleeding is seen in
    Выберите один ответ:
    a. Placenta previa
    b. None
    c. Accidental haemorrhage
    d. PIH
    Вопрос 2
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    The risk factors for placental abruption include the following except:
    Выберите один ответ:
    a. Hypertension
    b. Diabetes mellitus
    c. History of placental abruption in previous previous pregnancy
    d. Preterm rupture of membranes
    Вопрос 4
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    All of the following can predispose to coagulopathy EXCEPT
    Выберите один ответ:
    a. Dead fetus
    b. Placenta previa
    c. Placental abrupion
    d. Amniotic fluid embolism
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Placenta previa is characterized by all of the following except
    Выберите один ответ:
    a. Presents in 1st trimester
    b. Causeless bleeding
    c. Painless bleeding
    d. Recurrent in nature
    Вопрос 7
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 34-year-old G3P3 begins having brisk bright red bleeding following
    completion of a vaginal delivery. You give her carboprost tromethamine and
    perform the maneuver pictured below. What else should be immediately
    considered?

    Выберите один ответ:


    a. Place large-bore intravenous lines, order blood, and begin volume
    resuscitation
    b. Ask for urgent help from anesthesia
    c. Call for help
    d. All of the mentioned
    Вопрос 8
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    The slide from lung tissue pictured below is consistent with a fatal
    syndrome. Which of the following proposed diagnostic criteria are required
    to make the diagnosis?

    Выберите один ответ:


    a. Abrupt onset of cardiorespiratory arrest, or both hypotension and
    respiratory compromise
    b. All of the mentioned
    c. Documentation of overt disseminated intravascular coagulopathy must
    be detected prior to enough blood loss to cause dilutional coagulopathy
    d. Clinical onset during labor or within 30 minutes of placental delivery
    Вопрос 9
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which hemostatic surgical procedure is demonstrated in the picture below?

    Выберите один ответ:


    a. Vaginal artery ligation
    b. B-Lynch procedure
    c. Uterine artery ligation
    d. Ovarian artery ligation
    Вопрос 10
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    The postpartum patient with severe haemorrhage after all necessary
    measures undergoes a hysterectomy and 5 units of packed red blood cells
    are given, but bleeding continues. What is the most likely etiology of the
    bleeding?
    Выберите один ответ:
    a. Vaginal cuff bleeding
    b. Placental implantation on the omentum
    c. Dilutional coagulopathy
    d. Lacerated internal iliac artery
    CASE

    Question 1
    Correct
    Marked out of 1.00
    Flag question
    Question text
    An 18-year-old adolescent female is noted to have a marginal placenta
    previa on an ultrasound examination at 22 weeks’ gestation. She does not
    have vaginal bleeding or spotting. Which of the following is the most
    appropriate management?
    Select one:
    a. Reassess placental position at 34 to 35 weeks’ gestation by
    ultrasound.
    b. Schedule cesarean delivery at 39 weeks.
    c. Schedule an amniocentesis at 36 weeks and deliver by cesarean if the
    fetal lungs are mature.
    d. Schedule an MRI examination at 35 weeks to assess for possible percreta
    involving the bladder.
    e. Recommend termination of pregnancy.
    Question 2
    Correct
    Marked out of 1.00
    Flag question
    Question text
    An 18-year-old pregnant woman is noted to have vaginal bleeding. She is
    bleeding from venipuncture sites, IV sites, and from her gums. Which of the
    following is the most likely underlying diagnosis?
    Select one:
    a. Placenta previa
    b. Placental abruption
    c. Multifetal gestation
    d. Gestational trophoblastic disease
    e. Gestational diabetes
    Question 3
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 33-year-old woman G3 P2 who had two prior cesareans is currently at 38
    weeks’ gestation. She is noted to have a posterior placenta.On ultrasound,
    there is evidence of possible placenta accreta. The patient is counseled
    about the possible risk of need for hysterectomy. Which of the following is
    the most accurate statement?
    Select one:
    a. Having two prior cesareans is associated with a 50% risk for placenta
    accreta.
    b. If the patient had gestational diabetes, the risk for placenta accreta
    would be even higher.
    c. The posterior placenta is associated with less of a risk for accreta
    than an anterior placenta.
    d. Placenta accreta is associated with a defect in the myometrial layer of
    the uterus.
    Question 4
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 33-year-old woman G3 P2 who had two prior cesareans is currently at 38
    weeks’ gestation. She is noted to have a posterior placenta.On ultrasound,
    there is evidence of possible placenta accreta. The patient is counseled
    about the possible risk of need for hysterectomy. Which of the following is
    the most accurate statement?
    Select one:
    a. If the patient had gestational diabetes, the risk for placenta accreta
    would be even higher.
    b. Placenta accreta is associated with a defect in the myometrial layer of
    the uterus.
    c. Having two prior cesareans is associated with a 50% risk for placenta
    accreta.
    d. The posterior placenta is associated with less of a risk for accreta
    than an anterior placenta.
    Question 5
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 21-year-old patient at 28 weeks’ gestation has vaginal bleeding and is
    diagnosed with placenta previa. Which of the following is a typical feature
    of this condition?
    Select one:
    a. Painful bleeding
    b. First episode of bleeding is usually profuse
    c. Associated with postcoital spotting
    d. Commonly associated with coagulopathy
    Question 6
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 26-year-old G2 P1 woman underwent a normal vaginal delivery.A viable
    3.9kg male infant was delivered. The placenta delivered spontaneously. The
    obstetrician noted significant blood loss from the vagina, totaling
    approximately 700 mL. The uterine fundus appeared to be well contracted.
    Which of the following is the most common etiology for the bleeding in this
    patient?
    Select one:
    a. Uterine atony
    b. Endometrial ulceration
    c. Genital tract laceration
    d. Coagulopathy
    e. Retained placenta
    Question 7
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 34-year-old woman is noted to have significant uterine bleeding after a
    vaginal delivery complicated by placenta abruption. She is noted to be
    bleeding from multiple venipuncture sites. Which of the following is the
    best (etiopathologycal) therapy?
    Select one:
    a. Hypogastric artery ligation
    b. Packing of the uterus
    c. Ligation of utero-ovarian ligaments
    d. Immediate hysterectomy
    e. Correction of coagulopathy
    Question 8
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 23-year-old G1 P0 woman at 38 weeks’ gestation delivered a 4.3kg baby
    boy vaginally. Upon delivery of the placenta, there was noted to be an
    inverted uterus, which was successfully managed including replacement of
    the uterus. Which of the following placental implantation sites would most
    likely predispose to an inverted uterus?
    Select one:
    a. Anterior
    b. Lateral
    c. Fundal
    d. Posterior
    e. Lower segment
    Question 9
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    A 33-year-old G5 P5 woman, who is being induced for preeclampsia
    delivers a 5kg baby. Upon delivery of the placenta, uterine inversion is
    noted. The physician attempts to replace the uterus, but the cervix is
    tightly contracted, preventing the fundus of the uterus from being
    repositioned. Which of the following is the best therapy for this patient?
    Select one:
    a. Infuse oxytocin intravenously.
    b. Halothane anesthesia
    c. Dührssen incisions of the cervix.
    d. Discontinue the magnesium sulfate.
    e. Vaginal hysterectomy.
    Question 10
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 24-year-old woman underwent a normal vaginal delivery of a term infant
    female. After the delivery, the placenta does not deliver even after 30
    minutes. Which of the following would be the next step for this patient?
    Select one:
    a. Estrogen intravaginally
    b. Attempt a manual extraction of the placenta.
    c. Hysterectomy.
    d. Wait for an additional 30 minutes.
    e. Initiate oxytocin.
    Вопрос 1
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 25-year-old woman at 34 weeks’ gestation is noted to have a placenta
    previa, after she presented with vaginal bleeding and has undergone
    sonography. At 37 weeks, she has a scheduled cesarean. Upon cesarean
    section, bluish tissue densely adherent between the uterus and maternal
    bladder is noted. Which of the following is the most likely diagnosis?
    Выберите один ответ:
    a. Placental polyp
    b. Placenta percreta
    c. Placenta melanoma
    d. Placenta accreta
    Вопрос 2
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 32-year-old woman is seen in the obstetrical unit at the hospital. She is at
    29 weeks’ gestation, with a chief complaint of significant vaginal bleeding.
    She had a stillbirth with her prior pregnancy due to placental abruption. The
    patient asks the physician about the accuracy of ultrasound in the
    diagnosis of abruption. Which of the following statements is most accurate?
    Выберите один ответ:
    a. Fetal ultrasound is more accurate in diagnosing placental abruption than
    placenta previa.
    b. Fetal ultrasound is quite sensitive in diagnosing placental abruption.
    c. Fetal ultrasound is not sensitive in diagnosing placental abruption
    d. Ultrasound is sensitive in diagnosing abruption that occurs in the lower
    aspect of the uterus.
    Вопрос 10
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 24-year-old G1 P0 woman at 39 weeks’ gestation had induction of labor
    due to gestational hypertension. She was placed on magnesium sulfate for
    seizure prophylaxis. She was placed on oxytocin for 15 hours and reached a
    cervical dilation of 6 cm. After being at 6 cm dilation for 3 hours despite
    adequate uterine contractions as judged by 240 Montevideo units, she
    underwent a cesarean delivery. The baby was delivered without difficulty
    through a low-transverse incision.Upon delivery of the placenta, profuse
    bleeding was noted from the uterus, reaching 1500 mL. Which of the
    following is the most likely cause of hemorrhage in this patient?
    Выберите один ответ:
    a. Retained placenta
    b. Uterine laceration
    c. Uterine atony
    d. Uterine inversion
    e. Coagulopathy
    Вопрос 1
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 32-year-old woman is seen in the obstetrical unit at the hospital. She is at
    29 weeks’ gestation, with a chief complaint of significant vaginal bleeding.
    She had a stillbirth with her prior pregnancy due to placental abruption. The
    patient asks the physician about the accuracy of ultrasound in the
    diagnosis of abruption. Which of the following statements is most accurate?
    Выберите один ответ:
    a. Fetal ultrasound is more accurate in diagnosing placental abruption than
    placenta previa.
    b. Ultrasound is sensitive in diagnosing abruption that occurs in the lower
    aspect of the uterus.
    c. Fetal ultrasound is quite sensitive in diagnosing placental abruption.
    d. Fetal ultrasound is not sensitive in diagnosing placental abruption
    Вопрос 2
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 35-year-old woman presents with bright red vaginal bleeding at 30
    weeks’ gestation. Her urine drug screen is positive. Which of the following
    is most likely to be present in her drug screen?
    Выберите один ответ:
    a. Cocaine
    b. Marijuana
    c. Barbiturates
    d. Benzodiazepines
    e. Alcohol
    Вопрос 3
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following statements concerning myomectomy for subserosal
    (outside surface of the uterus) uterine fibroids without entrance of the
    uterine cavity is most likely to be correct regarding the risk of placental
    accreta?
    Выберите один ответ:
    a. Her risk of accreta is most likely not affected by the myomectomy.
    b. Her risk of accreta is most likely to be decreased due to the
    myomectomy.
    c. If the myomectomy incisions are anterior, then she has an increased risk
    of a placental polyp
    d. Her risk of accreta is most likely to be increased due to the
    myomectomy.
    Вопрос 6
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 32-year-old G1 P0 woman at 40 weeks’ gestation undergoes a normal
    vaginal delivery. Delivery of the placenta is complicated by an inverted
    uterus, with subsequent hemorrhage leading to 1500 mL of blood loss. She
    is managed with a transfusion of erythrocytes. Which of the following is the
    best explanation of the mechanism of hemorrhage?
    Выберите один ответ:
    a. Inverted uterus causes muscular abrasions and lacerations leading to
    bleeding.
    b. Inverted uterus leads to inability for an adequate myometrial
    contraction effect.
    c. Inverted uterus causes a local coagulopathic reaction to the uterus and
    endometrium.
    d. Inverted uterus stretches the uterus, causing trauma to blood vessels
    leading to bleeding.
    Вопрос 2
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 22-year-old G1 P0 woman at 34 weeks’ gestation presents with moderate
    vaginal bleeding and no uterine contractions. Her blood pressure (BP) is
    110/60 mm Hg and heart rate (HR) 103 beats per minute (bpm). The
    abdomen is nontender. Which of the following sequence of examinations is
    most appropriate?
    Выберите один ответ:
    a. Ultrasound examination, digital examination, speculum examination
    b. Speculum examination, ultrasound examination, digital examination
    c. Ultrasound examination, speculum examination, digital
    examination
    d. Digital examination, ultrasound examination, speculum examination
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 28-year-old woman at 32 weeks’ gestation is seen in the obstetrical
    triage area for vaginal bleeding described as significant with clots. She
    denies cramping or pain. An ultrasound is performed revealing that the
    placenta is covering the internal os of the cervix. Which of the following is a
    risk factor for this patient’s condition?
    Выберите один ответ:
    a. Multiple gestations
    b. Polyhydramnios
    c. Hypertension
    d. Prior salpingitis
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 29-year-old G1P0 woman at 39 weeks’ gestation delivered vaginally.Her
    placenta does not deliver easily. A manual extraction of the placenta is
    attempted and the placenta seems to be adherent to the uterus.A
    hysterectomy is contemplated, but the patient refuses due to strongly
    desiring more children. The cord is ligated with suture as high as
    possible.The patient is given the option of methotrexate therapy. Which of
    the following is the most likely complication after this intervention?
    Выберите один ответ:
    a. Utero-vaginal fistula
    b. Infection
    c. Malignant degeneration
    d. Coagulopathic bleeding

    A 32-year-old woman has severe postpartum hemorrhage that does not respond
    to medical therapy. The obstetrician states that surgical management is the best
    therapy. The patient desires future child bearing.Which of the following is most
    appropriate to achieve the therapeutic goals?
    Select one:
    a. Cervical cerclage X
    b. Ligation of the external iliac artery
    c. Utero-ovarian ligament ligation
    d. Supracervical hysterectomy
    e. Hypogastric artery ligation
    PUBERTY

    Question 1
    Correct
    Marked out of 1.00
    Flag question
    Question text
    When an individual experiences difficulty identifying with their phenotypic
    gender, perceiving themselves to be of the opposite gender, the condition
    is termed which of the following?
    Select one:
    a. Homosexuality
    b. Gender o rearing mismatch
    c. Sexual identity conflict
    d. Gender dysphoria
    Question 2
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which of the following organisms is most likely to cause prepubertal
    vulvitis?
    Select one:
    a. Group A β-hemolytic streptococcus
    b. Candida albicans
    c. Group B streptococcus
    d. Staphylococcus aureus
    Question 3
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Delayed puberty is characterized by a lack of initial pubertal changes,
    usually thelarche, by what threshold age?
    Select one:
    a. 16 years
    b. 15 years
    c. 14 years
    d. 13 years
    Question 4
    Correct
    Marked out of 1.00
    Flag question
    Question text
    According to the U.S. FDA vaccines targeting human papillomavirus
    infection are approved from what age (in years) for females or males?
    Select one:
    a. 15
    b. 9
    c. 12
    d. 21
    Question 5
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which of the following is true regarding isolated premature thelarche?
    Select one:
    a. Bone age is advanced.
    b. None of the mentioned
    c. Gonadotropin levels are elevated.
    d. It is most common in girls younger than 2 years.
    Question 6
    Correct
    Marked out of 1.00
    Flag question
    Question text
    What approximate percentage of malignant tumors diagnosed in childhood
    are of ovarian origin?
    Select one:
    a. 10 percent
    b. 30 percent
    c. 0.1 percent
    d. 1 percent
    Question 7
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Mastitis is unusual in children and adolescents. What is the most common
    pathogen isolated from breast abscesses in the pediatric population?
    Select one:
    a. Staphylococcus epidermidis
    b. Escherichia coli
    c. Streptococcus pyogenes
    d. Staphylococcus aureus
    Question 8
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Pubarche, with development of axillary and pubic hair, is stimulated by the
    androgens derived primarily from which of the following?
    Select one:
    a. Adrenal glands
    b. Physiology continues to be poorly understood.
    c. Ovarian stroma
    d. Peripheral aromatization of estrogens
    Question 9
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    A primary goal of therapy or central precocious puberty includes prevention
    of which of the following consequences?
    Select one:
    a. Excessive breast size
    b. None of the mentioned
    c. Learning disabilities
    d. Short stature
    Question 10
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Accessory nipples, when present, are located along the embryonic milk line
    extending from the axilla to the groin bilaterally. Their presence is termed
    which of the following?
    Select one:
    a. Multimomium
    b. Areola duplicata
    c. Polymammoma
    d. Polythelia
    Question 1
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which of the following generally occurs first among the major
    developmental events of female puberty?
    Select one:
    a. Menarche
    b. Pubarche
    c. Thelarche
    d. Growth spurt
    Question 2
    Correct
    Marked out of 1.00
    Flag question
    Question text
    All states in the United States legally allow a minor woman to consent to
    medical examination and treatment on her own behalf in all of the following
    situations EXCEPT:
    Select one:
    a. Emancipated minor status
    b. Requesting a school-sponsored sports’ physical examination
    c. Living permanently apart from parents
    d. Pregnancy
    Question 3
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    With prepubertal vulvovaginitis, what approximate percentage of bacterial
    cultures obtained from vaginal swabs show only normal genital flora?
    Select one:
    a. 25 percent
    b. 90 percent
    c. 50 percent
    d. 75 percent
    Question 4
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    Which of the following is required before initiating a contraceptive method
    or a healthy, sexually active adolescent?
    Select one:
    a. Human papillomavirus (HPV) vaccination
    b. Pelvic examination
    c. Cervical cancer screening
    d. None of the mentioned
    Question 5
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which of the following statements is true regarding pelvic anatomy in the
    female infant and child?
    Select one:
    a. All the above are true statements.
    b. The ovaries have obtained their normal adult size by birth.
    c. At birth, the uterus and cervix are approximately equal in size.
    d. Presence of an endometrial stripe or fluid within the endometrial
    cavity of the newborn uterus is a normal finding with sonography.
    Question 6
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    Which of the following statements is FALSE regarding the development of
    the hypothalamic–pituitary-ovarian axis in the female fetus and neonate?
    Select one:
    a. Neonatal breast budding, minor uterine bleeding, and transient ovarian
    cysts may occur as a normal response to initially high gonadotropin levels.
    b. The gonadotropin-releasing hormone (GnRH) “pulse generator” remains
    functionally dormant until several months after birth.
    c. By 5 months’ gestation, 6 to 7 million oocytes have been created from
    accelerated germ cell division.
    d. At birth, follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
    concentrations rise and remain high during the first 3 months of life.
    Question 7
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    Delayed puberty in women is defined as the lack of lack of menarche by
    what age?
    Select one:
    a. 16
    b. 14
    c. 15
    d. 18
    Question 8
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Abnormal breast development may be due to either fascial adherence to the
    underlying muscle layer or due to high-dose exogenous hormone exposure
    during puberty. In such cases, breasts have excessive forward but limited
    lateral growth, which causes an abnormal shape. This condition is referred
    to as which of the following?
    Select one:
    a. Aberrant breast hypertrophy
    b. Perithelia
    c. Asymmetric lactiferous hyperplasia
    d. Tuberous breasts
    Question 9
    Correct
    Marked out of 1.00
    Flag question
    Question text
    How do BMI correlate with pubertal development?
    Select one:
    a. higher BMI correlate with late development
    b. no correlation was observed with BMI and pubertal development
    c. lower BMI correlate with early development
    d. higher BMI correlate with early development
    Question 10
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    Compared with several decades ago, the age at which U.S. girls currently
    experience thelarche and menarche has shown which of the following
    trends?
    Select one:
    a. In general, later than in past
    b. No clear trend observed
    c. In general, earlier than in past
    d. For girls with a higher body mass index, later than in the past
    Вопрос 1
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    In the United States, adolescents can obtain medical care without parental
    knowledge or consent or which of the following “medically emancipated”
    conditions?
    Выберите один ответ:
    a. Contraception
    b. Pregnancy
    c. All of the mentioned
    d. Substance abuse
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following is the most common cause of central precocious
    puberty?
    Выберите один ответ:
    a. Congenital central nervous system anomaly
    b. Head trauma
    c. Idiopathic
    d. Hydrocephalus secondary to surgery
    Вопрос 6
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following physiologic or anatomic characteristics predispose
    to prepubertal vulvovaginitis?
    Выберите один ответ:
    a. All of the mentioned
    b. Nonestrogenized vulvovaginal epithelium
    c. Lack of labial fat pads and labial hair
    d. Poor vulvar hygiene

    Which of the following organs is correctly paired with its embryologic origin?
    Select one:
    a. Bladder—mesonephric duct
    b. Uterus—mesonephric duct
    c. Testes and ovaries—genital ridge
    d. Kidney—paramesonephric duct

    During a first-trimester ultrasound or pregnancy dating, you discover that your patient has a subseptate
    uterus. While counseling her, you explain that this mullerian anomaly developed in utero secondary to
    failure of the midline uterine septum to reabsorb completely. Normally, reabsorption of the uterine
    septum in a fetus should occur by how many weeks of gestation?
    Select one:
    a. 28
    b. 36
    c. 32
    d. 20

    Septate uterus, as shown in the sonogram below, has a significantly higher spontaneous abortion rate
    and early pregnancy loss rate than bicornuate uterus. What is the primary mechanism thought to be
    responsible for this extraordinarily high pregnancy wastage?

    Select one:
    a. Associated cervical anomalies
    b. Distortion of the uterine cavity
    c. Partial or complete Implantation on the largely avascular septum
    d. Distortion of the uterine serosal contour

    Which of the following are seen in offspring of women who took diethylstilbestrol (DES) during the
    associated pregnancy?
    Select one:
    a. Impaired conception rates in female offspring
    b. T-shaped uterus, "cockscomb" cervix, and increased rates of clear cell adenocarcinoma in female
    offspring
    c. Cryptorchidism, testicular hypoplasia, and malformations of the penis in male offspring
    d. All of the mentioned

    During a first-trimester ultrasound or pregnancy dating, you discover that your patient has a subseptate
    uterus. While counseling her, you explain that this miillerian anomaly developed in utero secondary to
    failure of the midline uterine septum to reabsorb completely. Normally, reabsorption of the uterine
    septum in a fetus should occur by how many weeks of gestation?
    Select one:
    a. 28
    b. 36
    c. 32 X
    d. 20

    Which of the following anatomic structures is correctly paired with its embryologic origin?
    Select one:
    a. All of the mentioned
    b. Genital tubercle—clitoris
    c. Urethral folds—labia minora
    d. Labioscrotal folds—labia majora

    Congenital anatomic disorders of the female reproductive tract may result from which of the following
    mechanisms?
    Select one:
    a. Developmental arrest
    b. Genetic mutation
    c. All of the mentioned
    d. Epigenetic factors
    Which of the following are seen in offspring of women who took diethylstilbestrol (DES) during the
    associated pregnancy?
    Select one:
    a. T-shaped uterus, "cockscomb" cervix, and increased rates of clear cell adenocarcinoma in female
    offspring
    b. Cryptorchidism, testicular hypoplasia, and malformations of the penis in male offspring
    c. All of the mentioned
    d. Impaired conception rates in female offspring

    Compared with other müllerian duct defects,a transverse vaginal septum is associated with a lower rate
    of which of the following?Select one:a. Urologic abnormalitiesb. Need or surgical correctionc. None of
    the mentionedd. Endometriosis

    CASE

    Вопрос 1
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 5-year-old female child is brought into the physician’s office for breast
    development and menses. On examination, the child is found to have Tanner
    IV breast development and Tanner IV pubic and axillary hair. Which of the
    following is the most likely therapy for this patient?
    Выберите один ответ:
    a. Aromatase inhibitor
    b. Gonadotropin-releasing hormone (GnRH) agonist
    c. Surgical therapy and removal of an ovarian tumor
    d. Oral contraceptive use
    e. Reassurance and expectant management
    Вопрос 2
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 6-year-old girl is noted to have breast development and vaginal spotting.
    No abnormal hair growth is noted. A 10-cm ovarian mass is palpated on
    rectal examination. Which of the following is the most likely diagnosis?
    Выберите один ответ:
    a. Granulosa-theca cell tumor
    b. Congenital adrenal hyperplasia
    c. Idiopathic precocious puberty
    d. Benign cystic tumor (dermoid)
    e. Sertoli– Leydig cell tumor
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A smooth, firm, mobile, nontender right-breast mass is palpable during
    examination of a 12-year-old girl. It is 1 cm in its greatest dimension and
    appears solid sonographically, as shown here. She has had no major health
    problems to date. What is the most likely diagnosis?

    Выберите один ответ:


    a. Ductal ectasia
    b. Fibroadenoma
    c. Malignancy
    d. Asymmetric breast budding
    Вопрос 4
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    An 8-year-old girl presents with a mucopurulent and bloody vaginal
    discharge. Her parents report that, while traveling recently, the girl was
    briefly hospitalized for treatment of severe diarrhea. Examinations of the
    vagina in the office and under anesthesia reveal no tumor or foreign body.
    What is the most likely organism involved?
    Выберите один ответ:
    a. Shigella spp.
    b. Salmonella spp.
    c. Candidia glabrata
    d. Enterobius vermicularis
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Medication used in the treatment of idiopathic central precocious puberty
    include:
    Выберите один ответ:
    a. Exogenous gonadotropins
    b. Clomiphene citrate
    c. Ethinyl estradiol
    d. GnRH agonists

    ANATOMIC DISORDERS

    Вопрос 1
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Müllerian anomalies are associated with anomalies of all of the following
    systems EXCEPT:
    Выберите один ответ:
    a. Hepatic
    b. Skeletal
    c. Renal
    d. Neurological
    Вопрос 2
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following can cause virilization of a 46,XX infant?
    Выберите один ответ:
    a. Placental aromatase deficiency
    b. Maternal virilizing ovarian tumors, such as Sertoli–Leydig tumor, or
    maternal use of androgenic medication
    c. All of the mentioned
    d. Fetal congenital adrenal hyperplasia due to deficiency of 21-hydroxylase
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Appropriate techniques or the surgical correction of the imperforate hymen
    involve all of the following EXCEPT:
    Выберите один ответ:
    a. Needle aspiration of the hematocolpos
    b. Repair in infancy or after thelarche
    c. Hymenectomy
    d. Laparoscopy to exclude endometriosis
    Вопрос 4
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following is NOT true of Klinefelter syndrome?
    Выберите один ответ:
    a. Affected men are tall and excessively virilized.
    b. It confers an increased risk for germ cell tumors, osteoporosis, and
    breast cancer.
    c. The syndrome occurs in 1 in 500-600 births of all males.
    d. Affected men have significantly reduced fertility.
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following statements regarding bladder exstrophy is NOT
    true?
    Выберите один ответ:
    a. It is characterized by an exposed bladder lying outside the abdomen.
    b. External genitalia are typically normal except for occasional
    defects.
    c. Surgical closure is performed early in life and as a staged procedure.
    d. It occurs from failure of the cloacal membrane to be reinforced by an
    ingrowth of mesoderm.
    Вопрос 6
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following disorders of sex development is correctly paired with
    its category of abnormality?
    Выберите один ответ:
    a. All of the mentioned
    b. Hypospadias—ambiguous genitalia
    c. True hermaphroditism–ovotesticular disorder
    d. Streak gonad—gonadal dysgenesis
    Вопрос 7
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Both urinary and genital systems develop from which of the following cell
    types?
    Выберите один ответ:
    a. Ectoderm
    b. None of the mentioned
    c. Mesoderm
    d. Endoderm
    Вопрос 8
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    The vagina forms in part from both the müllerian ducts and which other
    structure?
    Выберите один ответ:
    a. Genital ridge
    b. Paramesonephric duct
    c. Urogenital sinus
    d. Mesonephric duct
    Вопрос 9
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    In the male fetus, dihydrotestosterone (DHT) is involved in which of the
    following?
    Выберите один ответ:
    a. Fusion of the labioscrotal folds to form the scrotum
    b. Enlargement of the phallus
    c. Lengthening of the anogenital distance
    d. All of the mentioned
    Вопрос 10
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    One of your patients brings her 13-year-old daughter for consultation
    regarding the girl’s complaints of pelvic pain. The daughter has
    experienced normal pubertal development to date but has not yet
    experienced menarche. She began having monthly pelvic pain about 1 year
    ago, and the pain has been progressively worsening. During physical
    examination, her external genitalia, including hymeneal ring, appear normal.
    However, proximal to the hymen, only a vaginal dimple is found.
    Rectovaginal examination confirms the presence of a uterus and cervix.
    What is your diagnosis?
    Выберите один ответ:
    a. Cervical atresia
    b. Müllerian agenesis
    c. Vaginal atresia
    d. Imperforate hymen

    CASE

    Вопрос 1
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Müllerian anomalies are associated with anomalies of all of the following
    systems EXCEPT:
    Выберите один ответ:
    a. Hepatic
    b. Renal
    c. Neurological
    d. Skeletal
    Вопрос 2
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Why is careful preoperative planning warranted with congenital vaginal
    cysts, as shown in sonogram below?

    Выберите один ответ:


    a. The recurrence rate after excision is high.
    b. Their typical location is in the posterior-lateral wall of the vagina.
    c. Some may extend up to the broad ligament and anatomically
    approximate the distal course of the ureter.
    d. They are frequently large, measuring greater than 8 cm in size.
    Вопрос 3
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 14-year-old nulligravida presents to the emergency department with
    complaints of worsening lower abdominal pain over the past few days. She
    states that she has had a similar pain in the past, usually for a few days
    each month, but then it subsides. She is afebrile with stable vital signs.
    Although she has breasts and axillary and pubic hair, she has never had a
    period. Examination reveals a tender midline lower abdominal mass and a
    bluish bulging vaginal mass, as shown here. Based on her history and your
    physical examination, which of the following conditions is your most likely
    diagnosis?

    Выберите один ответ:


    a. Gartner duct cyst
    b. Longitudinal vaginal septum
    c. Bartholin cyst
    d. Imperforate hymen
    Вопрос 4
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    When should surgical reconstruction of a bicornuate uterus (Strassman
    metroplasty) be performed?
    Выберите один ответ:
    a. Prior to conception
    b. With recurrent pregnancy loss and no other identifiable cause
    except the uterine anomaly
    c. In all women with the diagnosis of bicornuate uterus
    d. Procedure no longer performed for repair of bicornuate uterus
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    The pathogenesis of poor pregnancy outcomes with a unicornuate uterus is
    thought to be related to which of the following actors?
    Выберите один ответ:
    a. Cervical incompetence
    b. Anomalous distribution of the uterine artery
    c. All of the mentioned
    d. Reduced uterine capacity
    Вопрос 1
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Appropriate techniques for surgical correction of the müIIerian aplasia
    include which of the following?
    Выберите один ответ:
    a. Uterine transplantation
    b. Hysterectomy
    c. Hymenectomy
    d. Surgical creation of a neovagina
    Вопрос 2
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 16-year-old nulligravida presents to the emergency department with
    complaints of abdominal and vaginal pain, worsening during the past
    several months. She describes the pain as being mostly on her right side
    and much worse during menstruation. During your physical examination, a
    patent vagina and cervix are noted, but a lateral vaginal and pelvic mass is
    palpated. Transvaginal sonography demonstrates a single uterus and cervix
    but also a large pelvic mass filled with complex fluid, as shown below, and
    the absence of the right kidney. What is the most likely diagnosis?

    Выберите один ответ:


    a. Transverse vaginal septum
    b. OHVIRA syndrome
    c. Imperforate hymen
    d. Ovarian neoplasm
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which müllerian anomaly results from complete failure of the paired
    müllerian ducts to use? This anomaly is shown in this sonogram, and a
    gestational sac is seen on the image’s left side.
    Выберите один ответ:
    a. Uterine didelphys
    b. Unicornuate uterus
    c. Septate uterus
    d. Bicornuate uterus
    Вопрос 4
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Why is careful preoperative planning warranted with congenital vaginal
    cysts, as shown in sonogram below?
    Выберите один ответ:
    a. Their typical location is in the posterior-lateral wall of the vagina.
    b. Some may extend up to the broad ligament and anatomically
    approximate the distal course of the ureter.
    c. The recurrence rate after excision is high.
    d. They are frequently large, measuring greater than 8 cm in size.
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    While staffing labor and delivery, you are asked to evaluate a pelvic mass
    discovered during the performance of a postpartum tubal ligation. The
    mass is a thin-walled, translucent cystic structure measuring less than 1 cm
    in diameter. It is attached by a thin pedicle to the distal end of the right
    fallopian tube. The resident physician is concerned that the mass may be
    neoplastic, but you assure her that it is not. What is the likely diagnosis?
    Выберите один ответ:
    a. Accessory ovary
    b. Paratubal cyst (hydatid of Morgagni)
    c. Hydrosalpinx
    d. Supernumerary ovary
    AUB (abnormal uterine bleeding)

    Question 1
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which of the following is a limitation of Pipelle samplers used for
    endometrial biopsy to evaluate abnormal uterine bleeding?
    Select one:
    a. Low sensitivity and high false-negative rate or focal endometrial
    pathology
    b. Greater patient discomfort compared with a stif metal curette
    c. Rate of inadequate sampling that exceeds 50 percent
    d. Inability to be performed in an office setting
    Question 2
    Correct
    Marked out of 1.00
    Flag question
    Question text
    When should irregular spotting or bleeding be evaluated in a
    postmenopausal patient using hormone replacement therapy (HRT)?
    Select one:
    a. Continued bleeding after 6 months o HRT use
    b. All of the mentioned
    c. History of endometrial polyps
    d. Abnormal bleeding that develops after initial amenorrhea
    Question 3
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    A patient using the progestin-only implant (Nexplanon) complains of
    unscheduled light bleeding since her implant was placed 4 months ago.
    Which of the following treatment options would be LEAST likely to correct
    the bleeding?
    Select one:
    a. Addition of combination oral contraceptives for 1 month
    b. Use of a nonsteroidal anti-inflammatory medication for 1 week
    c. Use of a daily estrogen-only supplement such as ethinyl estradiol or
    conjugated equine estrogen for 1 month
    d. Single dose of depot medroxyprogesterone acetate (DMPA)
    Question 4
    Correct
    Marked out of 1.00
    Flag question
    Question text
    All of the following diagnostic tests are typically obtained during the initial
    evaluation of abnormal uterine bleeding EXCEPT:
    Select one:
    a. Complete blood count with platelets
    b. Pap test
    c. Liver function tests
    d. Pregnancy test
    Question 5
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    Which cause of abnormal uterine bleeding is NOT represented in the
    International Federation of Gynecology and Obstetrics (FIGO) classification
    acronym PALM-COEIN?
    Select one:
    a. Coagulopathy
    b. Pregnancy
    c. Leiomyoma
    d. Iatrogenic
    Question 6
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Control of blood loss during menses involves which of the following
    mechanisms?
    Select one:
    a. Platelet aggregation
    b. All of the mentioned
    c. Vasoconstriction of endometrial arteries
    d. Thrombus formation
    Question 7
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which is an effective first-line treatment or women with heavy menstrual
    bleeding and von Willebrand disease?
    Select one:
    a. Endometrial ablation
    b. Nonsteroidal anti-inflammatory drugs
    c. Combination oral contraceptive pills
    d. Dilatation and curettage
    Question 8
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A patient with heavy menstrual bleeding reveals a personal history of
    requent gingival bleeding and excessive bleeding during a recent tooth
    extraction. You screen her for a coagulation disorder. Which of the following
    laboratory tests is LEAST likely to be informative?
    Select one:
    a. Bleeding time
    b. Partial thromboplastin time (PTT)
    c. Prothrombin time (PT)
    d. Complete blood count (CBC) with platelets
    Question 9
    Correct
    Marked out of 1.00
    Flag question
    Question text
    According to the American College of Obstetricians and Gynecologists
    (2013), endometrial sampling to assess abnormal uterine bleeding is NOT
    recommended for a woman with which of the following characteristics?
    Select one:
    a. Has persistent abnormal uterine bleeding
    b. Is 35 years old
    c. Has ailed medical management
    d. Has history o unopposed estrogen exposure
    Question 10
    Correct
    Marked out of 1.00
    Flag question
    Question text
    Which layer of the endometrium sloughs and therefore is responsible or
    observed menstrual discharge?
    Select one:
    a. Functionalis
    b. Radial
    c. Spiral
    d. Basalis
    Вопрос 1
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following defnitions of abnormal uterine bleeding is incorrect?
    Выберите один ответ:
    a. Hypomenorrhea refers to menses with diminished flow or shortened
    interval.
    b. Heavy menstrual bleeding is defined as prolonged or heavy cyclic
    menstruation, with menses lasting longer than 8 days or exceeding 80 mL
    of blood loss.
    c. Oligomenorrhea refers to cycles with intervals shorter than 35
    days.
    d. Intermenstrual bleeding is bleeding that occurs between cycles.
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following statements regarding tranexamic acid is true?
    Выберите один ответ:
    a. It is an antifibrinolytic drug that permanently blocks lysine binding sites
    on plasminogen, thereby increasing plasmin levels and fibrinolytic activity.
    b. Contraindications to its use include a history or intrinsic risk of
    thromboembolic disease.
    c. To be most effective, it requires administration for 2 weeks before and
    during menses.
    d. It affects blood coagulation parameters, such as platelet count,
    prothrombin time (PT), and partial thromboplastin time (PTT).
    Вопрос 4
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    For what age group anovulation and coagulation defects as a cause of AUB
    are at disproportionately higher rates compared with other?
    Выберите один ответ:
    a. Adolescence
    b. Perimenopause
    c. Menopause
    d. Childhood
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Suggested etiologies or abnormal uterine bleeding associated with use of
    the device shown below in this three-dimensional (3-D) sonogram include
    which of the following?

    Выберите один ответ:


    a. All of the mentioned
    b. Malpositioned device
    c. Increased endometrial vascularity, congestion, and degeneration
    d. Unbalanced ratio of prostaglandin to thromboxane levels
    Вопрос 6
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 60-year-old postmenopausal woman presents for evaluation of genital
    tract bleeding, which is confirmed as uterine in origin by physical
    examination. Which diagnostic procedure is a logical first step in her
    evaluation?
    Выберите один ответ:
    a. Diagnostic hysteroscopy
    b. Colposcopy
    c. Transvaginal sonography
    d. Saline infusion sonography
    Вопрос 7
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    An advantage of transvaginal sonography for the evaluation of abnormal
    uterine bleeding includes which of the following?
    Выберите один ответ:
    a. Greater patient com ort compared with endometrial biopsy or
    hysteroscopy
    b. Simultaneous assessment of myometrium and endometrium
    c. Reduced use of endometrial biopsy
    d. All of the mentioned
    Вопрос 8
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 27-year-old woman who previously underwent dilatation and curettage
    for an incomplete abortion presents with new-onset heavy menstrual
    bleeding. Transvaginal sonography first reveals a hypoechoic tubular
    structure within the myometrium. With application of color Doppler, large-
    caliber vessels are seen in the second image. What is the most appropriate
    next step in her evaluation?

    Выберите один ответ:


    a. Pelvic computed tomography (CT) with contrast
    b. Saline infusion sonography
    c. Hysteroscopy
    d. Angiography
    Вопрос 9
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Pelvic sonography with applied color Doppler reveals an intrauterine growth
    with a single feeder vessel. Which statement is true regarding this
    abnormality?

    Выберите один ответ:


    a. The main diagnostic tool is the Pap test.
    b. Infertility has been linked directly to this condition.
    c. It is an uncommon cause of abnormal uterine bleeding.
    d. Use of oral contraceptive pills appears to be protective.
    A 18-year-old girl has been bleeding heavily for the past 2 weeks. She experienced menarche about 3
    years ago, and since that time her periods have been extremely irregular and heavy. She appears very
    pale and fatigued. Her blood pressure is 110/60mmHg and the pulse is 70/min. All of the following are
    appropriate tests to be done,except:Select one:a. Estradiol levelb. CBCc. Beta-HCG Xd. Bleeding time

    In the evaluation of abnormal uterine bleeding, what is the primary advantage of hysteroscopy
    compared with saline infusion sonography?Select one:a. Hysteroscopy permits simultaneous
    identification and removal of focal endometrial lesions.b. Hysteroscopy is more accurate in
    identifying global endometrial pathology.c. Hysteroscopy is less expensive.d. Hysteroscopy is less
    painful.

    A 60-year-old patient with breast cancer taking oral anticoagulants for recent deep-vein thrombosis is
    admitted for acute heavy menstrual bleeding. Which of the following management options is LEAST
    suitable for this patient?Select one:a. High-dose estrogen (intravenous Premarin)b. Intrauterine cavity
    insertion of a Foley catheter Xc. Reversal of anticoagulationd. All are suitable for this woman.

    What is the primary advantage of saline in fusion sonography compared with


    transvaginal sonography?
    Select one:
    a. Superior detection of intracavitary masses
    b. Less patient discomfort
    c. Simultaneous assessment of myometrium and endometrium
    d. Ability to perform at any time of the cycle

    CASE

    Question 1
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    A 28-year-old G1 P1 woman complains of painful menses and pain with
    intercourse. She has menses every month and denies a history of sexually
    transmitted diseases. Which of the following tests would most likely
    identify the etiology of the patient's abdominal pain?
    Select one:
    a. pelvic and abdominal MRI
    b. hysteroscopy
    c. transvaginal ultrasound
    d. endometrial biopsy
    e. laparoscopy
    Question 2
    Incorrect
    Marked out of 1.00
    Flag question
    Question text
    A 30-year-old nulliparous hypertensive woman has menorrhagia. The best
    treatment for her is:
    Select one:
    a. LNG-IUS Mirena
    b. Hysterectomy
    c. OCP
    d. Transcervical resection of endometrium
    Question 3
    Correct
    Marked out of 1.00
    Flag question
    Question text
    All of the following assist in predicting ovulation except:
    Select one:
    a. endometrial biopsy
    b. cervical mucus test
    c. basal body temperature
    d. serum progesterone in follicular phase
    Question 4
    Correct
    Marked out of 1.00
    Flag question
    Question text
    A 32-year-old patient complains of bleeding between her periods and
    increasingly heavy menses. Over the past 9 months, she has had two
    dilation and curettages (D&Cs), which have failed to resolve her symptoms,
    and contraceptives and antiprostaglandins have not decreased the
    abnormal bleeding. Of the following options, which is the most appropriate
    at this time?
    Select one:
    a. Perform hysteroscopy
    b. Treat with a GnRH agonist
    c. Perform hysterectomy
    d. Perform endometrial ablation
    Question 5
    Correct
    Marked out of 1.00
    Flag question
    Question text
    All are evidence-based treatments for menorrhagia, except:
    Select one:
    a. Progesterone 5–25 days cyclically
    b. Tranexamic acid
    c. OC pills
    d. Ethamsylate
    Вопрос 1
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    The continuous regimen of the combined oral contraceptives use means:
    Выберите один ответ:
    a. weeks of daily use, and non-hormonal break after
    b. 12-16 weeks of daily use, and non-hormonal break after
    c. 6-8 weeks of daily use, and non-hormonal break after
    d. 365 days of daily use, and non-hormonal break after
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Ritu, 15 years old, complains of heavy periods since 2 months. On
    examination: weight 40 kg and BP 120/80 mmHg. All of the following
    investigations are indicated, except:
    Выберите один ответ:
    a. TSH
    b. Bleeding and clotting time
    c. Platelet count
    d. None of the above
    Вопрос 4
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 46-year-old G3P3 complains of menorrhagia since 3 months. Next line of
    management is:
    Выберите один ответ:
    a. OC pills × 6 months
    b. Progesterone × 6 months
    c. Hysterectomy
    d. D&amp;amp;C
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    What definitive treatment is the most preferable in a 48-year-old parous,
    significantly obese, diabetic and hypertonic patient with recurrent DUB?
    Выберите один ответ:
    a. combined oral contraceptives
    b. hysterectomy
    c. endometrium ablation
    d. medroxiprogesterone acetate

    INFERTILITY

    Question 1
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    An infertile woman has bilateral tubal block at cornua diagnosed on
    hysterosalpingography. Next treatment of choice is:
    Select one:
    a. Laparoscopy and hysteroscopy
    b. Hydrotubation
    c. Tuboplasty
    d. IVF
    Question 2
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    A 34-year-old infertile woman is noted to have evidence of blocked
    fallopian tubes by hysterosalpingogram. Which of the following is the best
    next step for this patient?
    Select one:
    a. Laparoscopy
    b. Clomiphene citrate therapy
    c. Intrauterine insemination
    d. FSH therapy
    Question 3
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Artificial inseminationwithhusband’ssemenisindicatedinall thefollowing
    situations, except:
    Select one:
    a. Oligospermia
    b. Antisperm antibodies in the cervical mucous
    c. Impotency
    d. Azoospermia
    Question 4
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    A 27-year-old married nulligravid resident physician has been married or 3
    years. She is worried about delaying childbearing or another few years
    while she pursues fellowship training. She can be reassured that a
    significant decline in the fecundability rate does not begin until what age
    (years)?
    Select one:
    a. 26
    b. 32
    c. 44
    d. 38
    Question 5
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following Y-chromosome deletions carries the best prognosis
    or recovering sperm from the testes in an azoospermic patient?
    Select one:
    a. AZFd
    b. AZFa
    c. AZFc
    d. AZFb
    Question 6
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Of infertility causes, which of the following is most likely encountered?
    Select one:
    a. Tubal disease
    b. Unexplained
    c. Ovulatory dysfunction
    d. Male actors
    Question 7
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Regarding commercially available urinary luteinizing hormone kits, when
    does ovulation take place in relation to a positive result?
    Select one:
    a. Day before
    b. 48 hours after
    c. Same day
    d. Day after
    Question 8
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which of the following is true regarding letrozole, an aromatase inhibitor, in
    the context of ovulation induction?
    Select one:
    a. It is typically dosed daily or 4 to 6 weeks.
    b. Data regarding its teratogenicity are contradictory.
    c. It has become an accepted alternative to gonadotropins and clomiphene
    citrate.
    d. It is Food and Drug Administration (FDA) approved for this indication.
    Question 9
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of these statements regarding infertility is FALSE?
    Select one:
    a. Infertility generally is defined as the inability to achieve successful
    pregnancy after at least 12 months of regular, unprotected intercourse.
    b. Women are affected more than twice as often as men.
    c. Around 10 to 15 percent of the reproductive-aged population is infertile.
    d. Early evaluation after only 6 months may be justied for certain medical
    conditions or for women aged 35 years or older.
    Question 10
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Compared with in vitro fertilization, advantages of bilateral tubal
    reanastomosis to reverse tubal occlusion from a prior sterilization
    procedure do NOT include which of the following?
    Select one:
    a. Decreased risk of multifetal gestation X
    b. Avoidance of ovarian stimulation with exogenous hormonal therapy
    c. Ability to conceive naturally
    d. Negligible risk of ectopic pregnancy
    Вопрос 2
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Gold standard treatment for female infertility is:
    Выберите один ответ:
    a. Hysteroscopy
    b. Laparoscopy and hysteroscopy
    c. Laparoscopy X
    d. Transvaginal USG X
    Вопрос 3
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 26-year-old G0P0 woman has regular menses every 28 days. The semen
    analysis is normal. The patient had a postcoital test revealing motile sperm
    and stretchy watery cervical mucus. She has been treated for chlamydial
    infection in the past. Which of the following is the most likely etiology of her
    infertility?
    Выберите один ответ:
    a. Cervical factor
    b. Uterine factor
    c. Male factor
    d. Tubal factor
    e. Peritoneal factor
    f. Ovulatory factor
    Вопрос 4
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    When treating hypertension with β-blocking agents, which of the following
    semen abnormalities may be seen due to retrograde ejaculation?
    Выберите один ответ:
    a. Low semen volume
    b. Oligospermia
    c. Azoospermia X
    d. Teratospermia
    Вопрос 5
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    As shown here, sonography is clinically most useful for the diagnosis of
    which of the following conditions that contributes to a significant
    percentage of infertility cases?
    Выберите один ответ:
    a. Anovulation
    b. Periovarian adhesive disease
    c. Polycystic ovarian syndrome
    d. Sex cord-stromal tumors
    Вопрос 6
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 30-year-old nulligravida has been trying to conceive for the last 2 years.
    She has no medical problems. She consumes five alcoholic drinks weekly,
    smokes half a pack of cigarettes daily. She describes herself as a heavy
    coffee drinker. She works in a dry-cleaning facility. Which of the following
    exposures is LEAST likely affecting her fertility?
    Выберите один ответ:
    a. Dry cleaning fluid exposure
    b. Cigarettes
    c. Caffeine
    d. Alcohol
    Вопрос 7
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A woman complaining of infertility reports that her husband has already
    undergone evaluation by a urologist to exclude male actors. This leads to
    the surgical repair of a unilateral varicocele. With regard to varicoceles and
    infertility, which of the following is true?
    Выберите один ответ:
    a. Repair o subclinical varicoceles leads to correction of semen
    abnormalities.
    b. All should be repaired.
    c. A varicocele is present in nearly 20 percent of the adult male general
    population.
    d. They are an established cause of male infertility.
    Вопрос 8
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following assisted reproductive technologies, typically is used
    to treat male actor infertility, is shown here?
    Выберите один ответ:
    a. Assisted hatching
    b. Embryo biopsy X
    c. Oocyte in vitro maturation
    d. Intracytoplasmic sperm injection (ICSI)
    Вопрос 9
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following is the best treatment or a woman with a significant
    decline in ovarian reserve?
    Выберите один ответ:
    a. Clomiphene citrate ovulation induction X
    b. Use of donor eggs
    c. In vitro fertilization with intracytoplasmic sperm injection
    d. Exogenous gonadotropin ovulation induction
    Вопрос 10
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following treatment options offers the best chance or
    intrauterine pregnancy in a patient with the following problem?

    Выберите один ответ:


    a. In vitro fertilization after bilateral salpingectomy
    b. Fimbriectomy X
    c. Neosalpingostomy
    d. Tubal reanastomosis
    Вопрос 1
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 22-year-old nulliparous woman with irregular menses of 7 years’ duration
    complains of primary infertility. She has a family history of diabetes. She
    has mild hirsutism on examination. Which of the following is the most likely
    therapy?
    Выберите один ответ:
    a. Surgical excision of an ovarian tumor
    b. Oral clomiphene citrate or letrozole
    c. Excision of an adrenal tumor
    d. Cortisol and mineralocorticoid replacement
    e. Intrauterine insemination
    Вопрос 3
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Postcoital test is used to assess:
    Выберите один ответ:
    a. Tubal factor
    b. Uterine factor
    c. Any of the above
    d. Cervical factor
    Вопрос 4
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following tests are currently recommended components of a
    basic male factor infertility evaluation?
    Выберите один ответ:
    a. Antisperm antibody assay
    b. DNA integrity analysis
    c. None of the mentioned
    d. Sperm penetration assay
    Вопрос 5
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Hysterosalpingography is LEAST helpful or detecting which of the
    following?
    Выберите один ответ:
    a. Pelvic adhesions
    b. Asherman syndrome
    c. Tubal patency
    d. Congenital uterine anomalies
    Вопрос 6
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Congenital bilateral absence of the vas deferens is genetically related to
    which of the following?
    Выберите один ответ:
    a. Noonan syndrome
    b. Cystic fibrosis
    c. Red–green color blindness
    d. Klinefelter syndrome
    Вопрос 7
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 32-year-old woman undergoes infertility evaluation after trying to
    conceive for 5 years. She has cyclic but heavy menses. Prior to this, she
    experienced one pregnancy that ended in a first-trimester spontaneous
    abortion. What uterine abnormality is suggested by her
    hysterosalpingogram?

    Выберите один ответ:


    a. Normal
    b. Submucous leiomyoma
    c. Bilateral hydrosalpinges
    d. Asherman syndrome
    Вопрос 9
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 28-year-old woman with polycystic ovarian syndrome (PCOS) and
    infertility asks about the potential use of metformin to help achieve
    pregnancy. She can be counseled that current evidence LEAST supports
    which of the following benefits of metformin therapy in women with PCOS?
    Выберите один ответ:
    a. Higher frequency of spontaneous ovulation
    b. Improved menstrual cyclicity
    c. Improved live-birth rate
    d. Increased ovulatory response to clomiphene citrate therapy
    Вопрос 10
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    Which of the following tubal obstruction locations is LEAST amenable to
    surgical repair?
    Выберите один ответ:
    a. Isthmic
    b. Ampullary
    c. Fimbrial
    d. Interstitial

    Which of the following statements regarding antimullerian hormone level (AMH) is true?
    a AMH expression is strong in preantral follicles and weak in larger follicles
    b AMH levels are increased in women with polycystic ovanan syndrome
    c All of the mentioned statements are true
    d Compared with estradiol or follicle-stimulating hormone (FSH) levels, AMH levels correlate better
    with the number of ovarian primordial follicles (seen In photomicrograph above)

    Reduced secretion of which of the following hormones is most likely responsible or the rising serum
    follicle-stimulating hormone (FSH) level seen as a woman ages?
    a Inhibin
    b Follistatm X
    c Actwin
    d Estradiol

    Gynecomastia in a male patient may suggest the presence of which of the following conditions?
    a Klmefelter syndrome
    b Pituitary prolactmoma X
    c 17 beta-hydroxysteroid dehydrogenase defficiency
    d Noonan syndrome

    Which of the following is present in some gonadotropin preparations and provides the needed
    luteinizing hormone (LH) activity by virtue of its shared receptor with LH?
    a Human chononic gonadotropin
    b Follistatm
    c Activin
    d inhibin X

    As shown here, sonography is clinically most useful for the diagnosis of which of the following
    conditions that contributes to a significant percentage of infertility cases?
    a. Anovulation
    b. Periovarian adhesive disease
    c. Polycystic ovarian syndrome
    d. Sex cord-stromal tumors

    A 30-year-old nulligravida has been trying to conceive for the last 2 years. She has no medical
    problems. She consumes five alcoholic drinks weekly, smokes half a pack of cigarettes daily. She
    describes herself as a heavy coffee drinker. She works in a dry-cleaning facility. Which of the
    following exposures is LEAST likely affecting her fertility?
    a. Dry cleaning fluid exposure
    b. Cigarettes
    c. Caffeine
    d. Alcohol

    A woman complaining of infertility reports that her husband has already undergone evaluation by a
    urologist to exclude male actors. This leads to the surgical repair of a unilateral varicocele. With regard
    to varicoceles and infertility, which of the following is true?
    a. RePair o subclinical varicoceles leads to correction of semen abnormalities.
    b. All should be repaired. X
    c. A varicocele is present in nearly 20 percent of the adult male general population.
    d. They are an established cause of male infertility.

    Artificial insemination with husband’s semen is indicated in all of the following situations, except:
    a. Azoospermia
    b. Antisperm antibodies in the cervical mucous
    c. Impotency
    d. Oligospemia

    When treating hypertension with beta-blocking agents, which of the following semen abnormalities
    may be seen due to retrograde ejaculation?
    a. Low semen volume
    b. Oligospermia
    c. Azoospermia X
    d. Teratospermia

    Oligospermiais defined as less than which of the following sperm count thresholds per milliliter of
    semen?
    a. 15 million/mL
    b. 50 million/mL
    c. 150 million/mL
    d. 100 million/mL

    What is expected per cycle fecundability rate?


    Select one:
    a. 0.5 percent
    b. 5 percent X
    c. 85 percent
    d. 25 percent

    When providing treatment to increase sperm counts, it should be kept in mind that the process of
    spermatogenesis takes approximately how long?
    Select one:
    a. 30 days
    b. 100 days
    c. 6 months
    d. 9 months

    Which of the following is NOT true of basal body temperature testing to identify ovulation in adult
    women?
    Select one:
    a. Once the temperature rises, a patient should expect ovulation during the next 48 hours.
    b. With ovulation, the temperature rises from 0.4°F to 0.8°F.
    c. It is an inexpensive and easy test or ovulation monitoring.
    d. It can be an insensitive test in many women.

    Use of which of these is most likely to damage testicular function permanently,


    Select one:
    a. Anabolic steroids
    b. Gentamycin
    c. Alcohol consumption
    d. Spironolactone

    Which of the following is true of the process of sperm capitation?


    Select one:
    a. Involves sperm hyperactivation.
    b. Aids sperm penetration of the ovum's zona pellucida.
    c. Results in the sperm’s ability to release across all enzymes important to fertilization of the ovum.
    d. All of the mentioned

    Most adverse maternal or perinatal outcomes of higher-order muttifetal pregnancies are the result of
    which of the following?
    a. Advanced maternal age
    b. Venous thromboembolic events
    c. Fetal growth restriction and discordance X
    d. Premature delivery

    Which of the following gonadotropins is a recombinant product?


    Select one:
    a. Repronex X
    b. Bravelle
    c. FollIstim
    d. Menopur

    In cases of male hypogonadotropic hypogonadusm, which of the following semen analysis


    abnormalities is most typically seen?
    Select one:
    a. Oligospermia
    b. Asthenospermia
    c. Teratozoospermia
    d. Aspermia

    Preconception also carrier screening or cystic fibrosis is currently recommended or which group?
    Select one:
    a. All individuals considering pregnancy
    b. Non-Hispanic white race
    c. Family or personal history of cystic fibrosis
    d. Ashkenazi Jewish descent

    An in infertile couple presents or evaluation. Neither partner has ever conceived a pregnancy. Both
    believe that the female partner alone is the source of their failure to achieve a pregnancy. It should be
    explained that infertility can be attributed to the male partner in approximately one third of cases and to
    both partners in approximately what percentage of cases,
    Select one:
    a. 1 percent
    b. 66 percent
    c. 33 percent
    d. 10 percent X

    A 28-year-old nullipara who has been seeking pregnancy is diagnosed with polycystic ovarian
    syndrome (PCOS). She is generally healthy, but her body mass index (BMI) is in the obese range.
    Which of the following should be recommended as first-line management of her anovulation? Select
    one:
    a. Gonadotropins
    b. Weight loss and exercise
    c. Insulin-sensitizing agents
    d. Clomiphene citrate

    Which of the following complication is more common in pregnancies resulting from assisted
    reproductive technologies compared with spontaneously conceived pregnancies?
    Select one: -
    a. All of the mentioned
    b. Gestational diabetes
    c. Cesarean delivery
    d. Placental abruption

    Infertility thought secondary to which of the following scenarios warrants intracytoplasmic sperm
    injection (ICSI)?
    Select one:
    a. Bilateral distal fallopian tube occlusion with hydrosalpinxes X
    b. Chronic anovulation
    c. Diminished ovarian reserve in an older woman
    d. Severe oligospermia

    Which of the following midluteal progesterone level values signifies ovulation?


    Select one:
    a. 0.05 ng/mL
    b. 0.1 ng/mL
    c. 1.0 ng/mL X
    d. 5.0 ng/mL

    A couple seeking pregnancy has undergone a thorough infertility evaluation. Both partners are
    generally healthy. The Correct female partner is without apparent problems that would contribute to
    infertility. Semen analysis is performed. The sperm count is 4 million/mL, and semen volume is less
    than 1 mL. In addition to a serum testosterone level, which of of 1.00 the following should be
    rneasured during the hormonal evaluation of the male partner if an endocrinopathy is suspected?
    Select one:
    a. Follicle-stimulating hormone (FSH)
    b. Prolactin
    c. All of the mentioned
    d. Thyroid-stimulating hormone

    Which of the following is NOT a typical clinical manifestation of ovarian hyperstimulation syndrome,
    Select one:
    a. Seizures
    b. Hypercoagulability
    c. Hemoconcentration
    d. Ascites

    In women with inadequate cervical mucus quantity or quality as a suspected contributor to infertility,
    what is the most reasonable approach to achieving pregnancy?
    Select one:
    a. Cryotherapy
    b. Intrauterine insemination
    c. Ovulation Induction
    d. Flax seed oll supplementation

    LIVER PATHOLOGY

    Question 1
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    After delivery, the liver function deterioration of acute fatty liver of
    pregnancy halted. Nonetheless, you recommend continued intensive
    maternal surveillance due to the approximately 20% risk of developing
    which of the following in the days after delivery?
    Select one:
    a. Hemorrhage
    b. Sepsis
    c. Acute pancreatitis
    d. Diabetes mellitus
    Question 2
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which of the following combinations represents appropriate screening for
    hepatitis C in pregnancy?
    Select one:
    a. 37-year-old woman with a history of blood transfusion after her last
    pregnancy in 2014 screened via hepatitis C RNA
    b. 15-year-old woman whose mother was a chronic intravenous drug user
    and died of liver failure when the patient was 4 years old screened via
    hepatitis C RNA
    c. 27-year-old woman with human immunodeficiency virus screened via
    anti-hepatitis C antibody
    d. 26-year-old woman with a history of skin abscesses from heroin use
    screened via anti-hepatitis C antibody
    Question 3
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    The cytochrome P450 system is altered by which of the following during
    pregnancy?
    Select one:
    a. Placental expression
    b. Progesterone levels
    c. All of the above
    d. Estrogen levels
    Question 4
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which of the following viral infections has been associated with a marked
    increase in the risk for intrahepatic cholestasis of pregnancy?
    Select one:
    a. Hepatitis B
    b. Human immunodeficiency virus
    c. Cytomegalovirus
    d. Hepatitis C
    Question 5
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    What is the incidence and recurrence risk of acute fatty liver of pregnancy?
    Select one:
    a. 1 in 100,000 pregnancies, and recurrence is rare
    b. 1 in 1,000,000 pregnancies, and recurrence is rare
    c. 1 in 10,000 pregnancies, and recurrence is rare
    d. 1 in 100,000 pregnancies, and recurrence is common
    Question 6
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Chronic hepatitis B infection is most likely to develop after acquisition by
    which of the following patients?
    Select one:
    a. 28-year-old healthy woman
    b. Newborn infant
    c. 9-year-old child
    d. Risk is equivalent in all of the above
    Question 7
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Immunization is not available for which of the following?
    Select one:
    a. It is available for all three
    b. Hepatitis A
    c. Hepatitis C
    d. Hepatitis B
    Question 8
    Not answered
    Marked out of 1.00
    Flag question
    Question text
    A 27-year-old at 32 weeks’ gestation is brought to the emergency room by
    ambulance after consuming 6 grams of acetaminophen. Which of the
    following is true?
    Select one:
    a. All of the above
    b. N-Acetyl-p-benzoquinoneimine should be administered promptly.
    c. The fetus is not at risk, so no monitoring is necessary.
    d. This is the most common cause of acute liver failure in the United States.
    Question 9
    Not answered
    Marked out of 1.00
    Flag question
    Question text
    Which of the following have the best data for treatment of intrahepatic
    cholestasis of pregnancy?
    Select one or more:
    a. Dexamethasone
    b. Ursodeoxycholic acid
    c. Low-cholesterol diet
    d. Cholestyramine
    Question 10
    Not answered
    Marked out of 1.00
    Flag question
    Question text
    Risk of maternal death with acute fatty liver is related to which of the
    following?
    Select one:
    a. All of the above
    b. Renal failure
    c. Hemorrhage
    d. Sepsis
    Question 1
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Concerning the gastrointestinal tract during pregnancy, which of the
    following is correct?
    Select one:
    a. None of the above
    b. Intraesophageal pressures are lower during pregnancy.
    c. Gastric emptying time increases during pregnancy.
    d. Lower esophageal sphincter tone is increased during pregnancy.
    Question 2
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    During the hospital care of a patient with acute viral hepatitis, which of the
    following personal protective equipment should be used at all times?
    Select one:
    a. All of the above
    b. Gloves
    c. Negative-pressure ventilation hospital room
    d. N95 respiratory mask
    Question 3
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following findings make in case of elevated liver enzymes
    exclude intrahepatic cholestasis of pregnancy?
    Select one:
    a. Jaundice
    b. All of the above
    c. Liver biopsy showing bile plugs in the hepatocytes
    d. AST 800 U/L
    Question 4
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Maternal acute fatty liver of pregnancy is associated with all except with of
    the following recessively inherited abnormalities of mitochondrial fatty acid
    oxidation?
    Select one:
    a. Long-chain-3-hydroxyacyl-CoA-dehydrogenase
    b. Medium-chain acyl-CoA dehydrogenase
    c. Carnitine palmitoyltransferase 1
    d. Dihydrolipoamide dehydrogenase
    Question 5
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following pregnancy-related complications has the capacity to
    demonstrate the most prominent alterations of normal hepatic, renal,
    hematological, and coagulation laboratory studies?
    Select one:
    a. Intrahepatic cholestasis of pregnancy
    b. Hyperemesis gravidarum
    c. Preeclampsia
    d. Acute fatty liver of pregnancy
    Question 6
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Lactation is contraindicated for women infected with which of the
    following?
    Select one:
    a. HIV
    b. Hepatitis C
    c. Hepatitis B
    d. Hepatitis A
    Question 7
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    All EXCEPT which of the following liver-related changes are physiological in
    pregnancy?
    Select one:
    a. Elevated serum alkaline phosphatase levels
    b. Hypolipidemia
    c. Palmar erythema
    d. Spider angiomas
    Question 8
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    This image shows the typical nodular, fibrotic appearance of a cirrhotic
    liver. What is the most common cause of this condition in the general
    population?

    Select one:
    a. Nonalcoholic fatty liver disease
    b. Autoimmune hepatitis
    c. Viral hepatitis
    d. Alcohol exposure
    Question 9
    Correct
    Mark 1.00 out of 1.00
    Flag question
    Question text
    Which of the following statements regarding acute viral hepatitis is correct?
    Select one:
    a. Bilirubin levels typically fall as transaminase levels rise.
    b. Low-grade fever is more common with hepatitis A.
    c. Serum transaminase levels correspond with disease severity.
    d. Jaundice is usually the presenting symptom.
    Question 10
    Incorrect
    Mark 0.00 out of 1.00
    Flag question
    Question text
    Which imaging modality is recommended in discriminating acute fatty liver
    of pregnancy from other etiologies of elevated liver enzymes?
    Select one:
    a. Ultrasound with color Doppler
    b. Magnetic resonance imaging
    c. Computed tomography
    d. None of the above
    From an etiopathogenesis perspective, the pregnancy fatty liver pictured
    here is analogous to which childhood illness?
    Выберите один ответ:
    a. Epstein-Barr viral hepatitis
    b. Biliary atresia
    c. Reye-like syndromes
    d. Autoimmune hepatitis

    CASE

    Вопрос 1
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 32-year-old G1 at 32 weeks’ gestation is diagnosed with intrahepatic
    cholestasis of pregnancy. During the visit she inquires about whether this
    diagnosis will alter her prenatal care or delivery plans. What is the best
    evidence-based advice you can provide?
    Выберите один ответ:
    a. Since your bile acid levels are less 10 µmol/L, delivery will be
    recommended before 39 weeks’ gestation.
    b. None of the above
    c. We can avoid risk for stillbirth with weekly fetal nonstress testing.
    d. If we pursue delivery at 38–39 weeks’ gestation, we will avoid neonatal
    sequelae of intrahepatic cholestasis of pregnancy.
    Вопрос 2
    Верно
    Баллов: 1,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 28-year-old at 19 weeks’ gestation presents to the emergency room with
    complaints of right upper quadrant pain, fever, and vomiting. Exam reveals
    right upper quadrant tenderness, and she has a temperature of 38.7°C. One
    diagnostic image is shown here. Common bile duct obstruction is not
    suspected. What is the next most appropriate step in her management?
    Выберите один ответ:
    a. Laparoscopic cholecystectomy
    b. Admit for serial abdominal examinations and intravenous antibiotics
    c. Discharge home with oral antibiotics, pain medication, and antiemetics
    d. Endoscopic retrograde cholangiopancreatography
    Вопрос 3
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 36-year-old multigravida presents for preconception counseling. Her
    obstetric history includes two full-term vaginal deliveries after pregnancies
    complicated by gestational diabetes and a first-trimester pregnancy loss.
    She comes to you to discuss her recent diagnosis of nonalcoholic fatty liver
    disease (NAFLD) by her primary care physician. Diagnosis was based on
    imaging performed for an episode of abdominal pain. Her liver function
    tests are normal. Her medical history is otherwise notable for longstanding
    obesity (body mass index 34 kg/m2) and diabetes (hemoglobin A1c 8.2%)
    diagnosed 2 years ago. Which of the following should be included in your
    counseling?
    Выберите один ответ:
    a. Compared to women of similar weight, because of the NAFLD, she has a
    much higher risk for liver-related adverse pregnancy outcome.
    b. With normal liver enzymes, you question the diagnosis of NAFLD and
    recommend that she seek a second opinion from a gastroenterologist
    c. The best interventions to reduce the risk to a future pregnancy are
    weight loss and optimizing her glucose control.
    d. All of the above
    Вопрос 4
    Неверно
    Баллов: 0,00 из 1,00
    Отметить вопрос
    Текст вопроса
    A 29-year-old primigravida presents to you for prenatal care. She is known
    to have hepatitis C with no known risk factors, and your prenatal labs
    confirm presence of hepatitis C RNA and anti-hepatitis C antibody.
    Compared to a woman with anti-hepatitis C antibody who is RNA-negative,
    which of the following is more likely to complicate her pregnancy?
    Выберите один ответ:
    a. Fetal growth restriction
    b. None of the above
    c. Preterm delivery
    d. Vertical transmission of hepatitis C
    Вопрос 5

    A 27-year-old nulligravida and her husband present for preconception counseling. She has Wilson
    disease that is being treated with zinc sulfate. Which of the following should be included in your
    counseling?
    Select one:
    a. All of the above
    b. Upon confirmation of pregnancy, she should discontinue her chelation therapy.
    c. Her husband should consider carrier testing.
    d. Available data suggests she should convert to penicillamine prior to conception, as it is a better
    chelating agent

    A 27-year-old multigravida comes to you for her postpartum visit. Both of her pregnancies were
    complicated by intrahepatic cholestasis of pregnancy. She desires another child in about 2 years. Which
    of the following methods of contraception do you recommend?
    Select one:
    O a. Combination oral contraceptive pills
    O b. None of the above
    O c. Copper intrauterine device
    d. Vaginal ring

    Which combination of laboratory findings below would be most concerning for acute fatty liver of
    pregnancy
    a. Hematocrit 30%. creatinine 1.0 mg/dL platelets 200/L AST 600 U/L fibrinogen 420 mg/dL and
    glucose 120- mg/d1_
    b. Hematocrit 39%. creatinine 1.2 mg/dL platelets 90/L. AST 80 U/L fibrinogen 450 mg/dL and
    glucose 105 mg/dL
    Hematocrit 32%. creatinine 2.0 mg/dL platelets 90/L AST 400 U/L fibrinogen 130 mg/dL and
    glucose 65 mg/dL.
    d. Hematocrit 34%. creatinine 11 mg/dL platelets 190/L AST 60 U/L fibrinogen 450 mg/dL and
    glucose 96 mg/dL

    A 26-year-old primigravida presents at 34 weeks' gestation with nausea and vomiting, fatigue, and
    epigastric pain. All except which of the following are clinical characteristics that increase her risk for
    acute fatty liver of pregnancy as the underlying cause?
    Select one:
    a. Nulliparity
    b. Female fetus
    c. Twin gestation
    d. Third trimester

    A 32-year-old nulligravida presents for preconception counseling due to cirrhosis with esophageal
    varies. Which of the following should be included in your counseling?
    a. All of the above
    b. Without variceal rupture there is high risk for liver failure, preterm delivery, fetal growth
    restriction,maternal death.
    c. You do not recommend that she become pregnant.
    d. 1/3 to 1/2 of women with varices will have bleeding in pregnancy and this carries an 18% mortality

    The following are viral serologies of the pregnant patient. What is her diagnosis?
    1. IgA Anti-Hepatitis Bcore antibody +
    2. Hepatitis B surface antibody -
    3. Hepatitis Be antigen +
    a. Chronic hepatitis B infection, still active
    b. It is not possible to make a diagnosis from the serologies presented
    c. History of hepatitis B vaccination
    d. History of hepatitis B infection. now latent

    How do you counsel the early post delivery patient regarding her following viral serologies,
    • IgA Anti-Hepatitis B core antibody
    • Hepatitis B surface antibody --
    • Hepatitis Li e antigen +

    a. She has an active virus that can lead to cirrhosis and death. and you will refer her to a
    hepatologtst tor long-term management recomrnendations.
    b. She has a virus that can lead to cirrhosis and death, but it appears dormant. You will reter her to a
    hepatologIst for surveillance.
    c She has a virus that can lead to cirrhosis a. death. and you will refer her to a hepatologist dIscussion
    ot ribavirin therapy.
    d. She does not need to be concerned, Her results represent vaccination for Hepatitis B. and she should
    have lifelong antibodies.

    Maternal acute fatty liver of pregnancy is associated with all except with of the following recessively
    inherited abnormalities of mitochondrial fatty acid oxidation?
    Select one:
    a. Long-chain-3-hydroxyacyl-CoA-dehydrogenase
    b. Medium-chain acyl-CoA dehydrogenase
    c. Carnitine palmitoyltransferase 1
    d. Dihydrolipoamide dehydrogenase

    Which imaging modality is recommended in discriminating acute fatty liver of pregnancy from other
    etiologies of elevated liver enzymes?
    Select one:
    a. Ultrasound with color Doppler
    b. Magnetic resonance imaging
    c. Computed tomography
    d. None of the above

    You send a peripheral blood smear of the patient at 34 weeks’ gestation


    with an acute fatty liver, and a representative slide is shown below. What is
    the underlying etiology of the blood smear findings?
    Выберите один ответ:
    a. Autoimmune antibody binding
    b. Decreased cholesterol production
    c. Increased destruction in the spleen
    d. Thrombotic microangiopathy in microvessels

    OVARIAN CANCER

    A 55-year-old woman is noted to have an abdominal mass and increased abdominal girth. On
    examination, there is shifting dullness and a fluid wave. Which of the following malignancies is most
    likely to be found in this patient?
    Select one:
    a. Ovarian cancer
    b. Endometrial cancer
    c. Cervical cancer
    d. Vulvar cancer
    e. Colon cancer

    The cut surface of ovary has 4 layers. Which layer is the next from the very superficial?
    Select one:
    a. connective tissue
    b. cortex
    c. medulla
    d. cuboidal epithelium

    What type of ovarian cysts is associated with pregnancy (particularly multiple) and gestational
    trophoblastic disease?
    Select one:
    a. follicular cyst
    b. corpus luteal cyst
    c. para-ovarian cyst
    d. dermoid cyst
    e. theca luteal cyst

    From listed below what does not prevent ovarian cancer?


    Select one:
    a. bilateral salpingectomy
    b. nulliparity
    c. tubal ligation
    d. combined oral contraceptive pills use
    e. bilateral salpingo-oophorectomy

    Tumor maker related to both pancreatic carcinoma and mucinous ovarian carcinoma:
    Select one:
    a. CA-19-9
    b. CA-125
    c. All of the above
    d. CD-15-3

    Meigs' syndrome is diagnosed based on a triad of the following signs, except:


    Select one:
    a. oedema
    b. ascites
    c. pleural effusion
    d. ovarian tumour

    What biochemical tumour marker is used in diagnostics of ovarian mucinous tumours?


    Select one:
    a. alpha-fetoprotein
    b. inhibin
    c. CA 125
    d. Ca 19-9
    e. Beta-hCG

    What is incorrect regarding germ cell tumours?


    Select one:
    a. hair, teeth, fat, skin, muscle, cartilage, bone and endocrine tissue are frequently present
    b. these are the most common ovarian tumours in young women aged 20-40 years
    c. a peak incidence in the early 20s
    d. up to 10% of dermoid cysts are bilateral X
    e. the risk of malignant transformation is high (&gt; 20 %), usually occurring in women over 40 years

    Risk factors for ovarian cancer are the following, except:


    Select one:
    a. multiparity
    b. hereditary factor
    c. increasing age
    d. personal history of breast cancer
    e. postmenopausal hormone replacement therapy

    Kruti, 56 years old, complained of pain in abdomen, with USG showing 4 cm bilateral ovarian mass
    with increased vascularity. Next line of management is:
    Select one:
    a. Surgery
    b. Wait and watch X
    c. USG-guided ovarian tapping
    d. OC pills x three cycles X

    Indications for surgery in patients with functional ovarian cysts are the following, except:
    a arnenorrhea induced by functional ovarian cyst
    b. large ovarian cyst (&got; 7 cm)
    c. rupture or torsion of ovarian cyst
    d. if any cyst petsists more than 3 months

    What is the most common clinical manifestation of granulosa cell tumor in pre-puberty girls?
    a. Maids' syndrome
    b. delayed puberty
    c. isosexual precocious puberty
    d. ascites
    e. hirsutism

    What ovarian mass may be found in any female age period (from infancy to menopause)?
    a. benign ovarian tumor
    b. paratubal cyst
    c. follicular cyst
    d. endometrioma

    A 25-year-old woman is noted to have a 4-cm simple cyst of the right ovary. She denies any abdominal
    pain, nausea, or vomiting. Which of the following is the next best step?
    a Chemotherapy
    b. Expectant management
    c. Exploratory laparotomy
    d. LaparoScopy

    Conditions diagnosed as a pelvic mass in women of reproductive age are the following except
    a. Prolactinoma
    b. Ovarian or adnexal cysts and tumors
    c. Full urinary bladder
    d. Tuboavarian abscess

    What is a surgery of choice in a young, nulliparous patient with ovarian carcinoma stage la?
    a. unilateral oophorectomy
    b. total hysterectomy with unilateral salpingo- oophorectomy
    c. total hysterectomy with bilateral salpingo-oophorectomy, omentectomy X
    d. bilateral salpingo-oophorectomy X
    e. unilateral salpingoroophorectorny

    All conditions listed below are refered to functional ovarian cysts, except:
    a. paraovarian cyst
    b. corpus luteal cyst
    c. follicular cyst
    d. theca-lutein cyst

    These tumours may produce estrogens, except:


    a. juvenile granulosa cell tumour
    b. Sertoli-Leydig tumour
    c. thecoma
    d. adult granulosa cell tumour
    e. Brenner tumour

    The presentation with the different types of benign ovarian tumours varies with age. Mark the incorrect
    statement.
    a. the peak age for malignarn epithelial tumours is postmenopause
    b. germ cell tumours occur more commonly in older women
    c. functional cysts are common in young girls, adolescents and women in their reproductive years
    d. benign epithelial tumours are more prevalent in older and postmenopausal women

    A 44-year-old woman is noted to have a 30-cm tumor of the ovary. Which of the following is the most
    likely cell type?
    a. serous tumor
    b. Mucinous tumor
    c. Granulosa cell tumor
    d. Dermoid cyst

    What statement is incorrect regarding epithelial ovarian cancer?


    a. a combination of surgery and chemotherapy is almost always recommended for treatment X
    b. epithelial ovarian cancer is more common for nulliparous women X
    c. elderly women are more likely to develop ovarian cancer
    d. ovarian cancer is the most lethal of all gynecologic cancers
    e. oral contraceptives use increases the incidence of ovarian cancer

    What is a standard surgical approach In patient with benign epithelial tumour who already Completed
    childbearing?
    a unilateral cystectomy X
    b. total hysterectomy and bilateral salpingo-oophorectomy
    c. unilateral salpingo-oophorectomy
    d. bilateral salpingo-oophorectomy
    e. total hysterectomy

    Which biochemical tumour marker is used during treatment and follow-up of ovarian dysgerminoma?
    a. HE4
    b. alpha-fetoprotein
    c. lactate dehydrogenase
    d. beta-hCG X
    e. CA 125

    Theca-lutein cysts are most often assosiated with:


    a. ovulation induction
    b. Rh-sensitization
    c. hydatidiform moles and choriocarcinoma
    d. pregnancy

    What clinical sign of Sertoli-Leydig cell tumour in patients of reproductive age will not resolve after
    tumour removal?
    a. hirsutism
    b.amenorrhea
    c. acne vulgaris
    d. temporal balding
    e. clitoromegaly

    A lady has ovarian mass, pelvic X-ray shows a radio plaque shadow. The most likely diagnosis is:
    Select one:
    a. Serous cyst Aden’s a
    b. Mucinous cyst adenoma X
    c. Dysgerminoma
    d. Mature tera tona
    e. Follicular cyst

    What is a standard surgical approach in patient with benign epithelial tumour who already completed
    childbearing?
    ENDOMETRIUM CANCER
    Выберите один ответ:

    a. bilateral salpingo-oophorectomy
    What gestational age is known as a predisposing factor for developement of corpus luteal cysts?
    b.Select one:
    total hysterectomy
    a. Corpus luteal cysts may be found within all the pregnancy duration
    c. unilateral cystectomy

    d. total hysterectomy and bilateral salpingo-oophorectomy

    e. unilateral salpingo-oophorectomy
    .1 A5-year-oldgirlisnotedtohavebreastenlargement,vaginalbleeding,andan 8-cm pelvic mass.
    Which of the following is the most likely etiology?
    A. Benign cystic teratoma (dermoid)
    B. Endodermal sinus tumor
    C. Brenner tumor
    D. Choriocarcinoma
    E. Granulosa-theca cell tumor
    59.2 A25-year-oldwomanisnotedtohavea4-cmsimplecystoftherightovary. She denies any
    abdominal pain, nausea, or vomiting. Which of the following is the next best step?
    A. Expectant management
    B. Laparoscopy
    C. Exploratory laparotomy
    D. Chemotherapy
    59.3 Which of the following is the best treatment for a suspected dermoid cyst found in an
    18-year-old nulliparous woman?
    A. Total abdominal hysterectomy
    B. Unilateral salpingo-oophorectomy
    C. Ovarian cystectomy
    D. Observation

    59.7 A44-year-oldwomanisnotedtohavea30-cmtumoroftheovary.Whichof the following is the most likely cell type?


    A. Dermoid cyst
    B. Granulosa cell tumor
    C. Serous tumor
    D. Mucinous tumor

    What is incorrect regarding the characteristics of ovarian normal anatomy?


    Выберите один ответ:
    a. laterally, each ovary is attached to the suspensory ligament of the ovary with folds of peritoneum that becomes continuous
    with that of the overlying psoas major
    b. each ovary is attached to the cornu of the uterus by the broad ligament and at the hilum to the ovarian ligament by the
    mesovarium, which contains its supply of nerves and blood vessels

    All the following are true about Krukenberg’s tumor, except:


    Выберите один ответ:
    a. Enlarged ovaries
    b. Stomach is the most common site of primary tumor
    c. None of the above
    d. Bilateral

    Which ovarian tumour is known to be a risk factor for endometrial carcinoma?

    Выберите один ответ:

    a. ovarian endometrioma

    b. mucinous tumour

    c. thecoma

    d. serous tumour

    e. epithelial ovarian carcinoma Which biochemical tumour marker is used during treatment and follow-up of ovarian
    dysgerminoma?
    Indications for surgery in patients with functional ovarian cysts are the following, except:

    Выберите один ответ: Выберите один ответ:


    a. large ovarian cyst (&gt; 7 cm)
    a. beta-hCG
    b. amenorrhea induced by functional ovarian cyst

    c. rupture or torsion of ovarian cyst b. lactate dehydrogenase


    d. if any cyst persists more than 3 months
    c. HE4

    The Risk of Malignancy Index (RMI) is calculated using the following criteria, except:
    d. CA 125

    Выберите один ответ: e. alpha-fetoprotein


    a. serum CA-125 level

    b. serum HE4 level

    c. pelvic ultrasound features


    What type of ovarian cysts is traditionally associated with increased risk of rupture and subsequent
    d. menopausal status intraabdominal bleeding?

    Выберите один ответ:

    a. corpus luteal cyst

    b. theca luteal cyst

    c. follicular cyst

    d. dermoid cyst

    e. para-ovarian cyst
    ENDOMETRIUM CANCER
    What gestational age is known as a predisposing factor for developement of corpus luteal
    b. 3rd trimester cysts? Select one:
    c. 2ndt trimester a. Corpus luteal cysts may be found within all the pregnancy duration
    d. 1st trimester

    CERVICAL CANCER

    A 35-year-old lady with postcoital bleeding management is:


    Выберите один ответ:
    a. Visual examination with Lugol iodine
    b. Visual examination with acetic acid
    c. Colposcopy
    d. Clinical examination and PAP smear
    Вопрос 2
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Most common cause of postmenopausal bleeding in India is:
    Выберите один ответ:
    a. Endometrial cancer
    b. Endometrial atrophy
    c. Endometrial hyperplasia
    d. Carcinoma cervix
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 50-year-old P4L4 has PAP smear showing dysplasia. She undergoes colposcopic-directed cervical biopsy, the report of which is normal.
    Next line of management is:
    Выберите один ответ:
    a. Therapeutic cone biopsy
    b. Diagnostic cone biopsy
    c. Wait and watch
    d. Hysterectomy
    Вопрос 4
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 39-year-old woman is diagnosed with advanced cervical cancer that appears to have spread to her right pelvic sidewall. She has right
    hydronephrosis as evidenced by the intravenous pyelogram (IVP). The biopsy specimen confirms that it is a poorly differentiated carcinoma.
    Which of the following statements regarding this patient’s condition is most accurate?
    Выберите один ответ:
    a. Radical hysterectomy is an option in the therapy of this patient
    b. The best therapy for her is surgical excision
    c. The majority of cervical cancers are of adenomatous cell type
    d. Both brachytherapy and teletherapy are important in the treatment of this patient
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 35-year-old lady has undergone radical hysterectomy for Ca cervix. Histopathology shows stage IBI with outer one-third of cervix and lower
    uterine segment involvement. Next line of management is:
    Выберите один ответ:
    a. Chemotherapy
    b. Chemoradiation
    c. Radiation
    d. Follow-up
    Вопрос 6
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Stage lb cervical cancer is diagnosed in a young woman. Assuming that the cancer is confirmed to the cervix and that intraoperative biopsies
    are negative, which of the following structure would not be removed during the radical hysterectomy?
    Выберите один ответ:
    a. Pelvic nodes
    b. The entire parametrium on both sides of the cervix
    c. Uterosacral and uterovesical ligaments
    d. Both ovaries
    Вопрос 7
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 40-year-old woman is referred for a Pap smear showing high-grade squamous intraepithelial lesions. Which of the following statements is
    most accurate?
    Выберите один ответ:
    a. If an endocervical curetting shows cervical dysplasia, then an excisional procedure of the cervix is appropriate
    b. If HPV subtyping reveals no high-risk virus present, then routine cytology is recommended
    c. If colposcopy demonstrates the entire transformation zone, then no further analysis is needed
    d. Cervical cancer is highly unlikely due to the Pap smear revealing only HSIL
    A 33-year-old woman has a Pap smear showing moderately severe cervical dysplasia (high-grade squamous intraepithelial neoplasia). She
    denies a smoking history and does not recall having any sexually transmitted infections. Which of the following is the best next step?
    Выберите один ответ:
    a. Colposcopy-directed biopsies
    b. Computed tomography scan of the abdomen and pelvis
    c. Conization of the cervix
    d. Radical hysterectomy
    e. Repeat Pap smear in 3 months
    Вопрос 9
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 22-year-old nulliparous woman is seen by her gynecologist and given a routine Pap smear. The Pap smear revealed LSIL, and a colposcopy is
    performed. A biopsy at 3:00 shows CIN 2. Which of the following is the best therapy for this patient?
    Выберите один ответ:
    a. Offer hysterectomy
    b. Repeat Pap smear in 6 months
    c. LEEP excision of the cervix
    d. Conization of the cervix with top hat to address any endocervical involvement
    Вопрос 10
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 45-year-old woman is diagnosed with an early cervical cancer, noted to be confined to the cervix and about 3 cm in diameter. Which of the
    following is a risk factor for cervical cancer?
    Выберите один ответ:
    a. Obesity
    b. Early age of coitus
    c. Family history of cervical cancer
    d. Nulliparity
    e. Late menopause
    A 35-year-old lady has undergone radical hysterectomy for Ca cervix. Histopathology shows stage IBI with outer one-third of cervix and lower
    uterine segment involvement. Next line of management is:
    Выберите один ответ:
    a. Follow-up
    b. Chemotherapy
    c. Radiation
    d. Chemoradiation
    Вопрос 2
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Pap smear is useful in the diagnosis of all, except:
    Выберите один ответ:
    a. Gonorrhea
    b. Human papilloma virus
    c. Trichomonas vaginalis
    d. Inflammatory changes
    Вопрос 3
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Advantages of surgery over radiotherapy in cervical cancer treatment are all, except:
    Выберите один ответ:
    a. Preservation of vaginal function
    b. Conservation of ovaries
    c. Lesser surgical mortality
    d. None of the above
    Вопрос 4
    Неверно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 48-year-old healthy postmenopausal woman has a Pap smear performed, which reveals atypical glandular cells. She does not have a history of
    abnormal Pap smears. Which of the following is the best next step?
    Выберите один ответ:
    a. Hormone-replacement therapy
    b. Repeat Pap smear in 3 months
    c. Colposcopy, endocervical curettage, endometrial sampling
    d. Vaginal sampling
    Вопрос 5
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 39-year-old woman is diagnosed with advanced cervical cancer that appears to have spread to her right pelvic sidewall. She has right
    hydronephrosis as evidenced by the intravenous pyelogram (IVP). The biopsy specimen confirms that it is a poorly differentiated carcinoma.
    Which of the following statements regarding this patient’s condition is most accurate?
    Выберите один ответ:
    a. Both brachytherapy and teletherapy are important in the treatment of this patient
    b. The best therapy for her is surgical excision
    c. The majority of cervical cancers are of adenomatous cell type
    A 48-year-old woman who presents with postcoital vaginal bleeding is noted to have a cervical exophytic mass. A biopsy of the mass
    confirms squamous cell carcinoma. If molecular analysis of the cancer is performed, which of the following H PV subtypes is most likely to
    be found in the specimen?
    Выберите один ответ:
    a. 6 and 11
    b. 89 and 92
    c. 16 and 18
    d. 55 and 57
    Вопрос 7
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A 50-year-old P4L4 has PAP smear showing dysplasia. She undergoes colposcopic-directed cervical biopsy, the report of which is normal.
    Next line of management is:
    Выберите один ответ:
    a. Diagnostic cone biopsy
    b. Therapeutic cone biopsy
    c. Hysterectomy
    d. Wait and watch
    Вопрос 8
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    Cytogenetics is difficult in solid tumors, that too especially in carcinoma cervix, due to:
    Выберите один ответ:
    a. High mitotic activity
    b. Specimen often not adequate
    c. Good-quality metaphase
    d. Often contaminated and infeсted with microorganisms
    Вопрос 9
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    All are causes of postmenopausal bleeding except:
    Выберите один ответ:
    a. Carcinoma in situ cervix
    b. Ca ovary
    c. Ca fallopian tube
    d. Ca endometrium
    Вопрос 10
    Верно
    Балл: 1,00
    Отметить вопрос
    Текст вопроса
    A patient presents with Ca cervix with stage IIIb. Treatment of choice is:
    Выберите один ответ:
    a. Wertheim’s hysterectomy
    b. Intracavitatory brachytherapy followed by external beam radiotherapy
    c. Schauta’s operation
    d. Chemotherapy

    58.6 A 47-year-old woman G4P4 has a Pap smear which shows H SIL. Colpos- copy is performed
    which is adequate, and reveals CIN III. An endocervical curettage is negative. The patient also has
    menorrhagia caused by uterine fibroids. Thus, the patient undergoes a total abdominal
    hysterectomy, includ- ing removal of the cervix. The patient asks whether Pap smears need to be
    performed now that her cervix has been surgically removed. Which of the following is the most
    accurate statement?
    A. The patient should continue to have annual Pap smears of the vaginal cuff.
    B. The patient should have Pap smears every 2 to 3 years, which may be discontinued if negative
    after 10 years.
    C. The patient does not need Pap smears any longer.
    D. The patient should have the H PV vaccine.

    All of the following are indications for postoperative radiotherapy in a case of carcinoma
    endometrium, except:
    Выберите один ответ:
    a. Myometrial invasion &amp;gt; ½ thickness
    b. Endocervical involvement
    c. Positive lymph nodes
    d. Tumor positive for estrogen receptors
    A patient is receiving external beam radiation for the treatment of metastatic endometrial cancer. The treatment field
    includes the entire pelvis. Which of the following tissues within this radiation field is the most radiosensitive?
    Выберите один ответ:
    a. Vagina
    b. Rectovaginal septum
    c. Ovary
    d. Bladder

    A 35-year-old woman is diagnosed with endometrial cancer. Which of the following is most likely to be present?
    Выберите один ответ:
    a. BRCA-1 mutation
    b. Ascites
    c. Pelvic irradiation
    d. Galactorrhea
    e. Polycystic ovarian syndrome

    A 45-year-old postmenopausal woman with AUB has 8 mm thickness of endometrium. Next line of management is:
    Выберите один ответ:
    a. Hysterectomy
    b. Endometrial histopathological examination
    c. Progesterone therapy
    d. Follow-up and USG

    Choice of adjuvant treatment for endometrial carcinoma stage IA, grade I is:
    Выберите один ответ:
    a. Chemotherapy plus radiotherapy
    b. Chemotherapy
    c. No treatment
    d. Radiotherapy
    Choriocarcinoma metastasizes most commonly to:
    Выберите один ответ:
    a. Vagina
    b. Liver
    c. Lungs
    d. Brain
    The investigation of choice in a 55-year-old postmenopausal woman who has presented with postmenopausal bleeding is:
    Выберите один ответ:
    a. CA-125
    b. Pap smear
    c. Transvaginal ultrasound
    d. Fractional curettage
    A 60-year-old woman presents to her physician’s office with postmenopausal bleeding. She undergoes endometrial sampling, and is diagnosed with endometrial cancer. Which of the following is a risk factor
    for endometrial cancer?

    Выберите один ответ:

    a. Oral contraceptive use

    b. Smoking

    c. Multiparity

    d. Diabetes mellitus

    e. Herpes simplex infection

    57-year-old postmenopausal woman with hypertension, diabetes, and a history of polycystic ovarian syndrome complains of vaginal bleeding for 2 weeks. The endometrial sampling shows a few fragments of atrophic endometrium. Estrogen-replacement therapy is begun.
    The patient continues to have several episodes of vaginal bleeding 3 months later. Which of the following is the best next step?

    Выберите один ответ:

    a. Unopposed estrogen-replacement therapy

    b. Endometrial ablation

    c. Continued observation and reassurance

    d. Serum CA-125 testing

    e. Hysteroscopic examination

    All of the following are indications for postoperative radiotherapy in a case of carcinoma endometrium, except:

    Выберите один ответ:

    a. Endocervical involvement

    b. Positive lymph nodes

    c. Myometrial invasion &amp;gt; ½ thickness -

    d. Tumor positive for estrogen receptors

    Chemotherapy is recommended in postevacuation phase of molar pregnancy in all, except:

    Выберите один ответ:

    a. Plateau of hCG for 6 weeks

    b. Theca-lutein cysts &amp;gt;6 cm size

    c. Persistent vaginal bleeding

    d. Regression of uterine size

    Incidence of choriocarcinoma is seen more after:

    Выберите один ответ:

    a. Cesarean section

    b. Normal delivery

    c. Ectopic pregnancy

    d. Spontaneous abortion

    A 35-year-old G0P0 presents to her doctor for infertility. She also has heavy vaginal bleeding that persisted for 3 weeks. She has a
    long history of oligomenorrhea. An endometrial biopsy shows Grade 1 endometrial carcinoma. Which of the following is the best
    treatment for this patient?

    Выберите один ответ:

    a. Surgical staging

    b. Radiation therapy

    c. Clomiphene citrate

    d. Combination chemotherapy

    e. Progestin therapy
    A52-year-oldwoman,whohashypertensionanddiabetes,isdiagnosedwith endometrial cancer. H er diseases are well
    controlled. H er physician has diag- nosed the condition as tentatively stage I disease (confined to the uterus). Which of the
    following is the most important therapeutic measure in the treatment of this patient?
    A. Radiation therapy
    B. Chemotherapy
    C. Immunostimulation therapy
    D. Progestin therapy
    E. Surgical therapy

    Approximately what percentage of postpartum women require readmission to the hospital within 8 weeks of delivery?

    Выберите один ответ:

    a. 10%

    b. 3%

    c. 7%

    d. &lt;1%

    Отметить вопрос

    Текст вопроса

    What is the mean time to ovulation resumption in a postpartum woman who elects not to breastfeed?

    Выберите один ответ:

    a. 5 weeks

    b. 7 weeks

    c. 4 weeks

    d. 6 weeks

    Вопрос 3

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    What duration of time is encompassed in the puerperium?

    Выберите один ответ:

    a. 10–12 weeks

    b. 6–8 weeks

    c. 4–6 weeks

    d. 2–4 weeks

    Вопрос 4

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    Following an uncomplicated vaginal delivery, when can women be advised to resume coitus based on desire and comfort?

    Выберите один ответ:

    a. 2 weeks postpartum

    b. 1 week postpartum

    c. 4 weeks postpartum

    d. 3 weeks postpartum

    Вопрос 5

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    Which of the following has not been shown to lower the risk for infection after cesarean delivery?

    Выберите один ответ:

    a. Chlorhexidine-alcohol skin preparation

    b. Single-dose antibiotics prior to skin incision

    c. Spontaneous separation of the placenta

    d. Surgeons changing gloves after delivery of the placenta


    Which of the following is the best treatment for toxic shock syndrome?

    Выберите один ответ:

    a. There is no necessary treatment as it will resolve on its own over time

    b. Supportive care and antibiotics

    c. Supportive care

    d. Supportive care, antibiotics, and wound debridement if necessary

    Вопрос 7

    Неверно

    Баллов: 0,00 из 1,00

    Отметить вопрос

    Текст вопроса

    When is mastitis most likely to occur?

    Выберите один ответ:

    a. Postpartum day 1

    b. Postpartum day 5

    c. 3–4 weeks postpartum

    d. 6–9 months postpartum

    Вопрос 8

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    Which of the following is a risk factor for episiotomy dehiscence?

    Выберите один ответ:

    a. Genital warts

    b. Smoking

    c. All of the mentioned

    d. Infection

    Вопрос 9

    Неверно

    Баллов: 0,00 из 1,00

    Отметить вопрос

    Текст вопроса

    Which of the following is least likely to occur during surgery for uterine incisional necrosis?

    Выберите один ответ:

    a. Bilateral salpingo-oophorectomy

    b. Surgical debridement

    c. Hysterectomy

    d. Transfusion

    Вопрос 10

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    A 35-year-old woman is noted to have a blood pressure of 80/40 mm Hg, fever, and abdominal pain. Which of the following is the likely mechanism of the patient’s hypotension?

    Выберите один ответ:

    a. Cardiac bradycardia

    b. Vasodilation

    c. Third spacing of fluid

    d. Cardiac contractility dysfunction


    A 26-year-old G3P3 is postpartum day 1 following an uncomplicated vaginal delivery. She reports sharp, intermittent lower abdominal pain, which is more severe than in her prior deliveries. Her
    heart rate is 84 beats per minute, blood pressure 110/60 mmHg, and her temperature 99.3 °F. Her abdomen is soft on exam and there is no uterine tenderness. A scant amount of lochia is
    appreciated on bimanual exam. What is the most likely diagnosis?

    Выберите один ответ:

    a. Bladder flap hematoma

    b. Endometritis

    c. Septic pelvic thrombophlebitis

    d. Afterpains

    Вопрос 12

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    A 29-year-old G1P1 presents for a follow-up visit 4 weeks postpartum following an uncomplicated spontaneous vaginal delivery. She is overall doing well and has returned to most of her usual
    activities. However, she complains of low energy levels despite the fact that her baby is sleeping for long intervals at night. What should you offer her?

    Выберите один ответ:

    a. Reassurance only

    b. Psychiatry referral

    c. All of the mentioned

    d. Check her thyroid hormone levels

    Вопрос 13

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    A 27-year-old woman G1 P0 at 39 weeks’ gestation is noted to be in labor. She underwent artificial rupture of membranes, and experiences fetal bradycardia. Palpation of the vagina reveals a
    rope-like structure prolapsing through the cervix. She is diagnosed with a cord prolapse and underwent stat cesarean delivery. On postoperative day 2, the patient has a temperature of 102°F
    (38.8°C), and is diagnosed with endometritis. The patient who works in the microbiology laboratory asks which of the following is the most commonly isolated bacteria in her infection?

    Выберите один ответ:

    a. Group B streptococcus

    b. Staphylococcus aureus

    c. Bacteroides species

    d. Escherichia coli

    Вопрос 14

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    A 34-year-old G3P3 with a history of migraine headaches calls your office 1 week following an uncomplicated vaginal delivery complaining of severe headaches. She did receive epidural
    anesthesia during her labor course, but review of her chart confirms that the epidural placement was easy and uncomplicated. The patient reports that the headaches began a few days
    following delivery and are associated with nausea, but no vomiting, and are minimally improved with either rest or over-the-counter analgesics. What is the most likely trigger of this patient’s
    postpartum headaches?

    Выберите один ответ:

    a. Progesterone withdrawal

    b. Intracerebral hemorrhage

    c. Estrogen withdrawal

    d. Dural puncture

    Вопрос 15

    Верно

    Баллов: 1,00 из 1,00

    Отметить вопрос

    Текст вопроса

    A 32-year-old woman has just delivered a 40-week baby vaginally. She desires to breast-feed. Her physician recommends that she not breast feed. Which of the following conditions is most
    likely to be present?

    Выберите один ответ:

    a. Ampicillin therapy for cystitis

    b. Maternal HIV infection

    c. Maternal dilantin therapy for seizure disorder


    All except which of the following conditions are contraindications to breastfeeding?
    Выберите один ответ:
    a. Infant with galactosemia
    b. Maternal active and untreated tuberculosis
    c. Maternal hepatitis B infection
    d. Human immunodeficiency virus infection

    What percentage of women experience regression of high-grade dysplasia following delivery?


    Выберите один ответ:
    a. 35%
    b. 10%
    c. 50%
    d. 33%
    What vitamin is virtually absent in human breast milk?
    Выберите один ответ:
    a. All vitamins are equally represented in breast milk
    b. Vitamin C
    c. Vitamin A
    d. Vitamin K

    Which of the following regimens is the gold standard for treatment of a pelvic infection following a cesarean delivery?
    Выберите один ответ:
    a. Clindamycin and gentamicin
    b. Clindamycin and aztreonam
    c. Vancomycin
    d. Meropenem

    Which of the following has not been shown to lower the risk for infection after cesarean delivery?
    Выберите один ответ:
    a. Surgeons changing gloves after delivery of the placenta
    b. Single-dose antibiotics prior to skin incision
    c. Spontaneous separation of the placenta
    d. Chlorhexidine-alcohol skin preparation

    Which of the following is the best treatment for toxic shock syndrome?
    Выберите один ответ:
    a. Supportive care
    b. There is no necessary treatment as it will resolve on its own over time
    c. Supportive care and antibiotics
    d. Supportive care, antibiotics, and wound debridement if necessary

    Which of the following is least likely to occur during surgery for uterine incisional
    necrosis?
    Выберите один ответ:
    a. Bilateral salpingo-oophorectomy
    b. Surgical debridement
    c. Transfusion
    d. Hysterectomy

    Which of the following is frequently the first sign/symptom of peritonitis in a


    postpartum woman?
    Выберите один ответ:
    a. Skin erythema
    b. Adynamic ileus
    c. Abdominal rigidity
    d. Diarrhea

    A 24-year-old G1P1 complains of abdominal pain and subjective fever 1 day following an uncomplicated vaginal delivery.
    Which of the following physical exam signs or laboratory values would be most helpful to make a diagnosis of
    endometritis in this postpartum patient?
    Выберите один ответ:
    a. White blood cell count of 25,000/µL
    b. An absolute neutrophilia
    c. Fundal tenderness
    d. All of the mentioned

    A 26-year-old G3P3 is postpartum day 1 following an uncomplicated vaginal delivery. She reports sharp, intermittent lower abdominal pain, which is
    more severe than in her prior deliveries. Her heart rate is 84 beats per minute, blood pressure 110/60 mmHg, and her temperature 99.3 °F. Her
    abdomen is soft on exam and there is no uterine tenderness. A scant amount of lochia is appreciated on bimanual exam. What is the most likely
    diagnosis?
    Выберите один ответ:
    a. Bladder flap hematoma
    b. Endometritis
    c. Afterpains
    d. Septic pelvic thrombophlebitis

    Which of the following is an evidence-based statement about the use of vacuum-assisted wound closure devices in
    obstetrics?
    Выберите один ответ:
    a. It is significantly more cost effective than standard dressings.
    b. It is superior to standard dressings.
    c. It prevents wound infection.
    d. Provider time is decreased substantially.
    Your patient presents 5 days postpartum with an axillary mass. She noted it during pregnancy although reports it was much
    smaller. Yesterday, she noticed that the mass became larger and more tender. Her face is shielded and a sagittal photograph
    of her breast, axilla, and arm is show below. She denies fever and has no additional complaints. Management of the patient
    should primarily include which of the following?

    Выберите один ответ:


    a. Observation and reassurance
    b. Axillary lymph node excision
    c. Needle aspiration
    d. Antibiotic therapy with gram-positive coverage

    Which of the following is true regarding the condition shown in the pelvic radiograph?

    Выберите один ответ:


    a. All of the mentioned
    b. Symphyseal separation &gt;1.5 cm is diagnostic.
    c. Surgery is usually necessary for separation &gt;3 cm.
    d. Treatment is generally conservative and consists of rest and placement of a pelvic binder.

    29-year-old G2P2 with an 18-hour labor course is unable to void 5 hours following a vaginal delivery. What is the best management option?
    Выберите один ответ:
    a. A single in-and-out catheterization
    b. Place a Foley catheter for 24 hours
    c. Continue close observation without intervention
    d. Encourage increased fluid intake since the bladder is likely empty following delivery

    25.1 A 30-year-old G1P1 who underwent a cesarean section 3 days previously has a fever of 101°F (38.3°C).
    The skin incision is indurated, tender, and erythematous. Which of the following is the best management?
    A. Initiation of intravenous ampicillin
    B. Initiation of intravenous heparin
    C. Placement of a warm compress on the wound
    D. Opening of the wound

    25.2 A 29-year-old woman is diagnosed with postpartum endometritis based on fever, abdominal pain, fundal
    tenderness, and elimination of other etiologies. Which of the following is the most significant risk factor for
    postpartum endomyometritis?
    A. Numerous vaginal examinations
    B. Bacterial vaginosis
    C. Cesarean delivery
    D. Internal uterine pressure monitors
    E. Prolonged rupture of membranes
    25.3 A27-year-oldG1P0womanat39weeks’gestationisnotedtobeinlabor.She underwent artificial rupture of
    membranes, and experiences fetal bradycar- dia. Palpation of the vagina reveals a rope-like structure
    prolapsing through the cervix. She is diagnosed with a cord prolapse and underwent stat cesar- ean delivery.
    On postoperative day 2, the patient has a temperature of 102°F (38.8°C), and is diagnosed with endometritis.
    The patient who works in the microbiology laboratory asks which of the following is the most commonly
    isolated bacteria in her infection?
    A. Peptostreptococcus species
    B. Staphylococcus aureus
    C. Group B Streptococcus
    D. Escherichia coli
    25.4 A 22-year-old woman who underwent cesarean delivery has persistent fever of 102°F (38.8°C), despite
    the use of triple antibiotic therapy (ampicillin, gentamicin, and clindamycin). The urinalysis, wound, breasts,
    and uterine fundus are normal on examination. A CT scan of the pelvis is suggestive of septic pelvic
    thrombophlebitis. Which of the following is the best therapy for
    this condition?
    A. Hysterectomy
    B. Discontinue antibiotic therapy and initiate intravenous heparin
    C. Continue antibiotic therapy and begin intravenous heparin
    D. Surgical embolectomy
    What are myrtiform caruncles?
    Выберите один ответ:
    a. A sexually transmitted infection
    b. Scarred tags of hymenal tissue
    c. Microscopic tears in the vaginal epithelium
    d. Vaginal rugae

    Which of the following statements about necrotizing fasciitis is false?


    Выберите один ответ:
    a. Early diagnosis, surgical debridement, antimicrobials, and intensive care are paramount to successful treatment.
    b. Three risk factors are diabetes, obesity, and hypertension.
    c. It is common with low mortality rates.
    d. Surgical debridement of infected tissue should leave wide margins of healthy bleeding tissue.

    Which of the following statements about an ovarian abscess in the puerperium is true?
    Выберите один ответ:
    a. Women present 4–6 weeks after delivery
    b. Usually affects both ovaries
    c. It is thought to be caused by bacterial invasion of the ovary through a rent in the capsule.
    d. Rupture is rare
    In more than 90% of women, metritis responds to treatment with antibiotics within what period of time?
    Выберите один ответ:
    a. 12–24 hours
    b. 24–36 hours
    c. 72–96 hours
    d. 48–72 hours

    A 22-year-old nulliparous woman is noted to have a tender, red, right breast and enlarged, tender axillary lymph nodes that have persisted
    despite antibiotics for 3 weeks. She denies manipulation of her breasts and is not lactating. Which of the following is the most appropriate
    next step?
    Выберите один ответ:
    a. Mammographic examination of the breasts
    b. Check the serum prolactin level
    c. Biopsy of the breast
    d. Sonographic examination of the breasts
    e. Course of oral antibiotic therapy

    A 28-year-old G1 P1 woman has delivered vaginally 3 weeks ago. She is breast-feeding, and notes that the baby prefers to breast-feed from the right
    breast. On the left breast, she notes a 3-day history of a tender mass on the upper outer quadrant. On examination, she is afebrile. The left breast
    has a fluctuant mass of 4 × 8 cm of the upper outer quadrant without redness. It is somewhat tender. Which of the following is the best treatment for
    this condition?
    Выберите один ответ:
    a. Mastectomy
    b. Aspiration
    c. Bromocriptine therapy
    d. Oral antifungal therapy
    e. Oral antibiotic therapy

    A 30-year-old G1 P1 who underwent a cesarean section 3 days previously has a fever of 101°F (38.3°C). The skin incision is indurated, tender,
    and erythematous. Which of the following is the best management?
    Выберите один ответ:
    a. Opening of the wound
    b. Initiation of intravenous ampicillin
    c. Placement of a warm compress on the wound
    d. Initiation of intravenous heparin
    What is the mechanism of action by which surfactant prevents respiratory distress syndrome in neonatal lungs? (W25th)
    Выберите один ответ:
    a. Dilates the pulmonary vasculature
    b. Aids in maturation of the terminal bronchioles
    c. Lowers surface tension in the alveoli
    d. Clears fluid from the lungs
    Respiratory distress syndrome can be caused by which of the following? (W25th)
    All are tocolytics except: Выберите один ответ:
    Выберите один ответ: a. Infection
    a. Ritodrine b. Meconium aspiration
    b. Isoxsuprine c. Heart failure
    c. Salbutamol d. All of the mentioned
    d. Misoprostol

    Risk of preterm delivery is increased if cervical length is


    Выберите один ответ:
    a. 3.0 cm
    b. 3.5 cm
    c. 2.5 cm
    d. 4.0 cm

    True about premature rupture of membrane (PROM) before 32 wks:


    Выберите один ответ:
    a. Amnioinfusion is done
    b. Steroid is used
    c. Aseptic manual cervical examination indicated
    d. Amoxiclav antiobiotic should be given

    An infant born at 25 weeks gestation is at risk for all except which of the following complications? (W25th)
    Выберите один ответ:
    a. Blood cancers
    b. Blindness
    c. Pulmonary hypertension
    d. Asthma

    Which of the following lifestyle factors is not associated with preterm birth? (W25th)
    Выберите один ответ:
    a. Advanced maternal age
    b. Short stature
    c. fold increase
    d. Poverty
    e. Vitamin D deficiency
    Which of the following is true regarding transvaginal sonographic evaluation of the cervix as a part of the assessment for preterm labor? (W25th)
    Выберите один ответ:
    a. The WHO recommends it for all women with a history of a preterm birth
    b. It is not affected by maternal obesity, cervix position, or shadowing
    c. It can be performed any time after 14 weeks’ gestation
    d. All of the mentioned

    Compared to term infants, neonates born prematurely (all) have higher associated rates of which of the following? (W25th)
    Выберите один ответ:
    a. All of the mentioned
    b. Sleep apnea
    c. Congenital malformations
    d. Developmental delay

    Risk factors for poor progress of labour include the following except:
    Выберите один ответ:
    a. Big baby
    b. Meconium stained amniotic fluid
    c. Malpresentation
    d. Premature rupture of membrane

    Tocolytics are beneficial in preterm labour because:


    Выберите один ответ:
    a. They arrest preterm labour
    b. They prolong pregnancy to term
    c. They decrease prenatal mortality
    d. They provide time for antenatal steroids

    When evaluating a pregnant woman for rupture of membranes, which of the following has been
    associated with a false-positive nitrazine test result?
    Выберите один ответ:
    a. All of the mentioned
    b. Semen
    c. Blood
    d. Bacterial vaginosis
    On TVS(transvaginal sonography) which of the following shape of cervix indicates preterm labour:
    Выберите один ответ:
    a. Y
    b. O
    c. U
    d. T

    You perform a routine cervical exam on a 39-year-old G3P2 at 30 weeks gestation. You find her cervix to be 2 to 3 cm dilated. She denies having
    any contractions, discharge, pelvic pain or pressure. What is her chance of a preterm delivery before 34 weeks gestation? (W25th)
    Выберите один ответ:
    a. 25%
    b. 35%
    c. 5%
    d. 15%

    Of the responses listed below, which complication is most commonly associated with preterm delivery?
    Выберите один ответ:
    a. Placental abruption
    b. Fetal complications
    c. None of the above
    d. Hypertension

    Which of the following bacteria is frequently detected in the amnionic fluid of women with preterm labor? (W25th)
    Выберите один ответ:
    a. All of the mentioned
    b. Mycoplasma hominis
    c. Gardnerella vaginalis
    d. Ureaplasma urealyticum

    Respiratory distress syndrome can develop in the term infant as surfactant can be inactivated by which of the following
    substances? (W25th)
    Выберите один ответ:
    a. Vernix
    b. Blood
    c. Meconium
    d. All of the mentioned

    Drug given to reduce uterine contractions during preterm labour with least side effects:
    Выберите один ответ:
    a. Nifidipine
    b. Ritodrine
    c. Atosiban
    d. Magnessium sulphate

    In primi and in preterm labour, which of the following can be used as tocolytic:
    Выберите один ответ:
    a. Dexamethasone
    b. Misoprostol
    c. Ritodrine
    d. Propranolol

    All are risk factors for preterm delivery except:


    Выберите один ответ:
    a. Previous history of preterm baby
    b. Asymptomatic cervical dilatation
    c. Absence of fetal fibronectin at < 37 weeks
    d. Chylamydial infection of genital tract
    MEDICAL COMPLICATIONS

    Renal and Urinary Tract Disorders


    » Which of the following is the most commonly isolated
    etiologic agent causing pyelonephritis in pregnancy?
    A. Proteus species
    B. Candida species
    C. Escherichia coli
    D. Klebsiella species
    » If patient does not improve on adequate antibiotic therapy for
    48 hours and experiences continued severe flank tenderness and
    fever, which of the following should be next considered?
    A. Obstruction of the urinary tract
    B. Anaerobic organisms
    C. Hemolytic uremic syndrome
    D. Factitious fever
    » What severe condition is the most likely?
    A. Acute respiratory distress syndrome
    B. Septic shock
    C. Hemolytic uremic syndrome
    D. Factitious fever
    » Which of the following is the most common cause of this
    complication in pregnancy?
    A. Pelvic inflammatory disease
    B. Pyelonephritis
    C. Wound infection
    D. Mastitis
    ________________ From Willam’s Obstetrics 25th (Ch.53)_______________
    Which of the following is not a physiological change in
    pregnancy that contributes to the findings in the image below?
    a. Vesicoureteral reflux
    b. Glomerular hypertrophy
    c. Distal ureteral compression by the uterus
    d. Progesterone-induced relaxation of the muscularis

    Which of the following statements regarding physiological


    changes in pregnancy is true?
    a. Glomerular filtration decreases.
    b. Effective renal plasma flow increases.
    c. Serum creatinine concentration increases.
    d. The number of glomerular cells increases.
    Which of the following is the threshold for proteinuria in
    pregnancy, above which levels are considered
    abnormal?
    a. 100 mg/d
    b. 250 mg/d
    c. 300 mg/d
    d. 1000 mg/d

    Which of the following values is not a normal serum creatinine


    in pregnancy?
    a. 0.4 mg/dL
    b. 0.6 mg/dL
    c. 0.8 mg/dL
    d. 1.0 mg/dL
    A pregnant patient who previously donated a kidney and now
    has only one healthy kidney is at risk for
    which of the following obstetric complications?
    a. Placenta previa
    b. Normocytic anemia
    c. Gestational hypertension
    d. Preterm premature rupture of membranes

    Which of the following is an acceptable treatment regimen for


    newly diagnosed asymptomatic bacteriuria in pregnancy?
    a. Nitrofurantoin 100 mg by mouth at bedtime for 10 days
    b. Ampicillin 250 mg by mouth four times per day for one day
    c. Trimethoprim-sulfamethoxazole 160/800 mg by mouth one
    time
    d. Nitrofurantoin 100 mg by mouth four times daily for 21 days

    Lower urinary tract symptoms with pyuria but a sterile urine


    culture are likely due to which pathogen?
    a. Escherichia coli
    b. Proteus mirabilis
    c. Klebsiella pneumoniae
    d. Chlamydia trachomatis

    What is the leading cause of septic shock during pregnancy?


    a. Pneumonia
    b. Breast abscess
    c. Pyelonephritis
    d. Chorioamnionitis

    In the setting of aggressive fluid hydration, what percentage of


    pregnant women with pyelonephritis develop acute kidney
    injury?
    a. 5%
    b. 10%
    c. 15%
    d. 20%

    Once you have treated a pregnant patient for pyelonephritis as


    an inpatient, for how long should you
    continue oral therapy as an outpatient?
    a. 1–3 days
    b. 3–5 days
    c. 7–14 days
    d. 14–21 days

    What percentage of pregnant women experience a recurrent


    urinary tract infection after completion of
    treatment for pyelonephritis?
    a. 5–10%
    b. 10–20%
    c. 30–40%
    d. 50–60%

    Which of the following does not characterize nephrotic


    syndromes?
    a. Edema
    b. Heavy proteinuria
    c. Hyperalbuminemia
    d. Hypercholesterolemia

    Which of the following complications is not increased in


    pregnant patients with nephrotic
    syndrome?
    a. Anemia
    b. Preeclampsia
    c. Renal insufficiency
    d. Postterm pregnancy

    Which of the following is most likely to lead to end-stage renal


    disease?
    a. Diabetes
    b. Hypertension
    c. Glomerulonephritis
    d. Polycystic kidney disease

    ___________________________________________________
    ________________________________
    Hematological Disorders

    » Whichof the following is the most likely etiology of the anemia?


    A. Iron deficiency
    B. Folate deficiency
    C. Vitamin B12 deficiency
    D. Physiologic anemia of pregnancy
    E. Acute blood loss anemia
    F. Anemia of chronic disease
    » Which of the following is the most likely diagnosis?
    A. Iron deficiency anemia
    B. Thalassemia
    C. Hemolysis
    D. Folate deficiency
    E. Vitamin B12 deficiency
    » Which of the following would you advise based on her clinical
    status?
    A. Transfusion of 2 units of blood
    B. Repeat a complete blood count emergently
    C. Three months of iron supplementation at discharge
    D. All of the above
    ________________ From Willam’s Obstetrics 25th (Ch.56)_______________

    What hemoglobin value is used to define anemia in the second


    trimester of pregnancy?
    a. 9.5 g/dL
    b. 10.0 g/dL
    c. 10.5 g/dL
    d. 11.0 g/dL

    Which of the following adverse pregnancy outcomes is


    associated with anemia in pregnancy?
    a. Stillbirth
    b. Preeclampsia
    c. Preterm birth
    d. All of the above

    What is the maternal iron requirement in pregnancy for a typical


    singleton gestation?
    a. 500 mg
    b. 800 mg
    c. 1000 mg
    d. 1200 mg

    If you repeat a complete blood count one week after starting


    iron therapy, what would you expect to
    see if she is compliant with taking her iron?
    A. A 20% rise in her hematocrit
    B. An elevated reticulocyte count
    C. An increase in red cell distribution width
    D. An increase in the mean corpuscular volume
    Based on the picture below, what additional symptom is she
    most likely to complain of?
    a. Dry skin
    b. Anorexia
    c. Hair loss
    d. Excessive perspiration

    Which of the following is not a cause of vitamin B12 deficiency


    encountered in pregnancy?
    a. Crohn disease
    b. Ulcerative colitis
    c. History of Roux-en-Y gastric bypass
    d. Prior ileal resection following trauma

    Which of the following is true regarding paroxysmal nocturnal


    hemoglobinuria?
    a. Hemoglobinuria develops at irregular intervals
    b. Almost half of patients suffer venous thromboses
    c. Often precipitated by transfusions, infection or surgery
    d. All of the above

    Which of the following obstetric complications is not increased


    in the context of sickle-cell disease in
    pregnancy?
    a. Stillbirth
    b. Preeclampsia
    c. Gestational diabetes
    d. Fetal-growth restriction

    Thrombocytopenia, defined as a platelet count <150,000/µL,


    complicates what percentage of
    pregnancies?
    a. 1%
    b. 3%
    c. 5%
    d. 10%

    Which of the following treatments would you consider as first-


    line therapy for the 29 weeks pregnant patient with idiopathic
    thrombocytopenic purpura and platelet count 21,000/µL?
    a. Splenectomy
    b. Azathioprine
    c. Corticosteroids
    d. Intravenous immune globulin

    What determines the factor VIII activity level in women affected


    with hemophilia A?
    a. Mosaicism
    b. Lyonization
    c. Co-dominance
    d. None of the above

    What is the incidence of postpartum hemorrhage in women with


    von Willebrand disease?
    a. 10%
    b. 30%
    c. 50%
    d. 70%
    Diabetes Mellitus

    » What is the diagnosis?


    A. Gestational diabetes mellitus
    B. Type 1 diabetes
    C. Type 2 diabetes
    D. Transient glycosuria

    » Which of the following is a risk factor in pregnant women for impaired carbohydrate
    metabolism?
    A. Family history of diabetes
    B. Previous infant with polycystic kidney disease
    C. High serum levels of antiphospholipid antibodies
    D. All of the above
    » What further investigations need to be arranged?
    A. Retinal assessment if not performed in last 12 months
    B. 50-g oral glucose tolerance test
    C. Serum total cholesterol level
    D. Quad screen to assess fetal risk of aneuploidy and neural-tube defect

    » Outline the principles of management of the pregnancy.


    A. Reduction of maternal insulin regime
    B. Aim to keep fasting blood glucose between 3.5 and 5.9 mmol/L
    C. Folate supplementation
    D. Labor induction at 38 weeks’ gestation

    ________________ From Willam’s Obstetrics 25th (Ch.57)_______________


    What does in utero exposure to hyperglycemia lead to?
    a. Increase fetal fat cells
    b. Fetal hyperinsulinemia
    c. Insulin resistance in adolescence
    d. All of the above

    How is diabetes classified during pregnancy?


    a. Type 1 or type 2
    b. Pregestational or gestational
    c. Type 1, type 2, or gestational
    d. Using the White classification
    Which of the following findings are considered diagnostic for overt diabetes in pregnancy?
    a. Hemoglobin A1C >6%
    b. Glucosuria on urine dip
    c. Fasting plasma glucose ≥120 mg/dL
    d. Random plasma glucose ≥200 mg/dL

    Fetuses of overtly diabetic mothers have an increased risk for which of the following?
    a. Preterm delivery
    b. Spontaneous abortion
    c. Congenital malformation
    d. All of the above
    How does diminished fetal growth occur in pregestational diabetes?
    a. Substrate deprivation
    b. Fetal hyperinsulinemia
    c. Altered lipid metabolism
    d. All of the above

    Compared to women without diabetes, which fetal condition occurs more often in the setting of
    pregestational diabetes?
    a. Stillbirth
    b. Perinatal death
    c. Postpartum hemorrhage
    d. Gestational hypertension
    What might be said of the pregnancy yielding 5000-g newborn?
    a. The mother likely had poor glycemic control.
    b. The baby was at risk for neonatal hypoglycemia.
    c. The mother had an increased risk for shoulder dystocia.
    d. All of the above

    Which of the following are considered reasons for unexplained fetal demise in women requiring
    insulin during pregnancy?
    a. Nonketotic acidosis
    b. Elevated lactic acid levels
    c. Decreased fetal hematocrit
    d. None of the above

    Which of the following is a reasonable explanation for hydramnios in a pregnancy complicated


    by diabetes?
    a. Maternal endothelial leak caused by hyperglycemia
    b. Glucose reabsorption by the fetal glomerular collecting system
    c. Osmotic gradient created by high glucose concentrations in the amnionic fluid
    d. All of the above

    What is the most likely cause for the increased incidence of respiratory distress syndrome in the
    neonates of diabetic mothers?
    a. Indicated preterm delivery
    b. Delayed maturation of type II pneumocytes
    c. Decreased production of surfactant in a hyperglycemic environment
    d. All of the above
    Which of the following statements regarding cardiomyopathy in infants of diabetic mothers is
    true?
    a. Is reversible after birth
    b. Ventricular hypertrophy is due to insulin excess
    c. In severe cases may lead to pulmonary hypertension
    d. In the first trimester systolic dysfunction is already present

    Which of the following is true concerning management of overt


    maternal diabetes in the second trimester?
    a. Should undergo amniocentesis
    b. Should undergo a fetal echocardiogram
    c. Have higher rates of chromosomal abnormalities
    d. Should be offered genetic screening if >35 years of age

    All except which of the following statements regarding hypocalcemia in the newborn is
    accurate?
    a. Defined as <9 mg/dL
    b. Etiology is unexplained
    c. May be related to preterm birth
    d. Seen more often with strict glucose control

    Maternal mortality in women with type 1 diabetes results from which of the following?
    a. Infection
    b. Hypertension
    c. Diabetic ketoacidosis
    d. All of the above
    The first and most common visible retinal lesions in diabetes are small microaneurysms followed
    by blot hemorrhages. This describes which of the following
    conditions?
    a. Proliferative retinopathy
    b. Nonproliferative retinopathy
    c. Is irreversible with improved control
    d. The etiology of cotton wool exudates

    What is the most important component of diabetic ketoacidosis treatment in pregnancy?


    a. Restore euglycemia
    b. Provide intravenous hydration
    c. Provide intravenous potassium repletion
    d. Provide intravenous bicarbonate to correct acidosis

    Which of the following infections is increased in pregnant women with overt diabetes?
    a. Pyelonephritis
    b. Respiratory infections
    c. Wound infection after cesarean delivery
    d. All of the above

    The most difficult aspect of preconceptional control in women with diabetes is which of the
    following?
    a. Resistance to insulin therapy
    b. Unpredictable insulin requirements
    c. Half of pregnancies in the United States are unplanned
    d. All of the above

    Women with type 1 diabetes should achieve glycemic control with which of the following during
    pregnancy?
    a. Insulin
    b. Diet alone
    c. Insulin and diet
    d. Oral hypoglycemic agents

    Which of the following is associated with fasting blood glucose levels >120 mg/dL (6.7
    mmol/l)?
    a. Preeclampsia
    b. Cesarean delivery
    c. Birthweight >90th percentile
    d. All of the above
    Preeclampsia

    » What is the most likely diagnosis?


    A. HELLP syndrome
    B. Cardiac insufficiency
    C. Electrolyte abnormalities
    D. Aspiration
    E. Severe Preeclampsia
    » What is your immediate next step?
    A. Improve oxygenation
    B. Intravenous antihypertensive agents
    C. Platelet transfusion
    D. Intravenous immunoglobulin therapy
    E. Intravenous Mannitol

    » Which of the following is the best management?


    A. Oral antihypertensive therapy
    B. Platelet transfusion
    C. Magnesium sulfate therapy and induction of labor
    D. Intravenous immunoglobulin therapy

    » Which of the following will be the most common mechanism if seizures appear in this patient?
    A. Electrolyte abnormalities
    B. Intracerebral hemorrhage
    C. Myocardial infarction
    D. Aspiration

    » Which of the following is the best management for this patient?


    A. Induction of labor
    B. Cesarean section
    C. Antihypertensive therapy
    D. Expectant management
    » Which of the following findings is most likely present in this patient to necessitate delivery?
    A. Blood pressures persist in the range of 150/ 95 mm Hg
    B. The patient reaches 32 weeks’ gestation
    C. Patient develops pulmonary edema
    D. Repeat platelet count is 95 000/mm3

    » Which of the following is the best next step?


    A. Antihypertensive agent
    B. IV Mannitol
    C. MRI of the brain
    D. CT imaging of the brain
    E. Ophthalmic eye drops to both eyes

    » Which of the following is the best next step?


    A. Corticosteroids
    B. Antihypertensive agent
    C. Biophysical profile
    D. Magnesium sulfate and delivery
    E. Continued observation

    » Which of the following is the best next step?


    A. Corticosteroids
    B. Antihypertensive agent
    C. Biophysical profile
    D. Magnesium sulfate and delivery
    E. Continued observation

    » Which of the following is the best next step?


    A. Corticosteroids
    B. Antihypertensive agent
    C. Biophysical profile
    D. Magnesium sulfate and delivery
    E. Continued observation

    » Which of the following is the best next step?


    A. Corticosteroids
    B. Antihypertensive agent
    C. Biophysical profile
    D. Magnesium sulfate and delivery
    E. Continued observation

    What percentage of pregnancies are complicated by hypertension?


    A. 2–3%
    B. 4–5%
    C. 5–10%
    D. 10–20%
    What percentage of eclamptic seizures occur in women without significant proteinuria?
    A. 5–9%
    B. 10–17%
    C. 20–25%
    D. 30–33%
    What percentage of eclamptic seizures occur more than 48 hours after delivery?
    A. 2%
    B. 5%
    C. 10%
    D. 20%

    Many conditions and factors are associated with an increased risk for preeclampsia. Which of the
    following factors results in the greatest relative risk for a diagnosis of preeclampsia in the current
    pregnancy?
    A. Primigravida
    B. Advanced maternal age
    C. Systemic lupus erythematous
    D. History of preeclampsia in a prior pregnancy

    Which of the following is thought to play a significant role in the development of preeclampsia?
    A. Genetic factors
    B. Immunological factors
    C. Abnormal trophoblastic invasion
    D. All of the above

    Which of the following is not a pathophysiological change to the cardiovascular system seen in
    the setting of preeclampsia?
    A. Increased preload
    B. Decreased preload
    C. Increased afterload
    D. Endothelial activation
    Which statement best describes renal perfusion and glomerular filtration rates in women with
    preeclampsia that has not yet progressed to severe disease?
    A. Similar compared to normal pregnant values
    B. Increased compared to normal pregnant values
    C. Similar compared to normal nonpregnant values
    D. Decreased compared to normal nonpregnant values

    What is the underlying etiology of the proteinuria seen with preeclampsia?


    A. Increased capillary permeability
    B. Increased renal artery resistance
    C. Increased glomerular filtration rate
    D. Increased systemic vascular resistance
    Which of the following nutritional supplements has been shown to reduce the incidence of
    preeclampsia?
    A. Calcium
    B. Vitamin E
    C. Ascorbic acid
    D. None of the above

    Which of the following physiological responses is typically seen in preeclamptic patients?


    A. Increased production of nitric acid
    B. Increased sensitivity to angiotensin II
    C. Decreased reactivity to norepinephrine
    D. All of the above

    The typical blood volume of a gravida at term is 4500 mL. In patients with preeclampsia, which
    of the following would be the expected blood volume?
    A. 2500 mL
    B. 3200 mL
    C. 4500 mL
    D. 5000 mL

    Which of the following medical therapies has been associated with a modest decrease in the
    incidence of preeclampsia in women at increased risk?
    A. Aspirin
    B. Metformin
    C. Enoxaparin
    D. Heparin sulfate
    _________________From William’s Obstetric
    25th_____________________________
    Many conditions and factors are associated with an increased risk for preeclampsia. Which of the
    following factors results in the greatest relative risk for a diagnosis of preeclampsia in the current
    pregnancy?
    a. Primigravida
    b. Advanced maternal age
    c. Systemic lupus erythematous
    d. History of preeclampsia in a prior pregnancy

    Which of the following is thought to play a significant role in the development of preeclampsia?
    a. Genetic factors
    b. Immunological factors
    c. Abnormal trophoblastic invasion
    d. All of the above

    Which of the following angiogenic factors are elevated in women who proceed to develop
    preeclampsia?
    a. sFlt-1
    b. PIGF
    c. VEGF
    d. TGF-β

    A 21-year-old primigravida presents at 36 weeks’ gestation with new-onset headache. Her blood
    pressure is 150/90 mm Hg, her serum creatinine is 0.8 mg/mL, AST is 32 U/L, and platelet count
    is 28,000/µL. Which of the following criteria for severe preeclampsia is met?
    a. Hypertension
    b. Liver dysfunction
    c. Thrombocytopenia
    d. Elevated serum creatinine

    Which of the following is an indication for primary cesarean delivery without an attempt at
    induction?
    a. Malpresentation
    b. Unfavorable cervix
    c. Possible fetal thrombocytopenia
    d. None of the above

    Which statement best describes renal perfusion and glomerular filtration rates in women with
    preeclampsia that has not yet progressed to severe disease?
    a. Similar compared to normal pregnant values
    b. Increased compared to normal pregnant values
    c. Similar compared to normal nonpregnant values
    d. Decreased compared to normal nonpregnant values

    Patient is diagnosed with HELLP syndrome and undergoes an uncomplicated induction of labor.
    Her right upper quadrant pain persists, and a computed tomography scan of her abdomen/pelvis
    is completed with the findings as shown below. What is denoted by the asterisk (*)?

    a. Splenic infarction
    b. Intrahepatic infarction
    c. Subcapsular hematoma
    d. Periportal hemorrhagic necrosis

    A G3P2 at 16 weeks’ gestation presents to the emergency department complaining of vaginal


    bleeding. Her blood pressure is 148/96 mm Hg and she has 3+ proteinuria on a specimen
    obtained during bladder catheterization. Which of the following may explain the development of
    preeclampsia in this patient?

    a. Increased volume of chorionic villi


    b. Extensive remodeling of the spiral arterioles
    c. Increased invasion of extravillous trophoblastic tissue
    d. None of the above
    The following computed tomography image shows cerebral edema in a postpartum patient with
    hypertension, vision changes, and confusion. What associated morbidity is the patient at risk for?

    a. Hemiplegia
    b. Cystic leukomalacia
    c. Retinal artery occlusion
    d. Transtentorial herniation
    The below magnetic resonance imaging was performed postpartum. What is the most likely
    finding on imaging?

    a. Subdural hematoma
    b. Parenchymal hemorrhage
    c. Subarachnoid hemorrhage
    d. Posterior reversible encephalopathy syndrome
    Antenatal bleeding

    » Which of the following sequence of examinations is most appropriate?


    A. Speculum examination, ultrasound examination
    B. Ultrasound examination, digital examination
    C. Digital examination, ultrasound examination, speculum examination
    D. Ultrasound examination, speculum examination, digital examination

    » What is the most likely diagnosis?


    A. Placental abruption
    B. Placenta previa
    C. Gestational diabetes
    D. Multifetal gestation
    E. Gestational trophoblastic disease

    » What will be the long-term management of this patient?


    A. Induction of labor
    B. Tocolysis if fetal condition is stable
    C. Immediate cesarean delivery
    D. Expectant management as long as the bleeding is not excessive
    E. Intrauterine transfusion
    » Which of the following is a risk factor for this patient’s condition?
    A. Prior salpingitis
    B. Hypertension
    C. Multiple gestations
    D. Polyhydramnios
    » Which of the following is a typical feature of this condition?
    A. Painful bleeding
    B. Commonly associated with coagulopathy
    C. First episode of bleeding is usually profuse
    D. Associated with postcoital spotting
    » Which of the following is the best management for this patient?
    A. Induction of labor
    B. Tocolysis of labor
    C. Cesarean delivery
    D. Expectant management
    E. Intrauterine transfusion

    » What is uncommon cause of antepartum haemorrhage (APH) at term


    A. Blood-stained show
    B. Bleeding placenta praevia
    C. Placental abruption sure
    D. Cervical ectropion Not
    E. Bacterial vaginosis
    F. Vasa praevia

    » Which of the following sequence of examinations is most appropriate?


    A. Speculum examination, ultrasound examination, digital examination
    B. Ultrasound examination, digital examination, speculum examination
    C. Digital examination, ultrasound examination, speculum examination
    D. Ultrasound examination, speculum examination, digital examination

    » Which of the following is the most appropriate management?


    A. Schedule cesarean delivery at 39 weeks
    B. Schedule an amniocentesis at 34 weeks and deliver by cesarean if the fetal lungs are mature
    C. Schedule an MRI examination at 35 weeks to assess for possible percreta involving the
    bladder
    D. Reassess placental position at 32 weeks’ gestation by ultrasound
    E. Recommend termination of pregnancy

    How do you interpret the examination and blood test findings?


    A. DIC
    B. Liver failure sure
    C. Haemorrhagic shock not
    D. Kidney failure
    E. Electrolyte disorder
    Which of the following statements is most accurate?
    A. Fetal ultrasound is more accurate in diagnosing placental abruption than placenta previa.
    B. Fetal ultrasound is quite sensitive in diagnosing placental abruption.
    C. Ultrasound is sensitive in diagnosing abruption that occurs in the lower aspect of the uterus.
    D. Fetal ultrasound is not sensitive in diagnosing placental abruption.

    Which of the following is the most significant risk factor for abruption placentae?
    A. Prior cesarean delivery
    B. Breech presentation
    C. Trauma
    D. Marijuana use
    E. Placenta accreta

    Which of the following is most likely to be present in drug screen of the pregnant patient with
    bright vaginal discharges?
    A. Marijuana
    B. Alcohol
    C. Barbiturates
    D. Cocaine
    E. Benzodiazepines

    Which of the following is the best management for this patient?


    A. Admission and careful observation in the ICU
    B. Induction of labor with plan for vaginal delivery
    C. Partial exchange transfusion
    D. Urgent cesarean delivery
    E. Intravenous terbutaline

    What is the most appropriate next step in management?


    A. Admit to antenatal unit for bed rest and betamethasone. !

    B. Admit to antenatal unit for bed rest and blood transfusion.


    C. Induction of labour
    D. Perform emergency cesarean section.

    What is the best course of action?


    A. Emergent cesarean section
    B. Fetal umbilical blood transfusion
    C. Expectant management
    D. Induction of labour with prost aglandins
    Which of the following is most likely a complication of this patient’s present condition?
    A. DIC
    B. IUGR
    C. Subarachnoid hemorrhage 26
    D. Vasa previa

    Which of the following is the most likely cause of this patients abnormal lab tests (International
    Normalized Ratio of 2.3, partial thromboplastin time of 48 seconds, D-dimer elevated,
    fibrinogen decreased)?
    A. Disruption of placenta and release of fetal tissue into circulation
    B. Liver failure
    C. Haemorrhagic shock
    D. Release of thromboplastin by damaged placenta
    E. Ruptured ectopic

    Which of the following is the most appropriate first step in management?


    A. Administer a tocolytic
    B. Administer a corticosteroid.
    C. Administer fresh frozen plasma.
    D. Deliver the fetus immediately by LSCS
    It
    E. Observe closely.

    Which of the following statements is accurate concerning postpartum hemorrhage?


    A. The blood loss at delivery approaches the volume of blood added during pregnancy.
    B. Studies show that estimated blood loss reported is often less than the actual blood loss.
    C. The WHO defines postpartum hemorrhage as cumulative blood loss of >100 mL
    accompanied by symptoms and signs of hypovolemia.
    D. None of the above

    Which of the following is true concerning placental abruption?


    A. It may lead to a dilutional coagulopathy.
    B. Concealed abruption forces thromboplastin into large veins draining the implantation site.
    C. In most women with abruption severe enough to kill the fetus, the plasma fibrinogen level
    will be less than 150 mg/dL.
    D. All of the above

    How is a low-lying placenta defined?


    A. The placenta is implanted in the lower uterine segment.
    B. The placental edge covers the internal os, but not completely.
    C. The placental edge does not cover the internal os but lies within a 1-cm wide perimeter.
    D. The placental edge does not cover the internal os but lies within a 2-cm wide perimeter.

    What percentage of women who have a primary cesarean with a placenta previa have
    hysterectomies
    performed?
    A. 1%
    B. 2%
    C. 6%
    D. 10%

    Which of the statements below accurately depicts the difference between consumptive
    coagulopathy and disseminated intravascular coagulation?
    A. Abruption best represents a consumptive coagulopathy.
    B. Loss of procoagulants with massive hemorrhage is the basis of dilutional coagulopathy.
    C. A concealed abruption forces thromboplastin into the circulation and leads to the
    consumption of procoagulants.
    D. All of the above

    Which of the bacteria below are associated with consumptive coagulopathy?


    A

    A. Escherichia coli
    B. Klebsiella pneumoniae
    C. Group A streptococcus
    D. Group B streptococcus
    The use of whole blood for massive hemorrhage is supported by which of the following?
    A. Less renal failure
    B. Less pulmonary edema
    C. Fewer intensive care unit admissions
    D. All of the above
    PICTURES!!!
    1. Placenta previa
    2. Placenta accreta
    3. Couvelaire uterus
    Postpartum Haemorrhage

    » What is the most likely diagnosis?


    A. Retained placenta
    B. Genital tract laceration
    C. Uterine atony
    D. Uterine inversion
    » What is the most likely complication to occur in this patient?
    A. Postpartum hemorrhage
    B. Uterine laceration
    C. Coagulopathy
    D. Hysterectomy
    » Which of the following placental implantation sites would most likely predispose to an
    inverted uterus?
    A. Fundal
    B. Anterior
    C. Posterior
    D. Lateral
    E. Lower segment
    » What is the most likely complication to occur in this patient?
    A. Postpartum hemorrhage
    B. Uterine laceration
    C. Coagulopathy
    D. Hysterectomy
    » Which of the following is patient possible diagnosis?
    A. Placenta accreta
    B. Placental abruption
    C. Placenta previa
    D. Placental polyp
    » Which of the following would be the next step for this patient?
    A. Initiate oxytocin
    B. Wait for an additional 30 minutes
    C. Hysterectomy
    D. Attempt a manual extraction of the placenta
    E. Misoprostol estrogen intravaginally
    » Which of the following is the best explanation of the mechanism of hemorrhage?
    A. Inverted uterus stretches the uterus, causing trauma to blood vessels leading to bleeding.
    B. Inverted uterus leads to inability for an adequate myometrial contraction effect.
    C. Inverted uterus causes a local coagulopathy reaction to the uterus and endometrium.
    D. Inverted uterus causes muscular abrasions and lacerations leading to bleeding.
    » Which of the following is the most likely further complication?
    A. Uterine atony
    B. Cervical infection
    C. Vaginal haematoma
    D. Coagulopathic bleeding
    » What is the most likely diagnosis?
    A. Retained placenta
    B. Genital tract laceration
    C. Uterine atony
    D. Uterine inversion
    » What is the next step in therapy?
    A. Uterotonics, uterine massage
    B. Hypogastric artery ligation
    C. Supracervical hysterectomy
    D. Ligation of the external iliac artery
    E. Cervical cerclage
    » Which of the following is the most common etiology for the bleeding in this patient?
    A. Retained placenta
    B. Genital tract laceration
    C. Uterine atony
    D. Coagulopathy
    E. Endometrial ulceration
    » Which of the following is the best therapy?
    A. Immediate hysterectomy
    B. Packing of the uterus
    C. Hypogastric artery ligation
    D. Ligation of utero-ovarian ligaments
    E. Fresh frozen plasma transfusion
    Which of the following is the most likely cause of hemorrhage in this patient?
    A. Uterine atony
    B. Uterine laceration
    C. Coagulopathy
    D. Uterine inversion
    E. Retained placenta

    Which of the following is most appropriate to achieve the therapeutic goals?


    A. Utero-ovarian ligament ligation
    B. Hypogastric artery ligation
    C. Supracervical hysterectomy
    D. Ligation of the external iliac artery
    E. Cervical cerclage
    Which of the following is the best therapy?
    A. Immediate hysterectomy
    B. Packing of the uterus
    C. Hypogastric artery ligation
    D. Ligation of utero-ovarian ligaments
    E. Correction of coagulopathy
    Which of the following is the most likely diagnosis?
    A. Uterine atony
    B. Cervical laceration
    C. Vaginal laceration
    D. Subinvolution of the uterus
    E. Normal menses
    Which of the following is the most accurate statement?
    A. Having two prior cesareans is associated with a 50% risk for placenta accreta.
    B. Placenta accreta is associated with a defect in the myometrial layer of the uterus.
    C. If the patient had gestational diabetes, the risk for placenta accreta would be even higher.
    D. The posterior placenta may be associated with less of a risk for accrete than an anterior
    placenta.
    Which of the following is the most likely diagnosis?
    A. Placenta accreta
    B. Placenta melanoma
    C. Placenta percreta
    D. Placental polyp
    Which of the following is the most likely complication after this intervention?
    A. Coagulopathy
    B. Utero-vaginal fistula
    C. Infection
    D. Malignant degeneration

    Which of the following statements is most likely to be correct regarding the risk of placental
    accreta?
    A. Her risk of accreta is most likely to be increased due to the myomectomy.
    B. Her risk of accreta is most likely to be decreased due to the myomectomy.
    C. Her risk of accreta is most likely not affected by the myomectomy.
    D. If the myomectomy incisions are anterior, then she has an increased risk of a placental
    polyp.
    ________________ From Willam’s Obstetrics 25th (Ch.41)_______________

    Which of the following statements is accurate concerning postpartum hemorrhage?


    a. The blood loss at delivery approaches the volume of blood added during pregnancy.
    b. Studies show that estimated blood loss reported is often less than the actual blood loss.
    -
    -

    c. The American College of Obstetricians and Gynecologists defines postpartum hemorrhage as


    cumulative blood loss of >100 mL accompanied by symptoms and signs of hypovolemia.
    d. None of the above

    Given the diagram below, which of the following statements is true?

    a. Very few vaginal deliveries have blood loss less than 500 mL.
    b. All cesarean hysterectomies have blood loss greater than 1000 mL.
    c. A smaller percentage of vaginal deliveries have blood loss greater than 1000 mL than cesarean
    hysterectomies have blood loss less than 500 mL.
    d. None of the above

    For a woman measuring 5′0″ and 120 lb, what is her expected pregravid blood volume?
    a. 3000 mL
    b. 3250 mL
    c. 3500 mL
    d. 3800 mL
    Assuming a 50% increase in the blood volume of a woman during pregnancy, what would the
    blood volume of a 5′2″ woman who weighed 140 lb pregravid be at term?
    a. 4000 mL
    b. 4340 mL
    c. 4700 mL
    d. 4930 mL

    Causes of uterine atony include which of the following?


    a. Obesity
    b. Placenta previa
    c. Multiple fetuses
    d. Placental abruption
    e. Previous urine infection

    Which of the following maneuvers should be performed in the setting of postpartum hemorrhage
    following a vaginal delivery?
    a. Evaluate birth canal for lacerations
    b. Evaluate the placenta for possible retained fragments
    c. The uterus should be manually explored, and placental fragments removed
    d. All of the above

    @Choose the correct use of the uterotonics:


    a. Ergot alkaloids for patients with hypertension
    b. Carboprost tromethamine in patients with mild asthma
    c. Dinoprostone for patients with diarrhea
    d. Oxytocin in patient with HIV infection

    What is represented in the following image?


    a. Bakri balloon
    b. Foley catheter
    c. Blakemore tube
    d. Jackson-Pratt drain

    ÷
    Which of the following maneuvers might have avoided to be performed for this patient after
    uterotonics are given?
    a. Evaluate birth canal for lacerations
    b. Evaluate the placenta for possible retained fragments
    c. The uterus should be manually explored, and placental fragments removed
    d. Hysterectomy

    The patient with uterine atony continues bleeding after the interventions mentioned above. Which
    of the following maneuvers might be employed while you are preparing for surgery?
    a. Cervical cerclage
    b. Uterine balloon placement (tamponade)
    c. Wait for an additional 30 minutes
    d. Transfusion of platelets
    e.
    What percentage of women have lacerations at the time of vaginal delivery?
    a. 50%
    b. 90%
    c. 80%
    d. 65%

    What is the appropriate management of vulvovaginal hematomas?


    a. Surgical exploration in all cases
    b. To prevent infection they should all undergo ultrasound guided drainage.
    c. In a small hematoma, if pain is severe then ice packs and analgesia are appropriate.
    d. If bleeding ceases, small to moderate-sized hematomas can be treated expectantly.

    The hematoma in the following picture is in which location?


    a. Ischiorectal hematoma
    b. Periurethral hematoma
    c. Supralevator hematoma
    d. Left-sided anterior perineal triangle

    What percentage of women who have a primary cesarean with a placenta previa have
    hysterectomies performed?
    a. 1%
    b. 2%
    c. 6%
    d. 10%

    What is depicted in the following picture?


    a. Placenta previa
    b. Placenta accreta
    c. Couvelaire uterus
    d. None of the above

    What is represented in the following image?


    The picture below represents which of the following placental
    pathologies?

    a. Placenta increta
    b. Placenta accreta
    c. Placenta percreta
    d. Placental abruption

    Which hemostatic surgical procedure is to be performed in the picture below?

    a. B-Lynch procedure
    b. Uterine artery ligation
    c. Vaginal artery ligation
    d. Ovarian artery ligation

    Which hemostatic surgical procedure is demonstrated in the picture below?


    a. B-Lynch procedure
    b. Uterine artery ligation
    c. Vaginal artery ligation
    d. Ovarian artery ligation
    Ligation at which of the following labeled vessel points in the retroperitoneum will decrease the
    pulse pressure in the uterine artery?

    a. Posterior division
    b. Internal iliac vein
    c. Internal iliac artery
    d. External iliac artery
    Which of the following is a potential indication for a classical hysterotomy, as shown
    below?

    a. Maternal morbid obesity


    b. Densely adherent bladder
    c. Back-down transverse fetal lie
    d. All of the above

    Which of the following is a disadvantage of uterine exteriorization for repair of the


    hysterotomy, as show
    below?

    a. Increased blood loss


    b. Increased febrile morbidity
    c. Increased nausea and vomiting
    d. Increased postoperative infection

    During cesarean delivery a hysterotomy is made in the


    lower uterine segment, as shown here. In which of the
    following settings should the incision be made relatively
    higher on the uterus to avoid uterine vessel laceration or
    unintended entry into the vagina?

    a. Maternal anemia
    b. Fetal malpresentation
    c. A completely dilated cervix
    d. Cesarean performed prior to onset of labor

    Compared with manual extraction, spontaneous delivery


    of the placenta with fundal massage, as shown below, has
    been shown to reduce the risk of which complication?

    a. Retained placenta
    b. Postpartum infection
    c. Deep-vein thrombosis
    d. Amniotic fluid embolism
    Preterm delivery

    » What is the most likely diagnosis?


    A. Preterm labor
    B. Suspected placental abruption
    C. Chorioamnionitis
    D. Intrauterine growth retardation
    E. Cervical incompetence
    » What is your next step in management?
    A. Expectant management
    B. Intramuscular corticosteroids
    C. Induction of labor
    D. Ultrasound-guided amniocentesis
    E. Tocolysis

    » What test of the vaginal fluid prior to digital examination may indicate risk for preterm
    delivery?
    A. Fetal fibronectin assay
    B. HPV positive status
    C. Group B streptococcus of the vagina
    D. Positive amniotest

    » What medication can be given to decrease the risk of neurological impairment in the baby?
    A. Magnesium sulfate may be given for pregnancies of <32 weeks when there is imminent
    delivery
    B. Intravenous antibiotics (ampicillin and gentamicin) and induction of labor
    C. Antenatal corticosteroids (usually betamethasone intramuscular) prior to delivery
    D. Intravenous heparin therapy for suspected placental insufficiency
    E. Indomethacin for closure of ductus arteriosus

    » What screening test need to be provided to estimate the risk for preterm delivery?
    A. Fetal fibronectin assay
    B. Cervical length <25 mm on ultrasound
    C. HPV positive status
    D. Recent laparotomy
    E. Uterine fibroids

    » In screening for various types of infection, which of the following is most likely to be
    associated with preterm delivery?
    A. Herpes simplex virus
    B. Candida vaginitis
    C. Chlamydia cervicitis
    D. Gonococcal cervicitis
    E. Group B streptococcus of the vagina

    » Which one of the following is a contraindication for tocolysis?


    A. Suspected placental abruption
    B. Group B streptococcal bacteriuria
    C. Recent laparotomy
    D. Uterine fibroids

    » What medication can be given to decrease the risk of neurological impairment in the baby?
    A. Magnesium sulfate
    B. Broad-spectrum antibiotic
    C. IV heparin therapy
    D. IV furosemide
    E. Indomethacin.

    »Which of the following is the most likely tocolytic agent used in patient with tachypnea treated
    with terbutaline?
    A. Nifedipine
    B. Indomethacin
    C. Magnesium sulfate
    D. Terbutaline

    » What are reasons for tocolysis in case of preterm contractions?


    A. Prolong time to delivery
    B. Delay labour in order for the steroids to be maximally effective
    C. To settle contractions for in utero transfer of the mother to a tertiary unit
    D. Increase the chance for natural birth

    » What is the most likely diagnosis (PPROM and fever)?


    A. Intra-Amniotic Infection
    B. Thrombophlebitis
    C. Preterm labor
    D. Cervicitis

    » What is the best management for this patient (PPROM and fever)?
    A. Intravenous antibiotics
    B. Expectant management
    C. Intramuscular corticosteroids
    D. Induction of labor
    E. Ultrasound-guided amniocentesis
    F. Tocolysis

    » What is the most likely etiology of PPROM?


    A. Deep venous thrombosis
    B. Uterine fibroids
    C. Ascending infection from vagina
    D. Gestational hypertension

    » Which of the following statements is correct?


    A. Magnesium sulfate should be given for neuroprotectionin all cases.
    B. Broad-spectrum antibiotic therapy is indicated only with maternal fever.
    C. Labor is the most common acute complication to be expected.
    D. Vaginal candidiasis is a risk factor for preterm premature rupture of membranes.

    » Which of the following is the most accurate method to confirm the intra-amniotic infection?
    A. Serum maternal leukocyte count
    B. Speculum examination of the vaginal discharge
    C. Amniotic fluid Gram stain by amniocentesis
    D. Palpation of the maternal uterus
    E. Height of oral temperature

    »Which of the following organisms is most likely to be the underlying etiology of a preterm
    delivery in case of clinical presentation of intraamniotic infection without PPROM?
    A. Group B streptococci
    B. Listeria monocytogenes
    C. Clostridia difficile
    D. Chlamydia trachomatis
    E. Escherichia coli

    »Which of the following is the next step?


    A. Expectant management
    B. Intramuscular corticosteroids
    C. Induction of labor
    D. Ultrasound-guided amniocentesis

    »Which of the following is most likely to be seen?


    A. Early decelerations
    B. Late decelerations
    C. Variable decelerations
    D. Sinusoidal heart rate pattern

    What is the definition of very low birthweight? (W25th)


    A. <500 grams
    B. 500 to 1000 grams
    C. 1000 to 1500 grams
    D. 1500 to 2500 grams

    What is the approximate survival rate for infant weighing 1090 grams and immediately taken to
    the neonatal intensive care unit for evaluation? (W25th)
    A. 80%
    B. 70%
    C. 95%
    D. 99%

    An infant born at 25 weeks’ gestation is at risk for all except which of the following
    complications?
    A. Asthma
    B. Blindness
    C. Blood cancers
    D. Pulmonary hypertension

    Of the responses listed below, which complication is most commonly associated with preterm
    delivery?
    A. Hypertension
    B. Fetal complications
    C. Placental abruption
    D. None of the above
    Which of the following placental hormones may play a role in preterm birth caused by maternal–
    fetal stress?
    A. Estrogen
    B. Human placental lactogen
    C. Insulin-like growth hormone
    D. Corticotropin-releasing hormone

    Which of the following bacteria may enhance the risk for preterm birth by secretion of
    hyaluronidase?
    A. Escherichia coli
    B. Peptostreptococcus
    C. Bacterial vaginosis
    D. Group B streptococcus

    Which of the following bacteria is frequently detected in the amnionic fluid of women with
    preterm labor?
    A. Mycoplasma hominis
    B. Gardnerella vaginalis
    C. Ureaplasma urealyticum
    D. All of the above

    Which of the following is true regarding transvaginal sonographic evaluation of the cervix as a
    part of the assessment for preterm labor?
    A. It can be performed any time after 14 weeks’ gestation.
    B. It is not affected by maternal obesity, cervix position, or shadowing.
    C. The FIGO recommends it for all women with a history of a spontaneous preterm birth.
    D. All of the above

    Which of the following neonatal outcomes was potentially improved following antimicrobial
    therapy for pregnant woman with premature rupture of membranes before 35 weeks’ gestation?
    A. Improved survival
    B. Decreased risk for sepsis
    C. Decreased risk for intracranial hemorrhage
    D. Decreased risk for respiratory distress syndrome

    Which of the following is a potential consequence of bed rest for suspected preterm labor?
    A. Bone loss
    B. Venous thromboembolism
    C. Increased risk for preterm delivery
    D. All of the above

    Which of the following is true regarding indomethacin use in pregnancy?


    A. It can only be administered orally
    B. It can lead to reversible oligohydramnios
    C. It lowers the risk for necrotizing enterocolitis
    D. All of the above

    Cesarean delivery would be expected to decrease the risk for intracranial hemorrhage in which
    of the following scenarios?
    A. Estimated fetal weight <1000 grams
    B. Estimated fetal weight <1500 grams
    C. Estimated fetal weight <2000 grams
    D. None of the above
    Puerperium.
    » Which of the following is the most significant risk factor in this patient?
    A. Numerous vaginal examinations
    B. Bacterial vaginosis
    C. Cesarean delivery
    D. Internal uterine pressure monitors
    E. Prolonged rupture of membranes
    » What is the best therapy for the condition?
    A. Initiation of intravenous antibiotics with anaerobic coverage
    B. Initiation of intravenous heparin
    C. Placement of a warm compress on the wound
    D. Opening of the wound
    » What is the best therapy for the condition?
    A. Initiation of intravenous antibiotics with anaerobic coverage
    B. Initiation of intravenous heparin
    C. Placement of a warm compress on the wound
    D. Opening of the wound
    » Which of the following is the most significant risk factor for postpartum endomyometritis?
    A. Numerous vaginal examinations
    B. Bacterial vaginosis
    C. Cesarean delivery
    D. Internal uterine pressure monitors
    E. Prolonged rupture of membranes
    » What is the best therapy for the condition?
    A. Initiation of intravenous antibiotics with anaerobic coverage
    B. Initiation of intravenous heparin
    C. Placement of a warm compress on the wound
    D. Opening of the wound
    » The patient who works in the microbiology laboratory asks which of the following is the most
    commonly isolated bacteria in her infection?
    A. Peptostreptococcus species
    B. Staphylococcus aureus
    C. Group B Streptococcus
    D. Escherichia coli
    » Which of the following is the most significant risk factor in this patient?
    A. Numerous vaginal examinations
    B. Bacterial vaginosis
    C. Cesarean delivery
    D. Internal uterine pressure monitors
    E. Prolonged rupture of membranes
    » Which of the following is the best therapy for this condition?
    A. Hysterectomy
    B. Discontinue antibiotic therapy and initiate intravenous heparin
    C. Continue antibiotic therapy and begin intravenous heparin
    D. Surgical embolectomy
    E. Streptokinase therapy
    » What is the most likely diagnosis?
    A. Abscess of the right breast
    B. Galactocele
    C. Inflammatory breast carcinoma
    D. Mastitis
    » What is your next step in therapy?
    A. Incision and drainage of the abscess
    B. Oral antibiotic therapy
    C. Oral antifungal therapy
    D. Bromocriptine therapy
    E. Mastectomy
    » What is the most likely diagnosis?
    A. Abscess of the left breast
    B. Galactocele
    C. Inflammatory breast carcinoma
    D. Mastitis
    » Which of the following is the best treatment for this condition?
    A. Oral antibiotic therapy
    B. Oral antifungal therapy
    C. Bromocriptine therapy
    D. Aspiration
    E. Mastectomy

    What duration of time is encompassed in the puerperium?


    a. 2–4 weeks
    b. 4–6 weeks
    c. 6–8 weeks
    d. 10–12 weeks

    What are myrtiform caruncles?


    a. Vaginal rugae
    b. Scarred tags of hymenal tissue
    c. A sexually transmitted infection
    d. Microscopic tears in the vaginal epithelium

    At what point in the puerperium does the endocervical canal reform?


    a. 1 week postpartum
    b. 2 weeks postpartum
    c. 3 weeks postpartum
    d. 4 weeks postpartum

    What percentage of women experience regression of high-grade dysplasia following delivery?


    a. 10%
    b. 33%
    c. 35%
    d. 50%

    How long does complete uterine involution take following delivery?


    a. 1 week
    b. 2 weeks
    c. 3 weeks
    d. 4 weeks
    Secondary postpartum hemorrhage is defined as uterine hemorrhage occurring during what
    timeframe after delivery?
    a. 24 hours to 6 weeks
    b. 48 hours to 6 weeks
    c. 24 hours to 12 weeks
    d. 48 hours to 12 weeks

    What are common features of the urinary bladder in the postpartum period?
    a. Increased capacity
    b. Incomplete emptying
    c. Insensitivity to intravesical pressures
    d. All of the above

    Which of the following physical exam signs or laboratory values would be most helpful to make
    a diagnosis of endometritis in one-day postpartum patient?
    a. Fundal tenderness
    b. An absolute neutrophilia
    c. White blood cell count of 25,000/µL
    d. All of the above
    After delivery, how long do cardiovascular parameters including cardiac output, heart rate, and
    blood pressure take to return to nonpregnant levels?
    a. 48 hours
    b. 72 hours
    c. 7 days
    d. 10 days

    By which time interval following delivery most women first approach their prepregnancy
    weight?
    a. 3 months
    b. 6 months
    c. 9 months
    d. 12 months

    How long would postoperative (primary cesarean delivery) patient will expect colostrum
    production before beginning her conversion to a more mature milk?
    a. 2 to 5 days
    b. 2 to 10 days
    c. 5 to 14 days
    d. 5 to 21 days

    What vitamin is virtually absent in human breast milk?


    a. Vitamin C
    b. Vitamin A
    c. Vitamin K
    d. All vitamins are equally represented in breast milk

    Which hormone is most responsible for milk expression during lactation?


    a. Prolactin
    b. Oxytocin
    c. Dopamine
    d. Progesterone

    How would you advise a patient who is exclusively breastfeeding 4 weeks after delivery and
    develops nipple fissures?
    a. Wash the area with mild soap and water daily.
    b. Apply a steroid cream and use a nipple shield temporarily.
    c. Continue exclusive breastfeeding without interruption.
    d. Do not allow infant to feed on the affected side and empty the breast regularly with a pump.

    All except which of the following conditions are contraindications to breastfeeding?


    a. Infant with galactosemia
    b. Maternal hepatitis B infection
    c. Human immunodeficiency virus infection
    d. Maternal active and untreated tuberculosis
    Which of the following is true regarding the postpartum blues?
    a. May be affected by body image concerns
    b. Usually lasts for no more than 10 days after delivery
    c. Effective treatment involves recognition and reassurance
    d. All of the above

    Injury to what nerve is the most likely cause of the patient’s bilateral foot drop on day 1
    following a labor with 3 hours of pushing in stirrups?
    a. Femoral nerve
    b. Ilioinguinal nerve
    c. Common peroneal nerve
    d. Lateral femoral cutaneous nerve
    What is the mean time to ovulation resumption in a postpartum woman who elects not to
    breastfeed?
    a. 4 weeks
    b. 5 weeks
    c. 6 weeks
    d. 7 weeks
    What contraceptive option would you not recommend for this postpartum patient?
    a. Progestin-only pills
    b. Estrogen-progestin patch
    c. Depot medroxyprogesterone
    d. A levonorgestrel intrauterine device

    Following an uncomplicated vaginal delivery, when can women be advised to resume coitus
    based on desire and comfort?
    a. 1 week postpartum
    b. 2 weeks postpartum
    c. 3 weeks postpartum
    d. 4 weeks postpartum

    What treatment can be offered to the postpartum woman who is exclusively breastfeeding and
    complains of vaginal dryness during intercourse 7 weeks following delivery?
    a. Topical estrogen
    b. Reassurance only
    c. Topical testosterone
    d. Intercourse is not recommended within the first
    8 weeks of delivery.

    Approximately what percentage of postpartum women require readmission to the hospital within
    8 weeks of delivery?
    a. <1%
    b. 3%
    c. 7%
    d. 10%

    4 weeks postpartum patient is overall doing well but complains of low energy levels despite
    the fact that her baby is sleeping for long intervals at night. What should you offer her?
    a. Reassurance only
    b. Psychiatry referral
    c. Check her thyroid hormone levels
    d. All of the above
    MEDICAL COMPLICATIONS

    Renal and Urinary Tract Disorders


    CASE MP- 1
    A 36-year-old G1P0 woman at 27 weeks’ gestation is noted to have fever, right flank
    tenderness, and pyuria. She is diagnosed with pyelonephritis. A urine culture is performed.
    » Which of the following is the most commonly isolated etiologic agent causing pyelonephritis in
    pregnancy?
    A. Proteus species
    B. Candida species
    C. Escherichia coli
    D. Klebsiella species
    » If patient does not improve on adequate antibiotic therapy for 48 hours and experiences continued
    severe flank tenderness and fever, which of the following should be next considered?
    A. Obstruction of the urinary tract
    B. Anaerobic organisms
    C. Hemolytic uremic syndrome
    D. Factitious fever
    » What severe condition is the most likely?
    A. Acute respiratory distress syndrome
    B. Septic shock
    C. Hemolytic uremic syndrome
    D. Factitious fever
    » Which of the following is the most common cause of this complication in pregnancy?
    A. Pelvic inflammatory disease
    B. Pyelonephritis
    C. Wound infection
    D. Mastitis

    ________________ From Willam’s Obstetrics 25th (Ch.53)_______________


    Which of the following is not a physiological change in pregnancy that contributes to the findings
    in the image below?

    a. Vesicoureteral reflux
    b. Glomerular hypertrophy
    c. Distal ureteral compression by the uterus
    d. Progesterone-induced relaxation of the muscularis

    Which of the following statements regarding physiological changes in pregnancy is true?


    a. Glomerular filtration decreases.
    b. Effective renal plasma flow increases.
    c. Serum creatinine concentration increases.
    d. The number of glomerular cells increases.

    Which of the following is the threshold for proteinuria in pregnancy, above which levels are
    considered
    abnormal?
    a. 100 mg/d
    b. 250 mg/d
    c. 300 mg/d
    d. 1000 mg/d

    Which of the following values is not a normal serum creatinine in pregnancy?


    a. 0.4 mg/dL
    b. 0.6 mg/dL
    c. 0.8 mg/dL
    d. 1.0 mg/dL

    A pregnant patient who previously donated a kidney and now has only one healthy kidney is at risk
    for
    which of the following obstetric complications?
    a. Placenta previa
    b. Normocytic anemia
    c. Gestational hypertension
    d. Preterm premature rupture of membranes

    Which of the following is an acceptable treatment regimen for newly diagnosed asymptomatic
    bacteriuria in pregnancy?
    a. Nitrofurantoin 100 mg by mouth at bedtime for 10 days
    b. Ampicillin 250 mg by mouth four times per day for one day
    c. Trimethoprim-sulfamethoxazole 160/800 mg by mouth one time
    d. Nitrofurantoin 100 mg by mouth four times daily for 21 days

    Lower urinary tract symptoms with pyuria but a sterile urine culture are likely due to which
    pathogen?
    a. Escherichia coli
    b. Proteus mirabilis
    c. Klebsiella pneumoniae
    d. Chlamydia trachomatis

    What is the leading cause of septic shock during pregnancy?


    a. Pneumonia
    b. Breast abscess
    c. Pyelonephritis
    d. Chorioamnionitis

    In the setting of aggressive fluid hydration, what percentage of pregnant women with pyelonephritis
    develop acute kidney injury?
    a. 5%
    b. 10%
    c. 15%
    d. 20%

    Once you have treated a pregnant patient for pyelonephritis as an inpatient, for how long should
    you
    continue oral therapy as an outpatient?
    a. 1–3 days
    b. 3–5 days
    c. 7–14 days
    d. 14–21 days

    What percentage of pregnant women experience a recurrent urinary tract infection after completion
    of
    treatment for pyelonephritis?
    a. 5–10%
    b. 10–20%
    c. 30–40%
    d. 50–60%

    Which of the following does not characterize nephrotic syndromes?


    a. Edema
    b. Heavy proteinuria
    c. Hyperalbuminemia
    d. Hypercholesterolemia

    Which of the following complications is not increased in pregnant patients with nephrotic
    syndrome?
    a. Anemia
    b. Preeclampsia
    c. Renal insufficiency
    d. Postterm pregnancy

    Which of the following is most likely to lead to end-stage renal disease?


    a. Diabetes
    b. Hypertension
    c. Glomerulonephritis
    d. Polycystic kidney disease
    ________________________________________________________________________________
    ___
    Hematological Disorders

    CASE MP-3
    A 30-year-old G1P0 woman complains of nausea and vomiting for the first 3 months of her
    pregnancy. On examination, her blood pressure (BP) is 110/70 mm Hg, heart rate (HR) 83 beats per
    minute (bpm), and she is afebrile. The thyroid gland appears normal on palpation. The heart and
    lung examinations are unremarkable. The fundus is at the symphysis level. The evaluation of the
    anemia includes: hemoglobin level of 9.0 g/ dL and a mean corpuscular volume of 110 fL (normal
    90-105 fL).

    » Which of the following is the most likely etiology of the anemia?


    A. Iron deficiency
    B. Folate deficiency
    C. Vitamin B12 deficiency
    D. Physiologic anemia of pregnancy
    E. Acute blood loss anemia
    F. Anemia of chronic disease

    CASE MP-4
    A 29-year-old G2P1 woman at 28 weeks’ gestation, who had normal hemoglobin level 4 weeks ago
    at her first prenatal visit, complains of 1 week of fatigue. Her antenatal history is unremarkable
    except for a urinary tract infection treated with an antibiotic 1 weeks ago. On examination, her
    blood pressure (BP) is 100/60 mm Hg, heart rate (HR) 90 beats per minute (bpm), and she is
    afebrile. The thyroid gland appears normal on palpation. The heart and lung examinations are
    unremarkable. The fundal height is 26 cm. The fetal heart tones are in the 140- to 150-bpm range.
    The evaluation of the anemia includes: hemoglobin level of 7.0 g/ dL and a mean corpuscular
    volume of 100 fL (normal 90-105 fL). She noted dark-colored urine after taking an antibiotic for a
    urinary tract infection.

    » Which of the following is the most likely diagnosis?


    A. Iron deficiency anemia
    B. Thalassemia
    C. Hemolysis
    D. Folate deficiency
    E. Vitamin B12 deficiency
    » Which of the following would you advise based on her clinical status?
    A. Transfusion of 2 units of blood (NOT SURE!!!)
    B. Repeat a complete blood count emergently
    C. Three months of iron supplementation at discharge
    D. All of the above

    ________________ From Willam’s Obstetrics 25th (Ch.56)_______________

    What hemoglobin value is used to define anemia in the second trimester of pregnancy?
    a. 9.5 g/dL
    b. 10.0 g/dL
    c. 10.5 g/dL
    d. 11.0 g/dL
    Which of the following adverse pregnancy outcomes is associated with anemia in pregnancy?
    a. Stillbirth
    b. Preeclampsia
    c. Preterm birth
    d. All of the above

    What is the maternal iron requirement in pregnancy for a typical singleton gestation?
    a. 500 mg
    b. 800 mg
    c. 1000 mg
    d. 1200 mg

    If you repeat a complete blood count one week after starting iron therapy, what would you expect to
    see if she is compliant with taking her iron?
    A. A 20% rise in her hematocrit
    B. An elevated reticulocyte count
    C. An increase in red cell distribution width
    D. An increase in the mean corpuscular volume

    Based on the picture below, what additional symptom is she most likely to complain of?

    a. Dry skin
    b. Anorexia
    c. Hair loss
    d. Excessive perspiration

    Which of the following is not a cause of vitamin B12 deficiency encountered in pregnancy?
    a. Crohn disease
    b. Ulcerative colitis
    c. History of Roux-en-Y gastric bypass
    d. Prior ileal resection following trauma

    Which of the following is true regarding paroxysmal nocturnal hemoglobinuria?


    a. Hemoglobinuria develops at irregular intervals
    b. Almost half of patients suffer venous thromboses
    c. Often precipitated by transfusions, infection or surgery
    d. All of the above

    Which of the following obstetric complications is not increased in the context of sickle-cell disease
    in pregnancy?
    a. Stillbirth
    b. Preeclampsia
    c. Gestational diabetes
    d. Fetal-growth restriction

    Thrombocytopenia, defined as a platelet count <150,000/µL, complicates what percentage of


    pregnancies?
    a. 1%
    b. 3%
    c. 5%
    d. 10%

    Which of the following treatments would you consider as first-line therapy for the 29 weeks
    pregnant patient with idiopathic thrombocytopenic purpura and platelet count 21,000/µL?
    a. Splenectomy
    b. Azathioprine
    c. Corticosteroids
    d. Intravenous immune globulin

    What determines the factor VIII activity level in women affected with hemophilia A?
    a. Mosaicism
    b. Lyonization
    c. Co-dominance
    d. None of the above

    What is the incidence of postpartum hemorrhage in women with von Willebrand disease?
    a. 10%
    b. 30%
    c. 50%
    d. 70%

    Diabetes Mellitus

    CASE MP - 5
    A woman attends the antenatal day assessment unit to discuss the result of her glucose tolerance
    test. She is 42 years old and this is her sixth pregnancy. She has previously had three caesarean
    sections, one early miscarriage and a termination of pregnancy. All booking tests were normal as
    were her 11–14-week and anomaly ultrasound scans. She is now 26 weeks’ gestation and her
    midwife arranged a glucose tolerance test because of a family history of type 2 diabetes (her father
    and paternal aunt). Her body mass index (BMI) is 31 kg/m2. Blood pressure is 146/87 mmHg. The
    symphysiofundal height is 29 cm and the fetal heart rate is normal on auscultation.
    Her urinalysis shows glycosuria ++. Glucose tolerance test (75 g glucose drink): Pretest fasting
    blood glucose: 6.4 mmol/, 2 h blood glucose following glucose load: 11.2 mmol/L

    » What is the diagnosis?


    A. Gestational diabetes mellitus
    B. Type 1 diabetes
    C. Type 2 diabetes
    D. Transient glycosuria

    » Which of the following is a risk factor in pregnant women for impaired carbohydrate metabolism?
    A. Family history of diabetes
    B. Previous infant with polycystic kidney disease
    C. High serum levels of antiphospholipid antibodies
    D. All of the above
    » What further investigations need to be arranged?
    A. Retinal assessment if not performed in last 12 months
    B. 50-g oral glucose tolerance test
    C. Serum total cholesterol level
    D. Quad screen to assess fetal risk of aneuploidy and neural-tube defect

    » Outline the principles of management of the pregnancy.


    A. Reduction of maternal insulin regime
    B. Aim to keep fasting blood glucose between 3.5 and 5.9 mmol/L
    C. Folate supplementation
    D. Labor induction at 38 weeks’ gestation

    ________________ From Willam’s Obstetrics 25th (Ch.57)_______________


    What does in utero exposure to hyperglycemia lead to?
    a. Increase fetal fat cells
    b. Fetal hyperinsulinemia
    c. Insulin resistance in adolescence
    d. All of the above

    How is diabetes classified during pregnancy?


    a. Type 1 or type 2
    b. Pregestational or gestational
    c. Type 1, type 2, or gestational
    d. Using the White classification

    Which of the following findings are considered diagnostic for overt diabetes in pregnancy?
    a. Hemoglobin A1C >6%
    b. Glucosuria on urine dip
    c. Fasting plasma glucose ≥120 mg/dL
    d. Random plasma glucose ≥200 mg/dL

    Fetuses of overtly diabetic mothers have an increased risk for which of the following?
    a. Preterm delivery
    b. Spontaneous abortion
    c. Congenital malformation
    d. All of the above

    How does diminished fetal growth occur in pregestational diabetes?


    a. Substrate deprivation
    b. Fetal hyperinsulinemia
    c. Altered lipid metabolism
    d. All of the above

    Compared to women without diabetes, which fetal condition occurs more often in the setting of
    pregestational diabetes?
    a. Stillbirth
    b. Perinatal death
    c. Postpartum hemorrhage
    d. Gestational hypertension

    What might be said of the pregnancy yielding 5000-g newborn?


    a. The mother likely had poor glycemic control.
    b. The baby was at risk for neonatal hypoglycemia.
    c. The mother had an increased risk for shoulder dystocia.
    d. All of the above

    Which of the following are considered reasons for unexplained fetal demise in women requiring
    insulin during pregnancy?
    a. Nonketotic acidosis
    b. Elevated lactic acid levels
    c. Decreased fetal hematocrit
    d. None of the above

    Which of the following is a reasonable explanation for hydramnios in a pregnancy complicated by


    diabetes?
    a. Maternal endothelial leak caused by hyperglycemia
    b. Glucose reabsorption by the fetal glomerular collecting system
    c. Osmotic gradient created by high glucose concentrations in the amnionic fluid
    d. All of the above

    What is the most likely cause for the increased incidence of respiratory distress syndrome in the
    neonates of diabetic mothers?
    a. Indicated preterm delivery
    b. Delayed maturation of type II pneumocytes
    c. Decreased production of surfactant in a hyperglycemic environment
    d. All of the above

    Which of the following statements regarding cardiomyopathy in infants of diabetic mothers is true?
    a. Is reversible after birth
    b. Ventricular hypertrophy is due to insulin excess
    c. In severe cases may lead to pulmonary hypertension
    d. In the first trimester systolic dysfunction is already present

    Which of the following is true concerning management of overt maternal diabetes in the second
    trimester?
    a. Should undergo amniocentesis
    b. Should undergo a fetal echocardiogram
    c. Have higher rates of chromosomal abnormalities
    d. Should be offered genetic screening if >35 years of age

    All except which of the following statements regarding hypocalcemia in the newborn is accurate?
    a. Defined as <9 mg/dL
    b. Etiology is unexplained
    c. May be related to preterm birth
    d. Seen more often with strict glucose control

    Maternal mortality in women with type 1 diabetes results from which of the following?
    a. Infection
    b. Hypertension
    c. Diabetic ketoacidosis
    d. All of the above

    The first and most common visible retinal lesions in diabetes are small microaneurysms followed
    by blot hemorrhages. This describes which of the following
    conditions?
    a. Proliferative retinopathy
    b. Nonproliferative retinopathy
    c. Is irreversible with improved control
    d. The etiology of cotton wool exudates

    What is the most important component of diabetic ketoacidosis treatment in pregnancy?


    a. Restore euglycemia
    b. Provide intravenous hydration
    c. Provide intravenous potassium repletion
    d. Provide intravenous bicarbonate to correct acidosis

    Which of the following infections is increased in pregnant women with overt diabetes?
    a. Pyelonephritis
    b. Respiratory infections
    c. Wound infection after cesarean delivery
    d. All of the above

    The most difficult aspect of preconceptional control in women with diabetes is which of the
    following?
    a. Resistance to insulin therapy
    b. Unpredictable insulin requirements
    c. Half of pregnancies in the United States are unplanned
    d. All of the above

    Women with type 1 diabetes should achieve glycemic control with which of the following during
    pregnancy?
    a. Insulin
    b. Diet alone
    c. Insulin and diet
    d. Oral hypoglycemic agents

    Which of the following is associated with fasting blood glucose levels >120 mg/dL (6.7 mmol/l)?
    a. Preeclampsia
    b. Cesarean delivery
    c. Birthweight >90th percentile
    d. All of the above
    Which of the following is a potential indication for a classical hysterotomy, as shown
    below?

    a. Maternal morbid obesity


    b. Densely adherent bladder
    c. Back-down transverse fetal lie
    d. All of the above

    Which of the following is a disadvantage of uterine exteriorization for repair of the


    hysterotomy, as show below?

    a. Increased blood loss


    b. Increased febrile morbidity
    c. Increased nausea and vomiting
    d. Increased postoperative infection

    During cesarean delivery a hysterotomy is made in the lower uterine segment, as shown
    here. In which of the following settings should the incision be made relatively higher on the
    uterus to avoid uterine vessel laceration or unintended entry into the vagina?

    a. Maternal anemia
    b. Fetal malpresentation
    c. A completely dilated cervix
    d. Cesarean performed prior to onset of labor

    Compared with manual extraction, spontaneous delivery of the placenta with fundal
    massage, as shown below, has been shown to reduce the risk of which complication?
    a. Retained placenta
    b. Postpartum infection
    c. Deep-vein thrombosis
    d. Amniotic fluid embolism

    Postpartum Haemorrhage

    CASE PPH-1:After a 4-hour labor, a 31-year-old G4P3 woman undergoes an uneventful vaginal
    delivery of a 7lb 8oz (3.4 kg) infant over an intact perineum. During her labor, she is noted to have
    mild variable decelerations and accelerations that increase 20 beats per minute (bpm) above the
    baseline heart rate. At delivery, the male baby has Apgar scores of 8 at 1 minute, and 9 at 5 minute.
    Slight lengthening of the cord occurs after 28 minutes along with a small gush of blood per vagina.
    As the placenta is being delivered, a shaggy, reddish, bulging mass is noted at the introitus around
    the placenta.

    » What is the most likely diagnosis?


    E. Retained placenta
    F. Genital tract laceration
    G. Uterine atony
    H. Uterine inversion
    » What is the most likely complication to occur in this patient?
    A. Postpartum hemorrhage
    B. Uterine laceration
    C. Coagulopathy
    D. Hysterectomy

    CASE PPH-2: A 23-year-old G1P0 woman at 38 weeks’ gestation delivered a 7lb 4oz (3.170 kg)
    baby boy vaginally. Upon delivery of the placenta, there was noted to be an inverted uterus, which
    was successfully managed including replacement of the uterus.

    » Which of the following placental implantation sites would most likely predispose to an inverted
    uterus?
    E. Fundal
    F. Anterior
    G. Posterior
    H. Lateral
    I. Lower segment
    » What is the most likely complication to occur in this patient?
    A. Postpartum hemorrhage
    B. Uterine laceration
    C. Coagulopathy
    D. Hysterectomy

    CASE PPH-3: A 24-year-old woman underwent a normal vaginal delivery of a term infant female.
    After the delivery, the placenta does not deliver even after 30 minutes.

    » Which of the following is patient possible diagnosis?


    A. Placenta accreta
    B. Placental abruption
    C. Placenta previa
    D. Placental polyp
    » Which of the following would be the next step for this patient?
    A. Initiate oxytocin
    B. Wait for an additional 30 minutes
    C. Hysterectomy
    D. Attempt a manual extraction of the placenta
    E. Misoprostol estrogen intravaginally

    CASE PPH-4:A 32-year-old G1P0 woman at 40 weeks’ gestation undergoes a normal vaginal
    delivery. Delivery of the placenta is complicated by an inverted uterus, with subsequent hemorrhage
    leading to 1500 mL of blood loss. She is managed with a transfusion of erythrocytes.

    » Which of the following is the best explanation of the mechanism of hemorrhage?


    A. Inverted uterus stretches the uterus, causing trauma to blood vessels leading to bleeding.
    B. Inverted uterus leads to inability for an adequate myometrial contraction effect.
    C. Inverted uterus causes a local coagulopathy reaction to the uterus and endometrium.
    D. Inverted uterus causes muscular abrasions and lacerations leading to bleeding.
    » Which of the following is the most likely further complication?
    E. Uterine atony
    F. Cervical infection
    G. Vaginal haematoma
    H. Coagulopathic bleeding

    CASE PPH-5:A 29-year-old parous (G5P4) woman at 39 weeks’ gestation with preeclampsia
    delivers vaginally. Her prenatal course has been uncomplicated except for asymptomatic bacteriuria
    caused by Escherichia coli in the first trimester treated with oral cephalexin. She denies a family
    history of bleeding diathesis. After the placenta is delivered, there is appreciable vaginal bleeding
    estimated at 1000 ml. Under palpation uterus appears to be soft and on the level of umbilicus.

    » What is the most likely diagnosis?


    A. Retained placenta
    B. Genital tract laceration
    C. Uterine atony
    D. Uterine inversion
    » What is the next step in therapy?
    A. Uterotonics, uterine massage
    B. Hypogastric artery ligation
    C. Supracervical hysterectomy
    D. Ligation of the external iliac artery
    E. Cervical cerclage

    CASE PPH-6: A 26-year-old G2P1001 woman underwent a normal vaginal delivery. A viable 7 lb 4
    oz (3.4 kg) male infant was delivered. The placenta delivered spontaneously. The obstetrician noted
    significant blood loss from the vagina, totaling approximately 700 mL. The uterine fundus appeared
    to be well contracted.

    » Which of the following is the most common etiology for the bleeding in this patient?
    A. Retained placenta
    B. Genital tract laceration
    C. Uterine atony
    D. Coagulopathy
    E. Endometrial ulceration

    CASE PPH-7
    A 34-year-old woman is noted to have significant uterine bleeding after a vaginal delivery
    complicated by placenta abruption. She is noted to be bleeding from multiple venipuncture sites.

    » Which of the following is the best therapy?


    A. Immediate hysterectomy
    B. Packing of the uterus
    C. Hypogastric artery ligation
    D. Ligation of utero-ovarian ligaments
    E. Fresh frozen plasma transfusion
    Which of the following is the most likely cause of hemorrhage in this patient?
    A. Uterine atony
    B. Uterine laceration
    C. Coagulopathy
    D. Uterine inversion
    E. Retained placenta

    Which of the following is most appropriate to achieve the therapeutic goals?


    E. Utero-ovarian ligament ligation
    F. Hypogastric artery ligation
    G. Supracervical hysterectomy
    H. Ligation of the external iliac artery
    I. Cervical cerclage

    A 34-year-old woman is noted to have significant uterine bleeding after a vaginal


    delivery complicated by placenta abruption. She is noted to be bleeding from
    multiple venipuncture sites.Which of the following is the best therapy?
    A. Immediate hysterectomy
    B. Packing of the uterus
    C. Hypogastric artery ligation
    D. Ligation of utero-ovarian ligaments
    E. Correction of coagulopathy

    A 26-year-old G2P2 woman underwent a normal vaginal delivery 10 days previously. She
    comes into the doctor’s clinic complaining of a large amount of bright red bleeding
    beginning since 5 PM the previous day.
    Which of the following is the most likely diagnosis?
    A. Uterine atony
    B. Cervical laceration
    C. Vaginal laceration
    D. Subinvolution of the uterus
    E. Normal menses

    A 33-year-old G3P2002 woman who had two prior cesareans is currently at 38 weeks’
    gestation. She is noted to have a posterior placenta. On ultrasound, there is evidence of
    possible placenta accreta. The patient is counseled about the possible risk of need for
    hysterectomy.
    Which of the following is the most accurate statement?
    A. Having two prior cesareans is associated with a 50% risk for placenta accreta.
    B. Placenta accreta is associated with a defect in the myometrial layer of the uterus.
    C. If the patient had gestational diabetes, the risk for placenta accreta would be even higher.
    D. The posterior placenta may be associated with less of a risk for accrete than an anterior
    placenta.

    A 25-year-old woman at 34 weeks’ gestation is noted to have a placenta previa,


    after she presented with vaginal bleeding and has undergone sonography. At 37
    weeks, she has a scheduled cesarean. Upon cesarean section, bluish tissue
    densely adherent between the uterus and maternal bladder is noted.
    Which of the following is the most likely diagnosis?
    A. Placenta accreta
    B. Placenta melanoma
    C. Placenta percreta
    D. Placental polyp

    A 29-year-old G1P0 woman at 39 weeks’ gestation delivered vaginally. Her placenta does
    not deliver easily. A manual extraction of the placenta is attempted and the placenta
    seems to be adherent to the uterus. A hysterectomy is contemplated, but the patient
    refuses due to strongly desiring more children. The cord is ligated with suture as high as
    possible. The patient is given the option of methotrexate therapy.
    Which of the following is the most likely complication after this intervention?
    E. Coagulopathy
    F. Utero-vaginal fistula
    G. Infection
    H. Malignant degeneration

    A 32-year-old woman undergoes myomectomy for symptomatic uterine fibroids, all of


    which are subserosal. The endometrial cavity was not entered during the procedure.Which
    of the following statements is most likely to be correct regarding the risk of placental
    accreta?
    A. Her risk of accreta is most likely to be increased due to the myomectomy.
    B. Her risk of accreta is most likely to be decreased due to the myomectomy.
    C. Her risk of accreta is most likely not affected by the myomectomy.
    D. If the myomectomy incisions are anterior, then she has an increased risk of a placental polyp.
    ________________ From Willam’s Obstetrics 25th (Ch.41)_______________

    Which of the following statements is accurate concerning postpartum hemorrhage?


    a. The blood loss at delivery approaches the volume of blood added during pregnancy.
    b. Studies show that estimated blood loss reported is often less than the actual blood loss.
    c. The American College of Obstetricians and Gynecologists defines postpartum hemorrhage as
    cumulative blood loss of >100 mL accompanied by symptoms and signs of hypovolemia.
    d. None of the above

    Given the diagram below, which of the following statements is true?

    a. Very few vaginal deliveries have blood loss less than 500 mL.
    b. All cesarean hysterectomies have blood loss greater than 1000 mL.
    c. A smaller percentage of vaginal deliveries have blood loss greater than 1000 mL than cesarean
    hysterectomies have blood loss less than 500 mL.
    d. None of the above

    For a woman measuring 5′0″ and 120 lb, what is her expected pregravid blood volume?
    a. 3000 mL
    b. 3250 mL
    c. 3500 mL
    d. 3800 mL

    Assuming a 50% increase in the blood volume of a woman during pregnancy, what would the blood
    volume of a 5′2″ woman who weighed 140 lb pregravid be at term?
    a. 4000 mL
    b. 4340 mL
    c. 4700 mL
    d. 4930 mL

    Causes of uterine atony include which of the following?


    E. Obesity
    F. Placenta previa
    G. Multiple fetuses
    H. Placental abruption
    I. Previous urine infection

    Which of the following maneuvers should be performed in the setting of postpartum hemorrhage
    following a vaginal delivery?
    a. Evaluate birth canal for lacerations
    b. Evaluate the placenta for possible retained fragments
    c. The uterus should be manually explored, and placental fragments removed
    d. All of the above
    Choose the correct use of the uterotonics:
    a. Ergot alkaloids for patients with hypertension
    b. Carboprost tromethamine in patients with mild asthma
    c. Dinoprostone for patients with diarrhea
    d. Oxytocin in patient with HIV infection

    What is represented in the following image?

    a. Bakri balloon
    b. Foley catheter
    c. Blakemore tube
    d. Jackson-Pratt drain

    Which of the following maneuvers might have avoided to be performed for this patient after
    uterotonics are given?
    a. Evaluate birth canal for lacerations
    b. Evaluate the placenta for possible retained fragments
    c. The uterus should be manually explored, and placental fragments removed
    d. Hysterectomy

    The patient with uterine atony continues bleeding after the interventions mentioned above. Which of
    the following maneuvers might be employed while you are preparing for surgery?
    a. Cervical cerclage
    b. Uterine balloon placement (tamponade)
    c. Wait for an additional 30 minutes
    d. Transfusion of platelets (NOT SURE!!!!)

    What percentage of women have lacerations at the time of vaginal delivery?


    a. 50%
    b. 90%
    c. 80%
    d. 65%

    What is the appropriate management of vulvovaginal hematomas?


    a. Surgical exploration in all cases
    b. To prevent infection they should all undergo ultrasound guided drainage.
    c. In a small hematoma, if pain is severe then ice packs and analgesia are appropriate.
    d. If bleeding ceases, small to moderate-sized hematomas can be treated expectantly.

    The hematoma in the following picture is in which location?

    a. Ischiorectal hematoma b. Periurethral hematoma


    c. Supralevator hematoma
    d. Left-sided anterior perineal triangle

    What percentage of women who have a primary cesarean with a placenta previa have
    hysterectomies performed?
    a. 1%
    b. 2%
    c. 6%
    d. 10%

    What is depicted in the following picture?

    a. Placenta previa
    b. Placenta accreta
    c. Couvelaire uterus
    d. None of the above

    What is represented in the following image?


    The picture below represents which of the following placental pathologies?

    a. Placenta increta
    b. Placenta accreta
    c. Placenta percreta
    d. Placental abruption

    Which hemostatic surgical procedure is to be performed in the picture below?

    a. B-Lynch procedure
    b. Uterine artery ligation
    c. Vaginal artery ligation
    d. Ovarian artery ligation

    Which hemostatic surgical procedure is demonstrated in the picture below?


    a. B-Lynch procedure
    b. Uterine artery ligation
    c. Vaginal artery ligation
    d. Ovarian artery ligation

    Ligation at which of the following labeled vessel points in the retroperitoneum will decrease the
    pulse pressure in the uterine artery?

    a. Posterior division
    b. Internal iliac vein
    c. Internal iliac artery
    d. External iliac artery

    Preeclampsia

    CASE P-1
    A 19-year-old G1P0 woman at 29 weeks’ gestation arrives to the hospital because of severe
    dyspnea of 6 hours’ duration. Her prenatal course has been unremarkable, and she denies any
    medical problems. Her blood pressure (BP) is 160/114 mm Hg, heart rate (HR) is 105 beats per
    minute (bpm), respiratory rate (RR) is 40 breaths per minute and labored, and oxygen saturation is
    90%. The fetal heart tones are in the range of 140 bpm. A urine protein to creatinine ratio is 0.6.
    The serum alanine transaminase (ALT) is 84 IU/L (normal < 35) and aspartate transaminase (AST)
    is 90 IU/L (normal < 35). The prenatal records show the following:
    Gestational Age BP (mm Hg) Urine Protein FHT (bpm) Fundal Height (cm)
    8 weeks 100/60 0 140
    12 weeks 110/70 0 148
    16 weeks 100/76 0 150
    20 weeks 105/58 0 138 20
    26 weeks 130/89 1+ 142 25

    » What is the most likely diagnosis?


    E. HELLP syndrome
    F. Cardiac insufficiency
    G. Electrolyte abnormalities
    H. Aspiration
    I. Severe Preeclampsia

    » What is your immediate next step?


    F. Improve oxygenation
    G. Intravenous antihypertensive agents
    H. Platelet transfusion
    I. Intravenous immunoglobulin therapy
    J. Intravenous Mannitol

    CASE P-2
    A 18-year-old G1P0 woman at 28 weeks’ gestation is admitted to the hospital with a blood pressure
    of 160/ 110 mm Hg, elevated liver function tests, and a platelet count of 60 000/ µL. She complains
    of a severe headache.

    » Which of the following is the best management?


    E. Oral antihypertensive therapy
    F. Platelet transfusion
    G. Magnesium sulfate therapy and induction of labor
    H. Intravenous immunoglobulin therapy

    » Which of the following will be the most common mechanism if seizures appear in this patient?
    A. Electrolyte abnormalities
    B. Intracerebral hemorrhage
    C. Myocardial infarction
    D. Aspiration

    CASE P-3
    A 33-year-old woman at 29 weeks’ gestation is noted to have a blood pressure of 150/ 90 mm Hg
    and a protein/creatinine ratio of 0.6 (protein excretion is 300 mg in 24 hours). The platelet count,
    liver function tests, and creatinine are normal.

    » Which of the following is the best management for this patient?


    A. Induction of labor
    B. Cesarean section
    C. Antihypertensive therapy
    D. Expectant management

    » Which of the following findings is most likely present in this patient to necessitate delivery?
    E. Blood pressures persist in the range of 150/ 95 mm Hg
    F. The patient reaches 32 weeks’ gestation
    G. Patient develops pulmonary edema
    H. Repeat platelet count is 95 000/mm3

    CASE P-4
    On postpartum day 1, a 28-year-old G1P1 woman reports some headache and problems with her
    vision bilaterally. Her BP is 150/ 95 mm Hg and P/C ratio is 0.5. Her neurological examination is
    normal but her vision is impaired in both eyes.

    » Which of the following is the best next step?


    A. Antihypertensive agent
    B. IV Mannitol
    C. MRI of the brain
    D. CT imaging of the brain
    E. Ophthalmic eye drops to both eyes
    CASE P-5
    A 32-year-old G2P1 woman is at 35 weeks with chronic hypertension. The BP is in the 140/ 95
    range.
    » Which of the following is the best next step?
    A. Corticosteroids
    B. Antihypertensive agent
    C. Biophysical profile
    D. Magnesium sulfate and delivery
    E. Continued observation
    ​
    CASE P-6
    A 28-year-old G1P0 woman is at 30 weeks’ gestation with superimposed preeclampsia. The BP is
    150/ 100. The platelet count is 95 000 and LFT is 2× normal. BPP is 10/ 10.
    » Which of the following is the best next step?
    A. Corticosteroids
    B. Antihypertensive agent
    C. Biophysical profile
    D. Magnesium sulfate and delivery
    E. Continued observation

    CASE P-7
    A 30-year-old G2P1 woman is at 31 weeks with chronic hypertension, using oral labetolol. Her BP
    in the office is 160/95 and 162/90. The urine protein is negative.
    » Which of the following is the best next step?
    A. Corticosteroids
    B. Antihypertensive agent
    C. Biophysical profile
    D. Magnesium sulfate and delivery
    E. Continued observation

    CASE P-8
    A 24-year-old G3P2 woman at 34 weeks’ gestation is noted to have preeclampsia. The BP is 150/
    90 and P/ C ratio is 0.5. A fetal ultrasound shows the estimated fetal weight is at the 8th percentile.
    » Which of the following is the best next step?
    A. Corticosteroids
    B. Antihypertensive agent
    C. Biophysical profile

    What percentage of pregnancies are complicated by hypertension?


    e. 2–3%
    f. 4–5%
    g. 5–10%
    h. 10–20%

    What percentage of eclamptic seizures occur in women without significant proteinuria?


    J. 5–9%
    K. 10–17%
    L. 20–25%
    M. 30–33%

    What percentage of eclamptic seizures occur more than 48 hours after delivery?
    E. 2%
    F. 5%
    G. 10%
    H. 20%

    Many conditions and factors are associated with an increased risk for preeclampsia. Which of the
    following factors results in the greatest relative risk for a diagnosis of preeclampsia in the current
    pregnancy?
    A. Primigravida
    B. Advanced maternal age
    C. Systemic lupus erythematous
    D. History of preeclampsia in a prior pregnancy

    Which of the following is thought to play a significant role in the development of preeclampsia?
    e. Genetic factors
    f. Immunological factors
    g. Abnormal trophoblastic invasion
    h. All of the above

    Which of the following is not a pathophysiological change to the cardiovascular system seen in the
    setting of preeclampsia?
    E. Increased preload
    F. Decreased preload
    G. Increased afterload
    H. Endothelial activation

    Which statement best describes renal perfusion and glomerular filtration rates in women with
    preeclampsia that has not yet progressed to severe disease?
    J. Similar compared to normal pregnant values
    K. Increased compared to normal pregnant values
    L. Similar compared to normal nonpregnant values
    M. Decreased compared to normal nonpregnant values

    What is the underlying etiology of the proteinuria seen with preeclampsia?


    F. Increased capillary permeability
    G. Increased renal artery resistance
    H. Increased glomerular filtration rate
    I. Increased systemic vascular resistance

    Which of the following nutritional supplements has been shown to reduce the incidence of
    preeclampsia?
    F. Calcium
    G. Vitamin E
    H. Ascorbic acid
    I. None of the above

    Which of the following physiological responses is typically seen in preeclamptic patients?


    E. Increased production of nitric acid
    F. Increased sensitivity to angiotensin II
    G. Decreased reactivity to norepinephrine
    H. All of the above

    The typical blood volume of a gravida at term is 4500 mL. In patients with preeclampsia, which of
    the following would be the expected blood volume?
    E. 2500 mL
    F. 3200 mL
    G. 4500 mL
    H. 5000 mL

    Which of the following medical therapies has been associated with a modest decrease in the
    incidence of preeclampsia in women at increased risk?
    I. Aspirin
    J. Metformin
    K. Enoxaparin
    L. Heparin sulfate

    _________________From William’s Obstetric


    th
    25 _____________________________

    Many conditions and factors are associated with an increased risk for preeclampsia. Which of the
    following factors results in the greatest relative risk for a diagnosis of preeclampsia in the current
    pregnancy?
    a. Primigravida
    b. Advanced maternal age
    c. Systemic lupus erythematous
    d. History of preeclampsia in a prior pregnancy

    Which of the following is thought to play a significant role in the development of preeclampsia?
    a. Genetic factors
    b. Immunological factors
    c. Abnormal trophoblastic invasion
    d. All of the above

    Which of the following angiogenic factors are elevated in women who proceed to develop
    preeclampsia?
    a. sFlt-1
    b. PIGF
    c. VEGF
    d. TGF-β

    A 21-year-old primigravida presents at 36 weeks’ gestation with new-onset headache. Her blood
    pressure is 150/90 mm Hg, her serum creatinine is 0.8 mg/mL, AST is 32 U/L, and platelet count is
    28,000/µL. Which of the following criteria for severe preeclampsia is met?
    a. Hypertension
    b. Liver dysfunction
    c. Thrombocytopenia
    d. Elevated serum creatinine

    Which of the following is an indication for primary cesarean delivery without an attempt at
    induction?
    a. Malpresentation
    b. Unfavorable cervix
    c. Possible fetal thrombocytopenia
    d. None of the above

    Which statement best describes renal perfusion and glomerular filtration rates in women with
    preeclampsia that has not yet progressed to severe disease?
    a. Similar compared to normal pregnant values
    b. Increased compared to normal pregnant values
    c. Similar compared to normal nonpregnant values
    d. Decreased compared to normal nonpregnant values

    Patient is diagnosed with HELLP syndrome and undergoes an uncomplicated induction of labor.
    Her right upper quadrant pain persists, and a computed tomography scan of her abdomen/pelvis is
    completed with the findings as shown below. What is denoted by the asterisk (*)?

    a. Splenic infarction
    b. Intrahepatic infarction
    c. Subcapsular hematoma
    d. Periportal hemorrhagic necrosis

    A G3P2 at 16 weeks’ gestation presents to the emergency department complaining of vaginal


    bleeding. Her blood pressure is 148/96 mm Hg and she has 3+ proteinuria on a specimen obtained
    during bladder catheterization. Which of the following may explain the development of
    preeclampsia in this patient?
    a. Increased volume of chorionic villi
    b. Extensive remodeling of the spiral arterioles
    c. Increased invasion of extravillous trophoblastic tissue
    d. None of the above
    The following computed tomography image shows cerebral edema in a postpartum patient with
    hypertension, vision changes, and confusion. What associated morbidity is the patient at risk for?

    a. Hemiplegia
    b. Cystic leukomalacia
    c. Retinal artery occlusion
    d. Transtentorial herniation
    The below magnetic resonance imaging was performed postpartum. What is the most likely finding
    on imaging?

    a. Subdural hematoma
    b. Parenchymal hemorrhage
    c. Subarachnoid hemorrhage
    d. Posterior reversible encephalopathy syndrome

    Preterm delivery

    CASE PD-1
    A healthy 19-year-old G1P0 woman at 29 weeks’ gestation presents to the labor and delivery area
    complaining of intermittent abdominal pain. She denies leakage of fluid or bleeding per vagina. Her
    antenatal history has been unremarkable.
    She has been eating and drinking normally. On examination, her blood pressure (BP) is 110/70 mm
    Hg, heart rate (HR) is 90 beats per minute (bpm), and temperature is 99°F (37.2°C). The fetal heart
    rate tracing reveals a baseline heart rate of 120 bpm and a reactive pattern. Uterine contractions are
    occurring every 3 to 5 minutes. On pelvic examination, her cervix is 3 cm dilated, 90% effaced, and
    the fetal vertex is presenting at –1 station.

    » What is the most likely diagnosis?


    I. Preterm labor
    J. Suspected placental abruption
    K. Chorioamnionitis
    L. Intrauterine growth retardation
    M. Cervical incompetence

    » What is your next step in management?


    A. Expectant management
    B. Intramuscular corticosteroids
    C. Induction of labor
    D. Ultrasound-guided amniocentesis
    E. Tocolysis

    » What test of the vaginal fluid prior to digital examination may indicate risk for preterm delivery?
    e. Fetal fibronectin assay
    f. HPV positive status
    g. Group B streptococcus of the vagina
    h. Positive amniotest

    » What medication can be given to decrease the risk of neurological impairment in the baby?
    E. Magnesium sulfate may be given for pregnancies of <32 weeks when there is imminent
    delivery
    F. Intravenous antibiotics (ampicillin and gentamicin) and induction of labor
    G. Antenatal corticosteroids (usually betamethasone intramuscular) prior to delivery
    H. Intravenous heparin therapy for suspected placental insufficiency
    I. Indomethacin for closure of ductus arteriosus

    CASE PD-2
    A 26-year-old woman is noted to be at 29 weeks’ gestation. Her last pregnancy ended in delivery at
    30 weeks’ gestation. On examination, her temperature is 96.8°F (36.6°C), blood pressure (BP) is
    100/60 mm Hg, and heart rate (HR) is 80 beats per minute (bpm). Her lungs are clear to
    auscultation. No costovertebral angle tenderness is found. The uterine fundal height is 30 cm, and
    the uterus is slightly tender to palpation. No lower extremity cords are palpated. The fetal heart
    tones are persistently in the range of 150 to 155 bpm without decelerations. There are no uterine
    contractions.

    » What screening test need to be provided to estimate the risk for preterm delivery?
    G. Fetal fibronectin assay
    H. Cervical length <25 mm on ultrasound
    I. HPV positive status
    J. Recent laparotomy
    K. Uterine fibroids

    » In screening for various types of infection, which of the following is most likely to be associated
    with preterm delivery?
    A. Herpes simplex virus
    B. Candida vaginitis
    C. Chlamydia cervicitis
    D. Gonococcal cervicitis
    E. Group B streptococcus of the vagina

    CASE PD-3
    A 25-year-old G1P0 woman is at 28 weeks’ gestation. She is noted to have regular uterine
    contractions, and her cervix is dilated at 2 cm and 80% effaced.
    Preterm labor is diagnosed. The physician reviews the record and notes that the patient should not
    have tocolytic therapy.
    » Which one of the following is a contraindication for tocolysis?
    A. Suspected placental abruption
    B. Group B streptococcal bacteriuria
    C. Recent laparotomy
    D. Uterine fibroids

    » What medication can be given to decrease the risk of neurological impairment in the baby?
    I. Magnesium sulfate
    J. Broad-spectrum antibiotic
    K. IV heparin therapy
    L. IV furosemide
    M. Indomethacin.

    CASE PD-4
    A 35-year-old G1P0 woman at 32 weeks’ gestation was seen in the obstetric (OB) triage unit the
    previous day with uterine contractions. On admission, the fetal heart rate is 140 bpm with
    accelerations and no decelerations. A fetal fibronectin assay is performed, which was positive. Over
    the course of the next 24 hours, the patient was examined and noted to have cervical dilation from 1
    to 2 cm and effacement from 30% to 90%. A tocolytic agent is used. A repeat fetal heart rate pattern
    reveals a baseline of 140 bpm with moderate repetitive variable decelerations.

    »Which of the following is the most likely tocolytic agent used in patient with tachypnea treated
    with terbutaline?
    A. Nifedipine
    B. Indomethacin
    C. Magnesium sulfate
    D. Terbutaline

    » What are reasons for tocolysis in case of preterm contractions?


    N. Prolong time to delivery
    O. Delay labour in order for the steroids to be maximally effective
    P. To settle contractions for in utero transfer of the mother to a tertiary unit
    Q. Increase the chance for natural birth

    » What is the most likely diagnosis (PPROM and fever)?


    A. Intra-Amniotic Infection
    B. Thrombophlebitis
    C. Preterm labor
    D. Cervicitis

    » What is the best management for this patient (PPROM and fever)?
    F. Intravenous antibiotics (NOT SURE)
    G. Expectant management
    H. Intramuscular corticosteroids
    I. Induction of labor
    J. Ultrasound-guided amniocentesis
    K. Tocolysis

    » What is the most likely etiology of PPROM?


    E. Deep venous thrombosis
    F. Uterine fibroids
    G. Ascending infection from vagina
    H. Gestational hypertension

    » Which of the following statements is correct?


    A. Magnesium sulfate should be given for neuroprotectionin all cases.
    B. Broad-spectrum antibiotic therapy is indicated only with maternal fever.
    C. Labor is the most common acute complication to be expected.
    D. Vaginal candidiasis is a risk factor for preterm premature rupture of membranes.

    » Which of the following is the most accurate method to confirm the intra-amniotic infection?
    A. Serum maternal leukocyte count
    B. Speculum examination of the vaginal discharge
    C. Amniotic fluid Gram stain by amniocentesis
    D. Palpation of the maternal uterus
    E. Height of oral temperature

    »Which of the following organisms is most likely to be the underlying etiology of a preterm
    delivery in case of clinical presentation of intraamniotic infection without PPROM?
    A. Group B streptococci
    B. Listeria monocytogenes
    C. Clostridia difficile
    D. Chlamydia trachomatis
    E. Escherichia coli

    »Which of the following is the next step?


    A. Expectant management
    B. Intramuscular corticosteroids
    C. Induction of labor
    D. Ultrasound-guided amniocentesis

    »Which of the following is most likely to be seen?


    I. Early decelerations
    J. Late decelerations
    K. Variable decelerations
    L. Sinusoidal heart rate pattern

    What is the definition of very low birthweight? (W25th)


    i. <500 grams
    j. 500 to 1000 grams
    k. 1000 to 1500 grams
    l. 1500 to 2500 grams

    What is the approximate survival rate for infant weighing 1090 grams and immediately taken to the
    neonatal intensive care unit for evaluation? (W25th)
    E. 80%
    F. 70%
    G. 95%
    H. 99%

    An infant born at 25 weeks’ gestation is at risk for all except which of the following complications?
    J. Asthma
    K. Blindness
    L. Blood cancers
    M. Pulmonary hypertension

    Of the responses listed below, which complication is most commonly associated with preterm
    delivery?
    A. Hypertension
    B. Fetal complications
    C. Placental abruption
    D. None of the above

    Which of the following placental hormones may play a role in preterm birth caused by
    maternal–fetal stress?
    A. Estrogen
    B. Human placental lactogen
    C. Insulin-like growth hormone
    D. Corticotropin-releasing hormone

    Which of the following bacteria may enhance the risk for preterm birth by secretion of
    hyaluronidase?
    A. Escherichia coli
    B. Peptostreptococcus
    C. Bacterial vaginosis
    D. Group B streptococcus
    Which of the following bacteria is frequently detected in the amnionic fluid of women with preterm
    labor?
    J. Mycoplasma hominis
    K. Gardnerella vaginalis
    L. Ureaplasma urealyticum
    M. All of the above

    Which of the following is true regarding transvaginal sonographic evaluation of the cervix as a part
    of the assessment for preterm labor?
    M. It can be performed any time after 14 weeks’ gestation.
    N. It is not affected by maternal obesity, cervix position, or shadowing.
    O. The FIGO recommends it for all women with a history of a spontaneous preterm birth.
    P. All of the above

    Which of the following neonatal outcomes was potentially improved following antimicrobial
    therapy for pregnant woman with premature rupture of membranes before 35 weeks’ gestation?
    A. Improved survival
    B. Decreased risk for sepsis
    C. Decreased risk for intracranial hemorrhage
    D. Decreased risk for respiratory distress syndrome

    Which of the following is a potential consequence of bed rest for suspected preterm labor?
    I. Bone loss
    J. Venous thromboembolism
    K. Increased risk for preterm delivery
    L. All of the above

    Which of the following is true regarding indomethacin use in pregnancy?


    A. It can only be administered orally
    B. It can lead to reversible oligohydramnios
    C. It lowers the risk for necrotizing enterocolitis
    D. All of the above

    Cesarean delivery would be expected to decrease the risk for intracranial hemorrhage in which of
    the following scenarios?
    I. Estimated fetal weight <1000 grams
    J. Estimated fetal weight <1500 grams
    K. Estimated fetal weight <2000 grams
    L. None of the above

    Puerperium.
    CASE Pu-1
    A 24-year-old G1P1 woman underwent a low-transverse cesarean section 2 days ago for arrest of
    active phase of labor. The past medical and surgical histories were unremarkable. She denies a
    cough or dysuria. On examination, the temperature is 102°F (38.8°C), heart rate is 80 beats per
    minute, blood pressure is 120/70 mm Hg, and respiratory rate is 12 breaths per minute. The breasts
    are nontender. The lungs are clear to auscultation. The abdomen reveals that the skin incision is
    without erythema or tenderness. The uterine fundus is firm, at the level of the umbilicus, and
    somewhat tender. No lower extremity cords are palpated.

    » Which of the following is the most significant risk factor in this patient?
    I. Numerous vaginal examinations
    J. Bacterial vaginosis
    K. Cesarean delivery
    L. Internal uterine pressure monitors
    M. Prolonged rupture of membranes
    » What is the best therapy for the condition?
    m. Initiation of intravenous antibiotics with anaerobic coverage
    n. Initiation of intravenous heparin
    o. Placement of a warm compress on the wound
    p. Opening of the wound

    CASE Pu-2
    A 30-year-old G1P1 who underwent a cesarean section 3 days previously has a fever of 101°F
    (38.3°C). The skin incision is indurated, tender, and erythematous. Which of the following is the
    best management?

    » What is the best therapy for the condition?


    J. Initiation of intravenous antibiotics with anaerobic coverage
    K. Initiation of intravenous heparin
    L. Placement of a warm compress on the wound
    M. Opening of the wound

    CASE Pu-3
    A 29-year-old woman is diagnosed with postpartum endometritis based on fever, abdominal pain,
    fundal tenderness, and elimination of other etiologies.

    » Which of the following is the most significant risk factor for postpartum endomyometritis?
    Q. Numerous vaginal examinations
    R. Bacterial vaginosis
    S. Cesarean delivery
    T. Internal uterine pressure monitors
    U. Prolonged rupture of membranes
    » What is the best therapy for the condition?
    A. Initiation of intravenous antibiotics with anaerobic coverage
    B. Initiation of intravenous heparin
    C. Placement of a warm compress on the wound
    D. Opening of the wound

    CASE Pu-4
    A 27-year-old G1P0 woman at 39 weeks’ gestation is noted to be in labor. She underwent artificial
    rupture of membranes, and experiences fetal bradycardia. Palpation of the vagina reveals a rope-
    like structure prolapsing through the cervix. She is diagnosed with a cord prolapse and underwent
    stat cesarean delivery. On postoperative day 2, the patient has a temperature of 102°F (38.8°C), and
    is diagnosed with endometritis.

    » The patient who works in the microbiology laboratory asks which of the following is the most
    commonly isolated bacteria in her infection?
    A. Peptostreptococcus species
    B. Staphylococcus aureus
    C. Group B Streptococcus
    D. Escherichia coli
    » Which of the following is the most significant risk factor in this patient?
    N. Numerous vaginal examinations
    O. Bacterial vaginosis
    P. Cesarean delivery
    Q. Internal uterine pressure monitors
    R. Prolonged rupture of membranes

    CASE Pu-5
    A 22-year-old woman who underwent cesarean delivery has persistent fever of 102°F (38.8°C),
    despite the use of triple antibiotic therapy (ampicillin, gentamicin, and clindamycin). The
    urinalysis, wound, breasts, and uterine fundus are normal on examination. A CT scan of the pelvis
    is suggestive of septic pelvic thrombophlebitis.

    » Which of the following is the best therapy for this condition?


    A. Hysterectomy
    B. Discontinue antibiotic therapy and initiate intravenous heparin
    C. Continue antibiotic therapy and begin intravenous heparin
    D. Surgical embolectomy
    E. Streptokinase therapy

    CASE Pu-6
    A 20-year-old parous woman complains of right breast pain and fever. She states that 3 weeks
    previously, she underwent a normal spontaneous vaginal delivery. She had been breastfeeding
    without difficulty until 2 days ago, when she noted progressive pain, induration, and redness to the
    right breast. On examination, her temperature is 102°F (38.8°C), blood pressure is 100/70 mm Hg,
    and heart rate is 110 beats per minute. Her neck is supple. Her right breast has induration on the
    upper outer region with redness and tenderness. There is also significant fluctuance noted in the
    breast tissue. The abdomen is nontender and there is no costovertebral
    angle tenderness. The pelvic examination is unremarkable.

    » What is the most likely diagnosis?


    N. Abscess of the right breast
    O. Galactocele
    P. Inflammatory breast carcinoma
    Q. Mastitis
    » What is your next step in therapy?
    L. Incision and drainage of the abscess
    M. Oral antibiotic therapy
    N. Oral antifungal therapy
    O. Bromocriptine therapy
    P. Mastectomy

    CASE Pu-7
    A 28-year-old G1P1 woman has delivered vaginally 3 weeks ago. She is breastfeeding and notes
    that the baby prefers to breastfeed from the right breast. On the left breast, she notes a 3-day history
    of a tender mass on the upper outer quadrant. On examination, she is afebrile. The left breast has a
    fluctuant mass of 4 × 8 cm of the upper outer quadrant without redness. It is somewhat tender.

    » What is the most likely diagnosis?


    I. Abscess of the left breast
    J. Galactocele
    K. Inflammatory breast carcinoma
    L. Mastitis
    » Which of the following is the best treatment for this condition?
    N. Oral antibiotic therapy
    O. Oral antifungal therapy
    P. Bromocriptine therapy
    Q. Aspiration
    R. Mastectomy

    What duration of time is encompassed in the puerperium?


    a. 2–4 weeks
    b. 4–6 weeks
    c. 6–8 weeks
    d. 10–12 weeks

    What are myrtiform caruncles?


    a. Vaginal rugae
    b. Scarred tags of hymenal tissue
    c. A sexually transmitted infection
    d. Microscopic tears in the vaginal epithelium

    At what point in the puerperium does the endocervical canal reform?


    a. 1 week postpartum
    b. 2 weeks postpartum
    c. 3 weeks postpartum
    d. 4 weeks postpartum

    What percentage of women experience regression of high-grade dysplasia following delivery?


    a. 10%
    b. 33%
    c. 35%
    d. 50%

    How long does complete uterine involution take following delivery?


    a. 1 week
    b. 2 weeks
    c. 3 weeks
    d. 4 weeks
    Secondary postpartum hemorrhage is defined as uterine hemorrhage occurring during what
    timeframe after delivery?
    a. 24 hours to 6 weeks
    b. 48 hours to 6 weeks
    c. 24 hours to 12 weeks
    d. 48 hours to 12 weeks

    What are common features of the urinary bladder in the postpartum period?
    a. Increased capacity
    b. Incomplete emptying
    c. Insensitivity to intravesical pressures
    d. All of the above

    Which of the following physical exam signs or laboratory values would be most helpful to make a
    diagnosis of endometritis in one-day postpartum patient?
    a. Fundal tenderness
    b. An absolute neutrophilia
    c. White blood cell count of 25,000/µL
    d. All of the above

    After delivery, how long do cardiovascular parameters including cardiac output, heart rate, and
    blood pressure take to return to nonpregnant levels?
    a. 48 hours
    b. 72 hours
    c. 7 days
    d. 10 days

    By which time interval following delivery most women first approach their prepregnancy weight?
    a. 3 months
    b. 6 months
    c. 9 months
    d. 12 months

    How long would postoperative (primary cesarean delivery) patient will expect colostrum
    production before beginning her conversion to a more mature milk?
    a. 2 to 5 days
    b. 2 to 10 days
    c. 5 to 14 days
    d. 5 to 21 days

    What vitamin is virtually absent in human breast milk?


    a. Vitamin C
    b. Vitamin A
    c. Vitamin K
    d. All vitamins are equally represented in breast milk

    Which hormone is most responsible for milk expression during lactation?


    a. Prolactin
    b. Oxytocin
    c. Dopamine
    d. Progesterone

    How would you advise a patient who is exclusively breastfeeding 4 weeks after delivery and
    develops nipple fissures?
    a. Wash the area with mild soap and water daily.
    b. Apply a steroid cream and use a nipple shield temporarily.
    c. Continue exclusive breastfeeding without interruption.
    d. Do not allow infant to feed on the affected side and empty the breast regularly with a pump.

    All except which of the following conditions are contraindications to breastfeeding?


    a. Infant with galactosemia
    b. Maternal hepatitis B infection
    c. Human immunodeficiency virus infection
    d. Maternal active and untreated tuberculosis
    Which of the following is true regarding the postpartum blues?
    a. May be affected by body image concerns
    b. Usually lasts for no more than 10 days after delivery
    c. Effective treatment involves recognition and reassurance
    d. All of the above

    Injury to what nerve is the most likely cause of the patient’s bilateral foot drop on day 1 following a
    labor with 3 hours of pushing in stirrups?
    a. Femoral nerve
    b. Ilioinguinal nerve
    c. Common peroneal nerve
    d. Lateral femoral cutaneous nerve

    What is the mean time to ovulation resumption in a postpartum woman who elects not to
    breastfeed?
    a. 4 weeks
    b. 5 weeks
    c. 6 weeks
    d. 7 weeks
    What contraceptive option would you not recommend for this postpartum patient?
    a. Progestin-only pills
    b. Estrogen-progestin patch
    c. Depot medroxyprogesterone
    d. A levonorgestrel intrauterine device

    Following an uncomplicated vaginal delivery, when can women be advised to resume coitus based
    on desire and comfort?
    a. 1 week postpartum
    b. 2 weeks postpartum
    c. 3 weeks postpartum
    d. 4 weeks postpartum

    What treatment can be offered to the postpartum woman who is exclusively breastfeeding and
    complains of vaginal dryness during intercourse 7 weeks following delivery?
    a. Topical estrogen
    b. Reassurance only
    c. Topical testosterone
    d. Intercourse is not recommended within the first
    8 weeks of delivery.

    Approximately what percentage of postpartum women require readmission to the hospital within 8
    weeks of delivery?
    a. <1%
    b. 3%
    c. 7%
    d. 10%

    4 weeks postpartum patient is overall doing well but complains of low energy levels despite
    the fact that her baby is sleeping for long intervals at night. What should you offer her?
    a. Reassurance only
    b. Psychiatry referral
    c. Check her thyroid hormone levels
    d. All of the above

    Antenatal bleeding

    CASE AB-5:A 22-year-old G1P0 woman at 34 weeks’ gestation presents with moderate vaginal
    bleeding and no uterine contractions. Her blood pressure (BP) is 110/ 60 mm Hg and heart rate
    (HR) 103 beats per minute (bpm). The abdomen is nontender.

    » Which of the following sequence of examinations is most appropriate?


    Q. Speculum examination, ultrasound examination
    R. Ultrasound examination, digital examination
    S. Digital examination, ultrasound examination, speculum examination
    T. Ultrasound examination, speculum examination, digital examination

    CASE AB-1: A 30-year-old G5P4 woman at 32 weeks’ gestation complains of bright red
    vaginal bleeding. She denies uterine contractions, leakage of fluid, or trauma. The patient states that
    4 weeks previously, after she had engaged in sexual intercourse, she experienced some vaginal
    spotting. On examination, her blood pressure is 110/60 mm Hg, heart rate (HR) is 80 beats per
    minute (bpm), and temperature is 99°F (37.2°C). The heart and lung examinations are normal. The
    abdomen is soft and uterus nontender. Fetal heart tones are in the range of 140 to 150 bpm.

    » What is the most likely diagnosis?


    N. Placental abruption
    O. Placenta previa
    P. Gestational diabetes
    Q. Multifetal gestation
    R. Gestational trophoblastic disease

    » What will be the long-term management of this patient?


    R. Induction of labor
    S. Tocolysis if fetal condition is stable
    T. Immediate cesarean delivery
    U. Expectant management as long as the bleeding is not excessive
    V. Intrauterine transfusion
    CASE AB-2: A 28-year-old woman at 32 weeks’ gestation is seen in the obstetrical (OB) triage
    area for vaginal bleeding described as significant with clots. She denies cramping or pain. An
    ultrasound is performed revealing that the placenta is covering the internal os of the cervix.

    » Which of the following is a risk factor for this patient’s condition?


    N. Prior salpingitis
    O. Hypertension
    P. Multiple gestations
    Q. Polyhydramnios
    CASE AB-3: A 21-year-old patient at 28 weeks’ gestation has vaginal bleeding and is diagnosed
    with placenta previa.
    » Which of the following is a typical feature of this condition?
    V. Painful bleeding
    W. Commonly associated with coagulopathy
    X. First episode of bleeding is usually profuse
    Y. Associated with postcoital spotting

    CASE AB-4: A 33-year-old woman at 37 weeks’ gestation, confirmed by first-trimester


    sonography, presents with moderately severe vaginal bleeding. She is noted on sonography to have
    a placenta previa.

    » Which of the following is the best management for this patient?


    q. Induction of labor
    r. Tocolysis of labor
    s. Cesarean delivery
    t. Expectant management
    u. Intrauterine transfusion

    » What is uncommon cause of antepartum haemorrhage (APH) at term


    F. Blood-stained show
    G. Bleeding placenta praevia
    H. Placental abruption
    I. Cervical ectropion
    J. Bacterial vaginosis
    K. Vasa praevia

    » Which of the following sequence of examinations is most appropriate?


    I. Speculum examination, ultrasound examination, digital examination
    J. Ultrasound examination, digital examination, speculum examination
    K. Digital examination, ultrasound examination, speculum examination
    L. Ultrasound examination, speculum examination, digital examination
    CASE AB-6: An 18-year-old adolescent is noted to have a marginal placenta previa on an
    ultrasound examination at 22 weeks’ gestation. She does not have vaginal bleeding or spotting.

    » Which of the following is the most appropriate management?


    A. Schedule cesarean delivery at 39 weeks
    B. Schedule an amniocentesis at 34 weeks and deliver by cesarean if the fetal lungs are mature
    C. Schedule an MRI examination at 35 weeks to assess for possible percreta involving the bladder
    D. Reassess placental position at 32 weeks’ gestation by ultrasound
    E. Recommend termination of pregnancy

    How do you interpret the examination and blood test findings?


    M. DIC
    N. Liver failure
    O. Haemorrhagic shock
    P. Kidney failure
    Q. Electrolyte disorder

    Which of the following statements is most accurate?


    A. Fetal ultrasound is more accurate in diagnosing placental abruption than placenta previa.
    B. Fetal ultrasound is quite sensitive in diagnosing placental abruption.
    C. Ultrasound is sensitive in diagnosing abruption that occurs in the lower aspect of the uterus.
    D. Fetal ultrasound is not sensitive in diagnosing placental abruption.

    Which of the following is the most significant risk factor for abruption placentae?
    A. Prior cesarean delivery
    B. Breech presentation
    C. Trauma
    D. Marijuana use
    E. Placenta accreta

    Which of the following is most likely to be present in drug screen of the pregnant patient with
    bright vaginal discharges?
    A. Marijuana
    B. Alcohol
    C. Barbiturates
    D. Cocaine
    E. Benzodiazepines

    Which of the following is the best management for this patient?


    A. Admission and careful observation in the ICU
    B. Induction of labor with plan for vaginal delivery
    C. Partial exchange transfusion
    D. Urgent cesarean delivery
    E. Intravenous terbutaline

    What is the most appropriate next step in management?


    M. Admit to antenatal unit for bed rest and betamethasone.
    N. Admit to antenatal unit for bed rest and blood transfusion.
    O. Induction of labour
    P. Perform emergency cesarean section.

    What is the best course of action?


    i. Emergent cesarean section
    j. Fetal umbilical blood transfusion
    k. Expectant management
    l. Induction of labour with prostaglandins

    Which of the following is most likely a complication of this patient’s present condition?
    L. DIC
    M. IUGR
    N. Subarachnoid hemorrhage
    O. Vasa previa
    Which of the following is the most likely cause of this patients abnormal lab tests (International
    Normalized Ratio of 2.3, partial thromboplastin time of 48 seconds, D-dimer elevated, fibrinogen
    decreased)?
    M. Disruption of placenta and release of fetal tissue into circulation
    N. Liver failure
    O. Haemorrhagic shock
    P. Release of thromboplastin by damaged placenta
    Q. Ruptured ectopic

    Which of the following is the most appropriate first step in management?


    K. Administer a tocolytic
    L. Administer a corticosteroid.
    M. Administer fresh frozen plasma.
    N. Deliver the fetus immediately by LSCS
    O. Observe closely.

    Which of the following statements is accurate concerning postpartum hemorrhage?


    N. The blood loss at delivery approaches the volume of blood added during pregnancy.
    O. Studies show that estimated blood loss reported is often less than the actual blood loss.
    P. The WHO defines postpartum hemorrhage as cumulative blood loss of >100 mL
    accompanied by symptoms and signs of hypovolemia.
    Q. None of the above

    Which of the following is true concerning placental abruption?


    E. It may lead to a dilutional coagulopathy.
    F. Concealed abruption forces thromboplastin into large veins draining the implantation site.
    G. In most women with abruption severe enough to kill the fetus, the plasma fibrinogen
    level will be less than 150 mg/dL.
    H. All of the above

    How is a low-lying placenta defined?


    J. The placenta is implanted in the lower uterine segment.
    K. The placental edge covers the internal os, but not completely.
    L. The placental edge does not cover the internal os but lies within a 1-cm wide perimeter.
    M. The placental edge does not cover the internal os but lies within a 2-cm wide perimeter.

    What percentage of women who have a primary cesarean with a placenta previa have
    hysterectomies
    performed?
    M. 1%
    N. 2%
    O. 6%
    P. 10%

    Which of the statements below accurately depicts the difference between consumptive
    coagulopathy and disseminated intravascular coagulation?
    S. Abruption best represents a consumptive coagulopathy.
    T. Loss of procoagulants with massive hemorrhage is the basis of dilutional coagulopathy.
    U. A concealed abruption forces thromboplastin into the circulation and leads to the
    consumption of procoagulants.
    V. All of the above

    Which of the bacteria below are associated with consumptive coagulopathy?


    E. Escherichia coli
    F. Klebsiella pneumoniae
    G. Group A streptococcus
    H. Group B streptococcus

    The use of whole blood for massive hemorrhage is supported by which of the following?
    S. Less renal failure
    T. Less pulmonary edema
    U. Fewer intensive care unit admissions
    V. All of the above

    PICTURES!!!
    E. Placenta previa

    Culdocentesis Step-by-Step
    Explain the risks, benefits, potential complications, and alternatives (e.g., US or immediate
    laparoscopy) to culdocentesis to the patient and/or their representative. Provide emotional
    support and encouragement. Obtain a signed consent for the procedure.
    Perform bimanual pelvic examination to rule out a fixed pelvic mass and to assess the position
    of the uterus prior to culdocentesis. A bulging of the cul-de-sac into the posterior fornix suggests
    pooling of intraperitoneal fluid.
    Place the patient in the lithotomy position with the head of the table slightly elevated in reverse
    Trendelenburg position so that the intraperitoneal fluid gravitates into the posterior cul-de-sac.
    Insert speculum to visualize cervix. Cleanse vagina and cervix with antiseptic (povidone iodine).
    Apply 2 percent lidocaine gel to the posterior vagina and posterior cervical lip (optional).
    Grasp the posterior lip of the cervix with the tenaculum and lift the cervix slightly to expose the
    posterior fornix, which is bounded laterally by the uterosacral ligaments.
    Insert an 18-gauge needle attached to a 20 mL syringe containing 5 mL of normal saline (or air)
    through the posterior vaginal wall into the posterior cul-de-sac using a rapid, deliberate thrust.
    The insertion point is in the midline, about 1 to 2 cm below the insertion of the uterosacral
    ligaments onto the uterus and below where the vaginal mucosa sweeps off the cervix and
    crosses the posterior cul-de-sac. The needle should not extend more than 3 to 4 cm through the
    vaginal mucosa and is directed slightly caudad, away from the uterus and toward the sacrum.
    Inject 5 mL of normal saline (or air) to confirm placement and clear tissue from the needle point.
    Reposition the needle if there is resistance.
    Aspirate peritoneal fluid, and then remove the needle slowly. If no fluid is obtained, repeat the
    procedure at a different angle with a new needle. Discontinue the procedure if unsuccessful
    after two or three attempts.
    10 Apply pressure for any bleeding at the puncture or tenaculum site. Interpret obtained fluid (pus,
    blood, etc.)

    Endometrial Biopsy Using Pipelle Single-use Curette


    Any women of reproductive age or with the potential for pregnancy should have a documented
    negative pregnancy test prior to the procedure. The patient can take an NSAID 30 to 60 minutes
    prior to the procedure to reduce the pain associated with cramping. Prophylactic antibiotics are
    not necessary during endometrial sampling.
    The patient is first placed in the lithotomy position, and a bimanual examination is done to
    determine the uterine size and position of the uterus. The speculum can now be inserted to
    allow for cervical visualization.
    Once visualized the cervix can be anesthetized and cleansed by spraying a 20 percent
    benzocaine spray for 5 seconds then applying an iodine solution. At this time it is appropriate to
    wash hands and don sterile gloves.
    Stabilize the cervix with a tenaculum placed on the anterior lip of the cervix, it allows the
    provider to straighten the uterocervical angle. The uterine sound is then inserted to an average
    depth of 6 to 10 cm within the uterus. If the uterine sound will not pass through the internal
    cervical os, this can be overcome by using cervical dilators.
    Once achieving adequate os dilation, and determining the depth of the uterus, the sampling
    pipelle can be inserted. The same as the uterine sound the pipelle should be advanced until
    encountering resistance. This resistance should be at the same depth as the sounding of the
    uterus.
    Once the pipelle is in the uterine cavity, the internal piston on the catheter is fully withdrawn
    which creates suction at the catheter tip. This suction accompanied by moving the tip with an in
    and out motion allows for sample collection. This motion should be completed with a 360-
    degree twisting motion to reach all four quadrants of the endometrium.
    The pipelle is now removed. Expel the specimen into the formalin container by pushing the
    piston into the sheath, thereby discharging the specimen into the fixative. If there appears to be
    insufficient tissue for diagnosis, perform a second pass of the catheter. The same catheter may
    be used if it has not touched the formalin.
    Remove the instruments. Most bleeding can be controlled with pressure via cotton swabs or a
    sponge stick.
    Decontaminate all used instruments, gloves and blood soiled linen.

    Insertion Copper-Releasing IUD step-by-Step


    1
    Take into consideration possible contraindications, results of investigation (STD?) and
    menstrual cycle phase (IUDs may be inserted anytime during the menstrual cycle).
    2
    Discuss with the patient the risks and benefits of the IUD and, if necessary, other forms
    of contraception. Informed consent may be obtained after these steps are completed.
    3
    Administration of a nonsteroidal anti-inflammatory drug (e.g., 600 to 800 mg of
    ibuprofen) one hour before insertion may alleviate discomfort.
    4
    Prepare IUD prior to starting procedure (use sterile technique, review insertion
    technique in package insert).
    5
    Place vaginal speculum (short speculum may prevent pushing cervix posteriorly).
    6
    Prepare vaginal wall with antiseptic solution (povidone-iodine or chlorhexidine
    gluconate).
    7
    Apply tenaculum at anterior (12:00) cervical position to stabilize the uterus while
    inserting uterine sound and IUD. Mild traction to the tenaculum may also be used to
    reorient an anteflexed or retroflexed uterus.
    8
    Insert and remove uterine sound (confirm depth of uterus at least 6 cm, clears path for
    IUD insertion).
    9
    Place IUD according to package insert. If insertion is difficult dilate endocervical canal
    with both 3 mm and 4 mm sound. Consider paracervical block if discomfort occurs.
    10 Cut IUD threads 2-3 cm from cervical os.
    11 After insertion observe the patient's condition (weakness, pallor, tachycardia, etc.) and
    give her recommendations regarding the use of the IUD.

    Key Initial Management for Suspected Ruptured Ectopic Pregnancy.


    1
    Facial 100% oxygen by mask.
    2
    Lie flat with head down.
    3
    Two large-bore (a 16-18 gauge) cannulae with 2 L of intravenous fluid (Ringer's
    lactate or normal saline) given immediately. Ensure infusion is running well.
    4
    Give fluids at rapid rate if shock, systolic BP <90 mm Hg, pulse>110/minute, or heavy
    vaginal bleeding: infuse 1 litre in 15-20 minutes (as rapid as possible), infuse 1 litre in 30
    minutes at 30 ml/minute. Repeat if necessary.
    5
    Monitor every 15 minutes for: blood pressure (BP) and pulse, shortness of breath or
    puffiness. Monitor urine output. Record time and amount of fluids given.
    6
    Reduce the infusion rate to 3 ml/minute (1 litre in 6-8 hours) when pulse slows to less
    than 100/minute, systolic BP increases to 100 mmHg or higher.
    7
    Crossmatch 4 units (and alert haematologist to the haemorrhage).
    8
    Consent for laparoscopy/laparotomy and salpingectomy.
    9
    Transfer to theatre for salpingectomy

    Cervical cytology
    Procedure Steps
    Step 1 Introduce yourself to the patient and clarify her identity. Explain what you would like to do
    and obtain
    consent. Explain she should feel little, if any, discomfort and that the examination should be over
    fairly quickly.
    Step 2 Ensure you have all of the necessary equipment ready. This includes: Gloves, Speculum,
    Lubricant, A
    cervical brush, A pot of cytology preservative solution, A light source.
    Step 3 The patient should be exposed from the waist down. Ask her to lie on the bed with her
    ankles
    together and allow her knees to spread apart as much as possible.
    Step 4 Wash you hands, put on your gloves and examine the outer vagina checking for any obvious
    abnormalities.
    Step 5 Warm the blades of the speculum with warm water. The water also acts to lubricate the
    speculum)
    but you may also like to apply some lubricant. Ensure the lubricant is not placed at the end of the
    speculum as
    this may alter the result.
    Step 6 Inform the patient that you are about to start the procedure. Use your left hand to part the
    labia
    minora and insert the speculum with the screw facing sideways.
    Step 7 As you advance the speculum, turn it so that the screw faces upwards. Open the blades and
    fix them
    open with the screw. Ensure that you can see well by adjusting the light source. Check for any gross
    pathology
    and identify the transition zone.
    Step 8 Place the tip of the cervical brush into the external cervical os and rotate it three times
    through 360
    degrees ensuring that it is always in contact with the cervix.
    Step 9 Remove the brush ensuring it does not wipe against anything. Tap the brush 10 times on the
    edge of
    the pot of cytology medium. Tighten the cap, record the patient's name and history number on the
    vial or
    attach a printed patient identification label. Complete a cytopathology test request form.
    Step 10 Release the screw on the speculum and carefully remove it from the vagina, completing the
    examination.
    Step 11 Offer the patient some tissue, cover the patient, and thank her. You should explain to the
    patient that
    her smear results will be sent to them in approximately six weeks, thus ensuring appropriate follow-
    u

    pap test collection procedure


    THINPREP PAP TEST PROCUREMENT
    1. Assemble collection devices and ThinPrep Pap test vial.

    2. Obtain an adequate sampling of the ectocervix using a plastic spatula. (A wooden spatula is not
    suitable as the cellular material is more difficult to rinse into the collection fluid.)

    3. Rinse the spatula into the solution vial by swirling the spatula vigorously in the vial 10 times.
    Discard the spatula.

    4. Obtain an adequate sampling from the endocervix using an endocervical brush device. Insert the
    brush into the endocervical canal until only the bottom-most fibers are exposed. Slowly rotate ¼ or
    ½ turn in one direction. DO NOT OVER ROTATE.

    5. Rinse the brush in the solution vial by rotating the device in the solution 10 times while pushing
    against the vial wall. Swirl the brush vigorously to further release material. Discard the brush.

    6. Tighten the cap so that the torque line on the cap passes the torque line on the vial.

    7. Record the patient’s name and history number on the vial or attach a printed patient
    identification label. Complete a cytopathology test request form (in preprinted paper form or test
    order printed from Epic).

    8. Send labeled specimen vial and completed request form to the laboratory for processing. No
    refrigeration of the specimen is necess

    Dilatation and curettage


    Procedure steps
    When you arrive, a nurse or a technician will ask you to remove your clothing and put on a hospital
    gown. If you’re receiving general anesthetic or IV sedation, a nurse will insert a small plastic
    catheter into a vein. They’ll also hook you up to monitors that painlessly measure your blood
    pressure, breathing, and heartbeat.

    When your doctor is ready to start the procedure, they’ll ask you to lie back on an examination table
    as you would if you were having a Pap test. You’ll rest your feet in stirrups, and a sheet or blanket
    will cover your knees. Usually, one nurse is present to help the doctor and another is available to
    monitor your vital signs and provide support and reassurance.

    The operation will proceed as follows:

    Your doctor inserts a device called a speculum to spread your vaginal walls so that they can see the
    cervix.
    Your doctor dilates the cervix by inserting a series of rods into your cervical opening. Each rod is a
    little thicker than the one before it.
    After dilating the cervix, your doctor inserts a spoon-shaped device called a curette, and draws the
    sides of the device along the lining of the uterus.
    If the curette can’t loosen all the tissue, your doctor may use a suction device as well. If you’ve had
    a local anesthetic, you’ll probably notice some cramping.
    After removing the material from your uterus, your doctor removes the instruments from your body.
    Your doctor then sends the material removed from the uterus to a laboratory for analysis.
    Ant
    enat
    albl
    eedi
    ng

    CASEAB-
    1

    A30-year-
    oldG5P4womanat32weeks’ gestationcompl ai
    nsofbrightredvaginal bleedi
    ng.
    Shedeniesuteri
    necontracti
    ons, l
    eakageoff luid,ortrauma.Thepat ientstat
    est hat4weeks
    previ
    ously
    ,aft
    ershehadengagedi nsex ualintercourse, sheexperi
    encedsomev aginal
    spott
    ing.Onexaminati
    on, herbloodpr essurei s110/ 60mm Hg, heartrate(HR)is80beat s
    perminute(bpm),andtemper atureis99° F(37. 2°C).Thehear tandlungex aminat i
    onsar e
    normal.Theabdomenissof tandut er
    usnont ender.Fet alheartt
    onesar einther angeof140
    to150bpm.

    »Whatwi
    l
    lbet
    hel
    ong-
    ter
    m managementoft
    hispat
    ient
    ?

    Ans-Long-t
    erm management:
    Expect
    antmanagementasl
    ongast
    hebl
    eedi
    ngi
    snot
    excessi
    ve.Cesar
    eandeli
    ver
    yat34weeks’gest
    ati
    on

    22.
    1A21-year
    -ol
    dG1P0womani sseenforherfi
    rstprenat
    alvisi
    tatt
    heobst
    etri
    cian’
    soff
    ice.
    Basedont
    heLMP, thepati
    enti
    s36weeks’ gest
    ation.Onult
    rasound,
    themeasurements
    i
    ndicat
    e32weeksforall
    parameter
    sincl
    udingtheHC, AC,
    andFL.

    Whi
    choft
    hef
    oll
    owi
    ngi
    sthebestmanagementf
    ort
    hispat
    ient
    ?

    A.Ant
    enat
    alst
    eroi
    dsf
    orpr
    obabl
    yIUGR

    B.Recommendamni
    ocent
    esi
    sforkar
    yot
    ype

    C.Del
    i
    ver
    yin1week(
    att
    erm)

    D.Cont
    inuedmoni
    tor
    ingandr
    epeatul
    tr
    asound+

    22.2A27- y
    ear-ol
    dG2P1womani sat37weeks’ gestat
    ionsupportedbyLMPanda10- week
    ul
    trasound.Theesti
    matedf et
    al weightis2000g,whichislessthanthe3rdpercenti
    l
    efor
    gestati
    onalage.TheDopplerstudiesindicat
    ethepresenceofforwardend-di
    astol
    icfl
    ow.
    Your ecommenddel i
    ver
    yforthispat i
    ent.

    Whi
    choft
    hef
    oll
    owi
    ngi
    sthebestr
    easonf
    ory
    ourr
    ecommendat
    ion?

    A.Af
    etal
    wei
    ghtof2000gcor
    rel
    ateswi
    thahi
    ghsur
    viv
    ali
    nthenur
    ser
    y

    B.I
    UGRcar
    ri
    esasi
    gni
    fi
    cantr
    iskoff
    etal
    deat
    h+

    C.TheDoppl
    erst
    udi
    esi
    ndi
    cat
    eaconcer
    nforcont
    inui
    ngt
    hepr
    egnancy

    D.Withdel
    i
    ver
    y,f
    urt
    herdi
    agnost
    icst
    udi
    essuchaskar
    yot
    ypeandv
    iral
    studi
    escanbe
    conduct
    ed

    22.3An18- y
    ear-
    oldG1P0womanat38weeks’ gestat
    ionconfi
    rmedbya12-weekultr
    asound
    hasaf undalhei
    ghtof34cm.Thepatienthasgained20lbsduri
    ngthepr
    egnancy.She
    deniessmokingoralcohol
    ori
    ll
    i
    citsubstanceuse.HerBPi s110/70mm Hg.
    Whi
    choft
    hef
    oll
    owi
    ngi
    sthebestmanagementoft
    hispat
    ient
    ?

    A.Per
    for
    m abasi
    cul
    tr
    asoundst
    udy+

    B.Schedul
    efordel
    i
    ver
    ysi
    ncet
    hepat
    ienthasr
    eachedat
    erm gest
    ati
    onal
    age

    C.Schedul
    ebi
    ophy
    sical
    prof
    il
    eandDoppl
    erst
    udi
    esf
    ort
    hispat
    ient

    D.Sendherur
    inef
    oradr
    ugscr
    eenandconsi
    deror
    der
    ingser
    um TORCHt
    it
    ers

    Ant
    enat
    alscr
    eeni
    ng

    CASEAS-
    1

    A20- year-
    oldG1P0womanat16weeks’ gestat
    ionhasr eceivedaserum mat er
    nalα-
    fetoprotei
    ntestthatretur
    nedas2. 8mul
    t i
    plesofthemedi an( MOM) .Shedeniesaf amil
    y
    historyofcongenital
    anomal i
    esorchromosomal abnormaliti
    es.Onex aminati
    on,sheis
    afebril
    e,herbl
    oodpr essure(BP)is100/
    70mm Hg, andherhear trat
    e( HR)is70beatsper
    mi nute(bpm).Thehear tandlungexaminationsarenormal .Thefundalheighti
    smi dway
    bet weenthesymphy sispubisandtheumbi li
    cus.Fetal
    hear ttonesareintherangeof140
    bpm.

    »Whati
    syournextdi
    agnost
    icst
    ep?

    Ans-
    Nextdi
    agnost
    icst
    ep:
    Basi
    cobst
    etr
    icul
    tr
    asoundexami
    nat
    iont
    oassessf
    ordat
    esand
    mult
    ipl
    egest
    ati
    ons.

    »Whati
    sthepur
    poseoft
    hemat
    ernal
    ser
    um α-
    fet
    opr
    otei
    n(msAFP)t
    est
    ?

    Ans-Pur
    poseofmsAFP:Thepur
    poseist
    oassesstheriskforafet
    alopenneur
    alt
    ubedefect
    ,
    andcanalsobeusedt
    oassessfort
    heri
    skofaneupl
    oidy,suchasfet
    alDownsyndromeor
    tr
    isomy18

    7.1A23- y
    ear-ol
    dG1P0womanat20weeks’ gestati
    onunder goesanultrasoundexami nati
    on
    forsi
    zegr eat
    erthanherdates.Theult
    rasoundr eveal
    shy dramnioswithanamni oti
    cf l
    uid
    i
    ndexof30cm.Thef etalabdomenr ev
    ealsacy sticmassi ntherightabdominalregi
    onanda
    cysti
    cmassi nthelef
    tabdomi nalar
    ea.Whichoft hef ol
    l
    owi ngisthemostl i
    kelyassociated
    condit
    ion?

    A.Gest
    ati
    onal
    diabet
    es

    B.Congeni
    tal
    ovar
    iant
    umor
    s

    C.Downsy
    ndr
    ome+

    D.Rhi
    soi
    mmuni
    sat
    ion

    7.
    3A22-
    year
    -ol
    dG2P1womanat25weeks’
    gest
    ati
    onwi
    thasur
    elastmenst
    rual
    per
    iodasks
    f
    orserum scr
    eening.Thepatient
    ’ssist
    erhasonechi
    ldwit
    hDownsyndromeand,ot
    her
    wise,
    t
    herei
    snof amil
    yhi st
    oryofanomaliesorgenet
    icdi
    sorder
    s.Whi
    chofthefol
    l
    owingi
    sthe
    mostappropr
    iat
    er esponse?

    A.Amni
    ocent
    esi
    sist
    heappr
    opr
    iat
    etest
    .B.Ser
    um scr
    eeni
    ngshoul
    dbeper
    for
    med.

    C.Expl
    aint
    othepat
    ientt
    hatitist
    oolateforser
    um screeni
    ng,
    butt
    hatherr
    iskf
    orDown
    syndr
    omeisnotmuchhigherthanherage-r
    elat
    edr
    isk.+

    D.Thepat
    ientbei
    ngonl
    y22y
    ear
    sofagedoesnotneedser
    um scr
    eeni
    ng.

    E.Thepat
    ienthasa25%chanceofherbabyhav
    ingDownsy
    ndr
    ome.

    7.4A28- y
    ear-ol
    dG1P0womanat16weeks’ gestat
    ionisnotedtohaveanelevatedmsAFP
    at2.9MOM.Sheunder wentatar
    getedultrasoundex aminati
    onwhichdidnotreveal
    aneural
    tubedefect.Herphysi
    cianal
    soundertakesadi l
    igentsearchforaneti
    ologyf
    ortheelev
    ated
    msAFPwi t
    houtidenti
    fyi
    nganeti
    ology
    .Whi choft hefoll
    owingcondit
    ionsist
    hispati
    entat
    i
    ncreasedrisk?

    A.I
    ncr
    easedi
    nci
    denceofst
    il
    lbi
    rt
    h+

    B.Gest
    ati
    onal
    diabet
    es

    C.Pl
    acent
    apr
    evi
    a

    D.Mol
    arpr
    egnancy

    E.Downsy
    ndr
    ome

    7.5A22-year-
    oldwomanisseenforherfir
    stprenatalvisi
    tat16weeks’gestat
    ionwi
    tha
    famil
    yhist
    oryofcongeni
    tal
    deafnessandneonat alrenaldi
    sease.Thepati
    ent’
    shear
    ingi
    s
    normal.Whichofthef
    oll
    owingi
    st hebestnextstep?

    A.Amni
    ocent
    esi
    sforkar
    yot
    ype

    B.Amni
    ocent
    esi
    sforr
    ubel
    l
    aPCR

    C.Genet
    iccounsel
    i
    ng+

    D.Gl
    ucosechal
    l
    enget
    est
    ing

    CASEAS-
    6

    Awomanaged23y earsi
    sreferredbyhergener alpr
    acti
    ti
    onert otheantenatal
    cli
    nicat12
    weeksinherfir
    stpregnancy.Shehasnosi gnif
    icantmedicalhistoryandisoneoffour
    si
    bli
    ngs.Ondirectquesti
    oni
    nghermot herapparentl
    yhadast i
    llbir
    thattr
    ibut
    edtosomef orm
    ofcongenit
    alabnormali
    ty28y earsago.Otherwisethepregnancyi sassessedtobelowrisk.
    Sheisoffer
    edascr eeni
    ngtestforDown’ ssyndrome.
    •Pr
    egnancy
    -associ
    atedpl
    asmapr
    otei
    n-A(
    PAPP-
    A):
    0.4mul
    ti
    plesoft
    hemean(
    MoM)

    •Fr
    eebet
    ahumanchor
    ioni
    cgonadot
    ropi
    n(hCG)
    :1.
    7mul
    ti
    plesoft
    hemean(
    MoM)

    •Nuchal
    transl
    ucency
    :2.
    9mm (
    nor
    mal
    )

    Ov
    eral
    lDown’
    ssy
    ndr
    omer
    iskcal
    cul
    atedas1i
    n118

    »Whatt
    est
    sar
    eav
    ail
    abl
    eforhert
    oconf
    ir
    m/ex
    cludeDown’
    ssy
    ndr
    ome?

    Ans-
    Amni
    ocent
    esi
    s,cel
    lfr
    eef
    etal
    DNA,chor
    ioni
    cvi
    l
    lussampl
    i
    ng

    »Whi
    choft
    hef
    oll
    owi
    ngi
    sanaccur
    atest
    atementr
    egar
    dingDown’
    ssy
    ndr
    ome?

    Ans-
    Downsy
    ndr
    omescr
    eeni
    ng-decr
    easedPAPP-A,
    incr
    easedNTandf
    reebet
    aHCG.

    CASEAS-
    7

    Awomanaged34y earsis12weeks’ gestati


    oninherthir
    dpregnancy.Herfi
    rstpregnancy
    endedi
    naf i
    rst
    -t
    rimestersuctionter
    mi nati
    onat18y earsofageandshehadami scarr
    iage8
    monthsagorequir
    ingsur gi
    calmanagement .Shei
    sgener al
    l
    ywellexceptformildasthma.
    Shehasnofamilyhistoryofcongenit
    al abnormali
    ti
    es.Heronlymedicati
    onisfoli
    cacid400
    mcgdail
    y.Herpartneris31y earsol
    dandwasadopt ed.Hehasnoknownmedi calproblems.

    Ther
    out
    inebooki
    ngbl
    oodandur
    inet
    est
    sar
    enor
    mal
    .

    Thef
    ir
    st-
    tr
    imest
    erul
    tr
    asoundf
    indi
    ngsar
    eshownbel
    ow

    Ul
    tr
    asoundr
    epor
    t:

    Si
    ngl
    efet
    us.Fet
    alhear
    tact
    ionnor
    mal

    Cr
    own–r
    umpl
    engt
    h:62.
    4m (
    cor
    respondst
    o12weeks3day
    s’gest
    ati
    on)

    Nuchal
    transl
    ucency(
    NT)
    :3.
    2mm

    Ri
    skoft
    ri
    somybymat
    ernal
    age(
    34y
    ear
    s):
    1:276

    Adj
    ust
    edr
    iskoft
    ri
    somyaf
    terNT:
    1:30

    »Wi
    thr
    egar
    dtot
    her
    out
    ineanomal
    yscani
    npr
    egnancy
    ,whatt
    hreshol
    dofnuchal
    -f
    old

    measur
    ementshoul
    dtr
    iggerar
    efer
    ral
    toaf
    etal
    medi
    ci
    nespeci
    ali
    st?

    »Thecouplechosetohaveafurt
    hert
    estandtheresul
    tsar
    enormal(
    46XYnor
    mal
    kar
    yot
    ype).Whatfur
    therdi
    agnost
    icopt
    ionsshoul
    dbeconsider
    ed?

    Ans-
    Nuchal
    transl
    ucencyt
    esti
    sscr
    eeni
    ngt
    est

    Fal
    seort
    rue
    Pl
    easemat
    cht
    rueamongt
    hef
    oll
    owi
    ngst
    atement
    s

    Phy
    siol
    ogyofobst
    etr
    ics:

    1Obst
    etr
    ichi
    stor
    y:

    I
    tisr
    ecommendedt
    hatwomenar
    eseenont
    hei
    rownatl
    eastoncedur
    ingant
    enat
    alcar
    e.T

    Af
    ami
    l
    yhi
    stor
    yofpr
    e-ecl
    ampsi
    ashoul
    dtr
    iggeri
    ncr
    easedant
    enat
    alsur
    vei
    l
    lance.
    T

    Dur
    ingpr
    egnancy3percentofwomenusei
    l
    li
    citdr
    ugs.

    Ahi
    stor
    yofsub-
    fer
    ti
    li
    tyi
    simpor
    tantev
    eni
    fthepat
    ienti
    scur
    rent
    lypr
    egnant
    .T

    Awomanwhohashadapr
    evi
    ousect
    opi
    cpr
    egnancyshoul
    dbeof
    fer
    edanear
    lypr
    egnancy
    ul
    tr
    asoundscanT

    2Thef
    oll
    owi
    ngt
    ermsar
    eappr
    opr
    iat
    e:

    Li
    e:cephal
    i
    c(v
    ari
    ant
    s:def
    lex
    ed,
    breech,
    shoul
    der
    ,longi
    tudi
    nal
    ,tr
    ansv
    erseet
    c.)
    .

    Posi
    ti
    on:
    flexed(
    var
    iant
    s:def
    lex
    ed,
    breech,
    shoul
    der
    ,longi
    tudi
    nal
    ,tr
    ansv
    erseet
    c.)
    .

    St
    ati
    on:
    att
    hel
    evel
    oft
    hespi
    nes(
    var
    iant
    s:-
    2,+3,
    brow,
    bregmat
    ic,
    2/5,
    etc.
    ).
    T

    Engagement
    :two-
    fi
    ft
    hs(
    var
    iant
    s:-
    2,+3,
    brow,
    bregmat
    ic,
    att
    hel
    evel
    oft
    hespi
    nes,
    etc.
    ).
    T

    Present
    ingpar
    t:shoul
    der(
    var
    iant
    s:def
    lexed,
    breech,
    shoul
    der
    ,longi
    tudi
    nal
    ,tr
    ansv
    erse
    et
    c.).
    T

    3Wi
    thr
    egar
    dtor
    out
    ineant
    enat
    alcar
    e:

    Al
    lwomenshoul
    dbeof
    fer
    edscr
    eeni
    ngf
    orhaemogl
    obi
    nopat
    hies.
    T

    Ahi
    ghv
    agi
    nal
    swabshoul
    dbesentr
    out
    inel
    yatbooki
    ng.

    Sy
    phi
    l
    ist
    est
    ingf
    ormspar
    toft
    her
    out
    inebooki
    ngv
    isi
    t.
    T

    Anul
    tr
    asoundscanf
    oranomal
    i
    esshoul
    dbeper
    for
    medat24weeksgest
    ati
    on.

    Ev
    erypat
    ientshoul
    dhav
    eanamedconsul
    tant
    .

    4Theai
    msoft
    he18–22weeksanomal
    yscani
    ncl
    ude:

    Tol
    ocat
    ethepl
    acent
    a.T
    Todet
    ermi
    net
    hechor
    ioni
    cit
    yofat
    winpr
    egnancy
    .

    Assessmentofamni
    oti
    cfl
    uidv
    olume.

    Pr
    omot
    ingpar
    ent
    albondi
    ngwi
    tht
    hef
    etus.
    T

    Toi
    dent
    if
    yfet
    alst
    ruct
    ural
    def
    ect
    s.

    5Humanmi
    l
    khast
    hef
    oll
    owi
    ngadv
    ant
    agesov
    erf
    ormul
    ami
    l
    k:

    Humanmi
    l
    kcont
    ainsmor
    epr
    otei
    n.

    Humanmi
    l
    kcont
    ainsmor
    elact
    ose.
    T

    Humanmi
    l
    kisassoci
    atedwi
    thar
    educt
    ioni
    nat
    opi
    cil
    l
    ness.
    T

    Humanmi
    l
    kcont
    ainsmor
    eir
    on.

    Humanmi
    l
    kisagoodsour
    ceofv
    itami
    nK.

    6Thef
    oll
    owi
    ngf
    act
    orsi
    nfl
    uencef
    etal
    bir
    thwei
    ght
    :

    Thepar
    it
    yoft
    hemot
    her
    .T

    Theexer
    cisehabi
    tsoft
    hemot
    her
    .

    Theet
    hni
    ci
    tyoft
    hemot
    her
    .T

    Thesexoft
    hef
    etus.
    T

    Mat
    ernal
    fol
    atesuppl
    ement
    ati
    on.

    Fet
    alassessment

    7Dur
    ingl
    ungdev
    elopment
    :

    Sur
    fact
    antpr
    oduct
    ionoccur
    sfr
    om about20weeks.

    Thepr
    edomi
    nantphosphol
    i
    pidi
    sphosphat
    idy
    lchol
    i
    ne.
    T

    Themajori
    tyofi
    nfant
    sbor
    nat27/
    40exper
    iencesomedegr
    eeofr
    espi
    rat
    orydi
    str
    ess
    syndr
    ome.T

    Fet
    albr
    eat
    hingmov
    ementoccur
    sleastdur
    ingREM sl
    eep.

    Thepr
    oduct
    ionofl
    eci
    thi
    nisenhancedbycor
    ti
    sol
    anddi
    abet
    es.
    8Regar
    dingt
    hef
    etal
    li
    ver
    :

    Gl
    ycogeni
    sst
    oredi
    nlar
    gequant
    it
    iesi
    nthet
    hir
    dtr
    imest
    er.
    T

    Theenz
    ymesr
    equi
    redt
    oconj
    ugat
    ebi
    l
    irubi
    nar
    enotpr
    esent
    .T

    Redbl
    oodcel
    lmanuf
    act
    urebegi
    nsat20/
    40.

    Der
    ivesf
    rom t
    hemesoder
    m.

    Hast
    hesameembr
    yol
    ogi
    cal
    ori
    ginast
    hegal
    lbl
    adder
    .T

    9Consi
    der
    ingDoppl
    erul
    tr
    asound:

    Abnor
    mal
    uter
    inear
    ter
    yDoppl
    erf
    lowi
    ndi
    cat
    esf
    etal
    hypoxaemi
    a.

    Abnor
    mal
    umbi
    l
    ical
    art
    eryf
    lowi
    ndi
    cat
    espoorpl
    acent
    alper
    fusi
    on.
    T

    Fet
    alhy
    poxaemi
    aisassoci
    atedwi
    thr
    edi
    str
    ibut
    ionofbl
    oodf
    low.
    T

    Fet
    alanaemi
    aisbestassessedusi
    ngmeasur
    ement
    sfr
    om t
    hemi
    ddl
    ecer
    ebr
    alar
    ter
    y.T

    Abnor
    mal
    duct
    usv
    enosusbl
    oodf
    lowoccur
    spr
    iort
    oar
    ter
    ial
    changes.

    10Thef
    oll
    owi
    ngar
    eev
    aluat
    edwhenper
    for
    mingaf
    etal
    biophy
    sical
    prof
    il
    e:

    Est
    imat
    edf
    etal
    wei
    ght
    .

    Fet
    alt
    one.
    T

    Mat
    ernal
    bloodpr
    essur
    e.

    Amni
    oti
    cfl
    uidv
    olume.
    T

    Pl
    acent
    albl
    oodf
    low.

    11Thef
    oll
    owi
    ngst
    atement
    sar
    etr
    uef
    orpr
    enat
    alt
    est
    s:

    Ser
    um bi
    ochemi
    str
    yissuper
    iort
    omat
    ernal
    ageasascr
    eeni
    ngt
    estf
    orDown’
    ssy
    ndr
    ome.
    T

    Mat
    ernal
    ser
    um al
    pha-
    fet
    opr
    otei
    nisadi
    agnost
    ict
    estf
    orneur
    alt
    ubedef
    ect
    s.

    Amni
    ocent
    esi
    shasahi
    gherpr
    egnancyl
    ossr
    atet
    hanchor
    ioni
    cvi
    l
    lussampl
    i
    ng.

    Test
    susi
    ngDNAt
    echnol
    ogycanbeper
    for
    medonamni
    ocent
    esi
    sspeci
    mens.
    T

    Chor
    ioni
    cvi
    l
    lussampl
    i
    ngcanbeper
    for
    medonl
    ybef
    ore12weeks’
    gest
    ati
    on.
    12Consi
    der
    ingneur
    alt
    ubedef
    ect
    s:

    Theseoccurasar
    esul
    tofapoorper
    i-
    concept
    ual
    mat
    ernal
    diet
    .

    Themaj
    ori
    tyoft
    hesedef
    ect
    soccuratt
    heendoft
    hespi
    ne.
    T

    Thepr
    ognosi
    sforspi
    nabi
    fi
    dadependsont
    hel
    evel
    oft
    hel
    esi
    on.
    T

    Wi
    thapr
    evi
    ousaf
    fect
    edsi
    bli
    ngt
    her
    iskofr
    ecur
    rencei
    s1percent
    .

    Asuppl
    ementof5mgf
    oli
    caci
    dsi
    gni
    fi
    cant
    lyr
    educest
    her
    iskofr
    ecur
    rence.
    T

    13Chor
    ioni
    cvi
    l
    lussampl
    i
    ng:

    Car
    ri
    esa2percentr
    iskofcausi
    ngmi
    scar
    ri
    age.
    T

    Mayshowapl
    acent
    almosai
    cphenot
    ype.
    T

    Maybeunsuccessf
    uli
    nobt
    aini
    ngasampl
    e.T

    Themostcommonappr
    oachi
    str
    anscer
    vical
    .

    Maybecar
    ri
    edoutat<11wksgest
    ati
    on.

    14Ol
    i
    gohy
    dramni
    osi
    sassoci
    atedwi
    tht
    hef
    oll
    owi
    ng:

    Tr
    acheo-
    oesophageal
    fist
    ula.

    Tal
    i
    pes.
    T

    I
    ntr
    aut
    eri
    negr
    owt
    hrest
    ri
    cti
    on.
    T

    Anencephal
    y.

    Pr
    emat
    urer
    upt
    ureoft
    hef
    etal
    membr
    anes.
    T

    15Pol
    yhy
    dramni
    osi
    sassoci
    atedwi
    tht
    hef
    oll
    owi
    ng:

    Mat
    ernal
    diabet
    es.
    T

    Neur
    omuscul
    arf
    etal
    condi
    ti
    ons.
    T

    Mat
    ernal
    non-
    ster
    oidal
    ant
    i-
    inf
    lammat
    orydr
    ugs(
    NSAI
    Ds)
    .

    Post
    -mat
    uri
    ty.

    Chor
    ioangi
    omaoft
    hepl
    acent
    a.T
    Pat
    hol
    ogyofobst
    etr
    ics

    16Dur
    inganassi
    stedbr
    eechdel
    i
    ver
    y:

    Anepi
    si
    otomymaybecutoncet
    heanusi
    sseenatt
    hef
    our
    chet
    te.
    T

    Pi
    nar
    d’smanoeuv
    recanbeusedt
    odel
    i
    vert
    hel
    egsi
    nanex
    tendedposi
    ti
    on.
    T

    Maur
    iceau–Smel
    l
    ie–Vei
    tisusedt
    odel
    i
    verex
    tendedar
    ms.

    For
    cepsshoul
    dnotbeappl
    i
    edt
    othef
    etal
    head.

    Epi
    dur
    alanal
    gesi
    aismandat
    ory
    .T

    17Thef
    oll
    owi
    ngar
    econt
    rai
    ndi
    cat
    ionst
    oext
    ernal
    cephal
    i
    cver
    sion:

    Pol
    yhy
    dramni
    os.
    T

    Compl
    etebr
    eechposi
    ti
    on.

    Pr
    eecl
    ampsi
    a.T

    Sy
    mphy
    sispubi
    sdy
    sfunct
    ion.
    T

    Twi
    npr
    egnancy
    .T

    18Wi
    thr
    egar
    dtot
    hepl
    acent
    a:

    I
    trecei
    vest
    hehi
    ghestbl
    oodf
    lowofanyf
    etal
    organ.
    T

    Ther
    esi
    stanceoft
    hespi
    ral
    art
    eri
    olesi
    ncr
    easessi
    gni
    fi
    cant
    lyi
    nthesecondt
    ri
    mest
    er.

    Abnor
    mallyi
    ncr
    easedbor
    eoft
    hespi
    ral
    art
    eri
    escont
    ri
    but
    est
    opat
    hogenesi
    sinpr
    e-
    ecl
    ampsia.

    I
    tisamaj
    orendocr
    ineor
    gan.
    T

    Eachcot
    ely
    doncont
    ainsapr
    imar
    yst
    em v
    il
    lus.
    T

    19Pr
    eecl
    ampsi
    aismor
    ecommoni
    n:

    Mul
    ti
    grav
    idwomen.

    Womenwi
    thcongeni
    tal
    car
    diacdi
    sease.
    Mul
    ti
    plepr
    egnancy
    .T

    Womenwi
    thdi
    abet
    esi
    nsi
    pidus.

    Womenwi
    thpr
    e-ex
    ist
    ingr
    enal
    disease.
    T

    20Themanagementofpr
    eecl
    ampsi
    aincl
    udes:

    Hospi
    tal
    assessment
    .T

    Labet
    alol
    .T

    Ear
    lydel
    i
    ver
    y.T

    Fur
    osemi
    de.

    Magnesi
    um sul
    phat
    e.T

    21Thef
    oll
    owi
    ngar
    eri
    skf
    act
    orsf
    ori
    ntr
    aut
    eri
    negr
    owt
    hrest
    ri
    cti
    on:

    Mul
    ti
    plepr
    egnancy
    .T

    Aspi
    ri
    nusei
    npr
    egnancy
    .

    Ant
    iphosphol
    i
    pidsy
    ndr
    ome.
    T

    Fet
    alkar
    yot
    ypeanomal
    i
    es.
    T

    Mat
    ernal
    age>35.

    22Consequencesofpl
    acent
    alabr
    upt
    ioni
    ncl
    ude:

    Hy
    pov
    olaemi
    cshock.
    T

    Fet
    alanemi
    a.

    Amni
    oti
    cfl
    uidembol
    us.

    I
    ncr
    easedper
    inat
    almor
    tal
    i
    ty.
    T

    I
    ntr
    aut
    eri
    nedeat
    h.T

    23Wi
    thr
    egar
    dtoshoul
    derdy
    stoci
    a:al
    ltr
    ue

    I
    toccur
    sinappr
    oxi
    mat
    ely1percentofl
    abour
    s.

    I
    tismor
    ecommoni
    nassi
    stedv
    agi
    nal
    del
    i
    ver
    y.
    McRober
    t’
    smanoeuv
    rewi
    l
    lbeef
    fect
    ivei
    n90percentofcases.

    Fundal
    pressur
    eshoul
    dbeav
    oided.

    Av
    oidl
    ater
    alf
    lex
    ionoft
    heheadont
    heneck.

    24Thesy
    mpt
    omsofpr
    eecl
    ampsi
    aincl
    ude:

    Rest
    lessness.
    T

    Sl
    eepi
    ness

    Fl
    ashi
    ngl
    i
    ght
    sinv
    isi
    on.
    T

    Rash

    Epi
    gast
    ri
    cpai
    n.T

    25I
    nit
    ial
    managementofsev
    erepost
    par
    tum haemor
    rhager
    equi
    res:

    Faci
    aloxy
    gen.
    T

    Admi
    nist
    rat
    ionofI
    Vfl
    uidsv
    iaacent
    ral
    li
    ne

    Seni
    orhaemat
    ologi
    stpr
    esent

    Seni
    oranaest
    het
    istpr
    esent
    .T

    Ul
    tr
    asoundscanoft
    heut
    erus

    26Ext
    raf
    act
    orst
    oconsi
    deri
    nmat
    ernal
    resusci
    tat
    ioni
    ncl
    ude:

    Ti
    l
    tingoft
    hegr
    avi
    dabdomen.
    T

    Lar
    gebr
    east
    scr
    eat
    ingdi
    ff
    icul
    ti
    esi
    nvent
    il
    ati
    on.
    T

    Needf
    orper
    imor
    tem Caesar
    eansect
    ion.
    T

    I
    ncr
    easedf
    unct
    ional
    lungcapaci
    ty.

    Lowerr
    iskofaspi
    rat
    ion.

    27Thef
    oll
    owi
    ngcompl
    i
    cat
    ionsar
    emor
    ecommonaf
    teri
    nst
    rument
    aldel
    i
    ver
    y:

    Anaemi
    a.T

    Pr
    olongedper
    ineal
    discomf
    ort
    .T
    Mast
    it
    is.

    Obst
    etr
    icpal
    sy.
    T

    Puer
    per
    ali
    nfect
    ion.
    T

    28I
    nfor
    medconsentr
    equi
    rest
    hatapat
    ientshoul
    d:

    Beabl
    etounder
    standt
    hebenef
    it
    soft
    hepr
    oposedt
    reat
    ment
    .T

    Si
    gnaf
    ormal
    wri
    tt
    enconsentf
    orm.

    Under
    standt
    heconsequencesofr
    efusi
    ngt
    hepr
    oposedt
    reat
    ment
    .T

    Beabl
    etor
    etai
    nandwei
    ghupt
    hei
    nfor
    mat
    ionpr
    ovi
    ded.
    T

    Begi
    vensev
    eral
    hour
    stoconsi
    derandev
    aluat
    etheopt
    ions.

    I
    ugr

    A32-y ear-ol
    dpr i
    mi gravidaisseeni ny ourof f
    iceat33weeks’ gestat
    ionforar outinepr enatal
    vi
    sit
    .Hergest ati
    onal age( GA)wascal culatedbyherl astnormal menstrualperiod, which
    wasconsi st
    entwi thanul tr
    asoundper formedat8weeks’ gestat
    ion.Herpregnancyhasbeen
    unevent f
    ul t
    odat e,althoughshehascont inuedtosmokeonepackormor eofci garett
    es
    dai
    ly.Shest at
    est hatshehasbeenf eelingnor malfetalmov ementandnout eri
    ne
    cont
    r actions.Onex ami nation,herheightis5f t6in.
    ,herwei ghti
    s118l b(53.5kg) , andher
    bl
    oodpr essure(BP)i s90/ 60mm Hg.Herf undalheightis26cm.Onul t
    rasound, younot ea
    si
    nglepr egnancywi t
    hanest imatedf etalweightof900g, whichisatthethirdper centil
    ef or
    gest
    at ionalage.

    »Whati
    sthemostl
    i
    kel
    ydi
    agnosi
    s?

    Ans-
    Mostli
    kel
    ydi
    agnosi
    s:I
    ntr
    aut
    eri
    negr
    owt
    hrest
    ri
    cti
    on(
    IUGR)
    ,li
    kel
    yduet
    oci
    gar
    ett
    e
    smoking

    »Whatot
    heri
    mpor
    tanti
    temsshoul
    dbenot
    edont
    heul
    tr
    asound

    Ans-
    .Otherult
    rasoundi
    tems:(a)Det
    ermi
    newhet
    hert
    hisi
    ssy
    mmet
    ri
    corasy
    mmet
    ri
    cIUGR,
    and(b)assesstheamni
    oticf
    luid

    22.1A21-y
    ear-ol
    dG1P0womani sseenforherfi
    rstprenat
    alvisi
    tatt
    heobstetr
    ician’soff
    ice.
    BasedontheLMP, thepati
    enti
    s36weeks’ gest
    ation.Onult
    rasound,
    themeasur ement s
    i
    ndicat
    e32weeksf orall
    parametersi
    ncl
    udingtheHC, AC,
    andFL.Whi chofthefollowingis
    thebestmanagementforthi
    spatient
    ?

    A.Ant
    enat
    alst
    eroi
    dsf
    orpr
    obabl
    yIUGR

    B.Recommendamni
    ocent
    esi
    sforkar
    yot
    ype

    C.Del
    i
    ver
    yin1week(
    att
    erm)
    D.Cont
    inuedmoni
    tor
    ingandr
    epeat
    edul
    tr
    asound+

    Whati
    sthef
    ir
    str
    easont
    obeex
    cluded?

    Ans–Ther
    eisl
    i
    kehoodofwr
    ongdat
    es

    22.2A27- y
    ear-ol
    dG2P1womani sat37weeks’ gestat
    ionsupportedbyLMPanda10- week
    ult
    rasound.Theesti
    matedf et
    al weightis2000g,whichislessthanthe3rdpercenti
    lefor
    gestati
    onalage.TheDopplerstudiesindicat
    ethepresenceofforwardend-di
    astol
    icflow.
    Your ecommenddel i
    ver
    yforthispat i
    ent.Whichofthefoll
    owingisthebestreasonforyour
    recommendat i
    on?

    A.Af
    etal
    wei
    ghtof2000gcor
    rel
    ateswi
    thahi
    ghsur
    viv
    ali
    nthenur
    ser
    y

    B.I
    UGRcar
    ri
    esasi
    gni
    fi
    cantr
    iskoff
    etal
    deat
    h+

    C.TheDoppl
    erst
    udi
    esi
    ndi
    cat
    eaconcer
    nforcont
    inui
    ngt
    hepr
    egnancy

    D.Withdel
    i
    ver
    y,f
    urt
    herdi
    agnost
    icst
    udi
    essuchaskar
    yot
    ypeandv
    iral
    studi
    escanbe
    conduct
    ed

    Whatar
    ethepot
    ent
    ial
    compl
    i
    cat
    ionofpat
    ientdi
    sor
    der
    ?

    Ans-
    fet
    aldeat
    h

    22.3An18- y
    ear-
    oldG1P0womanat38weeks’ gestat
    ionconfi
    rmedbya12-weekultr
    asound
    hasaf undalhei
    ghtof34cm.Thepatienthasgained20lbsduri
    ngthepr
    egnancy.She
    deniessmokingoralcohol
    ori
    ll
    i
    citsubstanceuse.HerBPi s110/70mm Hg.

    Whi
    choft
    hef
    oll
    owi
    ngi
    sthebestmanagementoft
    hispat
    ient
    ?

    A.Per
    for
    m abasi
    cul
    tr
    asoundst
    udy+

    B.Schedul
    efordel
    i
    ver
    ysi
    ncet
    hepat
    ienthasr
    eachedat
    erm gest
    ati
    onal
    age

    C.Schedul
    ebi
    ophy
    sical
    prof
    il
    eandDoppl
    erst
    udi
    esf
    ort
    hispat
    ient

    D.Sendherur
    inef
    oradr
    ugscr
    eenandconsi
    deror
    der
    ingser
    um TORCHt
    it
    ers

    Whatar
    ethepossi
    blecasesf
    ort
    hiscondi
    ti
    onexcept
    ?

    Ans–chr
    omosomal
    anamol
    i
    es

    CASEGR-
    5

    A31- year-ol
    dwomanat t
    endsar outi
    neant enatalappointmentat28weeks’ gestati
    on.Shei s
    G3P2.Herchi l
    drenareaged4and2y earsandwei ghed3.7and3. 6kgrespectivel
    yatbi rt
    h.
    Sher eportsnoant enatalconcerns,t
    herei snoabdomi nalpain,nov agi
    nalbleedingandgood
    fetalmov ement sarereported.I
    niti
    alantenatalbookingbloodt est
    sandf ir
    st-t
    rimesterand
    20-weekanomal yscanswer enormal.Shei sanon- smokerandhasabst ai
    nedf rom alcohol
    duringthepr egnancy.Thewomanappear swellwi t
    hnosi gnsofoedema.HerBMIi s24.
    Bloodpr essureis115/ 74mmHg.Thesy mphy siofundalheightis24cm.Thef etusi
    sf eltto
    beacephalicpr esent
    ation.Auscult
    ati
    onwi t
    hhand-hel
    dDoppl erconfi
    rmst hefet
    alhear
    tbeat
    tobe150/mi n.Onul t
    rasound:bipari
    etal
    diameterandfemurl engthareonthe10thcenti
    le.
    Abdominalcircumf er
    enceandest imatedfetal
    weightarebelowt hefi
    fthcenti
    l
    e.Theli
    quor
    vol
    umei snormal .Umbilical
    arter
    yresist
    anceindexiswithi
    nnor malrange.

    »Whatar
    ethepossi
    blecausesf
    ort
    hiscondi
    ti
    on,
    EXCEPT?

    Ans-
    Mal
    nut
    ri
    ti
    on,congeni
    tal
    inf
    ect
    ion

    »Whi
    choft
    hef
    oll
    owi
    ngi
    sthebestmanagementf
    ort
    hispat
    ient
    ?

    Ans-
    Managementbasedont
    hei
    nvest
    igat
    ionr
    esul
    ts

    I
    fthechromosomalanal
    ysi
    sisabnor
    mal
    thenwomenshoul
    dbeabl
    etodi
    scusst
    heopt
    ion
    ofcont
    inui
    ngthepr
    egnancy

    I
    freducedamnioti
    cfl
    uidt
    henshouldbeadmini
    sterMater
    nalcor
    ti
    coster
    oidi
    nject
    ionsi
    t
    r
    educestheinci
    denceofRespi
    rat
    orydi
    str
    esssyndromeinNeonates

    LAbour

    A26-year-
    oldG1P0womanat39weeks’ gest
    ationi sadmi t
    tedtot hehospitalinl
    abor.Sheis
    notedtohaveuteri
    necont ractionsevery2t o3mi nutes.Herant epart
    um historyi
    s
    si
    gnifi
    cantforanonimmuner ubell
    astatus.Onexami nati
    on, herbloodpressure(BP)is
    110/70mm Hgandhear tr ate(HR)is80beat spermi nut
    e(bpm) .Theesti
    mat edfet
    al wei
    ght
    i
    s7l bs.Onpelvi
    cex aminat i
    on, shehasbeennot edt ohaveachangei ncervical
    examinati
    onsfrom 4-cm dilat
    iont o5-cm overthel ast2hour s.Thepelvisisassessedt obe
    adequateondigit
    alexami nation.

    »Whati
    syournextst
    epi
    nthemanagementoft
    hispat
    ient
    ?

    Ans-
    Nextst
    epi
    nmanagement
    :Cont
    inuet
    oobser
    vet
    hel
    abor
    .

    Whi
    choft
    hef
    oll
    i
    ngbestdescr
    ibet
    hel
    abour?

    Ans-l
    atentphase

    CASEL-
    2

    A32- year-ol
    dwomani nhersecondpr egnancyhasar ri
    vedont helabourwardat38weeks3
    days.Shehadanor mal deli
    very18monthsago.Thi spregnancyhasbeencompl i
    catedby
    persi
    st entvomi t
    inguntil 20weeksandmor erecentl
    ybyanaemi a.Shereportscontracti
    ons
    commenci ngappr oximat el
    y4hago.Shet ookparacetamolathomeandt ri
    edtor eli
    evethe
    pai
    nwi thabat h,butnowf eelsshecannotcopewi ththepain.Twohour sagoshef eltagush
    ofclearf l
    uidfr
    om t hev aginaandsincethenpai nshavebecomemuchmor esever enow
    occurringev er
    y4mi n,l
    ast i
    ngf or45s.Shehasf eltt
    hebabymov i
    ngnormal l
    yallday.

    Thebl
    oodpr
    essur
    eis110/
    58mmHgandhear
    trat
    eis98/
    min.Thepr
    esent
    ati
    oni
    scephal
    i
    c
    wit
    h2/5pal pabl
    eabdomi nal
    l
    y .Uter
    inecontr
    acti
    onsarepalpabl
    eandtheuter
    usis
    noni
    rr
    it
    able.Speculum examinati
    onshowscl earf
    lui
    dpooledinthepost
    eri
    orvagi
    nalforni
    x.
    Onvaginalexaminati
    onthecer v
    ixis5cm dil
    atedandtheheadis1cm abovetheischial
    spi
    nes.Thef et
    alposi
    tionisr
    ightoccipi
    tot
    ransver
    sewithmi l
    dcaputandmouldi
    ng.

    »
    Whi
    choft
    hef
    oll
    owi
    ngbestdescr
    ibest
    hel
    abor
    ?ans-
    cgti
    nter
    per
    tat
    ion

    »Whatshoul
    dbey
    oursubsequentmanagement
    ?ans-
    rul
    eof3’
    s

    A33- year-oldwomani nlaboris41weeks2day s’


    gest ationofherfirstpregnancy.The
    pregnancywasuncompl i
    cateduntil2daysagowhenshedev el
    opedmi l
    dhypertensi
    on,
    withoutpr oteinuri
    a.Invi
    ewoft hegest at
    ionalageadeci sionwasmadef ori
    nductionof
    l
    aboury esterday.Shehad2mgpr ostagl
    andingel admi nister
    edintot hevaginaat6pm last
    ni
    ghtandagai nat6am t hismorning.Spontaneousr upt ureofmembr anesoccur r
    edat10
    am todayaf t
    erwhi chcontract
    ionscommenced.Bl oodpr essureis135/ 68mmHg, hear
    trat
    e
    90/min, andt emper atur
    eis37.1°C.Onabdomi nalpalpat i
    onthef et
    usi scephali
    c,1/5
    palpable,andst r
    ongcont r
    acti
    onsar efel
    t.

    Vagi
    nal
    l
    ythecer
    vixisf
    ull
    yeff
    acedand6cm di
    l
    ated.Thef
    etusiscephal
    i
    cati
    schi
    alspi
    nes
    wit
    hmil
    dcaputbutnomouldi
    ng.Gr
    ade1meconium i
    snoted.

    TheCTG,
    asshownbel
    ow,
    hasdemonst
    rat
    edasi
    mil
    arpat
    ter
    nforappr
    oxi
    mat
    ely50mi
    n.

    Adeci
    si
    onismadef
    orf
    etal
    bloodsampl
    i
    ngandt
    her
    esul
    tisasf
    oll
    ows:
    pH:
    7.10(
    nor
    mal
    7.
    25-7.35)
    .

    »Howwoul
    dyoui
    nter
    prett
    heCTGandf
    etal
    bloodsampl
    eresul
    t?ct
    gshowsbasel
    i
    ne
    155/
    min

    »Howwoul
    dyoumanaget
    hepat
    ientdel
    i
    ver
    ybyv
    ent
    ousf
    orcep

    CASEL-
    4

    Ami dwi f
    eisconcernedaboutacar diotocogr aph(CTG)ont helaborwar d.Thewomani s42
    yearsold;sheisnowatagest ati
    onalageof38weeksand1dayandpr esent edt othel abor
    wardanhourago.Att het i
    meofar ri
    val
    , exami nati
    onrev ealedasy mphy siofundal heightof
    39cm, cephal
    icpr
    esent ati
    onand3/ 5pal pableabdomi nall
    yandt hreecont r
    actionsi n10mi n
    l
    asting50seach.Vagi nalexaminati
    onr evealedintactmembr aneswi t
    ht hehead1cm abov e
    theischialspi
    nes,occipi
    toanteri
    orposi
    tionandt hecer vi
    x5cm di l
    ated.Shewas
    commencedoncont i
    nuousCTGmoni t
    or i
    ng( becauseoft heprev i
    ouscaesar eansect ion),
    whichshowedani nit
    ialbaseli
    nerateof135/ mi n,goodv ari
    abil
    i
    t y
    ,accelerationsandno
    decelerati
    ons.Twentymi nutesago,spont aneousr uptureofmembr anesoccur redwi thclear
    l
    iquorleaking.

    TheCTGt
    race
    »Descr
    ibet
    heCTG

    »Whati
    sthemostpossi
    blecausef
    ort
    hisCTGpat
    ter
    n?

    »Whatisyournextst
    epint
    hemanagementoft
    hispat
    ient
    ?immegi
    atev
    agi
    nal
    assesment
    ,
    babydel
    iv
    eryinst
    rument
    al

    CASEL-
    5

    A22-year
    -oldG3P0womanpr esent
    stothelabourwardwit
    habdominalpai
    n.Sheisnow40
    weeksand6day s.Al
    lpregnancybloodtest
    sandultr
    asoundscanshavebeennormal.The
    babywasbr eechat34weeksbutcephal icat37weeks.Shehadashow2day sagobuthas
    hadnobleedingsincethismor ni
    ngshehadamucus- l
    ikedarkr
    eddischar
    gefol
    lowedbythe
    onsetofi
    rregularper
    iod-
    typepains.Thebabyhasmov ednormall
    yduri
    ngtheday.

    Onexaminat
    ionsheiscomfortabl
    ebetweenpai
    ns.Herbl
    oodpr
    essur
    eis129/76mmHgand
    pul
    se101/min.Symphysi
    ofundalhei
    ghti
    s37cm andthefet
    usi
    scephal
    icwit
    h2/5pal
    pabl
    e.

    Vaginalexaminat
    ionreveal
    sthecerv
    ixtobeful
    lyef
    facedand4cm dil
    ated.Theposi
    tionis
    ri
    ghtoccipit
    opost
    eriorandtheheadis2cm abovet
    heischi
    alspi
    nes.Thereisnofet
    al caput
    moulding.

    Themembr anesar
    eint
    actbutr
    upt
    urespont
    aneousl
    ydur
    ingexami
    nat
    ion,
    wit
    hcl
    earl
    i
    quor
    drai
    ning.

    Thewomanrequest
    sanepidur
    alforpai
    nreli
    efandisther
    efor
    ecommencedoncont i
    nuous
    car
    diot
    ocogr
    aphmonit
    ori
    ng.Aft
    er20miny ouarecall
    edintorev
    iewt
    hesi
    tuat
    ion.TheCTG
    asyouwalki
    nisbel
    ow

    »Descr
    ibet
    heCTG

    »Whatar
    epossi
    blecausesf
    ort
    hisCTGpat
    ter
    n,EXCEPT?

    »Whati
    syournextst
    epint
    hemanagementoft
    hispat
    ient
    ?noev
    idenceoff
    etal
    ormat
    eranal
    di
    sor
    dert
    hatrequi
    recar
    e

    CASEL-
    6

    A22- year-ol
    dwomani sadmitt
    edt othelabourwardforinductionoflabourat40weeks’
    gestation.Thisi
    sherfir
    stongoingpregnancy,hav
    inghadaf i
    rst-
    tri
    mestermiscarri
    age13
    mont hspr evi
    ousl
    y.Shebookedat9weeksandhadnor mal bookingbloodtests.The11–14-
    weekscanand21- weekanomal yscandidnotshowanyobv i
    ousf et
    alabnormalit
    y.Bl
    ood
    pressur eanduri
    nalysi
    shavealwaysbeennor mal.
    Ather32-
    weekmidwif
    eappointmentsherepor
    tedfeeli
    ngveryuncomf
    ort
    ableabdomi nal
    l
    y,
    andthemidwi
    femeasuredthesymphysi
    ofundalhei
    ghttobe36cm.Af ur
    therul
    trasound
    scanwasther
    efor
    erequest
    edwhichshowednor malfetal
    growthbuti
    ncr
    easedli
    quor
    vol
    ume.

    Shehadbeenr evi
    ewedintheant enatalcli
    nicandwast est
    edforgestati
    onaldiabet eswith
    glucosetol
    erancetestbutthi
    swasnor mal .Adecisionhadbeenmadef orinductionof
    l
    abourat40weeksbecauset hewomanhadbecomesouncomf ort
    ableandbr eathless.On
    palpati
    onthefetuswascephal i
    cwi t
    ht hehead4/ 5pal pabl
    eabdomi nall
    y.Cardiotocograph
    (CTG)wasr eassuri
    ng;2mgofpr ostaglandingelhadbeeni nsert
    edintothepost eri
    orf or
    nix
    ofthev agi
    naandCTGmoni tori
    ngcont inuedforaf urt
    her20mi n.

    Thewomant henmobi li
    zedandcont
    ract
    ionsstar
    tedwit
    hinanhour
    .Sherequest
    edan
    epidural
    foranalgesiaandwhil
    ethi
    swasbeingpreparedCTGmonitor
    ingwascommenced.
    Atthisstage,
    spont aneousr
    uptur
    eofmembr anesoccurr
    edwit
    hav er
    ylar
    gev ol
    umeofcl
    ear
    l
    iquorsoakingthebedsheets.

    TheCTGi
    sshownbel
    ow

    »Descr
    ibet
    heCTGshowesdeepat
    ypi
    cal
    var
    iabl
    edecel
    erat
    ion,
    prol
    aapseofcor
    d

    »Whati
    sthemostpossi
    blecausef
    ort
    hisCTGpat
    ter
    n?suddenct
    gdet
    eri
    orat
    ionaf
    ter
    r
    apur
    eofmemberane

    »Whati
    syournextst
    epi
    nthemanagementoft
    hispat
    ient
    ?ex
    ami
    nat
    ionofv
    agi
    nabyf
    inger

    1.1A31-year
    -ol
    dG2P1womanat39weeks’ gest
    ationcompl
    ainsofpai
    nfulut
    eri
    ne
    cont
    ract
    ionsthatar
    eoccurr
    ingev
    ery3t
    o4mi nutes.Hercer
    vixhasnotchangedfr
    om 6-cm
    di
    lat
    ionover3hours.Whi
    choneofthef
    oll
    owingmanagementplansismostappropri
    ate?

    A.Cesar
    eandel
    i
    ver
    y

    B.I
    ntr
    avenousoxy
    toci
    n

    C.Obser
    vat
    ion+

    D.Fet
    alscal
    ppHmoni
    tor
    ing

    E.I
    ntr
    anasal
    gonadot
    ropi
    nther
    apy

    1.2A26-year
    -ol
    dG2P1womanat41weeks’ gestati
    onhasbeenpushingfor3hour swithout
    progr
    ess.Thr
    oughoutt
    histi
    me,hervagi
    nalexami nati
    onhasremainedcomplet
    elydil
    ated,
    complet
    elyeff
    aced,
    and0stati
    on,wi
    ththeheadper si
    stent
    lyi
    ntheocci
    putpost
    eriorpositi
    on.
    Whichofthefol
    lowi
    ngstat
    ementsaccurat
    elydescribesthesi
    tuat
    ion?

    A.Theocci
    putpost
    eri
    orposi
    ti
    oni
    sfr
    equent
    lyassoci
    atedwi
    thagy
    necoi
    dpel
    vi
    s.
    B.Thelaborprogr
    essi
    snor
    malift
    hepati
    entdoesnothaveanepi
    dur
    alcat
    het
    erf
    or
    anal
    gesia,buti
    sabnor
    mali
    fepi
    dural
    anal
    gesiai
    sbeingused.

    C.Thepat
    ienti
    sbestdescr
    ibedashav
    inganar
    restofdescent
    .+

    D.Thebonypar
    toft
    hef
    etal
    headi
    sli
    kel
    ytobeatt
    hepl
    aneoft
    hepel
    vi
    cinl
    et.

    E.Mi
    sopr
    ost
    olf
    orcer
    vical
    ripeni
    ng.

    1.
    3A31- year-
    oldG2P1womanat40weeks’gest
    ati
    onhasprogressedinlaborfr
    om 5t
    o6
    cm cer
    vicaldi
    lat
    ionov
    er3hour
    s.Whi
    chofthefoll
    owingbestdescr
    ibesthelabor?

    A.Pr
    olongedl
    atentphase

    B.Pr
    olongedact
    ivephase

    C.Ar
    restofact
    ivephase

    D.Pr
    otr
    act
    edact
    ivephase

    E.Nor
    mal
    labor+

    1.4A24-year
    -ol
    dG2P1womanat39weeks’ gest
    ati
    onpresentswit
    hpai
    nful
    uter
    ine
    cont
    ract
    ions.Sheal
    socompl
    ainsofdark,
    vaginalbl
    oodmi x
    edwi t
    hsomemucus.Whichof
    thef
    oll
    owingdescri
    best
    hemostli
    kelyeti
    ologyofherbl
    eeding?

    A.Pl
    acent
    apr
    evi
    a

    B.Pl
    acent
    aabr
    upt
    ion

    C.Bl
    oodyshow+

    D.Vasapr
    evi
    a

    E.Cer
    vical
    lacer
    ati
    on

    1.6A32- year-
    oldG1P0womanat40weeks’ gestationalagear r
    ivest othelaborf l
    oorwit
    h
    frequentandstrongcont ract
    ions.Thepatienthadbeenseen24hour spreviouslyand
    thoughtt obeinlatentl
    aborat2cm di lat
    ed, 70%ef faced,fetalvert
    exat–1st ati
    on.Shewas
    admi tt
    edat3-cm di l
    ati
    on/80%ef facement ,
    –1st ation.Sheunder goesamni otomy,andis
    startedonoxy t
    ocinforprolongedlatentphase.Af ter4hour sofoxy toci
    n, sheisstil
    lat3-
    cm
    dilat
    ion,90%effacement ,–1st at
    ion.Whichoft hef oll
    owingi sthebestmanagementoft hi
    s
    pat i
    ent’
    slaboratthispoint?

    A.Cesar
    eandel
    i
    ver
    y

    B.Cont
    inuedobser
    vat
    iononoxy
    toci
    n+

    C.Di
    schar
    gehomewi
    thf
    oll
    ow-
    upi
    n3day
    s

    D.Fol
    eybul
    bdi
    l
    ati
    onoft
    hecer
    vix
    1.5A24- y
    ear-ol
    dG2P1001womanat38weeksbyLMPandsuppor tedbya9-week
    ul
    trasoundstatesthathermotheri
    sintownfort
    henext4day sandwillbeav
    ailabl
    eto
    assisti
    ntakingcareofherbaby.Sherequest
    saninduct
    ionoflabor
    .Whichofthefoll
    owi
    ng
    i
    st hebestresponsetothisr
    equest?

    A.Si
    ncethepat
    ienti
    ster
    m, t
    her
    eisnoincr
    easedneonat
    alcompl
    i
    cat
    ions,
    butani
    ncr
    eased
    ri
    skofcesar
    eanascomparedtospont
    aneouslabor
    .

    B.Ifthecervi
    xisunf
    avor
    abl
    e,t
    henpr
    ost
    agl
    andi
    nri
    peni
    ngwoul
    dincr
    easet
    hechangesf
    or
    vaginaldel
    i
    very.

    C.I
    nducti
    onat38weeksi
    ncr
    easesneonat
    alcompl
    i
    cat
    ionsascompar
    edt
    odel
    i
    ver
    yto39
    weeks.

    D.Thepati
    ent
    ’srequesti
    sreasonabl
    e,andi
    nduct
    ioncanbeper
    for
    medwi
    thl
    i
    ttl
    eneonat
    alor
    mater
    nalcompli
    cati
    ons.+

    Medi
    cal
    pat
    hol
    ogyi
    npr
    egnancy

    23.1A36- year-
    oldG1P0womanat27weeks’ gestati
    onisnotedt
    ohav efev
    er,r
    ightfl
    ank
    tenderness,andpyuri
    a.Sheisdi
    agnosedwi
    thpyelonephri
    ti
    s.Auri
    necult
    ureisperfor
    med.
    Whichoft hefoll
    owingisthemostcommonlyi
    solatedeti
    ologi
    cagentcausi
    ngpy el
    onephr
    it
    is
    i
    npr egnancy?

    A.Pr
    oteusspeci
    es

    B.Candi
    daspeci
    es

    C.Escher
    ichi
    acol
    i+

    D.Kl
    ebsi
    ell
    aspeci
    es

    »Ifpati
    entdoesnotimproveonadequat
    eantibi
    oti
    ctherapyf
    or48hoursandexper
    iences
    conti
    nuedseveref
    lanktender
    nessandfever
    ,whichofthefol
    lowi
    ngshoul
    dbenext
    consi
    dered?

    Ans-
    USGandCTt
    oassesshy
    dronephr
    osi
    s.St
    one,
    uter
    ineobst
    ruct
    ion

    23.2A21-y
    ear
    -ol
    dG1P0womanat15weeks’ gestat
    ionisnotedtohav
    efeverof101°
    F
    (38.
    3°C)
    ,BPof80/40mm Hg,anddecreasedurineoutput.Whichoft
    hefol
    lowingi
    sthe
    mostcommoncauseofsept
    icshocki
    npr egnancy?

    A.Pel
    vi
    cinf
    lammat
    orydi
    sease

    B.Py
    elonephr
    it
    is+

    C.Woundi
    nfect
    ion

    D.Mast
    it
    is

    2.
    1A30-
    year
    -ol
    dG1P0womancompl
    ainsofnauseaandv
    omi
    ti
    ngf
    ort
    hef
    ir
    st3mont
    hsof
    herpr
    egnancy
    .Sheisnot
    edtohav
    eahemoglobinl
    evelof9.
    0g/dLandameancorpuscul
    ar
    vol
    umeof110f L(
    normal90-
    105f
    L).Whi
    chofthef
    oll
    owingist
    hemostl
    ikel
    yet
    iol
    ogyofthe
    anemia?

    Or

    A30- y
    ear -
    oldG1P0womancompl ai
    nsofnauseaandv omi t
    ingforthefi
    rst3monthsofher
    pregnancy.Onex aminat
    ion,
    herbloodpressur
    e(BP)is110/ 70mm Hg, heartr
    ate(HR)83
    beatspermi nute(bpm),
    andsheisafebril
    e.Thethyr
    oidglandappearsnormal onpal
    pati
    on.
    Thehear tandlungexaminati
    onsareunremarkabl
    e.Thefundusi satthesymphysisl
    evel
    .
    Theev al
    uationoftheanemiaincl
    udes:hemoglobinl
    evelof9.0g/dLandamean
    corpuscularvol
    umeof110f L(normal90-105fL).

    A.I
    rondef
    ici
    ency

    B.Fol
    atedef
    ici
    ency+

    C.Vi
    tami
    nB12def
    ici
    ency

    D.Phy
    siol
    ogi
    canemi
    aofpr
    egnancy

    2.2A29-year
    -ol
    dG2P1womanat28weeks’ gest
    ati
    on,whohadnormalhemoglobi
    nlevel4
    weeksagoatherf i
    rstpr
    enatal
    visi
    t,complai
    nsof1weekoff at
    igueandnowhasa
    hemoglobinl
    evelof7.0g/dL.Shenot eddark-
    col
    oreduri
    neaft
    ertaki
    nganant
    ibiot
    icfora
    uri
    nar
    yt r
    acti
    nfecti
    on.Whichofthefollowi
    ngisthemostli
    kel
    ydiagnosi
    s?

    Or

    A29-year-
    oldG2P1womanat28weeks’ gestati
    on,whohadnor malhemogl obinlevel4
    weeksagoatherf irstprenatalv i
    sit,compl ainsof1weekoff ati
    gue.Herant enatalhist
    oryis
    unremarkableex ceptf oraurinaryt r
    actinf ectiontr
    eatedwi t
    hanant ibi
    oti
    c1weeksago.On
    examinati
    on, herbloodpr essure( BP)i s100/ 60mm Hg, heartrate(HR)90beat spermi nute
    (bpm),andshei saf ebril
    e.Thet hyroidgl andappear snor malonpalpation.Thehear tand
    l
    ungex aminat i
    onsar eunr emarkabl e.Thef undalheighti
    s26cm.Thef et
    alhearttonesarein
    the140-to150- bpm r ange.Theev aluati
    onoft heanemi aincl
    udes:hemogl obinlevelof7.0
    g/dLandameancor puscularv olumeof100f L(normal 90-
    105f L)
    .Shenot eddar k-
    color
    ed
    uri
    neaftertakinganant i
    bioti
    cf oraur inaryt r
    actinfecti
    on.

    A.I
    rondef
    ici
    encyanemi
    a

    B.Thal
    assemi
    a

    C.Hemol
    ysi
    s+

    D.Fol
    atedef
    ici
    ency

    E.Vi
    tami
    nB12def
    ici
    ency

    CASEMP-5
    Awomanat tendstheant enat
    al dayassessmentuni ttodi scusst her esul
    tofherglucose
    tolerancet est.Sheis42y earsoldandt hi
    sishersixthpr egnancy .Shehaspr evi
    ouslyhad
    threecaesar eansecti
    ons, oneear l
    ymi scar
    ri
    ageandat er minati
    onofpr egnancy.Al
    lbooking
    testswer enor malaswer eher11–14- weekandanomal yul t
    rasoundscans.Shei snow26
    weeks’ gestationandhermi dwifear r
    angedagl ucoset olerancet estbecauseofaf amily
    historyoft ype2di abetes(herfatherandpat er
    nalaunt ).Herbodymassi ndex(BMI)is31
    kg/ m2.Bl oodpr essureis146/87mmHg.Thesy mphy siofundal heightis29cm andt hefetal
    hear trateisnor malonauscul t
    at i
    on.

    Herur
    inal
    ysi
    sshowsglycosur
    ia++.Gl
    ucoset
    olerancet
    est(
    75gglucosedri
    nk)
    :Pret
    est
    f
    asti
    ngbloodgl
    ucose:
    6.4mmol /,2hbl
    oodglucosefol
    lowi
    nggl
    ucoseload:
    11.2mmol/L

    »Whati
    sthedi
    agnosi
    s?AnsGest
    ati
    onal
    diabet
    es

    »Whi
    choft
    hef
    oll
    owi
    ngi
    sar
    iskf
    act
    ori
    npr
    egnantwomenf
    ori
    mpai
    redcar
    bohy
    drat
    e
    met
    abol
    i
    sm?

    AnsPresidentex
    ist
    ing-obesi
    ty,
    fai
    mlyhi
    stor
    y,mat
    ernal
    ageandi
    nthi
    scaseGl
    ycosur
    iaand
    pol
    yhy
    dr oamnios

    CASEMP-6

    A20- year-
    oldwomani spregnantforthefi
    rstti
    me.Thepregnancyisunplannedandt he
    partnerhasleftbutshei
    ssuppor t
    edbyhermot herandhasdecidedt
    ocont inue.Shewas
    diagnosedwi t
    ht y
    pe1diabetesatage15y ears.Shehasbeent aki
    nglong-actingandshort
    -
    actinginsul
    inunderthecareofhergeneralpracti
    ti
    oner(
    GP),butther
    eferrallett
    ersuggest
    s
    thatshehasnotal waysbeencompl iant
    .

    Shehadapositi
    vepregnancyt
    est2weeksagoandherGPhasref
    erredherur
    gent
    lyt
    othe
    ant
    enatal
    cli
    nicf
    orreviewinvi
    ewofthedi
    abet
    es.Byherdat
    essheisnow7weeksand5
    days’

    gest
    ati
    on.Shehasnoothersi
    gni
    fi
    cantgynaecol
    ogicalormedi
    cal
    hist
    ory.Thewomanhasa
    bodymassindexof29kg/m2.Bl
    oodpressureis131/68mmHgandpul seis81/
    min.

    Haemogl
    obi
    n(Hb)
    A1c7.
    8%(
    nor
    mal
    range<7.
    0%)Ur
    inal
    ysi
    s:gl
    ucose++

    »Whatf
    urt
    heri
    nvest
    igat
    ionsneedt
    obear
    ranged?Mat
    ernal
    wel
    lbei
    ngandal
    sof
    orf
    etal
    wel
    l
    bei
    ng

    »Out
    li
    net
    hepr
    inci
    plesofmanagementoft
    hepr
    egnancy
    .

    Ant
    enat
    al,I
    nlabor,
    postnat
    al

    Obst
    ret
    ri
    cemer
    gency

    CASEOE-
    1
    Awomanaged28y ears,G4P3isinlabourwhenshesuddenl ycollapses.Thi spr egnancyhas
    beenuncompl icatedandshehasbeenadmi t
    tedwi thcont racti
    onsat37weeksand6day s.
    Thedel i
    ver
    ypr ocesshasbeenuncompl i
    catedunt il
    spont aneousr uptureofmembr anes
    occurredduringacont r
    acti
    on,wit
    hal ar gegushofcl earf luidfrom thev agina.Thewoman
    report
    edanur get opushatt hatstageandt henbecameconf usedanddi sori
    entatedsay i
    ng
    thatshecouldnotbr eatheandwasgoi ngt odie.Immedi atelyfollowi ngt hi
    sshecol lapsed,i
    s
    unrouseabl
    et opai nfulsti
    muli
    .Thebl oodpr essur eis98/ 40mmHgandhear trat
    e120/ min.
    Theox ygensat urat i
    onis86percentonai randr espiratoryr ate20/ mi n.Thehear tsounds
    arenor malbutonchestex aminat
    iont herear einspiratorycr acklest hroughoutt hechest .

    Theabdomenissoftwi
    thint
    ermi
    tt
    entcont
    racti
    onsconti
    nui
    ng,
    andi
    nfactt
    hef
    etal
    headi
    s
    nowvisi
    bleatt
    heperi
    neum.Ther
    eisnovaginalbl
    eedi
    ng.

    »Whati
    sthel
    i
    kel
    ydiagnosisanddif
    fer
    enti
    aldi
    agnosi
    s?ans-
    amni
    oti
    cfl
    uidembol
    i
    sm,
    DD-
    pul
    monar
    yembol
    ism ,
    my ocar
    dial
    inf
    arct
    ion

    »Howwoul
    dyoumanaget
    hiswoman?
    ans-babydel
    i
    ver
    dimmedi
    atel
    y

    A31- y
    ear-
    oldwomani sadmit
    tedwi
    thcontr
    acti
    onsat40weeks’
    gest
    ati
    on.Thi
    sisherf
    our
    th
    pregnancy,hav
    inghadtwoter
    minat
    ionsappr
    oximat
    ely10y
    earsagoandanelect
    ive
    caesarean

    sect
    ionf
    orbr
    eechpr
    esent
    ati
    on3y
    ear
    sago.

    Shewasadmi t
    tedwi t
    hspont aneousr uptureofmembr anesaf ternex t2hcont racti
    ons
    becamest rongerandsher equestedanepi dural.Anepiduralwassi tedandani ndwelli
    ng
    uri
    narycatheteri nserted.Threehoursl aterthewomanr eportedmor esev erepainwhi chdi
    d
    notdisappearbet weencont ract
    ions.Att hattimeapprox i
    mat ely200mLoff reshbloodwas
    seencomi ngf rom thev agina.Thehear tratei s105/minandbl oodpr essure105/ 58mmHg.
    Thewomanf eelswar m andwel lperfused.Theabdomeni ssof tandt heut erusisalsosoft
    butverytender, witheasypal pati
    onoff etal part
    s.Onv aginalexami nationthecer vi
    xis6cm
    dil
    atedandt hef etalheadf eelshighint hepelv i
    sandpoor lyappliedtot hecer v
    ix.The
    cathetercontainsbl ood-stai
    nedur i
    ne.

    »Whati
    sthel
    i
    kel
    ydi
    agnosi
    s?ans-ut
    ri
    ner
    upt
    ure

    »Howwoul
    dyoumanaget
    hispat
    ient
    ?ans-gener
    alr
    esusci
    tat
    iongi
    veni
    mmedi
    atel
    y

    CASEOE-
    3

    A19- year-
    oldG1P0womanat20weeks’ gestationcomplainsoft heacuteonsetofpleuri
    ti
    c
    chestpainandsev eredyspnea.Shedeni esahi stor
    yofreact i
    veairwaydiseaseorcough.
    Shehasnohi storyoftrauma.Onex amination, hert
    emper aturei
    s98° F(36.6°
    C),heartr
    ate
    (HR)is120beat spermi nute,BPis130/ 70mm Hg, andrespirat
    oryrateis40breathsper
    minute.Thel ungex aminati
    onr evealscl
    earl ungsbilater
    all
    y.Thehear texaminati
    onshows
    tachycardi
    a.Thef etalhearttonesareint her angeof140t o150bpm.Theoxy gensaturat
    ion
    l
    ev el
    is89%.Suppl ementalox ygenisgiv
    en.

    »Whatt
    estwoul
    dmostl
    i
    kel
    yleadt
    othedi
    agnosi
    s?pul
    monar
    yembol
    usi
    npr
    egnancy
    »Whati
    stestmostl
    i
    kel
    ytol
    eadt
    othedi
    agnosi
    s?spi
    ral
    comput
    edt
    omogr
    aphy
    ,V/
    Q
    ,i
    magi
    ngoflung

    CASEOE-
    4

    Awomanaged26y earsisr eferredbyhergener alpr


    acti
    tioner.Sheis36weeks’ gestati
    onin
    herfourt
    hpr egnancy,havi
    nghadonemi scarr
    iageandtwot ermv agi
    nal deli
    ver
    ies.Forthe
    l
    ast2day sshehasbeenf eelinggener all
    yunwel lwit
    haf ever,decreasedappetiteanda
    headacheaswel lasabdomi naldiscomf ort
    .Shehasnotnot icedanyv aginalbl
    eedi ngbuther
    dischar
    gehasbeenmor et hannor mal andt hereisanoffensiveodourt oit.Hert emperatur
    e
    i
    s37. 8°
    C,bloodpr essure106/ 68mmHgandhear trat
    e109/ min.Thereisgener ali
    zed
    uteri
    netendernessandi rr
    itabilit
    y.Fetalheartrateis170-180bpm.Onspecul um exami nati
    on
    thecervi
    xisclosedandagr een/ greydischargeisseenwi thinthevagina.

    I
    nvest
    igat
    ion

    Nor
    mal
    rangef
    orpr
    egnancy

    Haemogl
    obi
    n

    10.
    9g/
    dL

    11–14g/
    dL

    Meancel
    lvol
    ume

    80f
    L

    74.
    4–95.
    6fL

    Whi
    tecel
    lcount

    17.
    3×109/
    L

    6–16×109/
    L

    Pl
    atel
    ets

    327×109/
    L

    150–400×109/
    L

    C-
    react
    ivepr
    otei
    n

    68mg/
    L

    <5mg/
    L

    »Whati
    sthemostl
    i
    kel
    ydi
    agnosi
    s?chor
    ioamni
    oni
    ti
    s
    »Howwoul
    dyoumanaget
    hispat
    ient
    ?ivbr
    oadspect
    rum ant
    ibi
    oti
    cs,
    I
    Vfl
    uids,
    ster
    oids

    CASEOE-
    5

    A25-year-
    oldG2P1womani sdeliv
    eri
    ngat42weeks’ gestat
    ion.Thewomani snotedtohave
    abodymassi ndexof42kg/ m2.Thefet
    alweightcl
    ini
    call
    yappearst obeabout3700g.Af t
    er
    a4-hourfi
    rststageofl aboranda2-hoursecondstageoflabor,t
    hef et
    al headdel
    i
    v er
    sbutis
    notedtoberet r
    actedbackt owardthepati
    ent’
    sint
    roit
    us.Thefetalshouldersdonotdeli
    ver
    ,
    evenwithmat ernalpushing.

    »Whati
    syournextst
    epi
    nmanagement
    ?mcr
    ober
    tsmaneuv
    er

    »Whatisali
    kel
    ycomplicat
    ionthatcanoccurbecauseoft
    hissi
    tuat
    ion?
    post
    par
    tum
    hemor
    rhage,
    neonat
    alcomplicat
    ions,

    Mat
    ernal
    gest
    ati
    onal
    diabet
    is

    Fet
    albr
    achi
    alpl
    exusi
    njur
    ies

    CASEOE-
    6

    A23-year-
    oldG2P1womanat16weeks’ gestati
    oncompl ai
    nsofa12- hourhistoryofcoli
    cky,
    ri
    ghtlowerabdomi nalpai
    n,andnauseawi thvomi ti
    ng.Shedeni esv aginalbl
    eedingor
    l
    eakageoff lui
    dperv agi
    na.Shedeniesdiarr
    heaoreat i
    ngst al
    ef oods.Shehasahi stor
    yofan
    8-cm ovar
    iancy st,andotherwi
    sehasbeeni ngoodheal th.Shedeni esdy sur
    iaorf ev
    er,and
    hashadnosur geries.HerBPis100/ 70mm Hg, heartr
    at e-105bpm, respir
    atoryrate-12
    breat
    hspermi nut e,andtemperatur
    e99°F( 37.2°C).Onabdomi nalexami nat
    ion,herbowel
    soundsarehy poact i
    ve.Theabdomeni stenderint herightlowerquadr antregionwith
    si
    gnifi
    cantinvoluntaryguardi
    ng.Thecervixisclosed.Thef etalhearttonesar eintherange
    of140bpm.

    »Whati
    sthemostl
    i
    kel
    ydi
    agnosi
    s?abdomi
    nal
    pai
    ninpr
    agnency(
    ovar
    ytor
    sion)

    »Whati
    sthebestt
    reat
    mentf
    ort
    hiscondi
    ti
    on?
    sur
    ger
    y,l
    apar
    otomy

    POSTPARTUM HAMERRHAGE

    Aft
    era4- hourlabor,a31-year-
    oldG4P3womanunder goesanuneventfulvagi
    nal
    deli
    ver
    yof
    a7lb8ozi nfantoveranintactperineum.Duri
    ngherl
    abor
    ,sheisnotedtohavemildvar
    iabl
    e
    decelerationsandaccel er
    ati
    onst hatincr
    ease20beat
    sperminute(bpm)abov et
    hebaseli
    ne
    heartrate.Atdel i
    very
    ,themal ebabyhasApgarscoresof8at1mi nute,and9at5minute.
    Sli
    ghtlengt
    heningofthecordoccur
    saft
    er28minutesalongwit
    hasmallgushofbl
    oodper
    vagina.Astheplacent
    aisbeingdel
    i
    ver
    ed,ashaggy
    , r
    eddish,
    bul
    gingmassisnot
    edatthe
    i
    ntroit
    usaroundt hepl
    acent
    a.

    »Whati
    sthemostl
    i
    kel
    ydi
    agnosi
    s?

    Ans-Mostl
    i
    kel
    ydi
    agnosi
    s:Ut
    eri
    nei
    nver
    sion.

    »Whati
    sthemostl
    i
    kel
    ycompl
    i
    cat
    iont
    ooccuri
    nthi
    spat
    ient
    ?

    Ans-
    Mostl
    i
    kel
    ycompl
    i
    cat
    ion:
    Post
    par
    tum hemor
    rhage

    3.1A23-y ear
    -ol
    dG1P0womanat38weeks’ gest
    ati
    ondeliver
    eda7l b4ozbabyboy
    vagi
    nall
    y.Upondeli
    veryoftheplacenta,therewasnotedtobeani nver
    tedut
    erus,
    whi
    chwas
    successfull
    ymanagedincl
    udingreplacementoftheuterus.Whichofthefol
    l
    owingpl
    acent
    al
    i
    mpl ant
    ationsit
    eswouldmostlikel
    ypr edisposet
    oani nv
    erteduter
    us?

    A.Fundal+

    B.Ant
    eri
    or

    C.Post
    eri
    or

    D.Lat
    eral

    E.Lowersegment

    Whati
    sthemostl
    i
    kel
    ycompl
    i
    cat
    ionoccuri
    nthi
    spat
    ient
    ?

    Secondar
    ypph

    3.2A24-year
    -ol
    dwomanunder wentanormalv
    agi
    naldel
    i
    veryofater
    minfantf
    emale.Aft
    er
    thedel
    iv
    ery,t
    heplacent
    adoesnotdeliv
    erev
    enaft
    er30minutes.Whi
    chofthef
    oll
    owing
    wouldbethenextstepfort
    hispat
    ient
    ?

    A.I
    nit
    iat
    eoxy
    toci
    n

    B.Wai
    tforanaddi
    ti
    onal
    30mi
    nut
    es

    C.Hy
    ster
    ect
    omy

    D.At
    temptamanual
    ext
    ract
    ionoft
    hepl
    acent
    a+

    E.Mi
    sopr
    ost
    olest
    rogeni
    ntr
    avagi
    nal
    l
    y

    Whi
    choft
    hef
    oll
    owi
    ngi
    sbestexpl
    ani
    tat
    ionofmechani
    smsofhamer
    rhage?

    Ansi
    nver
    tdut
    erus

    A29-year-
    oldparous( G5P4)womanat39weeks’ gestat
    ionwi t
    hpr eecl
    ampsiadel
    iv
    er s
    vagi
    nall
    y.Herprenatalcoursehasbeenuncompli
    catedex ceptforasymptomati
    cbact er
    iur
    ia
    causedbyEscherichiacolii
    nthefi
    rstt
    ri
    mestert
    reatedwithoral cephal
    exi
    n.Shedeniesa
    f
    ami
    lyhistor
    yofbl
    eedi
    ngdi
    athesi
    s.Af
    tert
    hepl
    acent
    aisdel
    ivered,ther
    ei sappr
    eci
    abl
    e
    v
    agi
    nalbleedi
    ngest
    imat
    edat1000cc.»Whati
    sthemostli
    kelydiagnosis?

    Ans-Mostl
    i
    kel
    ydi
    agnosi
    s:Ut
    eri
    neat
    ony
    .

    »Whati
    sthenex
    tst
    epi
    nther
    apy
    ?

    AnsNex tstepinther
    apy:Diluteint
    ravenous(I
    V)oxyt
    oci
    n,bedsi
    deuter
    inemassageand
    compression,andift
    hisisineffect
    ive,t
    henint
    ramuscul
    arprost
    agl
    andi
    nF2-al
    pha(H
    emabate)orrectalmisoprostol

    6.
    2A26- year-ol
    dG2P1001womanunder wentanormal vaginal
    deli
    ver
    y.Avi
    able7l b4oz
    maleinfantwasdel iver
    ed.Theplacentadeli
    veredspontaneousl
    y.Theobst
    etr
    iciannoted
    si
    gnifi
    cantbl oodlossfrom t
    hevagina,tot
    ali
    ngapproximately700mL.Theuteri
    nef undus
    appearedt obewel lcontr
    act
    ed.Whi chofthefoll
    owingisthemostcommonet iologyfort
    he
    bl
    eedingint hispati
    ent?

    A.Ret
    ainedpl
    acent
    a

    B.Geni
    tal
    tractl
    acer
    ati
    on+

    C.Ut
    eri
    neat
    ony

    D.Coagul
    opat
    hy

    E.Endomet
    ri
    alul
    cer
    ati
    on

    6.4A34-y
    ear
    -ol
    dwomani snotedtohavesi
    gnif
    icantut
    eri
    nebleedingaf
    teravaginaldel
    iver
    y
    compli
    cat
    edbyplacentaabrupt
    ion.Shei
    snotedtobebleedi
    ngf r
    om multi
    plevenipunct
    ure
    si
    tes.Whi
    choft
    hef ol
    lowingisthebestt
    her
    apy?

    A.I
    mmedi
    atehy
    ster
    ect
    omy

    B.Packi
    ngoft
    heut
    erus

    C.Hy
    pogast
    ri
    car
    ter
    yli
    gat
    ion

    D.Li
    gat
    ionofut
    ero-
    ovar
    ianl
    i
    gament
    s

    E.Cor
    rect
    ionofcoagul
    opat
    hy+

    Pr
    eecl
    ampsi
    A

    A19- y
    ear-oldG1P0womanat29weeks’ gestationar ri
    vest othehospi t
    albecauseofsev er
    e
    dyspneaof6hour s’ durati
    on.Herpr enatal coursehasbeenunr emarkable, andshedeni es
    anymedi cal problems.Herbl oodpr essure( BP)i s160/ 114mm Hg, heartrat e(HR)is105
    beatspermi nute( bpm) ,r
    espiratoryrate(RR)i s40br eathspermi nuteandl abor ed,and
    oxygensat urationi s90%.Thef etalhearttonesar einther angeof140bpm.Aur i
    neprotei
    n
    tocreati
    niner atiois0. 6.Theser um alaninet r
    ansami nase( ALT)i
    s84I U/L( normal <35)and
    aspartat
    et ransami nase(AST)i s90I U/L( normal <35).Thepr enatalrecordsshowt he
    fol
    lowing:Gest ational AgeBP( mm Hg)Ur inePr otei
    nFHT( bpm)Fundal Hei ght(cm)8weeks
    100/60014012weeks110/
    70014816weeks100/
    76015020weeks105/
    5801382026
    weeks130/891+14225

    »Whati
    sthemostl
    i
    kel
    ydi
    agnosi
    s?ansMostl
    i
    kel
    ydi
    agnosi
    s:Pr
    eecl
    ampsi
    awi
    thsev
    ere
    f
    eat
    ures

    »Whati
    syouri
    mmedi
    atenextst
    ep?

    AnsImmedi atenex tstep:Thehi ghestpri


    ori
    tymustbetoimproveoxygenati
    on.Suff
    ici
    ent
    oxygenmustbepr ovidedtor aisetheO2saturat
    ion>94%,andifthepati
    entisti
    ri
    ng,
    venti
    lat
    orsupportmayber equired.Thesecondpri
    ori
    tyi
    stolowertheBPwi thi
    ntrav
    enous
    (I
    V)antihyper
    tensi
    v eagent s.Ifpulmonaryedemaisconfi
    rmed,I
    Vdi ur
    esissuchas
    fur
    osemi deshouldbegi ven

    CASEP-
    2

    A18- year
    -ol
    dG1P0womanat28weeks’ gest
    ationisadmit
    tedt
    othehospitalwit
    hablood
    pressureof160/110mm Hg,el
    evatedl
    i
    verfuncti
    ontest
    s,andaplat
    eletcountof60000/μL.
    Shecompl ai
    nsofasever
    eheadache.

    »Whi
    choft
    hef
    oll
    owi
    ngi
    sthebestmanagement
    ?ansmagnesi
    um sul
    phat
    e

    »Whichoft
    hef
    oll
    owi
    ngwi
    l
    lbet
    hemostcommonmechani
    sm i
    fsei
    zur
    esappeari
    nthi
    s
    pat
    ient
    ?

    16.4A33-year
    -ol
    dwomanat29weeks’ gest
    ati
    onisnotedtohav eabloodpressur
    eof150/
    90mm Hgandapr ot
    ein/creat
    ini
    nerati
    oof0.6.Theplat
    eletcount
    ,li
    verfunct
    iontest
    s,and
    creat
    ini
    nearenormal
    .Whichofthefoll
    owingisthebestmanagementf orthi
    spati
    ent?

    A.I
    nduct
    ionofl
    abor

    B.Cesar
    eansect
    ion

    C.Ant
    ihy
    per
    tensi
    vet
    her
    apy

    D.Expect
    antmanagement+

    16.6Onpost part
    um day1,a28-year-ol
    dG1P1womanrepor
    tssomeheadacheandprobl
    ems
    withhervi
    sionbilat
    eral
    ly
    .HerBPi s150/95mm HgandP/Cr at
    ioi
    s0.5.Herneurol
    ogi
    cal
    examinati
    oni snormalbutherv
    isionisimpai
    redi
    nbot
    heyes.Whi
    chofthefol
    lowi
    ngisthe
    bestnextstep?

    A.Ant
    ihy
    per
    tensi
    veagent

    B.I
    VManni
    tol

    C.MRIoft
    hebr
    ain+

    D.CTi
    magi
    ngoft
    hebr
    ain

    E.Opht
    hal
    micey
    edr
    opst
    obot
    hey
    es
    16.
    7A32-year
    -ol
    dG2P1womani
    sat35weekswi
    thchr
    oni
    chy
    per
    tensi
    on.TheBPi
    sint
    he
    140/95r
    ange.

    A.Cor
    ti
    cost
    eroi
    ds

    B.Ant
    ihy
    per
    tensi
    veagent

    C.Bi
    ophy
    sical
    prof
    il
    e+

    D.Magnesi
    um sul
    fat
    eanddel
    i
    ver
    y

    E.Cont
    inuedobser
    vat
    ion

    16.
    8A28-y
    ear
    -ol
    dG1P0womani sat30weeks’gest
    ati
    onwit
    hsuper
    imposedpr
    eecl
    ampsi
    a.
    TheBPi
    s150/100.Thepl
    atel
    etcounti
    s95000andLFTis2×normal
    .BPPis10/10.

    A.Cor
    ti
    cost
    eroi
    ds+

    B.Ant
    ihy
    per
    tensi
    veagent

    C.Bi
    ophy
    sical
    prof
    il
    e

    D.Magnesi
    um sul
    fat
    eanddel
    i
    ver
    y

    E.Cont
    inuedobser
    vat
    ion

    16.
    9A30- year
    -ol
    dG2P1womani
    sat31weekswit
    hchroni
    chyper
    tensi
    on,usi
    ngoral
    l
    abetol
    ol.HerBPint
    heof
    fi
    cei
    s160/95and162/90.Theur
    inepr
    otei
    nisnegati
    ve.

    A.Cor
    ti
    cost
    eroi
    ds

    B.Ant
    ihy
    per
    tensi
    veagent+

    C.Bi
    ophy
    sical
    prof
    il
    e

    D.Magnesi
    um sul
    fat
    eanddel
    i
    ver
    y

    E.Cont
    inuedobser
    vat
    ion

    16.10A24- y
    ear-
    oldG3P2womanat34weeks’gestat
    ioni
    snotedtohav
    epreecl
    ampsi
    a.The
    BPi s150/90andP/Cr at
    ioi
    s0.
    5.Afet
    alul
    trasoundshowstheesti
    matedf
    etal
    wei
    ghtisat
    the8thpercent
    il
    e.

    A.Cor
    ti
    cost
    eroi
    ds

    B.Ant
    ihy
    per
    tensi
    veagent

    C.Bi
    ophy
    sical
    prof
    il
    e+

    D.Magnesi
    um sul
    fat
    eanddel
    i
    ver
    y

    E.Cont
    inuedobser
    vat
    ion
    PRETERM DELI
    VERY

    Aheal thy19-year-oldG1P0womanat29weeks’ gestat


    ionpresentst othel aboranddel iver
    y
    areacompl ainingofi nter mit
    tentabdomi nalpai
    n.Shedeni esleakageoff luidorbl eedingper
    vagina.Herant enat alhistoryhasbeenunr emarkable.Shehasbeeneat inganddr inking
    normal ly
    .Onex ami nati
    on, herbloodpressure(BP)is110/ 70mm Hg, hear trate(HR)i s90
    beatspermi nut e( bpm) ,andt emperatureis99°F(37.2°C)
    .Thef etalheartr at
    et r
    acing
    revealsabasel inehear tr at
    eof120bpm andar eacti
    vepat t
    ern.Uteri
    necont ract
    ionsar e
    occurringevery3t o5mi nutes.Onpel vi
    cexaminat i
    on,hercervi
    xis3cm di lated,90%
    effaced,andt hefet alvertexispresentingat–1st ati
    on.»Whati st hemostl i
    kelydiagnosis?
    AnsMostl i
    kelydi agnosi s:Preter
    ml abor.

    »Whati
    syournextst
    epi
    nmanagement
    ?

    Nextst
    epinmanagement:Tocol
    ysi
    s,tr
    ytoident
    if
    yacauseoft
    hepr
    eter
    mlabor
    ,ant
    enat
    al
    st
    eroi
    ds,andant
    ibi
    oti
    csf
    orGBSpr ophyl
    axi
    s

    17.
    1A26- year
    -ol
    dwomani snot
    edtobeat29weeks’gest
    ation.Herl
    astpregnancyended
    i
    ndeli
    veryat30weeks’ gest
    ati
    on.I
    nscreeni
    ngforv
    ari
    oustypesofinf
    ect
    ion,whichofthe
    fol
    l
    owingismostlikel
    ytobeassociat
    edwi t
    hpr
    eter
    m del
    iv
    ery ?

    Or

    A26- year-
    oldwomani snotedtobeat29weeks’ gest
    ation.Herl
    astpregnancyendedi n
    deli
    veryat30weeks’ gest
    ation.Onexami nation,
    hertemper at
    ureis96.8°F(36.6°C),blood
    pressure(BP)is100/60mm Hg, andheartrate(HR)is80beat spermi nut
    e( bpm) .Herlungs
    arecleartoauscult
    ati
    on.Nocost over
    tebralangletendernessisfound.Theut eri
    nef undal
    heightis30cm, andtheuterusissli
    ghtl
    yt endertopalpati
    on.Nol owerextr
    emi tycordsare
    palpated.Thefetal
    heartt
    onesar epersi
    stent l
    yintherangeof150t o155bpm wi thout
    decelerati
    ons.Ther
    earenout eri
    necontractions.

    »Whatscreeni
    ngt
    estneedtobeprov
    idedtoest
    imat
    ether
    iskf
    orpr
    eter
    m del
    i
    ver
    y?usg,
    l
    ab
    t
    est,
    uter
    inemonit
    eri
    ng,pel
    i
    v cexami
    nati
    on

    »Inscreeni
    ngforv
    arioustypesofinfect
    ion,whi
    choft
    hef
    oll
    owi
    ngi
    smostl
    i
    kel
    ytobe
    associ
    atedwit
    hpreterm del
    iver
    y?gonococcal

    A.Her
    pessi
    mpl
    exv
    irus

    B.Candi
    dav
    agi
    nit
    is

    C.Chl
    amy
    diacer
    vici
    ti
    s

    D.Gonococcal
    cer
    vici
    ti
    s+

    E.Gr
    oupBst
    rept
    ococcusoft
    hev
    agi
    na

    17.
    2A25-
    year
    -ol
    dG1P0womani
    sat28weeks’
    gest
    ati
    on.Shei
    snot
    edt
    ohav
    eregul
    ar
    uteri
    necont r
    acti
    ons,andhercer
    vixisdil
    atedat2cm and80%effaced.Pret
    ermlabori
    s
    diagnosed.Thephy si
    cianr
    evi
    ewst herecordandnot
    esthatt
    hepat i
    entshouldnothav
    e
    tocoly
    tictherapy
    .Whichoneofthef ol
    l
    owi ngi
    sacontrai
    ndi
    cat
    ionfortocoly
    sis?

    A.Suspect
    edpl
    acent
    alabr
    upt
    ion

    B.Gr
    oupBst
    rept
    ococcal
    bact
    eri
    uri
    a+

    C.Recentl
    apar
    otomy

    D.Ut
    eri
    nef
    ibr
    oids

    Whatmedi
    cat
    ioncanbegi
    vent
    odecr
    easet
    her
    iskofneur
    ologi
    cal
    impar
    ementi
    nthebaby
    ?

    Ansant
    enat
    alst
    eroi
    d,mgso4

    17.
    3A35- year -
    oldG1P0womanat32weeks’ gestati
    onwasseeni ntheobst etri
    c(OB)tri
    age
    uni
    tthepr ev i
    ousdaywi t
    huteri
    necont r
    acti
    ons.Onadmi ssion,
    thefet
    al heartrateis140bpm
    wit
    haccel erationsandnodecel erat
    ions.Afetalfi
    bronectinassayisperformed, whichwas
    posit
    ive.Ov erthecour seofthenext24hours, t
    hepat i
    entwasex aminedandnot edtohave
    cerv
    icaldilati
    onf rom 1to2cm andef f
    acementf r
    om 30%t o90%.At ocolyt
    icagenti sused.
    Arepeatf etalhear tr
    atepatt
    ernrevealsabaselineof140bpm wi t
    hmoder ater epeti
    ti
    ve
    var
    iabledecel erat
    ions.Whichofthef ol
    lowi
    ngi sthemostl ikel
    ytocol
    y t
    icagentused?

    A.Ni
    fedi
    pine

    B.I
    ndomet
    haci
    n+

    C.Magnesi
    um sul
    fat
    e

    D.Ter
    but
    ali
    ne

    »Whatar
    ereasonsfort
    ocol
    ysi
    sincaseofpr
    eter
    m cont
    ract
    ions?
    anscor
    dcompr
    essi
    on,
    r
    ept
    ureofmembr ane

    17.4A28- year-
    oldwomanG1P0at29weeks’ gestat
    ioni
    st r
    eatedwi t
    hterbut
    ali
    nef or
    preter
    ml abor.Hercervi
    xhaddilatedt
    o3cm andwas90%ef faced.Shealsoreceived
    betamethasonei nt
    ramuscular
    lytoenhancef
    etall
    ungmaturity.Thefoll
    owingday,the
    pati
    entdev el
    opsdy spnea,
    tachypnea,
    andanox y
    gensaturati
    onl ev
    elof80%.Ox ygenisgi
    ven.

    Whatcompl
    i
    cat
    ioni
    smostl
    i
    kel
    y?anspul
    monar
    yedema,
    respi
    rat
    orydepr
    essi
    on,
    duct
    us
    ar
    ter
    ious

    »Whatar
    ereasonsf
    ort
    ocol
    ysi
    sincaseofpr
    eter
    m cont
    ract
    ions?
    anscor
    dcompr
    essi
    on

    A24-year-oldG2P1womanat30weeks’ gestati
    onwasadmi ttedtothehospi
    tal2daysago
    forpr
    emat ur eruptur
    eofmembr anes.Herant enatal
    historyhasbeenunr emarkabl
    e.Today,
    shestatest hatherbabyismov i
    ngnor mall
    y,andshedeni esanyf everorchi
    ll
    s.Herpast
    medicalandsur gi
    calhi
    stor
    iesareunremarkable.Onex ami nat
    ion,hertemper
    aturei
    s100.8°F
    (38.
    2°C),bloodpr essur
    e(BP)is100/60mm Hg, andhear trate(HR)is90beatsperminute
    (bpm).Herlungsarecleartoauscultat
    ion.Nocost ov
    er t
    ebralangl
    etender
    nessisfound.The
    uter
    inefundalhei
    ghtis30cm, andtheuterusissl
    ightlytendertopal
    pati
    on.Nolower
    extr
    emitycordsarepalpated.Thefetalheartt
    onesar epersist
    entl
    yintherangeof170to
    175bpm wi t
    houtdecelerati
    ons.Therearenout er
    inecont r
    acti
    ons.

    »Whatist
    hemostl i
    kel
    ydi
    agnosi
    s?Mostl
    i
    kel
    ydi
    agnosi
    s:I
    ntr
    a-amni
    oti
    cinf
    ect
    ion
    (
    chor
    ioamnioni
    ti
    s).

    »Whatisthebestmanagementf
    orthi
    spat
    ient
    ?Bestmanagementforthispat
    ient
    :
    I
    ntr
    avenous(I
    V)anti
    biot
    ics(
    ampi
    cil
    l
    inandgent
    amici
    n)andinduct
    ionoflabor

    Puer
    per
    ium

    A24- year -
    oldG1P1womanunder wental ow-transv ersecesar eansect i
    on2day sagof or
    arrestofact i
    vephaseofl abor .Sher equi redoxy t
    ocinandani nternal ut
    erinepressur e
    catheter.Sher eachedandper sist
    edat6- cm dilationfor3hour sdespi t
    eadequat eut erine
    contractionsasj udgedby240Mont ev ideouni t
    s.Herbabywei ghed8l b9oz .Thepast
    medi cal andsur gical hi
    stori
    eswer eunr emar kable.Shedeni esacoughordy suri
    a.On
    exami nat i
    on,t
    het emper aturei s102° F( 38.8°C), heartrateis80beat spermi nute, bl
    ood
    pressur eis120/ 70mm Hg, andr espirat oryratei s12br eathspermi nute.Thebr eastsar e
    nontender .Thel ungsar ecleart oauscul tati
    on.Ther ei snocost overtebralanglet enderness.
    Theabdomenr ev ealsthattheski ninci sioniswi thouterythemaort enderness.Theut erine
    fundusi sf i
    rm,att heleveloftheumbi licus, andsomewhatt ender.Nol owerex tr
    emi tycor ds
    arepal pated.

    »Whichofthefoll
    owingi
    sthemostsi
    gnif
    icantr
    iskf
    act
    orinthi
    spat
    ient
    ?ansal
    cohal
    abuse,
    i
    nfer
    ti
    li
    ty,
    int
    erv
    oursesur
    ingmenses,l
    owbodyweight

    »Whati
    sthebestt
    her
    apyf
    ort
    hecondi
    ti
    on?
    ansI
    Vant
    ibi
    oti
    csgent
    amy
    cinecl
    i
    ndamy
    cine

    25.
    1A30-year
    -ol
    dG1P1whounderwentacesareansect
    ion3dayspr
    eviousl
    yhasafev
    erof
    101°F(
    38.
    3°C)
    .Theski
    nincisi
    oni
    sindur
    ated,
    tender
    ,andery
    themat
    ous.Whichoft
    he
    fol
    lowi
    ngi
    sthebestmanagement
    ?

    A.I
    nit
    iat
    ionofi
    ntr
    avenousampi
    ci
    ll
    i
    n

    B.I
    nit
    iat
    ionofi
    ntr
    avenoushepar
    in

    C.Pl
    acementofawar
    m compr
    essont
    hewound

    D.Openi
    ngoft
    hewound+

    »Whatisthebestt
    herapyfort
    heconditi
    on?
    ans-
    prophl
    act
    icant
    ibi
    oti
    csdur
    ing
    sur
    ger
    y,anti
    micr
    obi
    alagentduri
    ngdressi
    ngs

    25.2A29-year
    -ol
    dwomani sdiagnosedwithpostpartum endometri
    ti
    sbasedonfever
    ,
    abdominal
    pain,f
    undal
    tenderness,andeli
    minati
    onofot hereti
    ologi
    es.Whichoft
    he
    fol
    lowi
    ngisthemostsi
    gnifi
    cantriskfact
    orforpostpart
    um endomy ometr
    it
    is?

    A.Numer
    ousv
    agi
    nal
    exami
    nat
    ions
    B.Bact
    eri
    alv
    agi
    nosi
    s

    C.Cesar
    eandel
    i
    ver
    y+

    D.I
    nter
    nal
    uter
    inepr
    essur
    emoni
    tor
    s

    E.Pr
    olongedr
    upt
    ureofmembr
    anes

    Whati
    sthebestt
    her
    apyf
    ort
    hecondi
    ti
    on?
    ansI
    Vant
    ibi
    oti
    cs

    25.3A27- year-oldG1P0womanat39weeks’ gestati


    oni snot
    edtobei nlabor
    .She
    underwentar ti
    fici
    alruptureofmembr anes,andexper i
    encesfetal
    bradycardi
    a.Palpat
    ionof
    thevaginar evealsar ope-l
    ikestructureprolapsi
    ngt hroughthecervi
    x.Sheisdiagnosedwith
    acordpr olapseandunder wentst atcesareandel i
    very.Onpostoperati
    veday2, t
    hepatient
    hasat emper atureof102° F( 38.8°
    C) ,
    andi sdiagnosedwi thendometri
    ti
    s.Thepat i
    entwho
    worksint hemi crobiologylaboratoryaskswhi choft hefoll
    owingisthemostcommonl y
    i
    solatedbact eri
    ai nherinfection?

    A.Pept
    ost
    rept
    ococcusspeci
    es+

    B.St
    aphy
    lococcusaur
    eus

    C.Gr
    oupBSt
    rept
    ococcus

    D.Escher
    ichi
    acol
    i

    Whichoft
    hefol
    lowi
    ngi
    sthemostsi
    gni
    fi
    cantr
    iskf
    act
    ori
    nthi
    spat
    ient
    ?ans-Post
    par
    tum
    endomyomet
    ri
    ti
    s

    25.4A22- year
    -ol
    dwomanwhounder wentcesar eandel
    iv
    eryhaspersi
    stentfeverof102°
    F
    (38.
    8°C),despit
    etheuseoft r
    ipl
    eanti
    bioti
    ctherapy(ampici
    l
    li
    n,gent
    amicin,andcli
    ndamycin)
    .
    Theurinalysi
    s,wound,breast
    s,anduter
    inefundusarenormalonexamination.ACTscanof
    thepelvi
    sissuggestiv
    eofsept i
    cpelv
    icthrombophlebi
    ti
    s.Whichofthefoll
    owingisthebest
    ther
    apyf orthi
    scondit
    ion?

    A.Hy
    ster
    ect
    omy

    B.Di
    scont
    inueant
    ibi
    oti
    cther
    apyandi
    nit
    iat
    eint
    rav
    enoushepar
    in

    C.Cont
    inueant
    ibi
    oti
    cther
    apyandbegi
    nint
    rav
    enoushepar
    in+

    D.Sur
    gical
    embol
    ect
    omy

    E.St
    rept
    oki
    naset
    her
    apy

    A20- year-ol
    dparouswomancompl ainsofr i
    ghtbreastpai
    nandf ever.Shest atesthat3
    weekspr evi
    ousl
    y,sheunderwentanor mal spontaneousvaginaldeliv
    ery .Shehadbeen
    breastfeedingwit
    houtdiff
    icult
    yunti
    l2day sago, whenshenot edpr ogressivepain,indurat
    ion,
    andr ednesst ot
    her i
    ghtbreast.Onexamination,hertemperatureis102° F(38.8°C),blood
    pressurei s100/
    70mm Hg, andheartrat
    ei s110beat spermi nute.Hernecki ssupple.Her
    ri
    ghtbr easthasindurat
    ionont heupperouterregionwithrednessandt enderness.Ther ei
    s
    al
    sosigni
    fi
    cantfl
    uctuancenotedinthebr
    eastt
    issue.Theabdomenisnontenderandt
    her
    eis
    nocostov
    ert
    ebralangletender
    ness.Thepel
    vi
    cex aminat
    ioni
    sunremarkabl
    e.

    »Whati
    sthemostl
    i
    kel
    ydi
    agnosi
    s?Mostl
    i
    kel
    ydi
    agnosi
    s:Abscessoft
    her
    ightbr
    east
    .

    »Whatisyournextst
    epinther
    apy
    ?Nextst
    epi
    nther
    apy
    :Inci
    sionanddr
    ainageoft
    he
    abscessandant
    ibi
    oti
    cther
    apy

    26.3A28- year-
    oldG1P1womanhasdel i
    veredvagi
    nal
    ly3weeksago.Shei sbr eastfeeding
    andnot esthatthebabypr ef
    erstobr east
    feedfr
    om therightbreast
    .Ontheleftbr east, she
    notesa3- dayhistoryofatendermassont heupperouterquadrant.Onexami nati
    on, shei s
    afebri
    le.Theleftbreasthasafluctuantmassof4×8cm oft heupperout
    erquadr ant
    withoutredness.Itissomewhatt ender.Whichofthefol
    lowingisthebesttreatmentf orthi
    s
    conditi
    on?

    A.Or
    alant
    ibi
    oti
    cther
    apy

    B.Or
    alant
    if
    ungal
    ther
    apy

    C.Br
    omocr
    ipt
    inet
    her
    apy

    D.Aspi
    rat
    ion+

    E.Mast
    ect
    omy

    Whati
    sthemostl
    i
    kel
    ydi
    agnosi
    s?ansgal
    act
    ocel
    e(mi
    l
    kret
    ent
    ioncy
    st)

    You might also like