Questions
Each of the following questions or incomplete statements below is followed by suggested answers or completions. Select the ONE BEST ANSWER in each case.
1. Which of the following statements is true regarding herpes simplex virus (HSV) infections in newborns?
A) Most children have no symptoms related to their infection.
B) Most infants affected present with vesicular skin lesions.
C) Even in cases that are limited to the skin significant morbidity and mortality occur.
D) Disseminated disease can result in learning disabilities.
E) Diagnosis is easily made at the time of birth.
View Answer
Answer and Discussion
The answer is D. The diagnosis of neonatal HSV can be difficult initially. Signs and symptoms are nonspecific and include irritability, lethargy, fever, or failure to feed at about 1 week of age. Infants often do not have skin lesions (<50% of infants with encephalitis or disseminated disease). Unfortunately, by the time diagnosis is made, many infants have severe disease and have developed complications. When diagnosis is delayed, mortality is high despite antiviral therapy. There is virtually no mortality among infants with disease limited to the skin, eyes, and mouth, but mortality increases to 15% among infants with encephalitis and 57% among infants with disseminated disease, even with antiviral therapy. Long-term morbidity is common in infants who survive with encephalitis or disseminated disease, and may include seizures, psychomotor retardation, spasticity, blindness, or learning disabilities.
Rudnick CM, Hoekzema GS. Neonatal herpes simplex virus infections. Am Fam Physician. 2002;65:1138–1142, 1143.
2. A 21-year-old woman who is 12 weeks' pregnant with her first child presents to your office. A urinalysis shows evidence of bacteriuria. She is completely asymptomatic. Appropriate management at this time includes
A) no treatment; repeat urinalysis at her next visit
B) continue observation and reassure the patient that antibiotic administration is not necessary; she should notify you if she develops symptoms
C) no antibiotic treatment; ask the patient to drink more fluids and cranberry juice daily
D) discontinue urinalysis at OB visits because of the high rate of false positives
E) treat the patient with a 7-day course of amoxicillin
View Answer
Answer and Discussion
The answer is E. Asymptomatic bacteriuria, defined as more than 100,000 colonies of a single bacterial species per milliliter of urine, cultured from midstream sample, is present in 2% to 7% of pregnant women. The most commonly associated bacteria is Escherichia coli. Pregnancy does not increase the incidence of asymptomatic bacteriuria; however, pyelonephritis develops in a significant number of pregnant women with untreated asymptomatic bacteriuria. Asymptomatic bacteriuria in women is associated with a higher preterm delivery rate than women without bacteriuria. Treatment of group B Streptococcus (GBS) bacteriuria has also been shown to decrease the rate of preterm delivery. Additionally, GBS bacteriuria has been associated with heavy GBS genitourinary colonization. The Centers for Disease Control and Prevention (CDC) recommends that pregnant women with GBS bacteriuria be treated at the time of diagnosis and during labor. Intrapartum antibiotic prophylaxis is used to prevent early GBS infection in newborns. In most cases, women who do not have asymptomatic bacteriuria at the initial prenatal visit will not develop bacteriuria later in the pregnancy. Accordingly, routine screening for asymptomatic bacteriuria should be performed at the initial prenatal visit. Treatment options include a 3- to 7-day course of (1) oral amoxicillin, (2) nitrofurantoin (Macrobid), or (3) cephalexin (Keflex). After therapy is completed, a urine culture should be repeated to ensure eradication of infection. This repeat culture also identifies patients with persistent or recurrent bacteriuria. For patients who have persistent or recurrent bacteriuria, consideration should be given to administering suppressive doses of antibiotics.
Cram LF, Zapata MI, Toy EC, et al. Genitourinary infections and their association with preterm labor. Am Fam Physician. 2002;65:241–248.
Asymptomatic bacteriuria in women is associated with a higher preterm delivery rate than women without bacteriuria.
3. Preterm labor is defined as regular contractions with cervical change before
A) 40 weeks' gestation
B) 39 weeks' gestation
C) 38 weeks' gestation
D) 37 weeks' gestation
E) 36 weeks' gestation
View Answer
Answer and Discussion
The answer is D. According to the American College of Obstetricians and Gynecologists (ACOG), preterm labor is defined as regular contractions associated with cervical change before 37 weeks' gestation.
American College of Obstetricians and Gynecologists. Assessment of risk factors for preterm birth. ACOG Practice Bulletin; no. 31, Obstet Gynecol. 2001;98:709–716.
4. Which of the following bacterial infections is not generally associated with preterm labor?
A) Ureaplasma urealyticum
B) Mycoplasma hominis
C) Gardnerella vaginalis
D) Bacteroides species
E) All are associated with preterm labor.
View Answer
Answer and Discussion
The answer is E. Several bacterial infections have been associated with preterm labor, including Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, and Peptostreptococcus and Bacteroides species. These organisms are usually of low virulence, and it is unclear whether they are etiologic or associated with an acute inflammatory response of another etiology.
American College of Obstetricians and Gynecologists. Assessment of risk factors for preterm birth. ACOG Practice Bulletin; no. 31, Obstet Gynecol. 2001;98:709–716.
5. Which of the following tests has been shown to be a good predictor of preterm labor in the general obstetrical population and results in fewer preterm deliveries?
A) Home Uterine Activity Monitoring (HUAM)
B) Measurement of salivary estriol
C) Screening for bacterial vaginosis
D) Fetal fibronectin screening
E) None of the above
View Answer
Answer and Discussion
The answer is E. The following have been mentioned for detection of preterm labor; however, none have been shown to be beneficial:
· Home Uterine Activity Monitoring (HUAM). HUAM has been suggested as a method for predicting preterm birth in high-risk women. It combines telemetric recordings of uterine contractions using a tocodynamometer and daily telephone calls from a physician to offer support and advice. Because of study limitations, varying results, and flawed study designs, there is uncertainty about the usefulness of HUAM. The U.S. Preventive Services Task Force (USPSTF) and the U.S. Food and Drug Administration (FDA) concluded that the device was not effective. Data are insufficient to support HUAM in preventing preterm birth, and it is not recommended.
· Salivary estriol. Observational studies have shown that maternal levels of serum estradiol and salivary estriol increase before the onset of spontaneous term and preterm labor. A test using salivary estriol levels was designed to predict preterm delivery, but maternal estriol levels peak at night and may be suppressed by betamethasone administration. The test carries a high percentage of false-positive results and can add significantly to the cost of prenatal care if used in the low-risk population. Trials with salivary estriol testing have failed to establish its usefulness for anything more than investigational purposes.
· Bacterial vaginosis. The presence of bacterial vaginosis has been associated with preterm delivery independent of other known risk factors. Bacterial vaginosis is a common alteration of the normal vaginal flora and has been found in 10% to 25% of patients in general gynecology and obstetric patients, with 50% being asymptomatic. Trials of screening and treatment for bacterial vaginosis in pregnant women to reduce the incidence of preterm birth have been conducted in mixed populations with varying results. Some trials have shown an association with the presence of bacterial vaginosis and preterm delivery, but most results have failed to show if treatment for this condition can prevent preterm birth. There is insufficient data to support screening and treating women at low and high risk.
· Fetal fibronectin screening. Numerous trials have shown an association with the presence of the fetal fibronectin protein and preterm birth and a decrease in the risk of preterm birth when the test result for this protein is negative. Although a negative test result appears to be useful in ruling out preterm delivery within 2 weeks, the clinical implications of a positive result have not been evaluated fully because no intervention has been shown to decrease the risk of preterm delivery. The test has limited usefulness in low-risk women. For high-risk women, the following criteria should be met: intact amniotic membranes; minimal cervical dilatation; testing should be performed no earlier than 24 weeks, 0 days of gestation, and no later than 34 weeks, 6 days of gestation; and results must be available in time to allow for decision making, ideally within 24 hours.
· Cervical ultrasonography. Transvaginal cervical ultrasonography is a reliable and reproducible way to assess the length of the cervix. Results of a prospective trial showed that the relative risk of preterm delivery increased as the cervical length decreased. Despite the usefulness of measuring cervical length as a predictor of preterm delivery, it is not recommended because of lack of effective treatments.
ACOG has made the following recommendation: screening for risk of preterm labor by means other than historic risk factors is not beneficial in the general obstetric population.
American College of Obstetricians and Gynecologists. Assessment of risk factors for preterm birth. ACOG Practice Bulletin; no. 31, Obstet Gynecol. 2001;98:709–716.
6. Which of the following sports is contraindicated in pregnancy?
A) Walking
B) Stationary bicycle
C) Low-impact aerobics
D) Snow skiing
E) Swimming
View Answer
Answer and Discussion
The answer is D. Concerns have been raised about the safety of some forms of exercise during pregnancy. Because of the body changes associated with pregnancy as well as the hemodynamic response to exercise, some precautions should be observed. The physician should identify any contraindications to exercise and encourage patients to avoid overly vigorous activity, especially in the third trimester, when most pregnant women have a decreased tolerance for weight-bearing exercise. Adequate hydration and appropriate ventilation are important in preventing the possible teratogenic effects of overheating. Pregnant women should avoid exercise that involves the risk of abdominal trauma, falls, or excessive joint stress, as in contact sports and vigorous racquet sports. In the absence of any obstetric or medical complications, most women can maintain a regular exercise regimen during pregnancy. Some studies have found a greater sense of well-being, shorter labor, and fewer obstetric interventions in physically well-conditioned women as compared with other women.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:211.
7. During pregnancy, it is important to counsel pregnant patients to add an additional _____ calories to their dietary intake for normal activity.
A) 150
B) 300
C) 500
D) 1000
E) 1500
View Answer
Answer and Discussion
The answer is B. An increase of 300 calories per day is required in pregnancy. Caloric demands with exercise are even higher, although no studies have focused on exact requirements. The competing energy demands of the exercising mother and the growing fetus raise the theoretic concern that excessive exercise might adversely affect fetal development.
Rakel RE. Textbook of Family Practice, 6th ed. Philadelphia: WB Saunders; 2002:520–521.
8. Which of the following is not a contraindication to exercise during pregnancy?
A) Pregnancy induced hypertension (PIH)
B) Incompetent cervix
C) Preterm labor during a prior pregnancy
D) Placenta previa
E) All are contraindications
View Answer
Answer and Discussion
The answer is E. Although supportive data is limited, there appears to be no reason why women who are in good health should not be permitted to engage in exercise while pregnant. However, women with medical or obstetric complications should be encouraged to avoid vigorous physical activity. Given the current lack of data, a conservative approach is warranted when doubt exists. Contraindications to exercise during pregnancy include PIH, preterm rupture of membranes, preterm labor during the prior or current pregnancy, incompetent cervix or cerclage placement, persistent second- or third-trimester bleeding, placenta previa, and intrauterine growth retardation.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:211.
9. Maternal temperature elevations above _____ can be detrimental to the fetus in the first trimester of pregnancy.
A) 98.6°F
B) 100.0°F
C) 101.0°F
D) 102.0°F
E) Maternal temperature has no detrimental effects on the fetus.
View Answer
Answer and Discussion
The answer is D. Some data suggest a teratogenic potential when maternal temperatures rise above 39.2°C (102.6°F), especially in the first trimester.
Clapp JF III. Exercise in pregnancy: a brief clinical review. Fetal Med Rev. 1990;2:89–101.
10. Which of the following medications is generally avoided during pregnancy?
A) Acetaminophen
B) Chlorpheniramine
C) Pseudoephedrine
D) Diphenhydramine
E) Aspirin
View Answer
Answer and Discussion
The answer is E. High-dose aspirin has been theoretically associated with increased perinatal mortality, neonatal hemorrhage, decreased birth weight, prolonged gestation and labor, and possible birth defects, and in general should be avoided in pregnancy. Low-dose aspirin in combination with heparin has been used successfully in the treatment of antiphospholipid syndrome in pregnancy.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1027.
High-dose aspirin has been associated theoretically with increased perinatal mortality, neonatal hemorrhage, decreased birth weight, prolonged gestation and labor, and possible birth defects, and in general should be avoided in pregnancy.
11. During labor, the fetal heart tracing shows repeated late decelerations. You suspect
A) uteroplacental insufficiency
B) abnormal presentation
C) head engagement
D) rapid descent of the fetus
E) normal progression of labor
View Answer
Answer and Discussion
The answer is A. Repetitive late decelerations of the fetal heart rate may signal uteroplacental insufficiency.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:340.
12. Repetitive variable decelerations noted on fetal heart tracings suggest
A) umbilical cord compression
B) placenta previa
C) uterine rupture
D) polyhydramnios
E) normal progression of labor
View Answer
Answer and Discussion
The answer is A. Repetitive variable decelerations suggest umbilical cord compression, especially in the presence of oligohydramnios or amniotomy.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:341.
13. A 26-year-old woman is having difficulty delivering her first child. You suspect shoulder dystocia and ask the mother to stop pushing and notify your staff. The next appropriate step is
A) place the mother in the left lateral position
B) perform McRoberts' maneuver
C) apply fundal pressure
D) the Rubin maneuver (reverse Woods screw)
E) perform a cesarean section
View Answer
Answer and Discussion
The answer is B. The recommended sequence for reducing shoulder dystocia begins with calling for help and asking the mother to stop her pushing efforts. The first step is the McRoberts' maneuver, in which assistants hyperflex the mother's hips against her abdomen, thereby rotating the symphysis pubis anteriorly and decreasing the forces needed to deliver the fetal shoulders. A recent retrospective study found this maneuver to be the safest and most successful technique for relieving shoulder dystocia. An assistant can add gentle posterolateral suprapubic pressure while the physician continues moderate posterior traction on the fetal head. Fundal pressure should be avoided, because it tends to increase the impaction.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:382, 473.
14. The drug of choice for controlling eclamptic seizures is
A) hydralazine
B) phenobarbital
C) phenytoin
D) diazepam
E) magnesium sulfate
View Answer
Answer and Discussion
The answer is E. In the United States, magnesium sulfate is considered the drug of choice for controlling eclamptic seizures. Fewer intubations are required in the neonates of eclamptic women who are treated with magnesium sulfate. In addition, fewer newborns require placement in neonatal intensive care units. In the treatment of eclampsia and preeclampsia, magnesium sulfate is often given according to established protocols. If serum magnesium levels exceed 10 mEq/L (5 mmol/L), respiratory depression can occur. This problem may be counteracted by the rapid intravenous infusion of 10% calcium gluconate. Magnesium sulfate should be used with caution in patients with impaired renal or cardiac status. It should not be used in patients with myasthenia gravis.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:347.
15. The diagnosis of preeclampsia consists of all of the following except
A) elevated blood pressure
B) proteinuria
C) seizures
D) all are components of preeclampsia
View Answer
Answer and Discussion
The answer is C. The classic preeclamptic triad includes elevated blood pressure, proteinuria, and edema. More recently, edema has been removed as part of the criteria. Seizures are the distinguishing component of eclampsia.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York:McGraw-Hill; 2001:595–609.
16. The most common cause of postpartum bleeding is
A) retained placenta
B) vaginal laceration
C) uterine atony
D) coagulopathy
E) HELP syndrome
View Answer
Answer and Discussion
The answer is C. Hemorrhage after placental delivery should prompt vigorous fundal massage while the patient is rapidly given oxytocin in their intravenous fluid. If the fundus does not become firm, uterine atony is the presumed (and most common) diagnosis. While fundal massage continues, the patient may be given methylergonovine (Methergine) intramuscularly, with the dose repeated at 2- to 4-hour intervals if necessary. Methylergonovine may cause cramping, headache, and dizziness. The use of this drug is contraindicated in patients with hypertension. Carboprost (Hemabate), 15-methyl prostaglandin F2a, may be administered intramuscularly or intramyometrially every 15 to 90 minutes, up to a maximum dosage. As many as 68% of patients respond to a single carboprost injection, with 86% responding by the second dose. Because oxygen desaturation has been reported with the use of carboprost, patients should be monitored by pulse oximetry.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:637.
17. An 18-year-old woman pregnant with her first child is in the second stage of labor. She complains of abdominal pain between uterine contractions. You suspect
A) posterior presentation
B) breech presentation
C) abruption placenta
D) vasa previa
E) uterine atony
View Answer
Answer and Discussion
The answer is C. The patient in labor who develops abdominal pain between uterine contractions or a tender uterus must be presumed to have abruptio placentae. Ultrasound examination has a high false-negative rate in diagnosing abruption and as a result this complication is diagnosed clinically. In one prospective study, 78% of patients with abruptio placentae presented with vaginal bleeding, 66% with uterine or back pain, 60% with fetal distress, and only 17% with uterine contractions or hypertonus. The management of abruptio placentae is primarily supportive and entails both aggressive hydration and monitoring of maternal and fetal well-being. Coagulation studies should be performed, and fibrinogen and D-dimers or fibrin-degradation products should be measured to screen for disseminated intravascular coagulation (DIC). Packed red blood cells should be typed and held. If the fetus appears viable but compromised, urgent cesarean delivery should be considered.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:357–362.
18. A 25-year-old presents to your office complaining of abnormal vaginal bleeding. Your first consideration in the differential diagnosis is
A) infection
B) trauma
C) foreign body
D) pregnancy
E) coagulopathy
View Answer
Answer and Discussion
The answer is D. Pregnancy is the first consideration in women of childbearing age who present with abnormal uterine bleeding.
Shwayder JM. Pathophysiology of abnormal uterine bleeding. Obstet Gynecol Clin North Am. 2000;27:219–234.
Oriel KA, Schrager S. Abnormal uterine bleeding. Am Fam Physician. 1999;60:1371–1380.
19. Patients undergoing cesarean section should
A) always receive a preoperative antibiotic
B) not receive antibiotics because of the risk of resistant organisms
C) receive antibiotics only if the surgery is prolonged (>1.5 hours)
D) not receive antibiotics if they are considered low risk
E) receive antibiotics only if infection is suspected
View Answer
Answer and Discussion
The answer is A. According to ACOG, all high-risk patients undergoing cesarean delivery should receive prophylaxis with narrow-spectrum antibiotics such as cephalosporin. Several well-designed studies have documented the efficacy of prophylactic antibiotics in reducing the rates of postpartum endometritis and wound infection in patients who have undergone a cesarean delivery and are at high risk for infection. High-risk patients include those who have had cesarean deliveries after membrane rupture or labor and patients who undergo emergency procedures for which preoperative cleansing may have been inadequate. Other patients who may be at increased risk for postoperative infection include patients whose surgeries last for more than one hour and those who experience high blood loss. Risks of febrile morbidity, urinary tract infection, and wound infection also are reduced by antibiotic prophylaxis. Whether patients at lower risk for infection benefit from antibiotic therapy is less clear. No differences in rates of wound infection, endometritis, urinary tract infection, pneumonia, or febrile morbidity were noted in a randomized controlled study of 480 women undergoing cesarean delivery. In a prospective study of 82 women, the incidence of febrile morbidity and endometritis was reduced by antibiotic prophylaxis. Although the evidence is inconclusive, prophylactic antibiotics are recommended in low-risk patients undergoing cesarean delivery.
American College of Obstetricians and Gynecologists. Prophylactic antibiotics in labor and delivery. ACOG Practice Bulletin; no. 47, Obstet Gynecol. 2003;102:875–882.
20. In discussing the risk of placing an epidural during labor, you explain to your patient that
A) The ACOG recommends that epidural anesthesia in nulliparous women is not recommended until cervical dilation has reached 4 to 5 cm regardless of maternal request, because
B) early epidural anesthesia increases the risk of cesarean section
C) early epidural anesthesia may increase the rate of vacuum extraction
D) early epidural anesthesia has no effect on the rate of mid- to low forceps delivery
E) epidural anesthesia is of little help with pain management in early labor
View Answer
Answer and Discussion
The answer is C. Epidural analgesia during labor is an effective pain reliever that has become more commonly used. Despite wide acceptance of this use, the timing of epidural placement remains controversial, with conflicting reports on the risk for subsequent cesarean deliveries and the length of the latent phase of labor. Because of these concerns, ACOG recommended using other forms of analgesia in nulliparous women until they reach dilatation of 4 to 5 cm. However, some institutions did not follow these guidelines for all women in labor, so ACOG released a follow-up report recommending that maternal request is a sufficient indication for epidural analgesia during labor and that it should not be denied on the basis of cervical dilatation. To develop better information about epidural analgesia, Vahratian and colleagues compared the effect of early epidural analgesia with that of early intravenous analgesia on labor progression. The proportion of cesarean deliveries remained the same (18%) in both groups. In the epidural group, the use of outlet forceps or vacuum extraction increased from 10% to 14%, and the use of mid- to low forceps or vacuum extraction decreased from 14% to 10%. The authors conclude that it is unnecessary to withhold epidural analgesia before 4 cm of cervical dilatation is achieved. In their study, the only difference in labor progression between epidural and intravenous analgesia was at 4 to 5 cm and not in the early phase of labor.
Vahratian A, Zhang J, Hasling J. The effect of early epidural versus early intravenous analgesia use on labor progression: a natural experiment. Am J Obstet Gynecol. 2004;191:259–265.
Maternal request is a sufficient indication for epidural analgesia during labor. It should not be denied on the basis of cervical dilatation.
21. When using a vacuum extractor, the procedure should be abandoned after
A) 5 minutes
B) 10 minutes
C) 5 attempts
D) 3 attempts
P.186
View Answer
Answer and Discussion
The answer is D. Vacuum extraction should not be attempted if the head is not engaged. The procedure should be abandoned if delivery is not achieved or the labor does not progress. Under ordinary circumstances, the procedure should be abandoned after three attempts. The procedure should also be stopped if there is any evidence of fetal scalp trauma.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:506.
22. Proper placement of the vacuum extractor is
A) placed as far anteriorly as possible
B) over the sagittal suture extending to the posterior fontanel
C) covering the posterior fontanel
D) over the sagittal suture and 3 cm in front of the posterior fontanel
E) anywhere on the exposed cranium
View Answer
Answer and Discussion
The answer is D. When the vacuum extractor is placed on the fetal scalp, the center of the cup should be over the sagittal suture and about 3 cm (1.2 in.) in front of the posterior fontanel. As a general guide, the cup is generally placed as far posteriorly as possible. This cup placement maintains flexion of the fetal head and avoids traction over the anterior fontanel. In positioning the cup, the physician should be careful to avoid trapping maternal soft tissue (e.g., labia) between the cup and the fetal head.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:504.
23. Pregnant patients with established HIV infection
A) should avoid all antiviral medications because of their teratogenic potential
B) should receive only zidovidine at the time of delivery
C) should be treated the same as adults with HIV who are not pregnant
D) should avoid zidovidine because of its limited effectiveness
E) receive only zidovidine if their CD4+ counts are unacceptably low
View Answer
Answer and Discussion
The answer is C. Recommendations from the Centers for Disease Control and Prevention (CDC) regarding optimal antiretroviral therapy are to treat pregnant women infected with HIV the same as adults infected with HIV who are not pregnant, using clinical, virologic, and immunologic status to guide treatment decisions. One difference for pregnant women is to include zidovudine in every treatment regimen, given the extensive data demonstrating its benefits. A follow-up study trial showed that zidovudine was beneficial independent of its effect on viral load and regardless of the CD4+ lymphocyte count and viral load at the initiation of therapy.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1502.
24. When repairing perineal lacerations, it has been shown that
A) skin sutures may increase the incidence of perineal pain
B) skin sutures are required for adequate skin approximation
C) interrupted transcutaneous sutures are superior to running subcuticular sutures
D) sutures should begin at the anterior point of the skin laceration
E) repair with skin sutures leads to better outcomes
View Answer
Answer and Discussion
The answer is A. When the perineal muscles are repaired anatomically, the overlying skin is usually well approximated, and skin sutures generally are not required. Skin sutures have been shown to increase the incidence of perineal pain at 3 months after delivery. If the skin requires suturing, running subcuticular sutures have been shown to be superior to interrupted transcutaneous sutures. The 4-0 polyglactin 910 sutures should start at the posterior apex of the skin laceration and should be placed approximately 3 mm from the edge of the skin.
Kettle C, Johanson RB. Continuous versus interrupted sutures for perineal repair. Cochrane Database Syst Rev. 2003;(1):CD000947.
25. Laser conization and LEEP procedures have been associated with
A) premature rupture of membranes (PROM)
B) increased peripartum mortality
C) increased cesarean rates
D) higher rates of endometritis during pregnancy
E) no adverse effects during pregnancy
View Answer
Answer and Discussion
The answer is A. A recent study concludes that there is an increased risk of PROM and preterm delivery, but not overall preterm deliveries, following laser conization or LEEP. Although PROM leads to preterm deliveries, these were higher in the untreated group after adjustments compared with the treated group. The authors attribute this incongruity to the higher rate of iatrogenic preterm deliveries in the untreated group. The authors of the study suggest careful adherence to CIN management guidelines, avoidance of unnecessary excisions, and appropriate counseling of previously treated women when they become pregnant.
Sadler L, Saftlas A, Wang W. Treatment for cervical intraepithelial neoplasia and risk of preterm delivery. JAMA. 2004;291:2100–2106.
26. A 39-year-old mother presents to your office for preconception counseling. She has one child affected with neural tube defect. Appropriate counseling concerning folic acid supplementation should include ____ daily
A) 100 mcg
B) 400 mcg
C) 1 mg
D) 4 mg
E) none needed based on her current age
View Answer
Answer and Discussion
The answer is D. Taking folic acid supplementation before conception reduces the incidence of neural tube defects, including spina bifida and anencephaly. The average woman receives about 100 mcg of folic acid per day, mostly from fortified breads and grains. Supplementation should begin at least 1 month before conception and continue through the first 3 months of pregnancy; women should take a daily vitamin supplement containing at least 400 mcg of folic acid. Higher dosages are indicated for special-risk groups. A dosage of 1 mg per day is recommended for women with diabetes mellitus or epilepsy. Mothers who have given birth to children with neural tube defects should take 4 mg of folic acid per day for subsequent pregnancies.
Botto LD, Moore CA, Khoury MJ, et al. Neural-tube defects. N Engl J Med. 1999;341:1509–1519.
Werler MM, Louik C, Mitchell AA. Achieving a public health recommendation for preventing neural tube defects with folic acid. Am J Public Health. 1999;89:1637–1640.
Iqbal MM. Prevention of neural tube defects by periconceptional use of folic acid. Pediatr Rev. 2000;21:58–66.
27. A 36-year-old woman has a history of a prior deep venous thrombosis (DVT). She is pregnant for the first time. In view of her prior history of DVT, you should recommend
A) warfarin (Coumadin)
B) heparin
C) aspirin
D) clopidogrel (Plavix)
E) no prophylaxis is necessary
View Answer
Answer and Discussion
The answer is B. Women who have a personal or family history of venous thromboembolism should be offered testing for coagulopathy before pregnancy. Women with a prior history of DVT have a 7% to 12% risk of recurrence during pregnancy. Heparin (in regular or low-molecular-weight form) is indicated for prophylaxis and should be started as early in pregnancy as possible. Women receiving warfarin (Coumadin) as maintenance therapy for DVT should be switched to heparin before conception, because warfarin is teratogenic.
American College of Obstetricians and Gynecologists. Thromboembolism in pregnancy. ACOG Practice Bulletin; no. 19. Obstet Gynecol. 2000;96:1–10.
28. When advising mothers concerning anti-seizure medications during pregnancy, which of the following statements is true?
A) Multiple medications are preferred to maintain lower levels of medication.
B) Anti-seizure medications should be discontinued at the time pregnancy is determined.
C) Seizure activity in mothers has no impact on fetal outcomes.
D) Most anti-seizure medications are considered safe (category B).
E) Single agents are preferred over multiple medications.
View Answer
Answer and Discussion
The answer is E. Children of mothers with epilepsy have a 4% to 8% risk of congenital anomalies, which may be caused by anticonvulsant medication or may be related to an increased genetic risk. These children also have an increased risk of developing epilepsy. Preconception counseling should include optimizing seizure control, prescribing folic acid supplements of 1 to 4 mg per day, and offering referral to a genetic counselor. When possible, use of multiple anticonvulsants should be discouraged. It is advisable to aim to use the best single agent for the seizure type at the lowest protective level. There is no single drug of choice. The older agents are classified as FDA pregnancy risk category D and the newer agents are poorly studied. If the patient has been seizure-free for 2 years or longer, drug discontinuation with a long taper period (3 months) may be successful.
Malone FD, D'Alton ME. Drugs in pregnancy: anticonvulsants. Semin Perinatol. 1997;21:114–123.
Brundage SC. Preconception health care. Am Fam Physician. 2002;65:2507–2514, 2521–2522.
29. Which of the following statements is true regarding smoking during pregnancy?
A) Smoking increases the risk of attention-deficit disorder in the child.
B) Nicotine patches are a safe alternative during pregnancy.
C) Bupropion (Zyban) should be avoided during pregnancy.
D) Regardless of when she stops smoking, infants born to mothers with a smoking history are more at risk for neonatal complications.
E) When compared to total abstinence, reducing the number of cigarettes smoked has no effect on fetal outcomes.
View Answer
Answer and Discussion
The answer is A. Smoking increases the risk of miscarriage, low birth weight, perinatal mortality, and attention-deficit disorder in the child. If the mother smokes less than 1 pack of cigarettes per day, the risk of a low-birth-weight infant increases by 50%; with more than 1 pack per day, the risk increases by 130%. If the mother quits smoking by 16 weeks of pregnancy, the risk to the fetus is similar to that of a nonsmoker. Behavioral techniques, support groups, and family assistance may be beneficial. Nicotine patches or gum may be helpful before conception, but most authorities recommend avoiding them during pregnancy. Bupropion (Zyban) may be used during pregnancy. If the patient cannot stop smoking, the physician should help her establish a goal to decrease her number of cigarettes to fewer than 10 per day, because many of the adverse effects are dose related.
Brundage SC. Preconception health care. Am Fam Physician. 2002;65:2507–2514, 2521–2522.
30. The use of benzodiazepines during pregnancy has been associated with
A) polydactily
B) cleft lip
C) spina bifida
D) growth retardation
E) developmental delay
View Answer
Answer and Discussion
The answer is B. Maternal use of benzodiazepines during pregnancy has been associated with anomalies such as cleft lip and palate, as well as a withdrawal syndrome in the newborn.
Brundage SC. Preconception health care. Am Fam Physician. 2002;65:2507–2514, 2521–2522.
Maternal use of benzodiazepines during pregnancy has been associated with anomalies such as cleft lip and palate, as well as a withdrawal syndrome in the newborn.
31. Which of the following is not associated with maternal obesity during pregnancy?
A) hydrocephalus
B) maternal hypertension
C) preeclampsia
D) maternal diabetes
E) macrosomic infant
View Answer
Answer and Discussion
The answer is A. Obesity and being underweight increase pregnancy risks. Obesity increases the risks of maternal hypertension, preeclampsia, diabetes, and delivering a macrosomic infant. Women who are obese should diet prior to conception and then alter their consumption to a maintenance diet of 1,800 calories per day while trying to conceive.
Brundage SC. Preconception health care Am Fam Physician. 2002;65:2507–2514, 2521–2522.
32. A 26-year-old primagravida presents to your office. She is pregnant with a twin gestation and is in her third trimester. She complains of pruritic, vesicular skin lesions that have developed on her abdomen. Her face, palms and soles are spared. You suspect
A) varicella
B) scabies
C) pruritic urticarial papules and papules of pregnancy (PUPPP)
D) herpes zoster
E) hyperbilirubinemia
View Answer
Answer and Discussion
The answer is C. Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is the most common dermatologic complaint of pregnancy, occurring in up to 1 in 160 pregnancies, with an increased incidence in multiple gestations. It usually occurs in primigravidas in the third trimester and recurrence in subsequent pregnancies is unusual. The rash may first appear postpartum. PUPPP typically has a marked pruritic component, the onset of which coincides with the skin lesions. The rash typically begins over the abdomen, commonly involving the striae gravidarum, and may spread to the breasts, upper thighs, and arms. The face, palms, soles, and mucosal surfaces usually are spared. The lesions typically consist of polymorphous, erythematous, nonfollicular papules, plaques, and sometimes vesicles. The lesions can be painful. The rash usually resolves near term or in the early postpartum period. Topical moisturizers and moderately potent steroids in combination with oral antihistamines can provide symptomatic relief.
Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am Acad Dermatol. 2001;45:1–19.
33. Which of the following statements is true regarding pruritus gravidarum?
A) The condition is associated with a lacy, erythematous rash that affects the entire body.
B) The rash is limited to the soles of the feet and palms of the hand.
C) The onset is typically in the third trimester.
D) Emollients and antihistamines offer no relief.
E) The condition has no obvious dermatosis.
View Answer
Answer and Discussion
The answer is E. Pruritus gravidarum is a poorly defined condition of pregnancy associated with itching without an obvious dermatosis. The term pruritus gravidarum is classically associated with pruritus in the first trimester. Its etiology and incidence are unknown. The symptoms of pruritus gravidarum usually can be relieved by emollients and antihistamines.
Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am Acad Dermatol. 2001;45:1–19.
34. A 26-year-old woman who is 30 weeks' pregnant is involved in a motor vehicle accident. She has suspected neck trauma and is in need of transport. You suggest placing her
A) in the left lateral decubitus position
B) in the Trendelenberg position
C) prone position on a backboard
D) supine on a backboard with her right hip elevated
E) supine on a backboard
View Answer
Answer and Discussion
The answer is D. After 20 weeks of gestation, the enlarged uterus may compress the great vessels when a pregnant woman is in a supine position. This compression can cause a decrease of up to 30 mm Hg in maternal systolic blood pressure, a 30% decrease in stroke volume, and a consequent decrease in uterine blood flow. Manual deflection of the uterus laterally or placement of the patient in the lateral decubitus position avoids uterine compression. Because of suspected neck trauma in this patient, placing her supine on a backboard with her right hip elevated 4 to 6 in with towels is the safest treatment.
Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004;70:1303–1310, 1313.
35. Which of the following statements about the evaluation of infertility is true?
A) The woman should be evaluated before the man with a postcoital test.
B) A hysterosalpingogram should be performed as the first step in an infertility workup.
C) The first step is evaluation of the male factor with a sperm analysis.
D) Hormone level determination is the first test that should be ordered for the woman before the workup for the man.
E) An endometrial biopsy on the woman is the first test to consider in the workup of infertility.
View Answer
Answer and Discussion
The answer is C. Infertility affects as many as 10% to 15% of couples in the United States and appears to be increasing in incidence. The definition of infertility is the lack of conception after 1 year of unprotected intercourse. As many as 40% of infertility cases are the result of the male factor (i.e., inadequate sperm production, abnormal sperm motility, or abnormally formed sperm). Other factors involve the female factor and include previous pelvic infections with fallopian tube damage, anovulation, low progesterone levels, hypothyroidism, hyperprolactinemia, or the presence of antisperm antibodies. In the evaluation of infertility, the man is usually evaluated first with a sperm analysis, because the female evaluation may be more extensive. If the sperm is found to be adequate, the woman can be evaluated with a postcoital test, hormone level determination, endometrial sampling, and hysterosalpingogram, which determine patency of the fallopian tubes. Measurement of basal body temperature may show a 0.5°F to 1.0°F increase in temperature supporting ovulation. Further evaluation may require endocrine testing or CT scanning of the head to rule out pituitary tumors or testing to rule out polycystic ovary disease.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2138–2143.
36. Which of the following conditions is characterized by infarction of the pituitary gland during labor and delivery?
A) Asherman's syndrome
B) Stein-Leventhal syndrome
C) Sheehan's syndrome
D) Cushing's disease
E) Nelson's syndrome
View Answer
Answer and Discussion
The answer is C. Sheehan's syndrome is a complication of childbirth that results from shock and excessive peripartum bleeding. During pregnancy the pituitary gland usually enlarges and is vulnerable to infarction if excessive bleeding compromises blood flow. Necrosis of the pituitary can occur with varying loss of pituitary function. Symptoms of Sheehan's syndrome include lack of postpartum milk production as a result of low prolactin levels, breast atrophy, loss of pubic or axillary hair, amenorrhea, depressed mental status, low blood pressure, loss of libido, and lack of sweating. Laboratory findings include evidence of hypothyroidism, adrenal insufficiency, and decreased gonadotropin hormone secretion. Treatment involves the replacement of inadequate hormones, including thyroxine, glucocorticoids, and sex hormones.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:638.
37. Which of the following factors is associated with preterm labor?
A) Long cervix (>30 mm by vaginal ultrasound)
B) Positive fibronectin assay
C) Braxton-Hicks contractions
D) Nipple stimulation
E) Orgasm
View Answer
Answer and Discussion
The answer is B. Preterm labor is defined as labor pains occurring regularly at frequent intervals (generally more than 4 per hour, accompanied by cervical dilation between 20 and 37 weeks' gestation. Causes include infections, uterine abnormalities, cervical incompetency, premature rupture of membranes, multiple gestations, and other abnormalities (e.g., polyhydramnios, fetal abnormalities). A long cervix (>30 mm by transvaginal ultrasound) and a negative fibronectin assay both have an excellent negative predictive value for preterm labor. Treatment involves the correction of underlying factors (e.g., treatment of infection), bed rest, and the use of tocolytics, such as ritodrine, nifedipine, terbutaline, and magnesium sulfate.
Rakel RE. Textbook of Family Practice, 6th ed. Philadelphia: WB Saunders; 2002:534.
38. Which of the following statements is true regarding seatbelt use in pregnancy?
A) The use of seatbelts can increase the risk of fetal injury.
B) The lap belt should be placed under the gravid uterus and over the thighs with the shoulder harness placed between the breast and over the uterus.
C) The air bag should be disabled.
D) Seat belt-restrained women who are in motor vehicle crashes have the same fetal mortality rate as women who are not in motor vehicle crashes.
E) The shoulder harness should not be used during pregnancy.
View Answer
Answer and Discussion
The answer is D. Proper seat belt use is the most significant preventative measure in decreasing maternal and fetal injury and mortality after motor vehicle crashes. Seat belt-restrained women who are in motor vehicle crashes have the identical fetal mortality rate as women who are not in motor vehicle crashes, but unrestrained women who are in crashes are more than twice as likely to lose their fetuses. Prenatal care should include three-point seat belt instruction. The lap belt should be placed under the gravid abdomen, snugly over the thighs, with the shoulder harness off to the side of the uterus, between the breasts and over the midline of the clavicle. Seat belts placed directly over the uterus can cause fetal injury. Airbags should not be disabled during pregnancy.
Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004;70:1303–1310, 1313.
39. An ultrasound evaluation at 12 weeks' gestation detects nuchal translucency in the fetus. Based on the ultrasound report, you suspect
A) Down syndrome
B) brachial cleft cyst
C) spina bifida
D) anencephaly
E) normal development
View Answer
Answer and Discussion
The answer is A. There is no evidence that directly links improved fetal outcomes with routine ultrasound screening. However, there is sufficient evidence that early ultrasonography (i.e., before 14 weeks' gestation) accurately determines gestational age, decreases the need for labor induction after 41 weeks' gestation, and detects multiple pregnancies. Ultrasonography at 10 to 14 weeks' gestation can measure nuchal translucency as a screening test for Down syndrome. Pregnant women should be offered an ultrasound evaluation to search for structural anomalies between 18 and 20 weeks' gestation. Diagnostic ultrasound exposure has not been proved to harm the mother or fetus.
Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: Part I. General prenatal care and counseling issues. Am Fam Physician. 2005;71:1307–1316, 1321–1322.
Ultrasonography at 10 to 14 weeks' gestation can measure nuchal translucency as a screening test for Down syndrome.
40. The addition of progesterone to estrogen replacement therapy (ERT) prevents the development of
A) adenomyosis
B) fibroid tumors
C) cervical cancers
D) ovarian cancer
E) endometrial hyperplasia
View Answer
Answer and Discussion
The answer is E. Estrogen use without progesterone can lead to endometrial hyperplasia, a precursor to endometrial cancer. Thus, in postmenopausal women with an intact uterus, estrogen (0.625 mg/day) should be given along with low-dose progesterone (2.5 mg/day) in a continuous combined method; the more traditional cyclical pattern is 0.625 mg/day estrogen with 5 or 10 mg/day progesterone given on days 19 through 25. Transdermal estrogen is also available, but is less beneficial with regard to lipid metabolism. The addition of progesterone for at least 10 days per month reliably prevents the development of endometrial hyperplasia. Abnormal vaginal bleeding should be further evaluated with an endometrial biopsy and ultrasound of the uterus. If the endometrial thickness is less than or equal to 5 mm, the risk of endometrial hyperplasia or cancer is low. Significant controversy surrounds the use of estrogen replacement secondary to results from the Women's Health Initiative Survey. Many favor avoiding the use in postmenopausal women except in specific cases.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2121.
41. What percentage of babies born to human immunodeficiency virus (HIV)–positive mothers is HIV positive?
A) 0% to 1%
B) 20% to 30%
C) 50% to 75%
D) 90% to 100%
E) 100%
View Answer
Answer and Discussion
The answer is B. Prenatal screening for HIV should be offered to all pregnant women. Approximately 20% to 30% of babies who are born to mothers with HIV are HIV positive. Cesarean section is controversial, but generally recommended if the HIV-1 ribonucleic acid load is greater than 1,000 copies per milliliter. After delivery, if the infant screening test is negative, breast-feeding should be discouraged. HIV has been isolated from mothers' breast milk, and the potential for transmission exists. Azidothymidine administered during the second and third trimesters and then given to infants during the first 6 weeks of life decreases the risk of HIV transmission. A protease inhibitor (i.e., indinavir, ritonavir, or saquinavir) should also be offered to pregnant women, although recommendations are constantly changing with regard to treatment.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1501–1503.
42. The most appropriate management for fetal demise includes
A) observation for up to 4 weeks until the mother goes into labor
B) immediate cesarean section
C) administration of oxytocin (Pitocin) after the application of prostaglandin gel and laminaria tents to the cervix
D) administration of terbutaline after application of prostaglandin gel to the cervix
E) heparin plus antibiotic prophylaxis and observation for up to 4 weeks
View Answer
Answer and Discussion
The answer is C. The risk of DIC is increased if a dead fetus has been retained in utero for more than 3 to 4 weeks. Therefore, it is practical to provide expectant management for patients with in utero fetal demise for up to 2 weeks. However, because many mothers experience significant psychological stress from carrying a dead fetus, aggressive measures––including the administration of oxytocin and laminaria tents to provide cervical dilation, as well as prostaglandin E2––can be taken to facilitate cervical ripening and eventual delivery and should be performed as soon as a firm diagnosis is made.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2101–2202.
43. A standard dose of Rh immune globulin (300 µg) prevents sensitization from fetomaternal hemorrhage of up to
A) 30 ml of whole blood
B) 60 ml of whole blood
C) 100 ml of whole blood
D) 500 ml of whole blood
E) any amount of whole blood
View Answer
Answer and Discussion
The answer is A. Rh immune globulin (RhIg) must be administered to an Rh-negative mother immediately after abortion or delivery (live or stillborn) unless the infant is Rho(D) and Du negative, the mother's serum already contains anti-Rho(D), or the mother refuses. The standard dose of intramuscular RhIg (300 µg) prevents sensitization from fetomaternal hemorrhage of up to 30 mL whole blood. It is necessary to identify women with fetomaternal hemorrhage to calculate the doses needed to prevent sensitization via a screening rosette test, which, if positive, is followed by a quantitative test (e.g., Kleihauer-Betke).
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2195.
44. Which of the following statements regarding varicella during pregnancy is true?
A) If a pregnant woman has no history of varicella and tests negative for antibodies, she should be immunized as soon as possible.
B) Varicella vaccination should be avoided in breastfeeding women.
C) Susceptible pregnant women who are exposed to varicella are candidates for varicella zoster immune globulin.
D) Pregnancy should be delayed 6 months after varicella vaccination.
E) A single dose of varicella vaccine is safe during pregnancy and can be administered to help protect the fetus.
View Answer
Answer and Discussion
The answer is C. If varicella testing is performed in the preconception period, women can be offered two doses of varicella vaccine at least 1 month apart. Pregnancy should be delayed 1 month after vaccination. Varicella vaccine is contraindicated in pregnant women. Women found to be nonimmune during pregnancy should be counseled to avoid exposure to chickenpox and to report exposure immediately. Susceptible pregnant women who are exposed to varicella are candidates for varicella zoster immune globulin. Nonimmune women should be offered postpartum varicella vaccination. The vaccine is considered safe in breastfeeding women.
Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: Part II. Third-trimester care and prevention of infectious diseases. Am Fam Physician. 2005;71:1555–1560, 1561–1562.
45. Rho (D) immune globulin (RhoGAM) is indicated when
A) the mother has type AB blood
B) the father is Rh negative
C) the mother is Rh positive
D) none of the above
View Answer
Answer and Discussion
The answer is D. If the antibody test is negative, Rh-negative mothers should be given RhoGAM (an immune globulin preparation) at 28 weeks' gestation to prevent erythroblastosis fetalis. If the father is also Rh negative, the administration is unnecessary; however, extramarital pregnancies should be considered. If the antibody test is positive, the mother should be referred to a specialist. A dose of RhoGAM should also be given at the time of delivery. This dose can be determined by the Kleihauer-Betke (FetalDex) test, which measures the amount of fetal erythrocytes in the maternal blood. If the newborn is Rh negative, there is no need for RhoGAM administration. RhoGAM should also be given to Rh-negative women after elective or spontaneous abortion, placental abruption, ectopic pregnancy, or amniocentesis. Typically, the standard RhoGAM dose is 300 µg, which protects up to 10 mL of Rh-positive fetal red cells.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:296–299.
46. When there is first-trimester bleeding, fetal viability can be determined by which of the following tests?
A) Qualitative β–human chorionic gonadotropin (hCG) determination
B) Serial quantitative β-hCG determinations
C) α-Fetoprotein testing
D) Kleihauer-Betke test
E) Biophysical profile
View Answer
Answer and Discussion
The answer is B. Approximately 25% of pregnant women experience vaginal spotting or heavier bleeding during the first trimester of pregnancy, and 25% to 50% of these pregnant women experience spontaneous abortion. Genetic anomalies are the most common cause of spontaneous abortion in the first trimester. When first-trimester bleeding is present, viability of the fetus can be determined with a quantitative β-hCG determination, which is repeated 3 to 5 days later. The β-hCG level should double every 48 hours when a viable pregnancy is present. Other causes for first-trimester bleeding, such as infection, should be ruled out. A fetus should be seen with vaginal ultrasound by the 33rd to 35th day after the last menstrual period, or when the β-hCG level has reached 1,500 mIU/mL. If the β-hCG level exceeds 1,500 to 2,000 mIU/mL and no intrauterine pregnancy is found with vaginal ultrasound, an ectopic pregnancy should be suspected, especially if an adnexal mass is palpated on physical examination or the expecting mother experiences lower abdominal pain. Progesterone levels of <5 ng/dL indicate a nonviable pregnancy.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:884–893.
47. Which of the following is an acceptable form of exercise during pregnancy?
A) Horseback riding
B) Skiing
C) Volleyball
D) Tennis
E) Aerobics (high impact)
View Answer
Answer and Discussion
The answer is D. ACOG makes specific recommendations concerning exercise during pregnancy that include the following:
· Regular exercise (at least three times per week) is preferable.
· Extreme heat or humidity should be avoided.
· Ballistic or jerking-type movements should be avoided.
· Extreme flexion or extension of joints should be avoided.
· The warm-up should last for at least 5 minutes' minimum duration; the patient should also perform cooling-off exercises after the workout.
· Heart rate at peak activity should be measured.
· The patient should be aware of symptoms of orthostatic hypotension and make sure that she does not become dehydrated.
· The patient should drink plenty of fluids to avoid dehydration.
· The patient should begin with a light exercise program and advance the program slowly.
· The amount of exercise should be maintained at approximately the same level as before pregnancy.
In addition, the mother's core temperature should not exceed 38°C. Women who are at more than 4 months' gestation should avoid exercise in the supine position. They should also avoid repeated Valsalva maneuvers, and caloric intake should be adjusted to support maternal and fetal needs.
Racket sports, swimming, bicycling, and light weightlifting are acceptable as long as proper breathing techniques are used and the mother avoids Valsalva maneuvers. Horseback riding, volleyball, skiing, and high-impact aerobics are not recommended. Contraindications to exercise include cervical incompetence, uterine bleeding, previous premature labor, uncontrolled hypertension, or diabetes and significant anemia.
American College of Obstetrics and Gynecology. Exercise during pregnancy and the postpartum period. ACOG Technical Bulletin No. 189. Int J Gynaecol Obstet. 1994;45:65–70.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:238–239.
48. A 29-year-old woman is now in her 14th week of pregnancy and developed an initial outbreak of genital herpes. You explain to her
A) genital herpes that is acquired during pregnancy does not seem to increase rates of neonatal illness or congenital HSV infection as long as HSV seroconversion has completed by the time labor begins.
B) the fetus has a higher risk of congenital infection even if seroconversion has completed and in the absence of lesions at the time of delivery.
C) termination of the pregnancy should be considered.
D) the risk of fetal malformations is higher for her child.
E) antiviral medications such as acyclovir (Zovirax) cannot be used in pregnancy if she develops recurrent attacks.
View Answer
Answer and Discussion
The answer is A. Genital herpes that is acquired during pregnancy does not seem to increase rates of neonatal illness or congenital HSV infection as long as HSV seroconversion has completed by the time labor begins. Women with recurrent HSV infection should be counseled about the use of acyclovir (Zovirax) at term to decrease the rate of cesarean delivery, the role of cesarean delivery in decreasing vertical transmission, and avoiding postpartum transmission to the infant through direct contact.
Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: Part II. Third-trimester care and prevention of infectious diseases. Am Fam Physician. 2005;71:1555–1560, 1561–1562.
Genital herpes that is acquired during pregnancy does not seem to increase rates of neonatal illness or congenital herpes simplex virus (HSV) infection as long as HSV seroconversion has completed by the time labor begins.
49. Which of the following is not a risk factor for group B β-streptococcal infection?
A) Twin gestation
B) Less than 37 weeks' gestation
C) Prolonged rupture of membranes
D) Maternal fever
E) All are risk factors
View Answer
Answer and Discussion
The answer is A. Group B β-streptococcal (GBS) infection is responsible for a significant amount of neonatal morbidity and mortality. Up to 30% of women are colonized by GBS. Risk factors for neonatal infection include: less than 37 weeks' gestation, prolonged rupture of membranes (>18 hours), and maternal fever. Multiple organizations recommend that all women be offered GBS screening by vaginorectal culture at 35 to 37 weeks' gestation and that colonized women be treated with intravenous antibiotics [e.g., high-dosage penicillin or clindamycin (Cleocin)] at the time of labor or rupture of membranes. GBS bacteriuria indicates heavy maternal colonization. Women with GBS bacteriuria or a previous infant with GBS infection should be offered intrapartum antibiotics routinely and therefore do not require vaginorectal culture.
American College of Obstetricians and Gynecologists. Prevention of early-onset group B streptococcal disease in newborns. ACOG committee opinion; no. 279. Obstet Gynecol. 2002; 100:1405–1412.
50. Patients who have difficulty with infertility may have antisperm antibodies. Which of the following medications may help lower antisperm antibodies?
A) Medroxyprogesterone (Depo-Provera)
B) Oral contraceptive pills
C) Gonadotropin-releasing hormone (GnRH) agonist
D) Corticosteroids
E) None of the above
View Answer
Answer and Discussion
The answer is D. Immunologic infertility can occur in women as a result of the development of local and circulating antisperm antibodies. In men, there may also be circulating antibodies that prevent conception. Men with previous vasectomies have an increased risk of antisperm antibodies. Immunologic tests are now available for the detection of these antibodies. In some cases, spontaneous remission of antibodies has occurred. In cases in which they persist, steroids may be useful in lowering the levels of antibodies, thus allowing pregnancy.
Haas G, Cines D, Schreiber A. Immunologic infertility: identification of patients with antisperm antibodies. N Engl J Med. 1980;303:722–726.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2138.
51. A 26-year-old woman presents to your office with questions regarding an intrauterine device (IUD) for birth control. Which of the following statements is true?
A) The first IUD that was developed is still available and has now been determined to be safe to use.
B) Failure rates can be as high as 15%.
C) Newer IUDs pose less risk for pelvic inflammatory disease (PID).
D) Placement of an IUD may affect future fertility.
E) Copper IUDs have been associated with an increased risk for cervical cancer.
View Answer
Answer and Discussion
The answer is C. An IUD is a contraceptive method that involves placing a foreign body through the cervical os and into the uterus. Interest in the IUD started in the 1960s, and its use in this country increased over the next decade. A 1974 study, however, linked the Dalkon Shield to maternal death and found it to have a disproportionately higher rate of infection than any other IUD. The cause of infection was the multifilament string (or tail), which was a modification of the monofilament tails used by other IUDs. This multifilament tail provided a pathway for bacteria, enabling them to bypass the immunologic barrier provided by the endocervix. This design flaw caused a fivefold increase in PID and an increase in septic abortion. After the Dalkon Shield was removed from the market, the use of IUDs declined in the United States. Currently, the ParaGard copper T308A is a type of IUD that can be left in place for 8 to 10 years. The levonorgestrel-secreting IUD is effective for 5 years. The mechanism of action is through the prevention of implantation. Failure rates are <5%. Contraindications for the use of IUDs include cervical or uterine infections and pregnancy. Relative contraindications include a history of PID, ectopic pregnancy, multiple sexual partners, menorrhagia, or diabetes. If a pelvic infection is suspected, an IUD should be removed. The risk of ectopic pregnancy is slightly increased for those who use IUDs compared with those using oral contraceptives. A pregnancy test should be performed in patients who present with abdominal pain and an IUD in place. More recent IUDs have an improved design, and reevaluation has shown them to be a safe, efficacious, and cost-effective form of birth control. Careful patient selection and preinsertion counseling are crucial to success with the device. Recent studies conclude that the IUD poses little or no increased risk of PID or infertility when used by appropriately selected patients. Multiple studies have shown no increased risk for cervical or uterine malignancies in IUD users. Several reviews have indicated that women who use copper IUDs actually have a decreased risk of cervical malignancies with increasing duration of use, suggesting that copper ions may protect against cervical malignancies.
Canavan TP. Appropriate use of the intrauterine device. Am Fam Physician. 1998;58:2083.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2135–2136.
52. An 18-year-old woman has noted darkened areas of skin on her face following the initiation of oral contraceptives. The most likely diagnosis is
A) melasma
B) lupus pernio
C) malignant melanoma
D) sebaceous hyperplasia
E) adrenal hyperplasia
View Answer
Answer and Discussion
The answer is A. Melasma occurs in some women taking oral contraceptives. The condition is characterized by areas of darkened pigmentation that may affect the face. The condition is also seen in pregnancy. The condition is more common in African Americans and Latinas. Sun exposure can worsen the condition. Usually, the areas fade when pregnancy is complete or oral contraceptives are discontinued. Oral contraceptives do not increase the risk of malignant melanoma.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2135–2136.
53. Which of the following is the drug of choice for the prevention of group B β–streptococcal infection in the peripartum period?
A) Intramuscular ceftriaxone
B) Oral ciprofloxacin
C) Intravenous penicillin G
D) Intravenous vancomycin
E) Oral amoxicillin
View Answer
Answer and Discussion
The answer is C. Intravenous penicillin G is the preferred antibiotic for the prevention of group B β–streptococcal infection in newborns, with ampicillin as an alternative. Penicillin G should be administered at least 4 hours before delivery for maximum effectiveness. Cefazolin is recommended in women allergic to penicillin who are at low risk of anaphylaxis. Clindamycin and erythromycin are options for women at high risk for anaphylaxis, and vancomycin should be used in women allergic to penicillin and whose cultures indicate resistance to clindamycin and erythromycin or when susceptibility is unknown.
Schrag S, Gorwitz R, Fultz-Butts K, et al. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep. 2002;51(RR-11):1–22.
54. The diagnostic test of choice for the detection of ectopic pregnancy is
A) quantitative β-subunit human chorionic gonadotropin (β-hCG) levels
B) computed tomography (CT) of pelvis
C) magnetic resonance imaging (MRI) of the pelvis
D) ultrasound of the pelvis
E) hysteroscopy
View Answer
Answer and Discussion
The answer is D. Ectopic pregnancy is the most common cause of pregnancy-related death in the first trimester and a common diagnostic and management challenge. Because of its relatively high incidence, ectopic pregnancy represents a risk of mortality from ectopic rupture. When diagnosed early, ectopic pregnancy may be treated medically rather than surgically. Therefore, ectopic pregnancy should be considered and quickly ruled out in all women of reproductive age who present with abdominal pain or vaginal bleeding. Ultrasonography remains the diagnostic test of choice, but it is less specific in patients with low β-subunit human chorionic gonadotropin (β-hCG) levels and may not be available 24 hours a day in some hospitals and clinics.
Buckley RG, et al. History and physical examination to estimate the risk of ectopic pregnancy: validation of a clinical prediction model. Ann Emerg Med. 1999;34:589–594.
55. Which of the following statements about molar pregnancy is true?
A) Malignant transformation is monitored by serial α-fetoprotein levels.
B) Further pregnancies should be discouraged after a molar pregnancy.
C) It is usually associated with hyperemesis gravidarum.
D) Risk for recurrent molar pregnancy is not increased in women who have had previous molar pregnancies.
E) The majority of molar pregnancies result in malignant transformation.
View Answer
Answer and Discussion
The answer is C. A molar pregnancy (hydatidiform mole) occurs when the placenta undergoes trophoblastic transformation and results in a neoplasm of the placenta. The abnormal placenta is usually swollen, edematous, and vesicular, resembling a cluster of grapes. The condition usually affects women younger than 20 and older than 40 years of age, and those with a prior history of hydatidiform mole are at increased risk. Hydatidiform moles are usually associated with hyperemesis gravidarum and preeclampsia that occur before the third trimester. Other associated conditions include vaginal bleeding; signs and symptoms of hyperthyroidism; trophoblastic embolization that may cause cough, tachypnea, and cyanosis; enlarged uterus associated with gestation; and theca lutein cysts resulting in ovarian enlargement. In 80% of patients, the molar pregnancy resolves spontaneously without complications; however, in 20%, there is a malignant transformation of the tissue. Therefore, serum hCG determination (which is usually significantly elevated) should be monitored every 2 weeks after evacuation of the uterus until the value drops to nonpregnant values and then every 1 to 2 months for 1 year. Repeated pelvic examinations should be performed on a monthly basis after a molar pregnancy for the first year. In addition, a chest x-ray should be performed at the time of evacuation and 4 to 8 weeks after evacuation to check for metastasis. The lungs are the most common sites for metastasis. Patients should avoid pregnancy for at least 1 year after the development of a molar pregnancy. Those who have had prior molar pregnancies have an increased risk for recurrent molar pregnancies, and those who have recurrent molar pregnancies are at an increased risk for malignant transformation. Malignant transformation is usually treated with methotrexate.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:836–844.
Hydatidiform moles are usually associated with hyperemesis gravidarum and preeclampsia that occur before the third trimester.
56. A 44-year-old woman presents with irregular vaginal bleeding. Appropriate initial management includes
A) endometrial biopsy
B) trial of oral contraceptives
C) medroxyprogesterone injection
D) surgical referral
View Answer
Answer and Discussion
The answer is A. Women who are reproductively mature, are older than 40, and experience irregular vaginal bleeding should be evaluated with endometrial biopsy to rule out endometrial hyperplasia or carcinoma. In addition, other tests to rule out thyroid dysfunction and bleeding disorders should be considered. Adolescents with abnormal vaginal bleeding can be regulated with oral contraceptive medications once pregnancy and infection have been ruled out. Vaginal bleeding before the age of 9 and after the age of 52 in the absence of hormone replacement is cause for concern and requires investigation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2066–2069.
57. In the management of a pregnant patient, medications are classified based on their risk to the fetus. Category A medications
A) should never be given during pregnancy
B) are considered safe during pregnancy
C) should only be given in life-threatening situations
D) have unknown risk for the fetus
E) are associated with teratogenicity in animals
View Answer
Answer and Discussion
The answer is B. The following medication classifications are used to determine the risk of their use during pregnancy:
· Category A: Controlled studies in women fail to demonstrate risk to the fetus in the first trimester; considered safe with no harmful effects on the fetus.
· Category B: Animal studies do not indicate a risk; however, there are no human studies. Considered relatively safe during pregnancy.
· Category C: Unknown fetal risk with no human studies to support or disprove safety.
· Category D: Some risk has been proved for the fetus; these drugs should be used only in life-threatening situations.
· Category X: Proven harm to the fetus; should not be used in pregnancy.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1009.
58. Which of the following medications has been shown to be comparable to laparoscopic salpingostomy in the treatment of small ectopic pregnancy that has not ruptured?
A) Bromocriptine
B) Methotrexate
C) Thalidomide
D) Misoprostol
E) Oxytocin
View Answer
Answer and Discussion
The answer is B. In recent years, intramuscular methotrexate has been advocated as an alternative to salpingostomy for management of ectopic pregnancy. In addition, there is also interest in using serum human chorionic gonadotropin (hCG) or progesterone levels to monitor resolution of ectopic pregnancy after intervention. Based on study results a single dose of intramuscular methotrexate is comparable to laparoscopic salpingostomy for the treatment of a small, unruptured ectopic pregnancy. The fact that serum progesterone levels resolved faster than serum hCG levels suggests that serum progesterone may be a better marker for monitoring resolution of ectopic pregnancy.
Saraj AJ, Wilcox JG, Najmabadi S. Resolution of hormonal markers of ectopic gestation: a randomized trial comparing single-dose intramuscular methotrexate with salpingostomy. Obstet Gynecol. 1998:92: 989–994.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:904.
59. Which of the following medications is used for cervical ripening and labor induction?
A) Terbutaline
B) Methotrexate
C) Thalidomide
D) Misoprostol
E) Bromocriptine
View Answer
Answer and Discussion
The answer is D. Misoprostol (Cytotec) has been extensively investigated in the past few years for use in cervical ripening and labor induction. Marketed as a gastric cytoprotective agent, the drug is also an effective, safe, and inexpensive agent for cervical ripening and labor induction, although it is not FDA-labeled for that purpose.
Wing DA, Paul RH. Misoprostol for cervical ripening and labor induction: the clinician's perspective and guide to success. Contemp Ob/Gyn. 1999;44:46–61.
60. Which of the following statements about uterine adenomyosis is true?
A) The condition is associated with the invasion of myometrial tissue into the peritoneal cavity.
B) The condition commonly causes intense pelvic pain, dysuria, and dyspareunia.
C) Those affected with uterine adenomyosis have an increased risk of endometrial cancer.
D) The condition is considered benign and usually causes no associated symptoms.
E) The condition results from uterine atony after delivery.
View Answer
Answer and Discussion
The answer is D. Uterine adenomyosis is defined as the invasion of endometrial tissue into the myometrium. This common disorder is benign and usually causes no symptoms. Those who do have symptoms complain of menorrhagia, irregular vaginal bleeding, pelvic pain, and bladder or rectal discomfort. Pelvic examination may reveal an enlarged uterus that feels softer in consistency; there may be associated fibroid tumors. Hysterectomy may be indicated for those beyond their childbearing years if symptoms are severe. Oral contraceptives and GnRH agonists are not very effective in treatment. Uterine adenomyosis is more likely to cause secondary dysmenorrhea than fibroids, endometrial polyps, cervical papillomas, or polycystic ovary disease.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:669–670.
61. A 17-year-old girl is seen in the emergency room. She reports high fever, nausea, vomiting, myalgias, and lethargy. On examination, she is found to have hypotension and a generalized erythematous rash and desquamation of the hands and feet. Laboratory tests show an increased white blood cell count, increased blood urea nitrogen, and increased serum creatinine with decreased urine output. The most likely diagnosis is
A) gonorrhea
B) Lyme disease
C) toxic shock syndrome
D) tertiary syphilis
E) PID
View Answer
Answer and Discussion
The answer is C. Toxic shock syndrome is a condition that is characterized by high fever, nausea and vomiting, myalgias, mental status changes, and an erythematous, sandpaper-like skin rash with the development of severe hypotension and vascular collapse. Desquamation of the hands and feet is also common. First recognized in 1978, the condition tends to affect young menstruating women and is associated with the use of vaginal tampons. The syndrome is a result of staphylococcal or streptococcal infection that produces an exotoxin. Occasionally, the syndrome is associated with postoperative infections, diaphragm use, contraceptive sponges, septic abortions, insect bites, and other infections that involve staphylococcal and streptococcal organisms. Complications include multisystem failure, adult respiratory distress syndrome (ARDS), and even death in severe cases. Laboratory studies often reveal an elevated white blood cell count, increased blood urea nitrogen and serum creatinine with decreased urine output, and thrombocytopenia followed by thrombocytosis. Mortality may be as high as 5% to 15%. Recurrence is common if the woman continues to use tampons within the first 4 months after an infection. Treatment with a β-lactamase–resistant penicillin or cephalosporin is recommended, as is supportive treatment to replace fluid loss and electrolytes. Steroids may be indicated for severe cases. Patients with toxic shock syndrome should be encouraged not to use high-absorbency tampons or diaphragms. Oral contraceptives may help to reduce the number of recurrent cases.
Taylor RB, David AK, Fields SA, et al. Family Medicine: Principles and Practice, 6th ed. New York: Springer; 2003:915–916.
62. A 35-year-old woman presents to your office complaining of a copious white vaginal discharge. Microscopic examination shows evidence of pseudohyphae. The most appropriate treatment is
A) penicillin G
B) doxycycline
C) terconazole (Terazol) vaginal cream
D) metronidazole (Flagyl)
E) topical acyclovir
View Answer
Answer and Discussion
The answer is C. Yeast vaginitis (monilial vaginitis) is caused by Candida albicans. Predisposing factors include the recent use of wide-spectrum antibiotics, the use of oral contraceptives, pregnancy, menstruation, diabetes mellitus, constrictive undergarments, the use of immunosuppressive drugs (e.g., steroids), or immunodeficient states [e.g., acquired immunodeficiency syndrome (AIDS)]. As part of their vaginal flora, 20% of women harbor C. albicans and are asymptomatic. Symptoms include intense vulvar irritation, pruritus, and vaginal discomfort. Erythema that affects the vulvar area, vaginal lining, and cervix is usually present. A copious, white, cottage cheese–like vaginal discharge also generally occurs. Diagnosis is made by microscopic examination of vaginal secretions following the application of potassium hydroxide to a glass slide. Characteristic budding yeast-like cells are noted with projections of pseudohyphae. Vaginal pH is less than 4.5. Treatment consists of local antifungal vaginal cream [miconazole (Monistat), terconazole (Terazol) and others] applied nightly for 3 to 7 days; the newer oral antifungals usually produce satisfactory results.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2086.
63. Which of the following is true of oxytocin administration?
A) The drug must be given through a controlled infusion device.
B) Oxytocin be administered as a continuous infusion or in “pulsed” doses.
C) The medication can have an antidiuretic effect with high doses.
D) Hyperstimulation can result from oxytocin administration.
E) All of the above.
View Answer
Answer and Discussion
The answer is E. Oxytocin is mixed for use by placing 10 U in 1 L of isotonic intravenous solution to achieve a concentration of 10 mU/mL. Because severe hypotension can occur, especially during rapid intravenous administration, and because the drug is infused into the main intravenous line, a controlled infusion device must be used to determine its rate. It can be administered as a continuous infusion or in “pulsed” doses. Oxytocin's effect is noted within 3 to 5 minutes, and a steady state is achieved within 15 to 30 minutes. Studies show a wide range of effective dosages and change intervals, and no regimen has been shown to be clearly superior. Oxytocin has many advantages. The medication is potent and easy to titrate, has a short half-life (1 to 5 minutes), and is generally well tolerated. Dose-related adverse effects can occur. Because oxytocin is close to vasopressin in structure, it has an antidiuretic effect when given in high dosages (40 mU/min); thus, water intoxication is a possibility in prolonged inductions. Uterine hyperstimulation and uterine rupture can also occur. When the resting uterine tone remains >20 mm Hg, uteroplacental insufficiency and fetal hypoxia can result. This outcome emphasizes the importance of continuous fetal monitoring while administering oxytocin.
Harman JH Jr, Kim A. Current trends in cervical ripening and labor induction. Am Fam Physician. 1999;60:477–484.
64. Which of the following medications has been used with success in gestational diabetes?
A) Glipizide (Glucotrol)
B) Glyburide (Micronase, Diabeta)
C) Glimepiride (Amaryl)
D) Rosiglitazone (Avandia)
E) Repaglinide (Prandin)
View Answer
Answer and Discussion
The answer is B. Gestational diabetes mellitus (GDM) is carbohydrate intolerance that occurs during pregnancy. Those affected are at risk of developing diabetes and related conditions later in life and face a range of complications during pregnancy, including hypertension, preeclampsia, and cesarean delivery. Macrosomia is more common in infants exposed to GDM, as are the risks of operative delivery, shoulder dystocia, birth trauma, and obesity during childhood. Although the U.S. Preventive Services Task Force concluded that there was insufficient evidence to recommend universal screening for GDM, >90% of obstetric physicians report screening all patients. Screening based on risk factors such as obesity, family or personal history of diabetes, or previous adverse pregnancy outcome misses approximately one half of mothers with GDM. The most commonly used test is the 50-g 1-hour glucose challenge. The accepted optimal limits vary, but at the recommended level of 130 mg/dL (7.2 mmol/L), the screening test has an estimated sensitivity of 79% and a specificity of 87%. The diagnostic test specific to pregnancy and with the most supporting data is the 100-g 3-hour oral glucose tolerance test. Women with GDM are often treated initially with diets designed to achieve normal glycemic levels and avoid ketoacidosis. However, an acceptable diet has not been determined, and calorie restriction may increase the chance of ketosis. Several trials have demonstrated reduced fetal macrosomia if the mother is treated with insulin. Although insulin treatment is common in GDM, only 9% to 40% of treated mothers benefit. Treatment aims to achieve glucose levels of 130 mg/dL 1 hour postprandially. Oral hypoglycemic agents, with the exception of glyburide, are contraindicated in pregnancy. In one study, glyburide provided outcomes comparable to those achieved with insulin in patients with GDM who had failed to achieve adequate glycemic control with diet alone. When glycemic control is satisfactory and no complications occur, mothers with GDM routinely do not require early or operative delivery. Nevertheless, the high incidence of macrosomia and other complications often results in cesarean or other operative delivery.
American College of Obstetricians and Gynecologists. Gestational diabetes. ACOG Practice Bulletin no. 30. Obstet Gynecol. 2001;98:525–538.
Macrosomia is more common in infants exposed to gestational diabetes mellitus (GDM), as are the risks of operative delivery, shoulder dystocia, birth trauma, and obesity during childhood.
65. The diagnosis of endometriosis is generally made by
A) detection of increased estrogen levels
B) endometrial biopsy
C) pelvic ultrasound
D) laparoscopy
E) computed tomography (CT) of the pelvis
View Answer
Answer and Discussion
The answer is D. Endometriosis is the presence of endometrial tissue outside the uterus. Locations include the ovaries, fallopian tubes, uterosacral ligaments, peritoneal cul-de-sac, and uterovesical peritoneum. Rare locations include the nasal mucosa and lungs. Theories for the development of endometriosis are abundant, and include the migration of endometrial tissue through the fallopian tubes and into the peritoneal cavity or transformation of existing epithelium into endometrial-type tissue. Symptoms include dysmenorrhea, dyspareunia, infertility, dysuria, irregular vaginal bleeding, and pelvic pain. As many as 33% of affected individuals have no symptoms. Risk factors include nulliparity and a positive family history. Most patients have normal examination results; however, some have a tender retroverted uterus or adnexal masses that are tender with palpation. Diagnosis is usually accomplished with laparoscopy. Treatment involves the use of analgesics, progesterone, and oral contraceptives to regulate cycles for mild disease. More advanced disease can be treated with danazol (Danocrine), an anabolic steroid that has androgen activity. Side effects of danazol therapy include weight gain, fluid retention, fatigue, acne, chloasma, irregular vaginal bleeding, cholestatic jaundice with prolonged use, and hepatic dysfunction in patients who receive high doses. GnRH agonists are also used for treatment. Severe cases may require surgery.
Winkel CA. Evaluation and management of women with endometriosis. Obstet Gynecol. 2003;102:397–408.
66. Symptoms that present the greatest concern in pregnant women include
A) visual disturbances
B) nausea
C) heartburn
D) abnormal cravings
E) mild edema
View Answer
Answer and Discussion
The answer is A. Symptoms noted in early pregnancy that present concern to the physician include vaginal bleeding or fluid vaginal discharge, severe headaches, visual disturbances, chronic vomiting, fever or chills, dysuria, swelling of the face or hands, and pelvic pain. Abnormal cravings, nausea, mild lower extremity edema, and heartburn are common complaints of pregnancy.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:238–244.
67. Which of the following statements about primary dysmenorrhea is true?
A) The condition usually worsens with the use of oral contraceptives.
B) It is thought to be associated with excessive prostaglandin activity.
C) The onset of symptoms typically begins after 30 years of age.
D) Endometriosis is a common cause.
E) The condition is related to adenomyosis.
View Answer
Answer and Discussion
The answer is B. Primary dysmenorrhea is defined as menstrual-related pain that occurs during menstruation with the absence of pelvic pathology. The onset is usually before 20 years of age, and it affects women during the first day or two after the onset of menstruation. The cause is thought to be secondary to excessive prostaglandin activity, which leads to uterine contractions and ischemia, giving rise to pelvic discomfort. Other symptoms include headache, nausea, and occasionally vomiting, constipation, diarrhea, and urinary frequency. Premenstrual symptoms, including water retention, irritability, nervousness, and depression, may also persist during the early period of menstruation. Treatment usually involves reassurance, nonsteroidal anti-inflammatory agents (NSAIDs), and heating pads to the lower abdomen. A trial of oral contraceptives may be beneficial. In women who do not desire hormonal contraception, there is some evidence of benefit with the use of the Japanese herbal remedy toki-shakuyaku-san; thiamine, vitamin E, and fish oil supplements; a low-fat vegetarian diet; and acupressure.
P.197
In secondary dysmenorrhea, patients report the same symptoms as those of primary dysmenorrhea, except that there is evidence of pelvic pathology (i.e., endometriosis, fibroids, chronic PID, IUD use, cervical stenosis, or adenomyosis). The age of onset is usually older than 20 years, and the course can be progressive. The treatment is correction of the underlying cause.
French L. Dysmenorrhea. Am Fam Physician. 2005;71:285–291, 292.
68. A 33-year-old woman who delivered last week presents to your office with questions about her gestational diabetes that developed during the first trimester. You explain
A) her risk of developing type 2 diabetes in the future is no different than anyone else
B) she should be checked yearly for diabetes
C) no further monitoring is necessary unless she develops symptoms of diabetes
D) she should be tested for diabetes 6 months after delivery via fasting blood glucose measurements on two occasions or a 2-hour oral 75-g glucose tolerance test
View Answer
Answer and Discussion
The answer is B. Women with gestational diabetes are at high risk for developing type 2 diabetes in the future and should be tested for diabetes 6 weeks after delivery via fasting blood glucose measurements on two occasions or a 2-hour oral 75-g glucose tolerance test. Normal values for a 2-hour glucose tolerance test are less than 140 mg/dL. Values between 140 and 200 mg/dL (11.1 mmol/L) represent impaired glucose tolerance, and greater than 200 mg/dL are diagnostic of diabetes. Screening for diabetes should be repeated annually thereafter, especially in patients who had elevated fasting blood glucose levels during pregnancy.
Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care. 2002;25:1862–1868.
69. Which of the following medications is contraindicated for the management of hypertension in pregnancy?
A) Methyldopa
B) Hydralazine
C) Labetalol
D) Nitroprusside
E) Losartan
View Answer
Answer and Discussion
The answer is E. Most hypertensive women of childbearing age have stage I or II hypertension (systolic blood pressure of 140 to 179 mm Hg or diastolic blood pressure of 90 to 109 mm Hg) without target organ damage. Therefore, the risk for acute cardiovascular consequences during pregnancy is very low. Improved maternal or neonatal outcomes with antihypertensive therapy have not been documented in this group. Accordingly, the Working Group advises that antihypertensive medication might be safely withheld in such patients, provided that blood pressure remains less than 150 to 160 mm Hg systolic and 100 to 110 diastolic while the patient is off medications. Continuing pre-vious antihypertensive medication is another option, although angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers should not be used during pregnancy. Because methyldopa (Aldomet) has the longest track record of safety in pregnancy, it is preferred by many clinicians. Hydralazine, nifedipene, labetalol, and nitroprusside (for severe cases) are also used.
Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol; 2000;183(1):S1–S22.
70. Which of the following is most commonly associated with nongonococcal urethritis?
A) Gonorrhea
B) Ureaplasma
C) Chlamydia
D) Trichomonas
E) Syphilis
View Answer
Answer and Discussion
The answer is C. Nongonococcal urethritis is commonly caused by chlamydia infections (approximately 50% of cases). Chlamydia is currently the most common sexually transmitted disease in the United States. Other causes includeTrichomonas, Ureaplasma urealyticum, genital herpes, Mycoplasma genitalium, and Candida. Symptoms include clear vaginal or penile discharge, dysuria, pruritus, and occasionally meatal erythema. Women are often completely asymptomatic. Symptoms, when they are present, include vaginal discharge, dysuria, frequency, pelvic pain, and dyspareunia. The incubation period is between 7 and 28 days. Diagnosis of chlamydia infections is often difficult because it is an obligate intracellular parasite; diagnosis is usually accomplished by tissue cultures but can also be made with fluorescent antibody tests using smears of genital secretions. Chlamydia can result in infertility in women, and complications for men include epididymitis. Treatment of chlamydia is accomplished with oral doxycycline, 100 mg, taken twice a day for 7 days. Other alternatives include tetracycline, erythromycin, azithromycin, and ofloxacin.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1651–1652.
71. Dysfunctional uterine bleeding is most common
A) during pregnancy
B) after sexual intercourse
C) at the time of menopause
D) with the development of PID
E) in premenarchal women
View Answer
Answer and Discussion
The answer is C. Dysfunctional uterine bleeding is defined as abnormal uterine bleeding in the absence of inflammation, pregnancy, or tumors. The condition is most commonly associated with anovulation. It usually occurs just after menarche or around the time of menopause. Treatment depends on the age of the patient, the desire for fertility and contraception, and the duration and severity of bleeding. If the patient is young and healthy and the bleeding is not profuse, she can be treated medically with high-dose oral estrogens every 6 hours, which usually stops the bleeding within the first 24 hours. After the cessation of bleeding, the patient should continue with daily estrogen for the rest of the month, followed by the administration of progesterone during the final 10 days of the month. After the addition of the progesterone, withdrawal bleeding should occur within a few days, and the patient can then begin oral contraceptive pills to regulate her menstrual cycles. If bleeding continues, further evaluation with an endometrial biopsy or dilation and curettage may be necessary. Older women in the perimenopausal state may initially need endometrial biopsy and possible dilation and curettage to rule out endometrial hyperplasia or endometrial cancer.
Taylor RB, David AK, Fields SA, et al. Family Medicine: Principles and Practice, 6th ed. New York: Springer; 2003:878, 879–880.
72. Which of the following statements about exercise-induced amenorrhea is true?
A) The condition is rarely reversible with weight gain.
B) It usually affects women who weigh >115 lb or those who have gained >10% to 15% in muscle mass.
C) Osteoporosis can be associated.
D) It is usually associated with prolactinomas.
E) Hormone therapy is contraindicated in those affected.
View Answer
Answer and Discussion
The answer is C. Exercise-induced amenorrhea is a condition that is noted in competitive female athletes. The cause appears to be associated with the athlete's weight and weight loss. Menstrual irregularities or amenorrhea are most likely to develop in women who weigh <115 lb or those who have lost >10 lb (10% to 15% of normal weight) while training. The basis of amenorrhea is unknown but may be associated with hypothalamic dysfunction. In most cases, weight gain reverses the condition; however, many women are unwilling to gain the additional weight. The female athlete triad is defined as the combination of disordered eating, amenorrhea, and osteoporosis. This disorder often goes unrecognized. The consequences of lost bone mineral density can be devastating for the female athlete. Premature osteoporotic fractures can occur, and lost bone mineral density may never be regained. Early recognition of the female athlete triad can be accomplished by the family physician through risk factor assessment and screening questions. Instituting an appropriate diet and moderating the frequency of exercise may result in the natural return of menses. Hormone therapy should be considered early to prevent the loss of bone density.
Hobart JA, Smucker DR. The female athlete triad. Am Fam Physician. 2000;61:3357–3364, 3367.
73. Painless and profuse vaginal bleeding in the third trimester is most likely
A) placenta acreda
B) placenta previa
C) vaso previa
D) bloody show
E) cervical ripening
View Answer
Answer and Discussion
The answer is B. Painless hemorrhage is the hallmark sign of placenta previa. Although spotting may occur during the first and second trimesters of pregnancy, the first episode of hemorrhage usually begins at some point after the 28th week and is characteristically described as being sudden, painless, and profuse. With the onset, clothing or bedding is saturated by an impressive amount of bright red, clotted blood, but the blood loss usually is not extensive, seldom produces shock, and is almost never fatal. In about 10% of cases there is some initial pain because of coexisting placental abruption, and spontaneous labor may be expected over the next few days in 25% of patients. In rare cases, bleeding is less dramatic or does not begin until after spontaneous rupture of the membranes or the onset of labor. Occasionally, nulliparous patients can reach term without bleeding, possibly because the placenta has been protected by an intact cervix.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:362–365.
74. The normal amount of blood loss for a vaginal delivery is
A) 250 mL
B) 500 mL
C) 1000 mL
D) 1500 mL
E) 2000 mL
View Answer
Answer and Discussion
The answer is B. The normal pregnant patient typically loses 500 mL of blood at the time of vaginal delivery and 1,000 mL during a cesarean delivery. Appreciably more blood can be lost without clinical evidence of a volume deficit as a result of the 40% expansion in blood volume that occurs by the 30th week of pregnancy.
Benedetti TJ. Chapter 17: Obstetric hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: normal and problem pregnancies. 4th ed. New York: Churchill Livingstone; 2003:503.
75. Which of the following statements about epidural anesthesia is true?
A) It provides anesthesia only for lumbar and sacral nerve roots.
B) It should only be used for multigravida women.
C) It can be used in hemophiliacs.
D) It can be associated with hypotension.
E) Placement of the catheter should be at the L2–L3 level.
View Answer
Answer and Discussion
The answer is D. Epidural anesthesia is used as a regional block during childbirth. The procedure is performed by inserting a needle in the L3–L4 interspace and threading a catheter into the epidural space. The catheter is then aspirated to check for the presence of cerebrospinal fluid. If this occurs, the catheter must be repositioned. A test dose is then administered to reconfirm position. When position is confirmed, a full dose of anesthetic is administered through the catheter. Analgesia is usually established with fentanyl plus a small dose of bupivacaine. Fentanyl works better for the visceral pain that is associated with labor, whereas bupivacaine is more effective for somatic pain. The dose may need to be repeated to maintain anesthesia during delivery. In most cases, a full dose provides anesthesia of nerve roots T10–S5. Risks that are involved with epidural anesthesia include drug reaction, hypotension, and rare neurologic complications. If the dura is penetrated, a spinal headache eventually develops in many patients. Contraindications to epidural anesthesia include adverse affects to anesthesia, bleeding tendency, infection of the lumbar area, or underlying neurologic defects. Some studies have reported that epidural anesthesia may prolong labor, leading to an increased cesarean delivery rate.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:373–379.
Some studies have reported that epidural anesthesia may prolong labor, leading to an increased cesarean delivery rate.
76. Which of the following statements regarding anencephaly is true?
A) Intracerebral shunts can be used effectively in preventing central nervous system complications.
B) The condition should be suspected with elevations in α-fetoprotein levels.
C) Children who are affected may need additional tutoring during school.
D) Nicotinic acid may help prevent anencephaly when given antepartum.
E) Urinary tract infections are common in those affected.
View Answer
Answer and Discussion
The answer is B. The condition of anencephaly occurs when the cerebral hemispheres are absent. In some cases there may be some cystic neural remnants. In many instances the spinal cord and brainstem are affected. Diagnosis is suspected with elevated α-fetoprotein levels obtained at 16 to 18 weeks' gestation and confirmed with ultrasound examination. Unfortunately, the condition is incompatible with life, and these infants are usually stillborn or die within a few hours or days after birth. The use of prenatal vitamins that contain at least 0.4 mg folic acid can help to prevent neural tube defects such as anencephaly.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2442.
77. Which of the following medications is not used in the treatment of preterm labor?
A) Ritodrine
B) Magnesium sulfate
C) Terbutaline
D) Propanolol
E) Nifedipene
View Answer
Answer and Discussion
The answer is D. Tocolysis is the process of stopping preterm labor contractions with medication. Medications that are used for tocolysis include β-sympathomimetics, magnesium sulfate, prostaglandin synthetase inhibitors (indomethacin), and calcium-channel blockers (nifedipine). Of these, ritodrine (Yutopar), a β-sympathomimetic, although still used, is not used as frequently for labor tocolysis, and terbutaline is now often utilized because of its ease of administration. Tocolysis is usually not successful if the cervix has dilated to >4 cm and should be reserved for pregnancies between 20 and 36 weeks' gestation. Contraindications to tocolysis include fetal distress, fetal anomalies, significant risk to the mother, abruptio placentae, or placenta previa with heavy bleeding.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:290.
78. Which of the following is not considered as part of the Amsel criteria for diagnosing bacterial vaginosis?
A) Milky, homogeneous, adherent discharge
B) Vaginal pH greater than 4.5
C) Positive whiff test
D) Presence of clue cells on light microscopy
E) Vaginal itching
View Answer
Answer and Discussion
The answer is E. The Amsel criteria are considered to be the standard diagnostic approach to bacterial vaginosis and continue to be used for the diagnosis. The criteria include the following: milky, homogeneous, adherent discharge; vaginal pH >4.5; positive whiff test (the discharge typically has a fishy smell); and presence of clue cells in the vaginal fluid on light microscopy. If three of the four criteria are met, there is a 90% likelihood of bacterial vaginosis.
Sobel JD. Vaginitis. N Engl J Med. 1997;337:1896–1903.
79. A 24-year-old woman is noted to have the presence of Trichmonas found on a routine Pap smear that is performed at the student health center. Although the center diagnoses a number of cases each year, she is entirely asymptomatic. Appropriate manage-ment should be to
A) reassure patient that no treatment is necessary
B) repeat cultures after the next menstrual cycle and treat if the organism is present
C) treat only if the patient is pregnant
D) treat regardless of symptoms
E) treat only if symptoms are present
View Answer
Answer and Discussion
The answer is D. Unlike women with asymptomatic Gardnerella vaginalis or Candida colonization, women with asymptomatic Trichomonas vaginalis infection should be treated. Trichomonas vaginalis is highly transmissible and is associated with other sexually transmitted diseases (STDs). Asymptomatic infection may also increase the risk of acquiring HIV. When trichomoniasis is found during routine Pap testing, management should be based on the pretest probability of infection in the patient, which is determined by the prevalence of T. vaginalis infection in the community; information on prevalence usually can be obtained from the local health department.
Wiese W, Patel SR, Patel SC, et al. A meta-analysis of the Papanicolaou smear and wet mount for the diagnosis of vaginal trichomoniasis. Am J Med. 2000;108:301–308.
80. Which of the following statements about neural tube defects is true?
A) Laboratory testing is not useful in the diagnosis of neural tube defects.
B) Elevated α-fetoprotein levels should be further evaluated by obstetric ultrasound.
C) Nicotinic acid has been shown to help prevent neural tube defects.
D) α-fetoprotein testing should be done at 24 to 28 weeks' gestation.
E) Elevated α-fetoprotein levels are not associated with normal pregnancies.
View Answer
Answer and Discussion
The answer is B. Neural tube defects (e.g., spina bifida, meningomyelocele, anencephaly) can be screened for by performing a serum α-fetoprotein blood test, which is done at 16 to 18 weeks' gestation. Evaluation is based on maternal weight and length of gestation. The accuracy of the test approaches 95%. Causes for elevations of maternal α-fetoprotein include inaccurate gestation dates, multiple gestations, abdominal wall defects in the fetus, congenital nephrotic syndrome, fetal demise, and neural tube defects.
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In addition, normal pregnancies may be associated with elevations in α-fetoprotein levels. Low levels of α-fetoprotein are associated with inaccurate gestation dates, chromosome trisomy such as Down syndrome, molar pregnancy, and fetal demise. In addition, normal pregnancies may exhibit low α-fetoprotein levels. In most cases, an obstetric ultrasound should be performed if the α-fetoprotein level is abnormal. Recent studies have shown that the administration of folic acid before pregnancy may help to prevent neural tube defects. The current recommendations are that women who plan to conceive should consume at least 0.4 mg folate/day (which is usually contained in a prenatal vitamin). Preconception counseling should include a discussion of folic acid supplementation.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:980–982.
81. A 28-year-old woman who recently delivered a child presents with pelvic pain, fever, vaginal discharge, and nausea with vomiting. Examination shows a positive Chandelier sign. The most likely diagnosis is
A) ectopic pregnancy
B) pyelonephritis
C) PID
D) bacterial vaginosis
E) yeast vaginitis
View Answer
Answer and Discussion
The answer is C. Pelvic inflammatory disease (PID) is a condition that includes infection of the fallopian tubes, cervix, endometrium, or ovaries. It is usually seen in women younger than 30 years of age who are sexually active or who have recently experienced childbirth. Causative agents include chlamydia, gonorrhea, gram-negative and gram-positive bacteria, Mycoplasma, and viral infections. Many cases involve polymicrobial infections. Symptoms include pelvic pain, fever, vaginal discharge, dyspareunia, nausea, and vomiting. Physical examination reveals adnexal, uterine, and cervical motion tenderness (positive Chandelier sign). Laboratory findings include an elevated white blood cell count and elevated erythrocyte sedimentation rate. The differential diagnosis includes multiple conditions, including appendicitis, ectopic pregnancy, urinary tract infection, and peritonitis. Complications of PID include chronic PID, infertility, and ectopic pregnancy. Treatment consists of ceftriaxone (Rocephin) and doxycycline. Outpatient therapy with oral antibiotics can be used in the majority of patients with PID. Follow-up care must be available within 72 hours to evaluate the response to treatment. Hospitalization of patients with PID is recommended only in certain instances. The use of condoms lowers the risk of PID. The use of IUDs and multiple sex partners increases the risk.
Miller KE, Graves JC. Update on the prevention and treatment of sexually transmitted disease. Am Fam Physician. 2000;61:379–386.
82. A 27-year-old asymptomatic pregnant woman is found to have hyperthyroidism. Which of the following medications is the drug of choice for treatment?
A) Propylthiouracil
B) Radioactive iodine
C) Methimazole
D) Propranolol
E) Levothyroxine
View Answer
Answer and Discussion
The answer is A. Hyperthyroidism during pregnancy is usually associated with Graves' disease. Other causes include toxic nodular goiter, choriocarcinoma, hydatidiform mole, ovarian teratoma, and iatrogenic thyrotoxicosis. Symptoms may include weight loss, tachycardia, exophthalmos, pretibial myxedema, generalized weakness, and tremor. Laboratory findings include an elevated triiodothyronine, thyroxine, and low sensitive thyroid-stimulating hormone. Treatment depends on the situation. Antithyroid medications readily cross the placenta and inhibit fetal thyroid function. Propylthiouracil and methimazole cross the placenta but are used in the treatment of hyperthyroidism during pregnancy. Propylthiouracil does not cross the placenta as easily as methimazole and is the drug of choice. Radioactive iodine ablation of the thyroid is contraindicated during pregnancy. Close monitoring of thyroid hormones is required when administering antithyroid medications during pregnancy. Side effects of the medications include rash, urticaria, arthralgias, and agranulocytosis, which may predispose to maternal infection. Surgery is reserved for severe refractive cases. Untreated hyperthyroidism during pregnancy can lead to premature delivery, neonatal thyrotoxicosis, and spontaneous abortion.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:441–442.
83. Which of the following is a characteristic of atrophic vaginitis?
A) Vaginal pH of 5 to 7
B) Milky discharge
C) Increased vaginal rugae
D) Endometrial cells noted on wet-mount microscopic examination
E) Increased glycogen levels
View Answer
Answer and Discussion
The answer is A. The decline in estrogen levels during perimenopause and after menopause can cause vaginal atrophy and resulting atrophic vaginitis. One important physiologic change is thinning of the vaginal epithelium; another is loss of glycogen, which leads to changes in the vaginal pH and flora. Many women with these vaginal changes are minimally symptomatic and require only explanation and reassurance. In women with more severe changes, vaginal irritation, dyspareunia, and fragility may become problems. Atrophy is diagnosed by the presence of a thin, clear or bloody discharge, a vaginal pH of 5 to 7, loss of vaginal rugae, and the finding of parabasal epithelial cells on microscopic examination of a wet-mount preparation.
Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician. 2004;70:2125–2132, 2139–2140.
84. A 45-year-old woman is noted to have four yeast infections in 1 year. Appropriate management of this patient should be
A) continued observation and treatment only if symptomatic
B) further evaluation for hypothyroidism
C) blood test to look for the presence of diabetes
D) prophylactic therapy with weekly metronidazole
E) examination for endometrial structural abnormalities
View Answer
Answer and Discussion
The answer is C. Recurrent vulvovaginal candidiasis is defined as four or more yeast infections in 1 year. The possibility of uncontrolled diabetes mellitus or immunodeficiency should be considered in women with recurrent vulvovaginal candidiasis. When it has been determined that no reversible causes are present (e.g., antibiotic therapy, uncontrolled diabetes, oral contraceptive pill use) and initial therapy has been completed, maintenance therapy may be appropriate. Selected long-term regimens include the use of clotrimazole and fluconazole. The role of boric acid and lactobacillus therapy remains in question.
Sobel JD. Recurrent vulvovaginal candidiasis (RVVC). Int J STD AIDS. 2001;12(suppl 2):9.
The possibility of uncontrolled diabetes mellitus or immunodeficiency should be considered in women with recurrent vulvovaginal candidiasis.
85. Which of the following statements about dysfunctional uterine bleeding is true?
A) The condition is most common during the middle of a woman's reproductive years.
B) It typically occurs during pregnancy.
C) Most cases are seen with anovulatory cycles.
D) Gynecologic malignancies are related to dysfunctional uterine bleeding.
E) Inflammation is a commonly associated condition.
View Answer
Answer and Discussion
The answer is C. Dysfunctional uterine bleeding is defined as abnormal uterine bleeding in the absence of inflammation, pregnancy, or tumors. It is the most common form of abnormal uterine bleeding and is seen most commonly at the extremes of the reproductive cycle (menarche and menopause). Most cases are seen with anovulatory cycles. Causes include exogenous estrogen use, polycystic ovary syndrome, hyperthyroidism, and hypothyroidism.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2077–2078.
86. An 18-year-old woman presents to your office complaining of pelvic pain, dysuria, and a purulent yellowish-green vaginal discharge. A Gram's stain of cervical secretions shows gram-negative diplococci. The most appropriate medication is
A) ceftriaxone + doxycycline
B) penicillin G + azithromycin
C) cefuroxime + tetracycline
D) cefoxitin + doxycycline
E) metronidazole + doxycycline
View Answer
Answer and Discussion
The answer is A. Gonorrhea is caused by a gram-negative diplococcus, Neisseria gonorrhoeae. Symptoms include purulent, yellowish-green vaginal, rectal, or penile discharge; urethritis; and genital irritation and discomfort. Other symptoms include scrotal pain, abdominal or pelvic pain, and pharyngeal discomfort. Some patients, especially women, are completely asymptomatic. Disseminated gonococcal infection can give rise to polyarthralgias, tenosynovitis, and a hemorrhagic papular or pustular skin rash that affects the genitalia, hands, feet, and other areas of the body. The disease is spread by sexual contact. Incubation is 2 to 14 days for men and 7 to 21 days for women. Diagnosis is accomplished with Gram's stains that show leukocytes with intracellular gram-negative diplococci and more accurately with cultures made on Thayer-Martin chocolate agar media. Treatment is ceftriaxone, 125 mg, given intramuscularly. Alternatives include cefixime, azithromycin, ciprofloxacin, norfloxacin, or ofloxacin given orally and spectinomycin, cefoxitin with probenecid, ceftizoxime, cefotaxime, or cefotetan given intramuscularly. Repeat cultures should be performed to ensure eradication, and sexual partners should also be treated. Because chlamydia may also coexist, most patients are treated with a course of doxycycline or azithromycin as well. Other sexually transmitted diseases (e.g., syphilis, HIV, hepatitis) may also coexist and need appropriate diagnosis and treatment.
Taylor RB, David AK, Fields SA, et al. Family Medicine: Principles and Practice, 6th ed. New York: Springer; 2003:349–350.
87. Which of the following fetal heart rate tracings is a warning sign of uteroplacental insufficiency?
A) Early accelerations
B) Late accelerations
C) Early decelerations
D) Late decelerations
E) Variable decelerations
View Answer
Answer and Discussion
The answer is D. Late decelerations on fetal heart tracings are defined as repetitive decelerations in fetal heart rate (usually <15–20 bpm from the baseline) that occur late in the contraction phase during labor. Usually, there are no associated accelerations. Late decelerations indicate uteroplacental insufficiency and fetal hypoxia. In most cases, this is a worrisome sign and a potentially dangerous situation. Other worrisome features include fetal tachycardia and loss of fetal heart rate variability. Treatment involves actions to improve fetal oxygenation and includes positioning the mother on her side, administering oxygen, discontinuing oxytocin, administering fluids to help relieve maternal hypotension, performing a vaginal examination to rule out a prolapsed cord, fetal scalp monitoring, and immediate delivery (possibly via cesarean section) if late decelerations persist.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:341.
88. You perform a Pap smear on a 48-year-old woman and the results reveal the presence of benign appearing endometrial cells. She reports no vaginal bleeding or any other associated symptoms. Appropriate management consists of
A) endometrial biopsy
B) ultrasound examination of the uterus
C) dilation and curettage
D) colposcopy
E) no further evaluation
View Answer
Answer and Discussion
The answer is E. Endometrial cancer is a relatively common gynecologic malignancy in the United States. Despite recent advances, approximately 6,000 deaths result from endometrial cancer each year. Several studies have suggested a correlation between endometrial cells (both normal and abnormal) on Papanicolaou smears and endometrial cancer, mainly in postmenopausal women. Kerpsack and associates conducted a study to evaluate a possible correlation between the presence of endometrial cells on a Pap smear and significant endometrial pathology. The study concludes that asymptomatic patients who have benign endometrial cells on a Pap smear but no abnormal vaginal bleeding do not require further evaluation. However, even if the endometrial cells are described as benign, a patient with abnormal vaginal bleeding should receive further evaluation with dilatation and curettage.
Kerpsack JT, Finan MA, Kline RC. Correlation between endometrial cells on Papanicolaou smear and endometrial carcinoma. South Med J. 1998;91:749–752.
89. A 56-year-old woman presents for her well-woman exam. She has been seen yearly for the last 10 years and is otherwise healthy. She has not had an abnormal Pap smear and is in a monogamous relationship with her husband of 30 years. She inquires about her Pap smear. An appropriate response is
A) A yearly Pap smear is necessary in her age group because of the risk of cervical cancer.
B) Pap smears are no longer required for women in her age group.
C) An appropriate interval for repeat Pap smear screening is 5 years.
D) An appropriate interval for Pap smear screening is 3 years.
E) She would need a repeat Pap smear only if she had another sexual partner.
View Answer
Answer and Discussion
The answer is D. Annual cervical cancer screening in women with three previously normal Pap smears provides a negligible benefit, and the screening interval may be extended safely to every 3 years in this low-risk group.
Sawaya GF, et al. Risk of cervical cancer associated with extending the interval between cervical-cancer screenings. N Engl J Med. 2003;349:1501–1509.
90. Live virus vaccines, such as measles, mumps, and rubella, should be administered to pregnant women
A) at the first prenatal visit following conception
B) at least 3 months before conception
C) during the third trimester
D) at 18 to 20 weeks' gestation
View Answer
Answer and Discussion
The answer is B. Immunizations with live attenuated vaccines, such as measles, mumps, rubella, varicella, and the oral vaccine for polio, are contraindicated in pregnancy and 3 months before conception. Immunizations with inactivated virus, such as influenza, Pneumococcus, tetanus, rabies, and the injectable poliovirus, as well as the hepatitis B recombinant vaccine, are safe to administer.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:241.
91. Women immunized for rubella should be counseled to avoid pregnancy for
A) 1 month
B) 3 months
C) 6 months
D) 1 year
E) Rubella immunization presents no dangers before or during pregnancy.
View Answer
Answer and Discussion
The answer is B. Rubella (“German measles”) is a highly contagious childhood disease that can affect pregnant mothers. As many as 15% of mothers do not have antibodies to the rubella virus. Symptoms include fever, cough, and conjunctivitis. Other symptoms include headaches, malaise, myalgias, arthralgias, and postauricular and suboccipital lymphadenopathy. An erythematous morbilliform rash usually develops on the face and spreads inferiorly. Generally, the symptoms of rubella are less severe than those of rubeola, and there is usually no prodrome seen with rubella (unlike with rubeola). Spontaneous abortion occurs two to four times more frequently in pregnancies that are complicated by rubella. Transmission to the fetus occurs by direct infection. If the woman is affected during the first trimester, the risk of birth defects is higher than if she is affected during the last two trimesters. Effects of the virus on the fetus (congenital rubella syndrome) include cataracts, glaucoma, blindness, cardiac abnormalities, deafness, mental retardation, cerebral palsy, growth retardation, hemolytic anemia, and cleft palate. In cases of maternal rubella, therapeutic abortion can be considered if infection occurs in the first two trimesters. All women should receive routine rubella testing during pregnancy. If negative the patient should be vaccinated during the immediate postpartum period. Women who are immunized with the live attenuated virus should not become pregnant for 3 months following immunization. The use of immune globulin for pregnant women who are exposed to rubella is not recommended.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1467.
92. An 18-year-old woman presents to your office complaining of irregular periods. On examination, she is found to be obese, has evidence of excessive facial hair, and reports that her mother had similar problems. Laboratory studies show normal estrogen levels, increased luteinizing hormone, low follicle-stimulating hormone, elevated testosterone level, and elevated urinary 17-ketosteroids. The most likely diagnosis is
A) pregnancy
B) Cushing's disease
C) polycystic ovary syndrome
D) adrenal adenoma
E) acromegaly
View Answer
Answer and Discussion
The answer is C. Polycystic ovary syndrome (Stein-Leventhal syndrome) is an inherited condition characterized by cystic ovaries, hirsutism, amenorrhea, and obesity. It is the most common cause of anovulation and hirsutism. Some patients present with primary amenorrhea, some have abnormal irregular periods, and some have normal periods. Laboratory studies show normal or increased levels of estrogen, increased luteinizing hormone, normal or decreased follicle-stimulating hormone, normal or increased testosterone, and increased urinary 17-ketosteroids. Pelvic ultrasound can also aid in the diagnosis by demonstrating bilateral enlargement of the ovaries. Administration of progesterone usually results in withdrawal bleeding for patients with amenorrhea. Glucose intolerance with increased insulin levels may also be present. Therapy includes the use of oral contraceptives to suppress hirsutism and small doses of glucocorticoid (dexamethasone) at bedtime to suppress the adrenal gland. Bromocriptine has shown some benefit for the menstrual irregularities and hirsutism. Antiandrogens can be combined with oral contraceptive pills for the treatment of hirsutism. If used alone, antiandrogens may produce irregular uterine bleeding. The most commonly used antiandrogens are spironolactone (Aldactone), flutamide (Eulexin), and cyproterone (Cyprostat). These agents should not be used in pregnant women. Spironolactone, in a dosage of 25 to 100 mg administered twice a day, is the most commonly used antiandrogen because of its safety, availability, and low cost. Flutamide is usually given in a dosage of 250 mg twice a day, and cyproterone is given in a dosage of 25 to 50 mg/day for 10 days each month.
GnRH analogs such as luprolide (Lupron) should be reserved for use in women who do not respond to combination hormonal therapy or cannot tolerate oral contraceptive pills. The GnRH analogs should be used cautiously, with particular attention given to long-term consequences (e.g., hot flushes, bone demineralization, atrophic vaginitis) that can occur secondary to hypoestrogenemia induced by these agents. Surgery (wedge resection of the ovary) has also been shown to restore ovulatory periods and fertility.
Hunter MH, Sterrett JJ. Polycystic ovary syndrome: it's not just infertility. Am Fam Physician. 2000;62:1079–1088, 1090.
93. A 48-year-old otherwise healthy woman has undergone a hysterectomy secondary to abnormal vaginal bleeding. Pathology results confirm no evidence of malignancy. She asks you how often she should have a Pap smear. The appropriate response is
A) yearly Pap smears for an additional 3 years are recommended
B) Pap smears should be reinstituted if she develops atrophic vaginitis
C) Pap smears should be repeated every 3 years
D) Pap smears should be performed every 5 years
E) no further Pap smears are necessary
View Answer
Answer and Discussion
The answer is E. Multiple studies have concluded that vaginal cuff smear testing is not necessary in women who have undergone hysterectomy for benign conditions.
Videlefsky A, Grossl N, Denniston M. Routine vaginal cuff smear testing in post-hysterectomy patients with benign uterine conditions: when is it indicated? J Am Board Fam Pract. 2001;13:233–238.
94. A Pap smear result shows atypical cells of undetermined significance (ACS-US). HPV typing is negative for high-risk HPV. Appropriate management at this time includes
A) repeat Pap smear at one year
B) repeat Pap smear at 6 months
C) colposcopy
D) LEEP procedure
E) cervical cryotherapy
View Answer
Answer and Discussion
The answer is A. Women with ACS-US who test negative for high-risk HPV types can have repeat cytology at 12 months. Colposcopy is recommended for women who test positive for oncogenic HPV types. If initial colposcopy does not identify a lesion, repeating the cytology at 6 and 12 months is acceptable. If the woman is HPV-positive and repeat cytology still reveals ASC-US or greater, repeat colposcopy is recommended. It is also acceptable to perform repeat HPV DNA testing at 12 months and refer the patient for colposcopy if oncogenic HPV types persist.
Wright TC Jr, Cox JT, Massad LS, et al. 2001 Consensus guidelines for the management of women with cervical cytological abnormalities. JAMA. 2002;287:2120–2129.
Women with atypical cells of undetermined significance (ACS-US) who test negative for high-risk human papilloma virus (HPV) types can have repeat cytology at 12 months.
95. Which of the following is the most common cause of postpartum hemorrhage?
A) Uterine atony
B) Uterine rupture
C) Lacerations of the cervix
D) Retained placenta
E) Primagravida birth
View Answer
Answer and Discussion
The answer is A. Postpartum hemorrhage is conventionally defined as the loss of >500 mL of blood after delivery. It occurs in approximately 4% of deliveries. The following are the most common causes of postpartum hemorrhage:
· Uterine atony: lack of contraction of the uterus after delivery; the most common cause
· Lacerations of the vagina, cervix, or perineum especially after a difficult or forceps delivery
· Hematomas: usually seen in association with lacerations
· Uterine rupture: seen in patients with fibroids, hyperstimulation of the uterus with oxytocin (Pitocin), or prolonged labor
· Retained placenta: seen in cases in which delayed hemorrhage occurs
· Uterine inversion
· Coagulation disorders
· Low placental implantation
Resuscitation with normal saline usually requires three times the volume of the estimated blood loss. It is best not to use glucose-containing fluids.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:635–652.
96. The most common cause of galactorrhea is
A) psychotropic medication
B) hypothyroidism
C) prolactinoma
D) nipple stimulation
E) sexual intercourse
View Answer
Answer and Discussion
The answer is C. Galactorrhea is defined as the presence of lactation in the absence of pregnancy. It can occur in men and in women. The most common cause is a prolactinoma in the pituitary gland. Other causes include psychotropic medications, opioids, antihypertensive drugs (α-methyldopa), hypogonadism, nipple stimulation, bronchogenic carcinomas, herpes zoster, hypothyroidism, and trauma. Many women who are affected may also have amenorrhea. Diagnosis involves determination of prolactin levels and CT scanning or MRI scans of the sella turcica to exclude pituitary adenomas. Visual field defects may also be present if tumors impinge on the optic chiasm. Other testing may be necessary to exclude other precipitating causes, such as medication-induced hyperprolactinemia. Patients who are affected with small microadenomas can be treated with bromocriptine; however, those with macroadenomas are usually treated with surgery or radiation.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1187–1189.
97. The definition of dyspareunia is
A) painful intercourse
B) abnormal hip alignment
C) disturbed pelvic sensation
D) altered menstrual cycles
E) difficult labor
View Answer
Answer and Discussion
The answer is A. Dyspareunia is painful intercourse, and the causes can be organic or psychogenic. Organic causes include inflammatory diseases of the vulva or vagina; infections, including fungal, bacterial, and viral (herpes, condyloma); tight-fitting clothes; a contracted vaginal orifice (caused by scarring from previous episiotomy or trauma); atrophic vaginitis; lack of lubrication; foreign bodies; an intact or constricted hymen; or a reaction to chemicals that are involved in contraception, deodorant sprays, and douches. Other pelvic disorders, including pelvic infections, masses, or endometriosis, can lead to dyspareunia. Psychogenic causes may include fear, anxiety, disinterest, or previous abuse or rape. Treatment involves adequate lubrication, correction of organic causes, and psychotherapy and education for psychogenic causes.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2100–2101, 2104.
98. A Pap smear result comes back atypical cells of undetermined significance and the report cannot exclude high-grade intraepithelial lesion (ASC-H). Appropriate management at this time includes
A) repeat Pap smear at 1 year
B) repeat Pap smear at 6 months
C) colposcopy
D) LEEP procedure
E) cervical cryotherapy
View Answer
Answer and Discussion
The answer is C. Although ASC-H is less common than ASC-US, the risk of underlying grade 2 or 3 CIN is higher and colposcopy is recommended. If CIN is identified by biopsy, management is based on the grade of the lesion. If no lesion is found on colposcopy, a review of the colposcopic, cytologic, and histologic findings is recommended. If the diagnosis remains the same after the review, repeat cytology at 6 and 12 months or HPV DNA testing at 12 months is acceptable. If the diagnosis changes, physicians should follow accepted management guidelines.
Wright TC Jr, Cox JT, Massad LS, et al. 2001 Consensus guidelines for the management of women with cervical cytological abnormalities. JAMA. 2002;287:2120–2129.
99. A 40-year-old woman's Pap smear result comes back atypical glandular cells–not otherwise specified (AGC-NOS). Appropriate management at this time includes
A) repeat Pap smear at 1 year
B) repeat Pap smear at 6 months
C) colposcopy
D) colposcopy and endometrial sampling
E) HPV testing and colposcopy only if high risk HPV identified
View Answer
Answer and Discussion
The answer is D. The category of atypical glandular cells (AGC) is divided into “not otherwise specified” (AGC-NOS) and “favor neoplasia” or adenocarcinoma-in-situ (AIS). Although AGC is an uncommon cytologic diagnosis, up to 54% of women with AGC have an underlying SIL, 8% have AIS, and up to 9% may have an invasive squamous or adenocarcinoma. Cervical cytology has low sensitivity for detection of glandular lesions, and it is unknown if HPV DNA testing has a role in management of AGC. Therefore, colposcopy with endocervical sampling is recommended in women with all categories of AGC. Endometrial sampling at the time of colposcopy is recommended in women older than 35 years and in younger women with unexplained vaginal bleeding.
Wright TC Jr, Cox JT, Massad LS, et al. 2001 Consensus guidelines for the management of women with cervical cytological abnormalities. J Lower Genital Tract Dis. 2002;6:127–143.
100. When testing fetal well-being, which of the following factors is not measured with a biophysical profile?
A) Fetal tone
B) Amniotic fluid
C) Fetal heart rate
D) Fetal size
E) Body movements
View Answer
Answer and Discussion
The answer is D. Biophysical profile testing is a more extensive method of testing fetal well-being than nonstress testing. Indications include the following:
· Maternal hypertension
· Maternal diabetes
· Postterm pregnancies
· Multiple gestations
· Oligohydramnios
· Intrauterine growth deficiencies
· Placental abnormalities
· Decreased fetal movement
· Previous abnormal pregnancies
The test involves the testing of five different aspects of fetal well-being with real-time ultrasound, including the following:
· Fetal breathing
· Body movements
· Fetal tone
· Amniotic fluid volume
· Fetal heart rate monitoring (nonstress test)
Each aspect is given either a score of 0 for abnormal findings or 2 for normal findings. A score of 4 or less is a poor prognostic indicator, whereas a score of 8 or 10 is reassuring for fetal well-being. A score of 6 is suspicious for chronic asphyxia.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1104–1105.
101. The most sensitive method to diagnose endometrial cancer is with
A) Papanicolaou (Pap) smear
B) ultrasound
P.205
C) CT of the pelvis
D) endometrial biopsy
E) fractionated endometrial curettage
View Answer
Answer and Discussion
The answer is E. Adenocarcinoma of the endometrium usually occurs in postmenopausal women between 50 and 60 years of age. It usually arises from the columnar cells of the endometrial lining. Associated conditions that constitute risk factors include adenomatous hyperplasia; unopposed estrogen use; delayed menopause; infertility (nulliparity); Stein-Leventhal syndrome; previous breast, colon, or ovarian cancer; diabetes; chronic tamoxifen use; hypertension; and obesity. The hallmark symptom is unexplained irregular vaginal bleeding, particularly in postmenopausal women. The diagnosis can be made with Pap smears in 40% of patients; however, because of the relatively high rate of false-negative results, diagnosis is better made with endometrial biopsy, ultrasound, or the gold standard fractionated endometrial curettage. Treatment involves surgical excision with total abdominal hysterectomy and bilateral oophorectomy followed by lymph node sampling. Chemotherapy using cytotoxic drugs as well as progesterone and radiation is also used in the treatment of endometrial cancer. Prognosis depends on the stage and differentiation of the cancer. Well-differentiated, well-localized tumors have a 5-year survival rate of close to 95%, whereas poorly differentiated tumors with metastasis have less than a 20% 5-year survival rate.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:556.
102. Which of the following is recommended for postpartum breast engorgement?
A) Firm binding of breast with a comfortable wrap
B) Cabbage leaves
C) Bromocriptine
D) Initiation of oral contraceptives
E) Topical vitamin E
View Answer
Answer and Discussion
The answer is A. The best way to prevent postpartum breast engorgement is to bind the breasts firmly with a comfortable wrap. Other suggestions include cold packs, analgesics, and the avoidance of direct warm water during showering. The use of bromocriptine (a dopamine agonist) to stop lactation is associated with rebound lactation after discontinuation of the medication, hypotension, hypertension, seizures, and stroke; it is no longer approved by the U.S. Food and Drug Administration for this use. Other medications, such as estrogen and testosterone combinations, are not recommended because of their increased risk for thromboembolism and hair growth, respectively. In most cases, breast engorgement resolves within 72 hours.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:412.
103. A 38-year-old woman has a Pap smear result of atypical glandular cells (AGC)–favor neoplasia. She undergoes colposcopy and no invasive disease is found. Appropriate management at this time includes
A) repeat Pap smear at 1 year
B) repeat Pap smear at 6 months
C) repeat colposcopy at 6 months
D) LEEP procedure
E) cold-knife conization procedure
View Answer
Answer and Discussion
The answer is E. The category of atypical glandular cells (AGC) is divided into “not otherwise specified” (AGC-NOS) and “favor neoplasia” or adenocarcinoma-in-situ (AIS). Women with AGC-favor neoplasia or AIS who are not found to have invasive disease on initial colposcopic evaluation should undergo a diagnostic excisional procedure, preferably cold-knife conization to avoid thermal artifact from the loop electrosurgical excision procedure, which may preclude a diagnosis.
Geier CS, Wilson M, Creasman W. Clinical evaluation of atypical glandular cells of undetermined significance. Am J Obstet Gynecol. 2001;184:64–69.
104. Which of the following medications is associated with an increased risk of endometrial carcinoma?
A) Bromocriptine (Parlodel)
B) Oral contraceptives
C) Progesterone
D) Alendronate (Fosamax)
E) Tamoxifen (Nolvadex)
View Answer
Answer and Discussion
The answer is E. Risk factors for endometrial cancer include anovulatory cycles, obesity, nulliparity, age greater than 35 years, unopposed estrogen use, and tamoxifen therapy.
Ries LA, Eisner MP, Kosary CL, et al., eds. SEER cancer statistics review, 1975–2000. Bethesda, MD: National Cancer Institute, 2003. Accessed December, 12, 2004, at http://seer.cancer.gov/csr/1975_2000.
Risk factors for endometrial cancer include anovulatory cycles, obesity, nulliparity, age greater than 35 years, unopposed estrogen use, and tamoxifen therapy.
105. Which of the following is an absolute contraindication of tocolysis?
A) Chorioamnionitis
B) 4-cm cervical dilation
C) Biophysical profile score of 8
D) Oligohydramnios
E) Hyperthyroidism
View Answer
Answer and Discussion
The answer is A. The arresting of labor has certain contraindications that must be ruled out before tocolytics are given. Absolute contraindications include the following:
· Severe abruptio placentae
· Infection (chorioamnionitis)
· Severe bleeding
· Severe pregnancy-induced hypertension
· Fetal anomalies that are incompatible with life
· Fetal death
· Severe growth retardation
· Fetal distress
Relative contraindications include the following:
· Hyperthyroidism
· Uncontrolled diabetes
· Maternal heart disease
· Hypertension
· Mild abruptio placentae
· Stable placenta previa
· Fetal distress
· Mild growth retardation
· Cervical dilation greater than 5 to 6 cm
Corticosteroids are recommended to help prevent RDS if there is premature rupture of membranes before 34 weeks' gestation. Delay of labor for >1 week after rupture of membranes is usually not recommended unless the fetus is very small (<1,250 g).
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:288.
106. When testing fetal well-being, which of the following statements about the nonstress test is true?
A) Two or more fetal heart accelerations (at least 15 beats above baseline) that last for 15 seconds in a 20-minute period are reassuring.
B) Late decelerations are usually noted with fetal movements.
C) An abnormal nonstress test should be followed by a contraction stress test.
D) The presence of oligohydramnios is accurately predicted with the results of a nonstress test.
E) Nonstress tests should be routinely performed beginning at 38 weeks until delivery.
View Answer
Answer and Discussion
The answer is A. Nonstress tests are used for antenatal well-being studies. Nonstress testing includes the use of a fetal heart monitor and contraction monitor. Testing is usually reserved for difficult problem pregnancies (e.g., intrauterine growth retardation, gestational diabetes, pregnancy-induced hypertension, multiple gestations, previous difficulties in childbirth) or postdate pregnancy. A reassuring nonstress test shows two or more fetal movements with a fetal heart rate acceleration of at least 15 beats/sec above the baseline that last for at least 15 seconds during a 20-minute period. If this criterion is not met, a biophysical profile should be performed. Late or variable decelerations are concerning findings. Oligohydramnios is a risk for cord compression but is not well predicted by nonstress testing. Simplistically, the nonstress test is primarily a test of fetal well-being, whereas the contraction stress test is a test of uteroplacental function.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1100–1102.
107. RhoGAM should be given to Rh-negative mothers at
A) first prenatal visit and at delivery
B) 12 and 36 weeks' gestation
C) 16 weeks' gestation and delivery
D) 28 weeks' gestation and delivery
E) 28 and 36 weeks' gestation
View Answer
Answer and Discussion
The answer is D. The condition of erythroblastosis fetalis is the result of blood incompatibility between the mother and fetus. It results when an Rh-negative woman is impregnated by an Rh-positive man. Red blood cells (RBCs) cross the placenta into the mother's bloodstream and evoke the production of her antibodies to the child's RBCs. The antibodies can cross the placenta and result in severe anemia that may cause death to the fetus. To compensate, the fetal bone marrow releases immature RBCs and erythroblasts (thus, the name erythroblastosis fetalis). The condition rarely affects the first pregnancy, and the risk for sensitization increases with each pregnancy. As a result of the antibody destruction of RBCs, there is an increased production of bilirubin that can result in kernicterus, which is characterized by poor feeding, apnea, poor fetal tone, mental retardation, seizures, and death. In the United States, approximately 15% of marriages involve Rh-positive fathers and Rh-negative mothers, but the potential may be underestimated because of the number of children who are born out of wedlock with unknown fathers. Of this 15%, only 1 in 27 are affected with erythroblastosis fetalis. Prevention of the disease is accomplished by administering RhoGAM, an anti-Rh antibody, to the mother. RhoGAM attacks and destroys the fetal blood cells when they cross the placenta, before they can involve the production of antibodies. RhoGAM is administered at 28 weeks' gestation and then at the time of delivery. It should also be given if abortion or ectopic pregnancy occurs or in any case in which there is fetal–maternal transfer of blood. All mothers should be screened for Rh status at their initial prenatal visit.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2194–2195.
108. A 17-year-old woman presents to your office complaining of dysfunctional uterine bleeding. Appropriate management consists of
A) endometrial sampling
B) ultrasound examination of the uterus
C) endometrial sampling and ultrasound evaluation
D) dilation and curettage
E) use of oral contraceptives and observation
View Answer
Answer and Discussion
The answer is E. Endometrial cancer is rare in 15- to 18-year-old women. Therefore, most adolescents with dysfunctional uterine bleeding can be treated safely with hormone therapy and observation, without diagnostic testing.
Elford KJ, Spence JE. The forgotten female: pediatric and adolescent gynecological concerns and their reproductive consequences. J Pediatr Adolesc Gynecol. 2002;15:65–77.
109. In treating atrophic vaginitis, which of the following statements is true?
A) In women with an intact uterus, progestin treatment is not needed for short-term local estrogen treatment.
B) Current breast cancer is not a contraindication for topical estrogens.
C) Topical estrogen can be used in women with a history of endometrial cancer.
D) Topical estrogen can be used during breast feeding.
E) Postmenopausal bleeding during use of topical estrogen can be observed.
View Answer
Answer and Discussion
The answer is A. Vaginal estrogen therapy is indicated for short-term (6 months or less) treatment of symptoms related to vaginal atrophy in postmenopausal women. In women with an intact uterus, progestin treatment is not needed for short-term local estrogen treatment. However, data are limited about the use of local estrogen therapy for longer than 6 months. Patients should not be prescribed vaginal estrogens if they have undiagnosed vaginal bleeding, current breast cancer, history of endometrial cancer, or a thromboembolic disorder, or are pregnant or breastfeeding. Local estrogen therapy should be used with caution in patients with impaired liver function. Postmenopausal bleeding in women using local estrogen therapy should be evaluated as in any other postmenopausal patient. Manufacturers of topical estrogens available in the United States recommend limiting treatment to 3 to 6 months. However, many physicians prescribe vaginal estrogens for periods much longer than 3 to 6 months, but data on long-term safety are lacking. Further trials that provide data on long-term safety of local estrogen therapy are needed.
Willhite LA, O'Connell MB. Urogenital atrophy: prevention and treatment. Pharmacotherapy. 2001;21:464–480.
110. Fibroid tumors can be associated with which of the following conditions?
A) Amenorrhea
B) Renal lithiasis
C) Postpartum hemorrhage
D) Increased risk of ovarian carcinoma
E) Increased risk for endometrial hyperplasia
View Answer
Answer and Discussion
The answer is C. Fibroid tumors are irregular enlargements of the uterus. They are the most common benign tumors of the female genital tract, with as many as 20% of 40-year-old women affected. The tumors are composed of smooth muscle and connective tissue. In most cases, the condition is asymptomatic; however, it can cause dysmenorrhea with heavy menstrual blood loss leading to anemia and irregular periods. Occasionally, the fibroids degenerate, giving rise to intense pelvic pain and the development of pelvic infections. In some cases, infertility can occur when a fibroma blocks the fallopian tube. Other complications include difficult pregnancies with dystocia and excessive postpartum hemorrhage and urinary frequency or difficulty in defecating when the tumors press on the bladder or colon. Diagnosis is usually made with ultrasound, CT scan, MRI, or hysteroscopy. Treatment involves GnRH analogs (leuprolide), which may decrease the size of the fibroid; however, regrowth often occurs after the medication is discontinued. For severe cases, surgery, including myomectomy or hysterectomy, may be indicated. Treatment with estrogen can produce growth of the tumors and worsening of symptoms.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:693–699.
111. The most appropriate medication for the treatment of pyelonephritis in pregnancy is
A) ampicillin + gentamicin
B) trimethoprim–sulfamethoxazole
C) tetracycline
D) nitrofurantoin
E) ciprofloxacin
View Answer
Answer and Discussion
The answer is A. Pyelonephritis is one of the most common serious complications in pregnancy. It occurs in approximately 2% of pregnancies and more frequently in the third trimester. Symptoms include fever, chills, dysuria, flank pain, nausea, vomiting, and malaise. Treatment of choice is ampicillin or cefazolin, with the possible addition of an aminoglycoside (gentamicin) for severe cases. Sulfonamides are contraindicated in the third trimester of pregnancy because of the risk of kernicterus in newborns. Quinolone antibiotics (e.g., ciprofloxacin) interfere with cartilage development and should be avoided. Tetracyclines are contraindicated because they can cause yellowish discoloration in the child's teeth. Nitrofurantoin is used frequently in pregnancy but can induce hemolysis in patients who are deficient in glucose-6-phosphate dehydrogenase (G6PD; affects approximately 2% of African Americans). Treatment of pyelonephritis is necessary because of the increased risk of premature labor. All pregnant patients with pyelonephritis should be hospitalized, and periodic fetal monitoring should be instituted. Follow-up cultures are indicated to ensure eradication.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:422–423.
112. Which of the following tests is indicated at the time of the first prenatal visit in a healthy mother?
A) α-Fetoprotein testing
B) Quantitative β-HCG
C) Antibody test (indirect Coomb's test)
D) Glucose tolerance test
E) Sensitive thyroid-stimulating hormone
View Answer
Answer and Discussion
The answer is C. Prenatal testing is usually performed at the initial prenatal visit. Tests include Pap smear, complete blood count, urinalysis with culture, ABO blood type, Rh status, antibody test (indirect Coombs' test), rubella antibody titer, VDRL, and hepatitis B surface antigen. Other tests may include cervical cultures for chlamydia and gonorrhea, tuberculosis skin test, sickle cell prep, cytomegalovirus titers, and toxoplasmosis, and HIV testing should be offered to all patients. α-fetoprotein testing is usually done at 15 to 18 weeks' gestation, glucola test at 24 to 28 weeks' gestation, hematocrit determination at 28 to 32 weeks' gestation, and Rh antibody screening if indicated at 36 weeks' gestation. Patients at high risk for sexually transmitted diseases may need repeated cultures later in pregnancy. Routine ultrasound examination is controversial, but is generally performed in most pregnancies.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:86–87.
113. Which of the following would support the diagnosis of menopause in a woman taking no medications?
A) Vaginal pH >4.5
B) FSH level <10 mIU/mL
C) Endometrial cells noted on Pap smear
D) TSH >5.6
E) Progesterone >10 ng/dL
View Answer
Answer and Discussion
The answer is A. A vaginal pH >4.5 indicates menopause in women who are without vaginitis and are not receiving estrogen therapy. Studies have shown that vaginal pH is similar to FSH levels in establishing the diagnosis of low estrogen levels or menopause, and that a vaginal pH of 4.5 or less can be used to monitor adequate response to estrogen replacement therapy. Bacterial vaginosis can also cause a vaginal pH to be >4.5.
Roy S, Caillouette JC, Roy T. Vaginal pH is similar to follicle-stimulating hormone for menopause diagnosis. Am J Obstet Gynecol. 2004;190:1272–1277.
114. Which of the following is an absolute contraindication for the use of oral contraceptives in women over the age of 35?
A) Family history of stroke
B) Hypertension without vascular disease
C) Mild hyperlipidemia
D) Diabetes with neuropathy
E) Smoker (<10 cigarettes/day)
View Answer
Answer and Discussion
The answer is D. Risks associated with combination oral contraceptive pills (OCPs) may limit their use in women older than 35 years of age. Most concerns are based on early studies of oral contraceptive formulations with a high ethinyl estradiol content, rather than more recent studies of lower dose formulations. Although use of OCPs increases the risk of venous thromboembolism, the degree of risk appears to be the same in women taking formulations that contain 20 to 35 mcg of estrogen. The absolute risk of venous thromboembolism is very low (1 case per 10,000 OCP users per year). Oral contraceptive pills also contain progestins, including desogestrel and gestodene. These two progestins have been associated with an increased risk of venous thromboembolism. The risk of myocardial infarction may be increased in women using OCPs, especially if smoking (>10 cigarettes per day) or other cardiovascular risk factors are present. The association between OCP use and ischemic stroke is not clear, although increased risk has been demonstrated in OCP users who have migraines. There is no documentation of an increased risk of breast cancer in women who use OCPs. One study has found a slightly increased risk of gallstones, although the risk was lower in women older than 35 years of age than in younger women. The potential benefits of OCP use in women older than 35 years of age include effective birth control, reduced risk of ovarian and endometrial cancers, possible reduced risk of colon cancer, improvement of perimenopausal symptoms, improvement of acne, and increased bone mineral density (although improved fracture rates have not yet been demonstrated). Before use of OCPs is initiated, a thorough medical history should be obtained and blood pressure should be measured. If a patient has risk factors for cardiovascular disease or a family history of dyslipidemia, a routine fasting lipid panel is recommended. Mild lipid abnormalities do not contraindicate use of OCPs, but lipid levels should be monitored. Because OCPs can increase blood pressure, they should be prescribed with caution in patients with mild hypertension and patients who smoke. Absolute contraindications include:
· Pregnancy
· Postpartum less than 6 weeks and breastfeeding
· Age more than 35 years and heavy smoker (>15 cigarettes per day)
· Systolic blood pressure >160 mm Hg, diastolic blood pressure greater than 99 mm Hg
· Hypertension with vascular disease
· Diabetes with neuropathy, retinopathy, nephropathy, or vascular disease
· History of deep venous thrombosis or pulmonary embolism
· Major surgery with prolonged immobilization
· History of ischemic heart disease
· History of stroke
· Complicated valvular disease (with atrial fibrillation, pulmonary hypertension, bacterial endocarditis)
· Severe headaches with focal neurologic symptoms
· Current breast cancer
· Active viral hepatitis, severe cirrhosis, benign or malignant liver tumors
The best OCP in women over 35 is the one with the lowest effective estrogen dose. Side effects are most common during the first 3 months. The most frequent adverse effects are abnormal menstrual bleeding, nausea, weight gain, mood changes, breast tenderness, and headache. Follow-up should include annual blood pressure measurements, lipid profiles in patients with a baseline abnormality, and a review of symptoms that could signify an important adverse effect. Breakthrough bleeding is common and usually resolves spontaneously after a few months. The incidence of breakthrough bleeding appears to be higher with formulations containing lower estrogen doses.
Seibert C, Barbouche E, Fagan J. Prescribing oral contraceptives for women older than 35 years of age. Ann Intern Med. 2003;138:54–64.
The potential benefits of oral contraceptive pill (OCP) use in women older than 35 years of age include effective birth control, reduced risk of ovarian and endometrial cancers, possible reduced risk of colon cancer, improvement of perimenopausal symptoms, improvement of acne, and increased bone mineral density (although improved fracture rates have not yet been demonstrated).
115. Which of the following is associated with preeclampsia?
A) Blood pressure elevations of 30 mm Hg systolic or 15 mm Hg diastolic over baseline
B) Trace proteinuria
C) Mild edema
D) Seizures
E) Scotomata
View Answer
Answer and Discussion
The answer is A. Preeclampsia is defined as follows:
· Hypertension (>90 mm Hg diastolic and >140 mm Hg systolic after 20 weeks on two separate occasions taken 6 hours apart; also blood pressure elevations of 30 mm Hg systolic or 15 mm Hg diastolic over baseline)
· Proteinuria (>300 mg/24 hours or 1+ on urine dipstick)
· Other laboratory abnormalities: increased uric acid, thrombocytopenia, and elevated liver function test
Note: Edema has been removed from the criteria
Risk factors include age younger than 20 or older than 40 years, primigravid state, previous preeclampsia, twin pregnancy, diabetes mellitus, hydatidiform mole, fetal hydrops, or chronic hypertension. Eclampsia is defined as the above criteria plus the development of seizures that cannot be attributed to other causes. Warning signs for the development of eclampsia may include severe headache, scotomas, blurred vision, and vomiting. HELLP syndrome (hemolysis, elevated liver function tests, and low platelets) may also occur.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:338–349.
116. Gestational diabetic screening during pregnancy should take place
A) at the first prenatal visit
B) at 12 to 16 weeks' gestation
C) at 24 to 28 weeks' gestation
D) at 30 to 34 weeks' gestation
E) randomly throughout pregnancy
View Answer
Answer and Discussion
The answer is C. Diabetes during pregnancy is associated with a number of abnormalities that affect the fetus, including increased risk of spontaneous abortion, congenital anomalies (e.g., neural tube defects, cardiac defects, skeletal abnormalities, malformations of the intestinal and urinary tract), and fetal macrosomia. White's criteria are used to classify gestational diabetes:
· A1: gestational diabetes not requiring insulin
· A2: gestational diabetes requiring insulin
· B: onset in a patient older than 20 years of age or lasting less than 10 years
· C: onset at 10 to 20 years of age or duration of 10 to 20 years
· D: onset in patients younger than 10 years of age or duration of more than 20 years
· F: nephropathy
· R: proliferative retinopathy or vitreous hemorrhage
· H: atherosclerotic heart disease that is clinically evident
· T: renal transplant
Risk factors for gestational diabetes include maternal age older than 35 years, obesity, positive family history of diabetes, and prior history of gestational diabetes. All pregnant women should be screened for diabetes between weeks 24 and 28 of gestation with the glucola (1-hour 50-g oral glucose) screening test. If values are >140 mg/dL, a 3-hour glucose tolerance test should be performed. In patients with White's classification A2 to D, periodic monitoring with contraction stress testing is recommended. Although most women experience a resolution of diabetes immediately postpartum, they are at increased risk of developing type II diabetes mellitus later in life.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1361.
117. Which of the following test results is associated with pregnancy?
A) Increased white blood cell count
B) Decreased alkaline phosphatase
C) Increased hemoglobin
D) Decreased lactic dehydrogenase
E) Decreased fibrinogen level
View Answer
Answer and Discussion
The answer is A. Many laboratory values are affected during pregnancy:
· Hemoglobin/hematocrit: decreased
· White blood cell count: increased
· Fibrinogen level: increased
· Erythrocyte sedimentation rate: increased
· Albumin level: decreased
· Fasting blood glucose: decreased
· Lactic dehydrogenase: increased
· Creatinine phosphokinase: increased
· Alkaline phosphatase: increased
· Calcium (total): decreased
· Cortisol: increased
· Prolactin: increased
· Thyroxine total: increased
Mild glycosuria and proteinuria are also common during pregnancy. Excessive amounts should prompt for further evaluation to rule out gestational diabetes and preeclampsia.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:143–163.
118. Studies have shown that the use of depot medroxyprogesterone acetate (DMPA) contraception is associated with
A) accelerated bone loss
B) increased migraines
C) increased endometrial cancer
D) increased pregnancy risk
E) increased teratogenicity in future pregnancies
View Answer
Answer and Discussion
The answer is A. Depot medroxyprogesterone acetate (DMPA) use for 12 months or more is associated with a loss of bone mineral density, whereas oral contraceptive use is associated with gains in bone strength. This effect is likely related to low serum levels of ethinyl estradiol and the finding calls for further studies.
Berenson AB, Radecki CM, Grady JJ. A prospective, controlled study of the effects of hormonal contraception on bone mineral density. Obstet Gynecol. 2001;98:576–582.
119. Which of the following tests would support the diagnosis of polycystic ovary syndrome (PCOS)?
A) Low dehydroepiandrosterone sulfate (DHEAS) levels
B) Low androstenedione levels
C) Low free testosterone levels
D) LH to FSH ratio of 3:1
E) Fasting glucose to insulin level >4.5
View Answer
Answer and Discussion
The answer is D. Although there is no agreement as to which laboratory tests should be used to diagnose polycystic ovary syndrome (PCOS), most experts agree that the evaluation should screen for hyperandrogenemia as well as for abnormalities that have serious consequences. Often, the presentation is readily apparent from the history and physical findings. Elevated bioavailable (free) testosterone levels may support the diagnosis, especially in a nonhirsute woman with other signs and symptoms of PCOS. Hyperandrogenemia also might be established by elevated serum levels of dehydroepiandrosterone sulfate (DHEAS) and androstenedione. Both free testosterone and sex hormone-binding globulin may be useful in monitoring the efficacy of androgen suppression therapy. Total testosterone levels greater than 20 ng/dL (0.7 nmol/L) or DHEAS levels greater than 700 ng/mL (1.9 µmol/L) are suggestive of androgen-secreting tumors; these patients should be referred for further gynecologic investigation. Morning 17a-hydroxyprogesterone (17-OHP) determination is important to exclude nonclassic adrenal hyperplasia secondary to 21-hydroxylase deficiency. When elevated 17-OHP is discovered, the next step should be a short adrenocorticotropic hormone stimulation test to further delineate the enzymatic defect. The ratio of LH to FSH is greater than 3:1 in about 30% of women with PCOS and may be diagnostically helpful in nonhirsute women with mild ovulatory dysfunction. Because nearly 30% of women with PCOS have impaired glucose tolerance, determinations of glucose tolerance and insulin resistance are of major importance. One approach is to perform standard oral glucose tolerance testing with insulin levels. Peak levels of insulin >100 µU/mL (718 pmol/L) are suggestive of insulin resistance. A more efficient assessment may be to use the ratio of fasting levels of glucose to insulin. When <4.5, this ratio has a significant correlation with insulin resistance and has been studied for use as a screening test in obese patients with PCOS. Assessments of total, HDL, and LDL cholesterol levels as well as triglyceride levels may assist in planning and follow-up of recommended dietary modifications to reduce obesity and cardiovascular risk. Finally, endometrial biopsy is helpful to rule out endometrial hyperplasia in patients with prolonged amenorrhea (more than 5 months).
Legro RS, Finegood D, Dunaif A. A fasting glucose to insulin ratio is a useful measure of insulin sensitivity in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 1998;83: 2694–2698.
Richardson M. Current perspectives in polycystic ovary syndrome. Am Fam Physician. 2003;68:697–704.
120. Which of the following is the most common endocrinopathy among women of reproductive age?
A) Diabetes mellitus
B) Hypothyroidism
C) Cushing's syndrome
D) Addison's disease
E) Polycystic ovary syndrome (PCOS)
View Answer
Answer and Discussion
The answer is E. PCOS is the most common endocrinopathy among women of reproductive age and is estimated to affect up to 10% of the U.S. population.
Hull MG. Epidemiology of infertility and polycystic ovarian disease: endocrinological and demographic studies. Gynecol Endocrinol. 1987;1:235–245.
121. Which of the following medications is used in polycystic ovary syndrome to restore menstrual cyclicity and induce ovulation?
A) Bromocriptine (Parlodel)
B) Misoprostol (Cytotec)
C) Rosiglitazone (Avandia)
D) Metformin (Glucophage)
E) Bupropion (Wellbutrin)
View Answer
Answer and Discussion
The answer is D. Metformin (Glucophage), a biguanide and insulin-sensitizing agent, has been used to restore menstrual cyclicity and induce ovulation in PCOS without the use of additional fertility drugs. Use of this agent is associated with reductions in serum levels of bioavailable androgen, LH, and atherogenic lipids. Metformin is presently classified as a category “B” risk in pregnancy, which indicates that there are no apparent fetal defects associated with its use in the late trimester of pregnancy, based on animal studies. Because the human effects of first-trimester use are unknown, discontinuation of therapy at the onset of pregnancy confirmation has been standard. However, a recent prospective study of women with PCOS who continued metformin therapy through the first trimester of pregnancy showed no evidence of fetal harm, calling into question this recommendation. Metformin therapy is associated with a slight risk of lactic acidosis and is not used in patients with impaired liver or renal function.
Velazquez EM, Mendoza S, Hamer T, et al. Metformin therapy in polycystic ovary syndrome reduces hyperinsulinemia, insulin resistance, hyperandrogenemia, and systolic blood pressure, while facilitating normal menses and pregnancy. Metabolism. 1994;43:647–654.
Richardson M. Current perspectives in polycystic ovary syndrome. Am Fam Physician. 2003;68:697–704.
122. Which of the following statements concerning oral contraceptive use is true?
A) Oral contraceptives may decrease the risk of cervical cancer.
B) Oral contraceptives increase the risk of cholelithiasis.
C) Women who use oral contraceptives have a higher incidence of ectopic pregnancy.
D) The use of oral contraceptives is associated with a higher incidence of PID.
E) Women who use oral contraceptives have a higher incidence of endometrial carcinoma.
View Answer
Answer and Discussion
The answer is B. The use of oral contraceptives for birth control is widely accepted and prescribed. Properly used, the pill approaches 100% effectiveness in preventing pregnancy. Its mechanism of action involves the prevention of ovulation by the regulation of hormones [suppression of follicle-stimulating hormone (FSH) and luteinizing hormone (LH)] during the menstrual cycle, induction of atrophic changes to the endometrium that are not conducive to implantation, and the alteration of cervical mucus. Basically, there are two types: combination pills that include estrogen and progestin components and pills that contain only progestin. Pills that contain only progestin are best suited for women older than 35 years, smokers, or those who cannot tolerate estrogen. Additionally, oral contraceptives are divided into monophasic (fixed combination of estrogen and progestin component) and multiphasic (varying amount of progestin during each of the 3 weeks of medication with a fixed amount of estrogen). Overall, the multiphasic oral contraceptives are highly effective and may provide a lower dose of estrogen and progestin. Absolute contraindications to oral contraceptives include pregnancy, active liver disease, uncontrolled hypertension, significant hyperlipidemia, diabetes with vascular changes, previous deep venous thrombosis, coronary artery disease, stroke, or estrogen-related cancers. Relative contraindications include migraine headaches, hypertension, smoking, diabetes, major surgery within 1 month, sickle cell disease, gallbladder disease, immobilization of the lower extremities, undiagnosed vaginal bleeding, and age older than 40 years with cardiovascular risk factors. Complications associated with oral contraceptive use include increased blood pressure, midcycle bleeding between periods, headaches, weight gain, hirsutism, acne, increased risk of cholelithiasis, melasma, increased risk for myocardial infarction in smokers older than 35 years, and, rarely, benign hepatic lipomas. Women who use oral contraceptives are at decreased risk for ovarian cancer, endometrial cancer, PID, and ectopic pregnancy. No consistent association has been found between breast cancer and oral contraceptive use, except for the possibility of a slightly elevated risk in users of oral contraceptives for more than 3 years before 25 years of age. Women who are taking antiepileptic medication have an increased risk for oral contraceptive failure because of the enzyme-inducing action of the antiseizure medication. Antibiotic use may also decrease the effectiveness of oral contraceptives.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:634–638.
123. Pap smears should be performed
A) typically 3 to 5 years before a woman becomes sexually active
B) every 5 years for sexually active women
C) every 2 to 3 years for women who are at low risk for cervical cancer and have had negative Pap smears in the past
D) until 50 years of age, when they can be discontinued
E) yearly, regardless of age, in sexually active women
View Answer
Answer and Discussion
The answer is C. Pap smears are used to detect abnormal cervical cells. The possibility of false-negative results may occur between 10% and 30% of the time. Most experts agree that Pap smears should be performed on a yearly basis once a woman becomes sexually active. Those at low risk for cervical cancer may elect for screening every 2 to 3 years if they have had previous normal Pap smears. If a patient is older than 65 years and has had previous normal Pap smears, some recommendations state the smears can be discontinued.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2125.
Those at low risk for cervical cancer may elect for screening every 2 to 3 years if they have had previous normal Pap smears.
124. Which of the following statements about the use of a cervical cap is true?
A) Cervical caps are more effective when used in multiparous women.
B) Use of the cervical cap increases the risk of vaginal and urinary tract infections.
C) Failure rates with cervical caps are significantly lower than with diaphragms.
D) The cervical cap can be left in place for no more than 12 hours.
E) Cervical cap use is higher in the United States than in Europe.
View Answer
Answer and Discussion
The answer is B. The cervical cap is a birth control method. The cap is similar to the diaphragm but is smaller in size and only covers the cervix and the cervical os. It comes in four different sizes and needs to be fitted by a physician before its use. The cervical cap is more effective in nulliparous than in multiparous women. It can be left in place for up to 72 hours. Failure rates are improved with the use of spermicidal gel and are similar to those of the diaphragm (approximately 8% to 15%). Use of the cervical cap increases the risk of vaginal and urinary tract infections. Patients should have a negative Pap smear before the use of the cervical cap, and a repeat Pap smear should be taken after 3 months of use. Use during menstruation should be discouraged because of the theoretical risk of the development of endometriosis. Reasons for discontinuing the cervical cap include patient or partner discomfort, difficulty with proper insertion, and unplanned pregnancy. The cervical cap is used more widely in Europe than in the United States and because of the difficulty in fitting the cap and routine insertion required it is unlikely to play an important role in contraception in the United States.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:633.
125. Which of the following statements is true regarding the placement of an Intrauterine device (IUD)?
A) IUDs should only be inserted during menses.
B) Multiparous women have a higher risk of expulsion.
C) Routine prophylactic antibiotics are recommended before the procedure.
D) Antibiotic prophylaxis in patients at risk for endocarditis is necessary before IUD insertion or removal.
E) An IUD should not be inserted if the depth of the uterus is <6 cm.
View Answer
Answer and Discussion
The answer is E. IUDs may be inserted anytime during the menstrual cycle. Documentation of a negative pregnancy test is recommended. Insertion may be performed during menstruation to provide additional reassurance that the woman is not pregnant. If insertion is planned during the luteal phase, another nonhormonal contraceptive should be used until completion of the next menses. A pregnancy test at this time cannot always rule out early pregnancy. An IUD should not be inserted in a woman with an STD. The American College of Obstetricians and Gynecologists recommends a pelvic examination before insertion to screen for Chlamydia and gonorrhea. Routine prophylactic antibiotic administration is not necessary. According to the American Heart Association, antibiotic prophylaxis in patients at risk for endocarditis is not necessary before IUD insertion or removal. IUDs are for parous women who are in a stable, mutually monogamous relationship, with no history of PID. Although not contraindicated in this group, nulliparous women tend to have higher expulsion and failure rates, and also offer more challenging insertion because they have a smaller uterine cavity. An adequate uterine depth is between 6 and 9 cm and should be documented in the patient's record. An IUD should not be inserted if the depth of the uterus is less than 6 cm.
Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician. 2005;71:95–102.
Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev. 2001;(1):CD001327. [Update in: Cochrane Database Syst Rev. 2001;(2):CD001327.]
Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Circulation. 1997;96:358–666.
126. The progestin-releasing IUD can be used for
A) 3 years
B) 5 years
C) 10 years
D) 15 years
E) indefinitely, as long as it's kept in proper placement
View Answer
Answer and Discussion
The answer is B. The progestin-releasing IUD can be used for 5 years. The copper-releasing IUD can be used for 10 years before replacement.
Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician. 2005;71:95–102.
127. Which of the following oral contraceptives is approved by the FDA for the treatment of acne vulgaris in women and adolescent females?
A) Ethinyl estradiol–norelgestromin (OrthoEvra patch)
B) Ethinyl estradiol–levonorgestrel (Preven)
C) Norethindrone (Micronor)
D) Ethinyl estradiol–drospirenone (Yasmin)
E) Ethinyl estradiol–norgestimate (Ortho Tri-Cyclen)
View Answer
Answer and Discussion
The answer is E. Oral contraceptives may be a useful adjunctive therapy for all types of acne in women and adolescent girls. Sebum production is controlled by androgens, and oral contraceptives are known to decrease androgen levels by increasing sex hormone binding globulin levels, thus reducing the availability of biologically active free testosterone. The third-generation progestin norgestimate has lower intrinsic androgenicity than other currently available progestins and is effective in treating moderate inflammatory acne. Ortho Tri-Cyclen is a triphasic combination of norgestimate and ethinyl estradiol that has been labeled by the U.S. Food and Drug Administration (FDA) for the treatment of acne vulgaris in women and adolescent girls. Other contraceptive agents that contain norgestimate (Ortho-Cyclen) or desogestrel (Desogen) are also reasonable choices. Two to 4 months of therapy may be required before improvement is noted, and relapses are common if medication is stopped.
Johnson BA, Nunley JR. Use of systemic agents in the treatment of acne vulgaris. Am Fam Physician. 2000;62:1823–1830, 1835–1836.
128. When considering treatment for osteoporosis which of the following is true?
A) Impaired eyesight is not a factor to consider in the decision to start medication.
B) Less than 30% of White women have an osteoporotic fracture at some point in their lifetime.
C) Bone mineral density testing is recommended in all women ages 65 and older, regardless of additional risk factors.
D) Bone mineral density testing should be performed only in postmenopausal women under age 65 who have two or more additional risk factors for osteoporosis (in addition to menopause).
E) Weight-bearing exercise should be avoided in postmenopausal women.
View Answer
Answer and Discussion
The answer is C. The National Osteoporosis Foundation (NOF) has issued recommendations for the prevention, risk factor assessment, diagnosis and treatment of osteoporosis, including specific guidelines on the use of bone mineral density tests.
· All women should be counseled about the risk factors for osteoporosis. Risk factors for osteoporotic fracture include personal history of fracture as an adult, history of fracture in a first-degree relative, white race, advanced age, female sex, dementia, poor health/frailty, cigarette smoking, low body weight [<127 lb (58 kg)], estrogen deficiency, lifelong low calcium intake, alcoholism, impaired eyesight despite adequate correction, recurrent falls, and inadequate physical activity. According to the NOF, osteoporosis is a “silent” risk factor for fracture; one out of two White women will have an osteoporotic fracture at some point in her lifetime.
· The NOF recommends that all postmenopausal women with a fracture be evaluated for osteoporosis using bone mineral density testing to determine if the woman has osteoporosis and to determine disease severity. According to the NOF, measurements of bone mineral density at any skeletal site can predict the risk of fracture, but a measurement of the hip is the best predictor of hip fractures, and hip measurement can predict fractures at other sites as well. The measurement of bone density can also be used to monitor changes in bone density associated with medical conditions or therapy.
· The NOF recommends bone mineral density testing in all postmenopausal women under age 65 who have one or more additional risk factors for osteoporosis (in addition to menopause).
· Bone mineral density testing is also recommended in all women ages 65 and older, regardless of additional risk factors.
· All adults should be advised to consume an adequate intake of dietary calcium (at least 1,200 mg/day, including supplements if necessary) and vitamin D (400 to 800 IU/day for persons at risk of deficiency).
· All patients should be counseled to avoid smoking and to limit alcohol intake to moderate levels. All patients should be encouraged to participate in regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures.
· Physicians should consider osteoporosis treatment for all postmenopausal women who present with vertebral fractures or hip fractures. The NOF emphasizes that these sites are the most common sites for osteoporotic fractures.
· Bone mineral tests provide physicians with a T score expressed in standard deviation; the more negative the number, the greater the risk of fracture. Each standard deviation represents a 10% to 12% bone loss, and a T score of -2.5 indicates osteoporosis. The NOF recommends therapy to reduce fracture risk in women with a bone mineral density T score below -2.0 in the absence of risk factors, and in women with a T score below -1.5 if other risk factors are present.
The National Osteoporosis Foundation (NOF) guidelines accessed at http://www.nof.org/osteoporosis/sgr_release.htm on 12/18/2005. Accessed 6/1/06.
129. Which of the following factors makes appendicitis during pregnancy difficult to diagnose?
A) Location of the appendix
B) Presence of fever
C) Rectal tenderness
D) Rebound tenderness
E) Presence of pyuria
View Answer
Answer and Discussion
The answer is A. Appendicitis during pregnancy may be difficult to diagnose. The white blood cell count is mildly elevated during a normal pregnancy, making it difficult to distinguish the leukocytosis seen with infection. In addition, as pregnancy progresses, the position of the appendix migrates superiorly (usually above the iliac crest in patients at more than 5 months' gestation). Therefore, there is a greater risk for perforation in those with appendicitis as pregnancy progresses. In addition, there is a greater risk of perinatal mortality when the appendix is perforated. In early pregnancies, the appendix is usually removed through a midline vertical incision; however, with more advanced pregnancies, an incision is generally made over the point of maximal tenderness. The complications involved with appendectomy include premature labor and infection. The differential diagnosis of abdominal pain during pregnancy is extensive and includes gastroenteritis, inflammatory bowel disease, cholecystitis, intestinal obstruction, pancreatitis, pyelonephritis, nephrolithiasis, spontaneous abortion, round ligament pain, ectopic pregnancy, uterine contractions, placental abruption, and pelvic infections.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1281–1282.
130. The treatment of choice for bacterial vaginosis is
A) metronidazole
B) doxycycline
C) ceftriaxone
D) nystatin vaginal tablets
E) vinegar douche
View Answer
Answer and Discussion
The answer is A. Bacterial vaginosis is a condition that is caused by proliferation of a number of organisms, including Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, and Peptostreptococcus species. The condition accounts for as many as 50% of all cases of vaginitis and is characterized by a gray, often frothy, foul-smelling vaginal discharge. When 10% to 20% potassium hydroxide is applied, the discharge gives off a characteristic amine-like fishy odor. Patients often report vaginal irritation and a foul-smelling discharge. Microscopic examination of the discharge shows “clue cells” (epithelial cells that are covered with coccobacilli on the cell walls). The vaginal secretion pH is >4.5. Treatment of choice is metronidazole. Topical 2% clindamycin cream can also be used. Cultures are not helpful because Gardnerella may be a normal inhabitant of the vagina. Studies indicate that treating the male sexual partner of a woman with bacterial vaginosis is not beneficial and that even women who are not sexually active can have the infection. Additional risk factors for bacterial vaginosis include the use of IUDs, douching, and pregnancy. Evidence suggests that bacterial vaginosis is a risk factor for premature rupture of membranes and preterm labor. Treating the infection in pregnancy decreases this risk. In pregnant women with bacterial vaginosis, treatment should be administered after the first trimester to lower the risk of premature rupture of membranes. Additional possible adverse outcomes include an increased frequency of abnormal Pap smears, PID, and endometritis. Vaginal cuff cellulitis, PID, and endometritis can occur if invasive gynecologic procedures or surgeries are performed when a patient has bacterial vaginosis.
Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. 2000;62:1095–1104.
131. Which of the following statements about sexual intercourse and uncomplicated pregnancy is true?
A) Intercourse should be avoided until 36 weeks' gestation because of the risk of premature labor.
B) Intercourse should be avoided 2 weeks before the estimated date of confinement because of the risk of infection.
C) Intercourse is safe during pregnancy; however, orgasm should be avoided because of the risk of preterm labor.
D) Intercourse is not considered dangerous during normal pregnancy.
E) Intercourse should be avoided during pregnancy because of the risk for placental abruption.
View Answer
Answer and Discussion
The answer is D. Sexual intercourse during pregnancy is generally considered safe as long as the mother has not had complications during pregnancy that would put the infant at risk (e.g., preterm labor, abnormal vaginal bleeding, premature rupture of membranes). Orgasm with uterine contractions does not induce labor; however, milk ejection may occur and is a normal response. In many cases, the woman has an increased desire for intercourse during pregnancy; however, other women may have a decrease in desire. Both responses are considered normal. Abstention from sexual intercourse was formerly recommended during the final months of pregnancy; however, it is no longer considered a risk in normal pregnancies.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:240.
132. The vaginal ring contraceptive can be left in place for
A) 3 days
B) 1 week
C) 3 weeks
D) 3 months
E) 1 year
View Answer
Answer and Discussion
The answer is C. After three weeks, the contraceptive vaginal ring is removed for 1 week, and a new ring is inserted. Withdrawal bleeding occurs during the ring-free week.
Herndon EJ, Zieman M. New contraceptive options. Am Fam Physician. 2004;69:853–860.
133. How long can the vaginal ring be out of the vagina before an additional form of contraception is necessary?
A) 30 minutes
B) 1 hour
C) 3 hours
D) 24 hours
E) 1 week
View Answer
Answer and Discussion
The answer is C. If the ring is removed from the vagina for more than 3 hours, additional back-up contraception should be used until the ring has been back in place for 7 days.
Bjarnadottir RI, Tuppurainen M, Killick SR. Comparison of cycle control with a combined contraceptive vaginal ring and oral levonorgestrel/ethinyl estradiol. Am J Obstet Gynecol. 2002;186:389–395.
If a vaginal ring is removed from the vagina for more than 3 hours, additional back-up contraception should be used until the ring has been back in place for 7 days.
134. A hypertensive woman uses enalapril for her blood pressure management. She has excellent control. Which of the following oral contraceptives when used with enalapril can lead to hyperkalemia?
A) ethinyl estradiol–norelgestromin (OrthoEvra patch)
B) ethinyl estradiol–levonorgestrel (Preven)
C) norethindrone (Micronor)
D) ethinyl estradiol–drospirenone (Yasmin)
E) ethinyl estradiol–norgestimate (Ortho Tri-Cyclen)
View Answer
Answer and Discussion
The answer is D. A combination OCP that contains the new progestogen drospirenone (Yasmin) has been available for the last several years. Drospirenone has antimineralocorticoid activity and has been shown to decrease the water retention, negative affect, and appetite changes that commonly are associated with menstrual cycle changes. Serum potassium levels should be monitored when using this OCP in conjunction with other medicines that also raise potassium levels, because of the risk of developing hyperkalemia.
Herndon EJ, Zieman M. New contraceptive options. Am Fam Physician. 2004;69:853–860.
135. The oral contraceptive levonorgestrel–ethinyl estradiol (Seasonale) is different from other oral contraceptives as a result of
A) a lower dose of ethinyl estradiol
B) once-a-month dosing
C) increased effectiveness
D) the duration of hormone therapy between periods
E) the addition of levonorgestrel
View Answer
Answer and Discussion
The answer is D. The U.S. Food and Drug Administration (FDA) recently approved the use of levonorgestrel ethinyl estradiol (Seasonale) in an extended OCP regimen consisting of 84 days of active pills and 7 days of nonhormonal pills.
Herndon EJ, Zieman M. New contraceptive options. Am Fam Physician. 2004;69:853–860.
136. A 15-year-old girl presents to the office complaining that she has not had a period in 3 months. The young girl emphatically states that she is not pregnant, and her mother assures you she is not pregnant. The most appropriate initial test would be
A) urine pregnancy test
B) thyroid function test
C) serum prolactin level
D) progesterone challenge test
E) serum cortisol level
View Answer
Answer and Discussion
The answer is A. Abnormal menses are normal in the immediate pubertal period. Lack of menses for 3 to 4 months presents no concern if there is no possibility that the girl is pregnant. However, the history given by young, sexually active girls often cannot be trusted. The first step in the evaluation of amenorrhea is to determine if the patient is pregnant. Other tests for the workup of amenorrhea include a serum prolactin level and sensitive thyroid-stimulating hormone. If these tests are normal and the pregnancy test is negative, a progesterone challenge test can be performed. In this test, medroxyprogesterone acetate is given for 7 to 10 days, and withdrawal bleeding is usually induced after administration. If withdrawal bleeding occurs (positive test), the diagnosis of anovulation can be made. If no withdrawal bleeding occurs (negative test), the differential diagnosis includes polycystic ovary syndrome or an adrenal enzyme deficiency that leads to an excess of progesterone. If amenorrhea continues on a regular basis and the patient is diagnosed with anovulation, a daily dose of medroxyprogesterone can be prescribed for the first 10 days of alternative months. Pathologic amenorrhea is divided into primary amenorrhea (absence of menses before the age of 16) and secondary amenorrhea (absence of menses for 3 months or more in patients who have had previous periods).
Taylor RB, David AK, Fields SA, et al. Family Medicine: Principles and Practice, 6th ed. New York: Springer; 2003:874–878.
137. Which of the following statements about postpartum depression is true?
A) Postpartum depression usually occurs 9 to 12 months after delivery.
B) Social support has little impact on the development of postpartum depression.
C) Those with obstetric complications are at increased risk.
D) Those affected are at increased risk for postpartum depression with subsequent pregnancies.
E) Patients who have postpartum depression have no higher risk of developing depression in later years when compared to the general population.
View Answer
Answer and Discussion
The answer is D. Mild postpartum depression (also referred to as the “baby blues”) is usually seen within the first few days after delivery. The incidence ranges up to 25%, and those with poor social support are more commonly affected. There appears to be no relationship with obstetric complications. Symptoms vary but are usually mild and self-limited. In most cases, reassurance that these feelings are common is all that is needed. In more severe cases, in which the mother's symptoms last for extended periods or if the mother shows a lack of interest in the newborn, has suicidal or homicidal thoughts or gestures, or shows psychotic behavior, further therapy (including medication and psychotherapy) may be needed. Women who are affected with severe postpartum depression are at risk for development of further depressive episodes and recurrent postpartum depression with subsequent pregnancies.
Taylor RB, David AK, Fields SA, et al. Family Medicine: Principles and Practice, 6th ed. New York: Springer; 2003:139.
138. Prenatal vitamins are important during pregnancy because they help to reduce the incidence of neural tube defects. Which of the following is responsible for this protective effect?
A) Calcium
B) Iron
C) Folic acid
D) Vitamin C
E) Vitamin B12
View Answer
Answer and Discussion
The answer is C. Prenatal vitamins are recommended for pregnant women when dietary intake does not satisfy nutritional needs (multiple gestations, drug abusers, vegetarians, epileptics, and women with hemoglobinopathies) and in those who are planning pregnancy. The supplementation of iron during pregnancy is needed to prevent severe anemia and is usually accomplished by the use of prenatal vitamins. The following are the recommended requirements for pregnant women:
· Calcium, 1,200 to 1,500 mg/day
· Iron, 30 mg/day
· Folic acid, at least 0.4 mg/day
The use of prenatal vitamins before pregnancy can supply adequate folic acid, which has been shown to help prevent neural tube defects. Excessive use of vitamin A supplements should be avoided because of a small number of case reports that suggest a link to birth defects. Furthermore, if the infant is breast-fed, the use of prenatal vitamins for the mother is usually encouraged.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:234–238.
139. Which of the following statements is true regarding bacterial vaginosis during pregnancy?
A) All studies have shown an increased risk of premature labor in women affected with bacterial vaginosis.
B) Symptomatic women should be treated.
C) Routine screening is recommended for all pregnant patients.
D) Vaginal pH <4.5 is supportive of bacterial vaginosis.
E) Treatment should be avoided until after pregnancy.
View Answer
Answer and Discussion
The answer is B. Routine screening of all pregnant women for bacterial vaginosis (BV) is not recommended. Well-designed studies of BV screening in women with a history of preterm delivery found inconsistent results. Physicians may consider screening women at increased risk of preterm labor with Gram stain or Amsel criteria (i.e., three of the following signs: homogeneous white or gray noninflammatory vaginal discharge, presence of clue cells, vaginal secretion pH of 4.5 or greater, and amine odor of vaginal discharge before or after addition of 10% potassium hydroxide [KOH]). Symptomatic women should be treated.
U.S. Preventive Services Task Force. Screening for bacterial vaginosis in pregnancy: recommendations and rationale. Am J Prev Med. 2001;20(3 suppl):59–61.
Guise JM, Mahon SM, Aickin M, et al. Screening for bacterial vaginosis in pregnancy. Am J Prev Med. 2001;20(3 suppl):62–72.
140. A 65-year-old woman presents to your office concerned about uterine prolapse. During her examination, you note the cervix is visible outside of the vaginal introitus. The uterus is not visible. Based on your findings, you classify her as having _____________.
A) first-degree prolapse
B) second-degree prolapse
C) third-degree prolapse
D) no prolapse
View Answer
Answer and Discussion
The answer is B. Uterine prolapse is classified by degree. In first-degree uterine prolapse, the cervix is visible when the perineum is depressed. In second-degree prolapse, the cervix is visible outside of the vaginal introitus while the uterine fundus remains inside. In third-degree prolapse, or procidentia, the entire uterus is outside of the vaginal introitus. Uterine prolapse is associated with urinary incontinence, vaginitis, cystitis, and, possibly, uterine malignancy.
Viera AJ, Larkins-Pettigrew M. Practical use of the pessary. Am Fam Physician. 2000;61:2719–2726, 2729.
141. The most common cause of first-trimester spontaneous abortion is
A) incompetent cervix
B) chromosomal abnormalities
C) increased maternal age
D) inadequate levels of progesterone during the luteal phase
E) lupus anticoagulant
View Answer
Answer and Discussion
The answer is B. It is estimated that spontaneous abortions during the first trimester affect 20% of all pregnancies. Because many cases go unreported, the true incidence may be much higher (50% to 75%). The most common cause is chromosomal abnormalities (usually autosomal trisomies), which are incompatible with life. Other factors that may contribute to spontaneous abortion include maternal smoking, increased maternal age, maternal illness, incompetent cervix, lupus anticoagulant, and inadequate levels of progesterone during the luteal phase of the menstrual cycle. Patients usually report vaginal bleeding and uterine cramps. Expulsion of fetal material generally occurs spontaneously, but in some cases dilation and curettage is needed. Misoprostol provides a safe and effective means of initial treatment for spontaneous abortion with retained products of conception. Although gastrointestinal side effects are common with medical management, they are seldom severe. The addition of misoprostol to routine management of spontaneous abortion can significantly reduce the need for surgical intervention and ultimately reduce the overall rate of complications. Patients should receive emotional support and reassurance. Vaginal bleeding develops in 25% of pregnant women during the first half of pregnancy, and 50% of those patients eventually abort.
Chung TK, Lee DT, Cheung LP, et al. Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertil Steril. 1999;71:1054–1059.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:874–875.
142. The presence of sterile pyuria in a sexually active individual is most commonly associated with
A) gonorrhea
B) syphilis
C) chlamydia
D) herpes genitalis
E) human papillomavirus virus
View Answer
The answer is C. Chlamydia is a sexually transmitted disease that is caused by Chlamydia trachomatis. Approximately 50% of nongonococcal urethritis and most cases of cervicitis are caused by chlamydia. Men usually report discomfort associated with the urethra, dysuria, or a clear to mucopurulent discharge that occurs 1 to 3 weeks after exposure. Most women are asymptomatic, although they may report dysuria, pelvic discomfort with dyspareunia, and vaginal discharge that may have a clear to yellow mucopurulent appearance. The cervix may bleed easily and is usually swollen and covered with a yellowish-green discharge. Diagnosis is made with immunologic studies performed on urine, secretions, or culture. The presence of sterile pyuria in a sexually active individual should raise the suspicion of chlamydia. The presence of gonorrhea must be ruled out and patients should be treated for gonorrhea if chlamydia is found, and vice versa. Because chlamydial infection is often asymptomatic and the sequelae can be serious, routine screening for disease during annual examinations is recommended in young sexually active women. Single-dose therapy with azithromycin is as effective as a 7-day course of doxycycline (Vibramycin). Doxycycline is less expensive, but azithromycin may be cost beneficial because it provides single-dose, directly observed therapy. Erythromycin and ofloxacin (Floxin) also can be used to treat C. trachomatis. Erythromycin is less efficacious than azithromycin and doxycycline, and its adverse gastrointestinal effects may decrease patient compliance. Ofloxacin is as effective as the recommended regimens but offers no dosing or cost advantages. Doxycycline and ofloxacin are contraindicated in pregnant women.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1651–1652.
143. Treatment for vaginismus includes which of the following?
A) Desensitization therapy with continued regular intercourse until it becomes comfortable.
B) Treatment with muscle relaxants.
C) Kegel exercises.
D) Dilation with vaginal probes.
E) Transcutaneous electrical nerve stimulation treatment.
View Answer
Answer and Discussion
The answer is D. Vaginismus is a condition that is characterized by involuntary spasm of the lower vaginal muscles, resulting in an unconscious effort to prevent penile penetration. Causes include psychiatric factors, local trauma, infection, or mechanical factors, including vaginal stenosis or dryness. Women report extreme discomfort with attempts at penetration. Treatment involves correction of reversible causes, sexual counseling, and gradual and repeated attempts at vaginal dilation with vaginal or (shorter) rectal probes. Treatment can be continued by the patient at home in a private environment after the appropriate technique is learned. Intercourse can be attempted once the patient is able to tolerate larger dilators without discomfort. Communication with the patient's partner often is helpful in overcoming the patient's fears.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2100–2104.
144. Which of the following is not useful in treating premenstrual syndrome?
A) Vitamin B6
B) Vitamin E
C) Calcium supplementation
D) Folate
View Answer
Answer and Discussion
The answer is D. A meta-analysis of randomized, placebo-controlled trials was conducted to ascertain the effectiveness of vitamin B6 in PMS management. The researchers concluded that vitamin B6, in dosages of up to 100 mg/day, is likely to benefit patients with premenstrual symptoms and premenstrual depression. In another study, the reviewers concluded that calcium supplementation in a dosage of 1,200 to 1,600 mg/day is a treatment option in women with PMS. Calcium supplementation (using Tums E-X) was found to reduce core premenstrual symptoms by 48%. Vitamin E, an antioxidant, seems to reduce the affective and physical symptoms of PMS. Tryptophan, a substrate for serotonin, may also benefit some patients.
Steinberg S, Annable L, Young SN, et al. A placebo-controlled clinical trial of l-tryptophan in premenstrual dysphoria. Biol Psychiatry. 1999;45:313–320.
Wyatt KM, Dimmock PW, Jones PW, et al. Efficacy of vitamin B-6 in the treatment of premenstrual syndrome. BMJ. 1999;318:1375–1381.
Ward MW, Holimon TD. Calcium treatment for premenstrual syndrome. Ann Pharmacother. 1999;33:1356–1358.
145. Which of the following statements is true regarding postcoital emergency contraception?
A) Birth defects often occur if the method is unsuccessful.
B) Emergency contraception is 95% effective.
C) Emergency contraception is most effective if administered within 72 hours.
D) Plan B has more side effects than Preven.
E) The dose of Plan B should be split to avoid side effects.
View Answer
Answer and Discussion
The answer is C. Women have the option to use emergency contraception to prevent pregnancy after known or suspected failure of birth control or after unprotected intercourse. Emergency contraception has been an off-label use of oral contraceptive pills since the 1960s. Products including the Yuzpe regimen (Preven) and levonorgestrel (Plan B) were marketed in the United States after 1998, but had been available in Europe for years before that. The Plan B option consists of two tablets, each containing 0.75 mg of levonorgestrel. (This amount differs from the 0.075 mg dose of norgestrel in certain progestin-only pills.) There is a general consensus that the levonorgestrel emergency contraception should be given in preference to the Yuzpe regimen where available because it is more effective and has fewer side effects. In addition, a World Health Organization (WHO) multicenter randomized trial shows that the levonorgestrel dose does not have to be split, but can be taken as a single 1.5-mg dose. One dose simplifies the use of levonorgestrel without causing an increase in side effects. A third approved method of emergency contraception is the insertion of an intrauterine device. Emergency contraception is about 75% to 85% effective. It is most effective when initiated within 72 hours after unprotected intercourse. The mechanism of action may vary, depending on the day of the menstrual cycle on which treatment is started. Despite the large number of women who have received emergency contraception, there have been no reports of major adverse outcomes. If a woman becomes pregnant after using emergency contraception, she may be reassured about the lack of negative effects emergency contraception has on fetal development.
Weismiller DG. Emergency contraception. Am Fam Physician. 2004;70:707–714, 717–718.
Emergency contraception is about 75% to 85% effective. It is most effective when initiated within 72 hours after unprotected intercourse.
146. Oligohydramnios is associated with an increased risk of
A) placenta previa
B) cord prolapse
C) Down syndrome
D) prolonged labor
E) endometritis
View Answer
Answer and Discussion
The answer is B. Oligohydramnios is defined as an amount of amniotic fluid that is less than what is expected for gestational age. In cases in which there is a lack of amniotic fluid, fetal movement is restricted and there is an increased risk of cord prolapse with fetal injury and demise. Other associated conditions include abnormal facies, limb contractures, and pulmonary hypoplasia. The cause of oligohydramnios is related to either a fluid loss with premature rupture of membranes or lack of amniotic fluid production with renal disturbances, including renal agenesis, dysplasia, or obstruction. The condition is more common in postterm pregnancies. Oligohydramnios seen early in pregnancy is a poor prognostic sign. The amount of amniotic fluid is usually quantified with ultrasound determination, including fluid pocket measurements. If the largest area of fluid accumulation is <1 cm × 1 cm, it is considered diagnostic for oligohydramnios. Fluid pockets of <2 cm × 2 cm are considered borderline. If the mother is suspected of having oligohydramnios, close monitoring by an obstetrician is usually recommended. Treatment of oligohydramnios as a result of spontaneous rupture of membranes can be achieved with amnioinfusion of warmed saline solution. If cord prolapse does occur, emergency cesarean section is necessary.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:821–824.
147. Which of the following statements about acute pyelonephritis during pregnancy is true?
A) It is associated with an increased risk of premature labor.
B) The medication of choice is a sulfonamide antibiotic.
C) Prophylaxis should never be instituted during pregnancy.
D) Most cases can be treated on an outpatient basis.
E) The drug of choice is intravenous ciprofloxacin.
View Answer
Answer and Discussion
The answer is A. An important complication that is seen in pregnancy is pyelonephritis. The most common infecting agents are E. coli and Klebsiella pneumoniae. In most cases, hospitalization is necessary. The drug of choice is ampicillin, usually combined with the aminoglycoside gentamicin. Sulfonamides should not be used during pregnancy because of the increased risk of kernicterus, and trimethoprim has been associated with teratogenicity. Tetracyclines should be avoided because their use is associated with discoloration of the infant's teeth and with bone abnormalities. Nitrofurantoin is often used but has been associated with hemolysis in women who are deficient in glucose-6-phosphate dehydrogenase (2% of African-American women) and therefore should be avoided. Extended-spectrum penicillins and third-generation cephalosporins are suitable alternatives. Prophylaxis should be considered for patients who have had more than two infections during pregnancy. Infections that involve the urinary tract are usually associated with an increased risk for premature labor.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1256–1257.
148. Rubella infection during pregnancy
A) rarely affects the fetus
B) has its most devastating effects during the third trimester
C) is associated with cataracts, cardiac defects, and cleft palate
D) is associated with neural tube defects
E) can be prevented with immunization during the pregnancy
View Answer
Answer and Discussion
The answer is C. Rubella infection (“German measles”) during pregnancy can have devastating effects on the fetus. They are most severe for those fetuses that are affected during the first trimester. Clinical findings of congenital rubella include cataracts, blindness, and cardiac abnormalities (including patent ductus arteriosus, pulmonary valve stenosis, and ventricular septal defect). Other findings include pigmented birthmarks, hemolytic anemia, cleft palate, deafness, mental retardation, cerebral palsy, and fetal death. Treatment is aimed at prevention by immunizing all prospective mothers. The vaccine should be given at least 3 months before conception because of the live attenuated vaccine.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1465.
149. The most frequently reported symptom in women with vulvar cancer is
A) bleeding
B) dyspareunia
C) vaginal dryness
D) itching
E) vaginal discharge
View Answer
Answer and Discussion
The answer is A. The most frequently reported symptom of vulvar cancer is vaginal bleeding. Other common presenting symptoms include vulvar itching, discharge, dysuria, and pain. The most common presenting sign of vulvar cancer is a vulvar lump or mass. Rarely, patients present with a large, fungating mass.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2129.
150. A 70-year-old woman has been treated for 6 months with topical estrogen for chronic lichen sclerosus. Despite treatment she continues to have vaginal pruritus. Appropriate treatment at this point includes
A) addition of moisturizing cream
B) oral estrogen replacement therapy
C) cryotherapy of the area affected
D) administration of topical antifungal cream
E) punch biopsy and tissue examination
View Answer
Answer and Discussion
The answer is E. Lichen sclerosus is a type of vulvar non-neoplastic epithelial disorder (VNED) that is thought to be a predisposing factor in the development of HPV-negative vulvar cancer. According to the “itch-scratch-lichen sclerosus hypothesis,” lichen sclerosus, by causing a severe pruritus, sets up an itch-scratch cycle that over a period of time causes the development of squamous cell hyperplasia. Further progression of the condition results in atypical formation, followed by VIN and eventual invasive squamous cell cancer. This hypothesis suggests that treatment of lichen sclerosus with topical steroids would prevent vulvar cancer in these patients, and some research may support this recommendation. Aggressive evaluation and treatment of VNEDs could have a dramatic impact on the incidence of vulvar cancer in this subgroup of patients.
Scurry J. Does lichen sclerosus play a central role in the pathogenesis of human papillomavirus negative vulvar squamous cell carcinoma? The itch-scratch lichen sclerosus hypothesis. Int J Gynecol Cancer. 1999;9:89–97.
151. A major risk factor for shoulder dystocia includes which of the following?
A) Young maternal age
B) Gestational diabetes
C) Precipitous delivery
D) Preterm delivery
E) Thin body habitus
View Answer
Answer and Discussion
The answer is B. Shoulder dystocia occurs in 1 of 300 deliveries. Risk factors include diabetes, postterm pregnancy, obesity, previous shoulder dystocia, prolonged second stage of labor, advanced maternal age, and multiparity. Warning signs for shoulder dystocia include a prolonged second stage of labor and retraction of the fetal head tightly against the vaginal introitus after delivery of the head. Complications include a fractured clavicle or humerus, brachial plexus injuries, anoxic brain injuries, and even death of the fetus. Treatment consists of moderate suprapubic pressure, McRobert's maneuver (i.e., flexing the patient's thighs at the hips back to the woman's abdomen and applying firm pressure to the suprapubic area), which may help dislodge the fetus' anterior shoulder that is lodged behind the pubic bone. A large episiotomy should be performed before the procedure. If McRobert's maneuver is unsuccessful, Wood's maneuver can be used, in which the infant's shoulders are rotated 180 degrees to dislodge the blocked shoulder by pulling on the posterior presenting arm. This maneuver is associated with a higher incidence of injury to the arm and clavicle.
Further efforts include an attempt to fracture the clavicle to facilitate delivery or pushing the infant's head back into the vagina and performing emergent cesarean section. In all cases in which dystocia is suspected, a newborn resuscitation team should be alerted. Risk of shoulder dystocia is related to the size of the fetus:
· Less than 3,000 g = 0%
· 3,001 to 3,500 g = 0.3%
· 3,501 to 4,000 g = 1.0%
· 4,001 to 4,500 g = 5.4%
· Greater than 4,500 g = 19%
· All weights = 0.9%
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:450–464.
152. Which of the following tumor markers can be used to follow the effectiveness of ovarian cancer treatment?
A) α-fetoprotein
B) Carcinoembryonic antigen
C) CA 125
D) β-hCG
E) None of the above
View Answer
Answer and Discussion
The answer is C. Ovarian carcinoma usually affects women in their 50s. It is the fifth most common cancer that affects women, and approximately 25,000 new cases are diagnosed yearly in the United States. Because of the difficulty in diagnosis, most cases have metastasized outside the pelvis at the time of diagnosis; therefore, prognosis is usually poor. Risk factors include a positive family history, BRCA1 gene mutation on chromosome 17, White race, high-fat diet, asbestos or talc exposure, and nulliparity or low parity. The use of oral contraceptives may be protective. Any ovarian mass >5 cm deserves careful follow-up. Postmenopausal women usually have atrophic ovaries that are not palpable; thus, any palpable ovary in a postmenopausal woman deserves further investigation. The types of tumors are divided histologically into those that arise from the ovarian epithelium:
· Serous cystadenocarcinomas (most common)
· Clear cell carcinomas
· Mucinous cystadenocarcinomas
· Endometrioid tumors
· Celioblastomas (Brenner tumors)
· Tumors not classified
In addition, tumors arise from germ cells and stroma, such as
· Sertoli-Leydig cell tumors
· Malignant teratomas
· Dysgerminomas
· Granulosa–theca cell tumors
Patients may report lower abdominal fullness or discomfort, gastrointestinal complaints, abnormal vaginal bleeding, or pelvic pain. Diagnosis is usually aided with ultrasound or CT examination. Treatment of ovarian carcinoma depends on the staging and cell type but involves surgical excision and in some cases chemotherapy or radiation. Metastasis is usually to lung or bone. The blood test CA 125 can be used to follow patients for recurrence of tumor after surgery or the response to chemotherapy but is not a suitable screening test. Benign masses that affect the ovary include functional cysts, which usually resolve within 2 months, and benign cystic teratoma (dermoid tumor), which may contain hair follicles or tooth formations. Another condition that may be seen with ovarian masses is Meigs' syndrome, which is associated with ascites, right hydrothorax, and benign fibroma or thecoma.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:553.
153. The most common side effect of the “morning after” pill is
A) nausea and vomiting
B) breast tenderness
C) insomnia
D) pelvic pain
E) headache
View Answer
Answer and Discussion
The answer is A. Emergency postcoital contraception, a method used to prevent pregnancy after unprotected sexual intercourse, is a highly effective but underused birth control option. Two hormone regimens, ethinyl estradiol (100 µg) with levonorgestrel (0.5 mg) or high-dose levonorgestrel (0.75 mg), given within 72 hours of intercourse and repeated 12 hours later, are available for this purpose. The two new dedicated products, Preven and Plan B, are now available. Plan B is available for purchase in pharmacies via physician prescription, having previously been distributed only in Title 10 clinics, Planned Parenthood clinics, state and county health departments, and university campus health centers. Preven has been available through pharmacies, but still is not readily available in many locations. Both dedicated products should become more accessible in all locations according to physician demand. The high-dose contraceptives cause shedding of the endometrium and prevent implantation of the fertilized ovum. Side effects include nausea and vomiting that may require antiemetics and disruption of the woman's normal menstrual cycle.
Wertheimer RE. Emergency postcoital contraception. Am Fam Physician. 2000;62:2287–2292.
154. Which of the following is true regarding symptoms of ovarian cancer?
A) Most women are asymptomatic.
B) Symptoms are less severe than in benign processes.
C) Symptoms are less frequent than in benign processes.
D) Symptoms are of greater duration than in benign processes.
E) Symptoms often involve a combination of gastrointestinal and genitourinary symptoms.
View Answer
Answer and Discussion
The answer is E. No effective screening test exists for ovarian cancer. The symptoms most commonly reported in patients with ovarian cancer include bloating, increased abdominal size, abdominal or pelvic pain, and urinary tract symptoms, although these also are common in women with benign masses. Symptoms tend to be more severe, more frequent, and of shorter duration in women with malignant masses than in women with benign masses. Women with ovarian cancer also are more likely to present with a combination of symptoms.
Goff BA, Mandel LS, Melancon CH. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2004;291: 2705–2712.
The symptoms most commonly reported in patients with ovarian cancer include bloating, increased abdominal size, abdominal or pelvic pain, and urinary tract symptoms, although these also are common in women with benign masses.
155. A 61-year-old woman is found to have a new 2.5 cm unilocular ovarian cyst (confirmed by ultrasound) during her routine well woman examination. Her CA 125 level is normal. Appropriate management at this time includes
A) serial ultrasounds and CA 125 levels
B) laparoscopic surgical removal
C) hysteroscopic evaluation and biopsy
D) cone radiation ablation
E) no further monitoring is necessary
View Answer
Answer and Discussion
The answer is A. In postmenopausal women, most ovarian cysts <50 mm in diameter are benign and can be managed safely by regular monitoring of cyst size and serum CA 125 level.
Nardo LG, Kroon ND, Reginald PW. Persistent unilocular ovarian cysts in a general population of postmenopausal women: is there a place for expectant management? Obstet Gynecol. 2003;102:589–593.
156. Which of the following statements about striae distensae (stretch marks) is true?
A) They usually respond to topical corticosteroids.
B) They rarely fade after pregnancy.
C) They may be related to excessive corticosteroids that are produced during pregnancy.
D) The condition is secondary to excessive weight gain (>40 lb) during pregnancy.
E) None of the above.
View Answer
Answer and Discussion
The answer is C. Striae distensae, also known as stretch marks, are abnormal skin findings that are noted with varying degree during pregnancy. They affect up to 50% of pregnant women. Typically, they are initially erythematous, pink or purple, and slightly raised to form ridges. They can occur in different areas but are usually found associated with the abdomen, breast, or hips. The cause of stretch marks was once believed to be excessive stretching of the skin; however, more recently it has been thought that they are secondary to excessive corticosteroids produced endogenously during pregnancy, combined with the body changes that occur with pregnancy. Excessive weight gain is not the reason for striae development. Unfortunately, there is no effective treatment for stretch marks. They usually fade after pregnancy and are barely noticeable.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed., New York: Lange/McGraw-Hill; 2003:434.
157. At what month during pregnancy does the mother's appendix move upward to a level above the iliac crest?
A) Third month
B) Sixth month
C) Ninth month
D) The appendix does not change location.
E) When the fetal head engages in the pelvis.
View Answer
Answer and Discussion
The answer is B. Because of the normal changes during pregnancy, such as leukocytosis, nausea, vomiting, anorexia, and abdominal discomfort, the diagnosis of appendicitis may be difficult. The condition occurs with equal frequency during each trimester of pregnancy. As the sixth month approaches, the appendix moves upward, above the iliac crest. The risk for perforation is particularly increased in the third trimester. With perforation, the perinatal risk is increased. Complications of appendectomy include premature labor and wound infection. The differential diagnosis includes placental abruption, round ligament pain, acute pyelonephritis, renal colic, and cholecystitis.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1281–1282.
158. An increase in blood pressure that is seen with oral contraceptive use is
A) rarely a problem in patients with underlying hypertension
B) more common in women with a positive family history for hypertension
C) not associated with increased age of the patient
D) related to a permanent increase in blood pressure despite discontinuation of the drug
E) most commonly associated with underlying renal disease
View Answer
Answer and Discussion
The answer is B. A slight increase in blood pressure (systolic, 5 to 6 mm Hg; diastolic, 1 to 2 mm Hg) is expected in some women who take oral contraceptives. In fact, hypertension is five to six times more likely to develop in women who use oral contraceptives than in those who do not use them. Women who are older or who have a positive family history for hypertension and those using oral contraceptives for longer durations are at increased risk. It is thought that hypertension is related to the progestin component, although estrogens may induce the synthesis of the renin substrate angiotensinogen, which increases the formation of angiotensin and leads to increases in blood pressure. Blood pressure increases may occur within weeks; however, it may not be noted for months or even years after starting medication. Switching to an oral contraceptive with lower progestin may alleviate the problem. Discontinuation of oral contraceptives in most patients allows the blood pressure to decrease to normal levels. Patients should be seen for a blood pressure check within 3 months after the initiation of the contraceptive. If significant increases occur, oral contraception medication should be discontinued. Underlying preexisting hypertension is a relative contraindication for oral contraceptive use.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1529.
159. Which of the following is an independent risk factor for the development of vulvar cancer?
A) Diabetes
B) Hypertension
C) Obesity
D) Syphilis
E) Human papillomavirus virus
View Answer
Answer and Discussion
The answer is E. Vulvar intraepithelial neoplasia (VIN) is clearly a premalignant finding and is associated with HPV infection, particularly subtypes 16 and 18. Hypertension, diabetes mellitus, and obesity have been found to coexist in up to 25% of patients, although they are not considered independent risk factors. In the past, syphilis and other granulomatous diseases have been associated with vulvar cancer.
Canavan TP, Cohen D. Vulvar cancer. Am Fam Physician. 2002;66:1269–1274, 1276.
160. In addition to a loss of menses and disordered eating, what other component of the female athlete triad causes significant problems for women?
A) Loss of libido
B) Sleep disturbances
C) Osteoporosis
D) Poor mentation
E) Thyroid dysfunction
View Answer
Answer and Discussion
The answer is C. The female athlete triad is defined as the combination of disordered eating, amenorrhea, and osteoporosis. This disorder often goes undiagnosed. The consequences of lost bone mineral density can be debilitating for the female athlete. Premature osteoporotic fractures can occur, and lost bone mineral density may never be regained. Early recognition of the female athlete triad is important. Instituting an appropriate diet and moderation of exercise may result in the natural return of menses. Hormone replacement therapy should be considered early to prevent the loss of bone density. A collaborative effort among coaches, athletic trainers, parents, athletes, and physicians is optimal for the recognition and prevention of the triad. Increased education of parents, coaches, and athletes in the health risks of the female athlete triad can prevent a potentially life-threatening illness.
Hobart JA, Smucker DR. The female athlete triad. Am Fam Physician. 2000;61:3357–3364, 3367.
161. Which of the following statements regarding estrogen replacement therapy (ERT) is true?
A) The addition of progesterone slightly raises the risk for endometrial carcinoma.
B) ERT lowers the risk for ovarian carcinoma.
C) All forms of estrogen delivery are equally effective in lowering cholesterol.
D) Patients with a prior history of thrombosis should avoid ERT.
E) Studies show that there is no increased risk for breast cancer with ERT.
View Answer
Answer and Discussion
The answer is D. The use of estrogen in postmenopausal women is controversial. Benefits include the prevention of osteoporosis and symptoms associated with estrogen deficiency (i.e., hot flashes, vaginal atrophy, vulvar irritation, mood swings, and dysuria). Recent studies have shown increases in the risk for breast cancer after years of estrogen use. Relative contraindications for ERT include undiagnosed abnormal genital bleeding, known or suspected pregnancy, a previous diagnosis of breast cancer, liver disease, and thromboembolic disease. If the patient has an intact uterus, estrogen should be given along with progesterone, which decreases the risk of endometrial hyperplasia. Different methods of administration have been developed:
· Transdermal patches: Some of the lipid-lowering benefits are eliminated with this route of administration.
· Cyclical combined low-dose therapy (0.625 mg/day estrogen and 10 mg progesterone given the first 10 to 14 days or last 10 to 14 days of the month): This regimen usually results in the development of mild menstruation after progesterone withdrawal.
· Continuous combined low-dose therapy (0.625 mg/day estrogen and 2.5 mg/day progesterone): This may result in irregular vaginal bleeding for up to 6 months after administration.
Taylor RB, David AK, Fields SA, et al. Family Medicine: Principles and Practice, 6th ed. New York: Springer; 2003:882–886.
162. Female children of women who are exposed to diethylstilbestrol during their pregnancy are at increased risk for which of the following?
A) Early menopause
B) Clear cell carcinoma of the vagina
C) Ovarian carcinoma
D) Severe limb defects in their offspring
E) Mental retardation
View Answer
Answer and Discussion
The answer is B. Diethylstilbestrol was widely used from the 1940s to the early 1970s to help prevent spontaneous abortion in diabetic pregnant women. Approximately 2 to 3 million fetuses were exposed to the medication. Unfortunately, later studies showed that girls who were born to mothers who took the medication while they were pregnant were at increased risk of developing clear cell carcinoma of the vagina as well as cervical and vaginal intraepithelial neoplasia. These patients are also at risk for vaginal adenosis (most common anomaly associated with exposure), septated vagina, cervical collar, hypoplasia of the cervix, and uterine abnormalities. In addition to lower genital tract anomalies, upper genital tract anomalies occur in 50% of patients. The most common is a T-shaped uterus and small uterine cavity. Daughters of women who took this drug may have difficulty in conceiving, higher rates of ectopic pregnancy, spontaneous abortion, and premature births as well as a slightly increased risk for breast cancer. All exposed women are encouraged to undergo thorough vaginal examinations, including colposcopy, starting at menarche or age 14, whichever comes first. Male children of women who took the medication may show testicular or epididymal abnormalities and low sperm counts.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1147.
163. Which of the following is a contraindication for vaginal birth after cesarean section (VBAC)?
A) Deliveries that require oxytocin administration
B) Two previous cesarean sections
C) Previous transverse incision in the lower segment of the uterus
D) Multiple gestation
View Answer
Answer and Discussion
The answer is D. VBAC has advantages that include increased maternal satisfaction and acceptance, lower morbidity and mortality, and less expense than repeat cesarean section, although these are controversial. Women who have had a previous cesarean section with a classic vertical incision should undergo repeat cesarean section for delivery because of the risk of uterine rupture. Other contraindications to VBAC may include multiple gestation, macrosomia (>4,000 g), abnormal presentation, and inadequate facilities for close monitoring. Those who have had previous cesarean section with a low transverse incision should be allowed a trial of labor and are quite successful (approximately 60% to 80%) in vaginal deliveries with subsequent births. Even if the woman has had multiple previous cesarean sections, there is not a definite contraindication for a vaginal delivery if low transverse incisions are used with previous cesarean sections. Women with previous cesarean sections (low transverse incision) can also receive oxytocin during labor, but the contractions and the fetus should be closely monitored.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:529.
Women who have had a previous cesarean section with a classic vertical incision should undergo repeat cesarean section for delivery because of the risk of uterine rupture.
164. Which of the following is associated with oral contraceptive use?
A) Increased risk of endometrial cancer
B) Increased risk of ovarian cancer
C) Decreased risk of cervical cancer
D) Decreased risk of liver cancer
E) Fewer ectopic pregnancies
View Answer
Answer and Discussion
The answer is E. The neoplastic effects of oral contraceptives have been extensively studied, and recent meta-analyses indicate that there is a reduction in the risk of endometrial and ovarian cancer, a possible small increase in the risk for breast and cervical cancer, and an increased risk of liver cancer. Benefits include reduction in menstrual-related symptoms, fewer ectopic pregnancies, a possible increase in bone density, and possible protection against pelvic inflammatory disease.
Burkman R, Schlesselmann JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. Am J Obstet Gynecol. 2004;190(4 Suppl. S):S5–S22.
165. Which of the following is the most common cause of hair loss in women?
A) Androgenetic alopecia
B) alopecia areata
C) Telogen effluvium
D) Cicatricial alopecia
E) Traumatic alopecia
View Answer
Answer and Discussion
The answer is A. Alopecia can be divided into disorders in which the hair follicle is normal but the cycling of hair growth is abnormal, and disorders in which the hair follicle is damaged. Androgenetic alopecia is the most common cause of hair loss in women. Other disorders include alopecia areata, telogen effluvium, cicatricial alopecia, and traumatic alopecias.
Thiedke CC. Alopecia in women. Am Fam Physician. 2003;67:1007–1014, 1017–1018.
166. Which of the following has been shown to help prevent neural tube defects in newborns?
A) Magnesium
B) Calcium
C) Folic acid
D) Vitamin B12
E) Vitamin C
View Answer
Answer and Discussion
The answer is C. The use of folic acid in the prenatal period can help to prevent neural tube defects, such as spina bifida and anencephaly. The use of prenatal vitamins that contain at least 0.4 mg/day folic acid are given before conception and are recommended during the entire pregnancy. Other sources of folic acid include leafy green vegetables, broccoli, mushrooms, and liver.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:207.
167. Which of the following statements about diaphragm contraception is true?
A) The diaphragm should be left in place for no more than 4 hours after intercourse.
B) The diaphragm should not be used with contraceptive jelly because of the risk of slippage.
C) The diaphragm is associated with an increase in vaginal and urinary infections.
D) The diaphragm can be prescribed based on patient's height and weight.
E) Diaphragm use is associated with an increased risk of cervical cancer.
View Answer
Answer and Discussion
The answer is C. The diaphragm is a contraceptive device. It is a round, dome-shaped piece of rubber that has a spring incorporated on the outer edge. The device is placed in the vagina and positioned so that it covers the cervix. The diaphragm should be placed in the vagina before intercourse and left in place for 8 hours after intercourse. Contraceptive foam or jelly should always be used with the diaphragm to improve its effectiveness. When used properly, pregnancy rates are approximately 3% but can be as high as 15% with improper use. The diaphragm is associated with an increased risk of vaginal and urinary infections. Patients who desire to use a diaphragm should have it fitted by a physician, and they should demonstrate proper diaphragm positioning to the physician before leaving the office to ensure proper use.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:633.
168. Pregnancy-induced hypertension is associated with
A) systolic blood pressure >140 mm Hg and diastolic blood pressure >90 mm Hg
B) proteinuria
C) edema
D) microscopic hematuria
E) seizures
View Answer
Answer and Discussion
The answer is A. Pregnancy-induced hypertension is defined as systolic blood pressure that is greater than 140 mm Hg or diastolic blood pressure >90 mm Hg or a rise >30 mm Hg over baseline systolic or a rise of 15 mm Hg over baseline diastolic blood pressure. Unlike preeclampsia, no proteinuria or edema is noted. Risk factors for pregnancy-induced hypertension include primigravida state, multiple gestation, family history of the condition, polyhydramnios, hydatidiform mole, or underlying vascular disease. Laboratory tests often reveal elevated uric acid levels with decreased chloride levels. In most cases, treatment is initiated with diastolic pressures >100 mm Hg. Initial treatment consists of bed rest and sodium restriction. The drug of choice used in the treatment of pregnancy-induced hypertension is α-methyldopa. Patients with this condition should be followed closely to watch for signs of preeclampsia. Other medications that are used in the acute treatment of hypertension during pregnancy include labetalol and hydralazine.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:338–346.
169. Which of the following is not an option for treating an abnormal Pap smear with results showing squamous cells of undetermined significance (ASCUS) with LSIL (low-grade squamous intraepithelial lesion)?
A) Immediate colposcopy
B) Repeat Pap smear and referral for colposcopy if high-grade squamous intraepithelial lesions (HSILs) are present
C) Screening for human papillomavirus (HPV) DNA and referral for colposcopy if HPV is detected
D) Cryotherapy
View Answer
Answer and Discussion
The answer is D. Significant controversy surrounds the optimal management of abnormal squamous cells of undetermined significance (ASCUS) reported on Papanicolaou (Pap) screening for cervical cancer. The recommendations of the ASCUS LSIL (low-grade squamous intraepithelial lesion) Triage Study (ALTS) have been controversial. Currently, for minimally abnormal Pap smears (ASCUS LSIL) there are basically three management options:
· The option of immediate colposcopy is considered appropriate.
· Repeat Pap screening is also retained as a recommended option, but the indications for referral to colposcopy are more stringent, requiring high-grade squamous intraepithelial lesions (HSIL) on follow-up screening to avoid colposcopy in women with minimal lesions.
· The new option introduces screening for human papillomavirus (HPV) DNA and referral for colposcopy if HPV is detected. The overall goal is to detect the maximum proportion of cancer cases with the minimum number of colposcopies.
Solomon D, Schiffman M, Tarone R. ASCUS LSIL triage study (ALTS) conclusions reaffirmed: response to a November 2001 commentary. Obstet Gynecol. 2002;99:671–674.
170. An 18-year-old man is diagnosed with Chlamydia after complaining of penile discharge. The patient has not been compliant with your recommendations in the past. Appropriate therapy for this infection is
A) azithromycin
B) doxycycline
C) erythromycin
D) ofloxacin
E) none of the above
View Answer
Answer and Discussion
The answer is A. Chlamydia genital infections are common among adolescents and young adults who are sexually active. C. trachomatis infection can be associated with pelvic inflammatory disease (PID), ectopic pregnancy and infertility. Chlamydial infection is often asymptomatic but the complications can be serious. As a result, routine screening for disease during annual examinations is recommended. Single-dose therapy with azithromycin is as effective as a 1-week course of doxycycline (Vibramycin). Doxycycline is cheaper, but azithromycin may be cost-beneficial because it provides single-dose, directly observed therapy. When compliance is an issue it is clearly superior. Erythromycin and ofloxacin (Floxin) also may be used to treat C. trachomatis. Erythromycin is less efficacious than azithromycin and doxycycline, and its adverse gastrointestinal effects may decrease patient compliance. Ofloxacin is as effective as the recommended regimens but offers no dosing or cost advantages. Doxycycline and ofloxacin are contraindicated in pregnant women. In addition, the safety and efficacy of azithromycin in pregnant women has not been established; therefore, a 7-day course of either erythromycin or amoxicillin is recommended in this group. Because neither regimen is considered highly effective, cultures should be repeated in 3 weeks.
Woodward C, Fisher MA. Drug treatment of common STDs: Part I. Herpes, syphilis, urethritis, chlamydia, and gonorrhea. Am Fam Physician. 1999;60:1387–1394.
171. Which of the following statements about premenstrual syndrome (PMS) is true?
A) Women with fibroids are more commonly affected.
B) Symptoms begin 3 to 7 days after menstruation.
C) Diuretics have no beneficial role in treatment.
D) Fluoxetine (Prozac) can be used in treatment.
E) Niacin has been shown to help reduce symptoms.
View Answer
Answer and Discussion
The answer is D. Premenstrual syndrome (PMS) is characterized by cyclical nervousness, irritability, emotional mood swings, depression, headaches, water retention with edema, abdominal bloating, and breast tenderness. The syndrome usually begins 7 to 10 days before the onset of menses and disappears once menstruation begins. A key feature is a symptom-free period after the completion of menstruation during the follicular stage of the menstrual cycle. The symptoms are attributed to hormone changes involving estrogen and progesterone. The type, duration, and severity of symptoms vary among individuals but in some women can be very debilitating. As many as 40% of women experience PMS. Diagnosis can be obtained by charting symptoms and comparing them with the patient's menstrual cycle. Treatment involves restriction of salt, caffeine, and fats; vitamin B6 supplementation; use of diuretics during periods of water retention; use of prostaglandin inhibitors; and use of oral contraceptives. For more severe cases, tranquilizers, fluoxetine (Prozac), progesterone vaginal suppositories, danazol, and bromocriptine have been used. More recently, calcium and magnesium supplementation have been advocated in the treatment of PMS.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:623–626.
172. Which of the following is the most important risk factor in the transmission of HIV from an infected mother to her newborn?
A) Preterm delivery (<34 weeks' gestation)
B) Low birth weight
C) Low maternal CD4 count
D) Prolonged rupture of membranes (>4 hours)
E) Intravenous drug use during pregnancy
View Answer
Answer and Discussion
The answer is D. HIV infection types 1 and 2 are diagnosed by the enzyme-linked immunosorbent assay (ELISA) test initially. If the ELISA is positive, the ELISA test should be repeated first, and then, if still positive, the results should be confirmed with the Western blot test. Antibodies to HIV generally appear in the circulation 2 to 12 weeks after infection. Detection in the newborn is more difficult when the mother is infected with HIV, because the child will be positive for the ELISA and the Western blot as a result of maternal transmission of the antibody transplacentally. Because of this, the HIV DNA (deoxyribonucleic acid) PCR (polymerase chain reaction) testing is the preferred test in developed countries. Almost 40% of infected newborns have positive tests in the first 2 days of life, with more than 90% testing positive by 2 weeks of age. Reported rates of transmission from mother to child have varied; most large studies in the United States and Europe have documented transmission rates in untreated women of between 12% and 30%. Rates are reported to be higher in Africa and Haiti. Perinatal treatment of HIV-infected mothers with antiretroviral drugs has dramatically decreased these rates to <8%. Several risk factors increase the rate of vertical transmission:
· Preterm delivery (<34 weeks' gestation)
· Low birth weight
· Low maternal antenatal CD4 count (<29%)
· Intravenous drug use during pregnancy
· Prolonged rupture of membranes (>4 hours), which is the most important variable that increases risk
Cesarean section combined with prenatal, intrapartum, and neonatal zidovudine therapy decreases the transmission rate by 87%. HIV can be transmitted via breast milk and colostrum. Homosexuals who practice the insertive role in intercourse are eight times more likely to get hepatitis B than HIV. Practicing the receptive role in intercourse increases the risk of HIV transmission. If a patient has either virus, he or she is at risk for contracting the other. Needle-stick injuries result in the transmission of HIV in approximately 0.3% of cases.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1079.
173. Which laboratory test would best support lung maturity in a fetus whose mother has shown signs of premature labor?
A) Lecithin–sphingomyelin (L/S) ratio of 1.75
B) L/S ratio of 1.5
C) Absence of phosphatidylinositol
D) Absence of phosphatidylglycerol (PG)
E) L/S ratio of 1.8 with a positive PG level
View Answer
Answer and Discussion
The answer is E. Premature birth can result in severe lung-related problems secondary to inadequate lung development. A number of different medications have been advocated to improve lung maturation. Currently, the use of antenatal corticosteroids reduces mortality and the incidence of RDS and intraventricular hemorrhage in new preterm infants. They are typically administered between 24 and 34 weeks. The benefits usually peak at 24 hours and continue for 7 days. Treatment consists of betamethasone given in two intramuscular doses 12 hours apart. Antenatal steroids should be administered unless immediate delivery is anticipated. Thyroid-releasing hormone (TRH) has been advocated but not proven to be beneficial for lung maturation in fetuses younger than 28 weeks' gestation. Because thyroid hormone does not pass across the placenta, TRH is used. TRH crosses the placenta and increases fetal thyroxine levels that are thought to improve lung maturation. Surfactant is also used for lung maturation, and studies support its beneficial use. Tests for lung maturity include the L/S ratio, phosphatidylinositol, and PG levels. The levels are measured by obtaining amniotic fluid via amniocentesis. RDS is rare if the L/S ratio is >2 and PG is present. If the L/S ratio is <2 but PG is present, RDS develops in <5% of infants. Meconium lowers the L/S ratio, and blood tends to normalize the value to 1.4. Other tests for lung maturation include the foam stability index and the lamellar body number density. Both are relatively fast tests and may be more accurate and useful than the L/S ratio.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2303–2304.
Respiratory distress syndrome (RDS) is rare if the lecithin-sphingomyelin ratio (L/S ratio) is greater than 2 and phosphatidylglycerol (PG) is present.
174. A 22-year-old man is diagnosed with primary syphilis. He has no allergies and is otherwise healthy. The drug of choice is
A) oral penicillin
B) oral azithromycin
C) intramuscular ceftriaxone
D) parenteral penicillin G
E) oral ciprofloxacin
View Answer
Answer and Discussion
The answer is D. Syphilis is a systemic disease caused by the sexual transmission of Treponema pallidum. It can occur as primary, secondary, or tertiary disease. Primary disease presents with one or more painless ulcers or chancres at the inoculation site. Secondary disease manifestations include rash and adenopathy. Cardiac, neurologic, ophthalmic, auditory, or gummatous lesions characterize tertiary infections. Latent disease may be detected by serologic testing, without the presence of signs and symptoms. Early latent disease is defined as disease acquired within the preceding year. All other cases of latent syphilis are considered late latent disease or disease of unknown duration. The recommended treatment regimens have not changed since the 1993 CDC Guidelines. Parenteral penicillin G is still the preferred drug for treating all stages of syphilis, including disease in pregnant women.
Woodward C, Fisher MA. Drug treatment of common STDs: Part I. Herpes, syphilis, urethritis, chlamydia, and gonorrhea. Am Fam Physician. 1999;60:1387–1394.
175. Which of the following is not an acceptable treatment for uncomplicated gonococcal infections of the cervix?
A) Doxycycline
B) Cefixime
C) Ceftriaxone
D) Ciprofloxacin
E) Ofloxacin
View Answer
Answer and Discussion
The answer is A. Four single-dose regimens are now available for treatment of uncomplicated gonococcal infections of the cervix, urethra, and rectum. They include cefixime (Suprax), ceftriaxone, ciprofloxacin, and ofloxacin.
Woodward C, Fisher MA. Drug treatment of common STDs: Part I. Herpes, syphilis, urethritis, chlamydia, and gonorrhea. Am Fam Physician. 1999; 60:1387–1394.
176. Which of the following is considered the drug of choice to treat preterm labor?
A) Magnesium sulfate
B) Terbutaline
C) Ritodrine
D) Indomethacin
E) Nifedipine
View Answer
Answer and Discussion
The answer is A. The drug of choice for preterm labor is magnesium sulfate given intravenously. Magnesium sulfate works by competing with calcium for entry into muscle cells. This results in myometrial relaxation. The levels of the medication need to be monitored to maintain optimal therapeutic levels. Adjustments need to be made in patients with renal disease and abnormal creatinine clearance. Once the preterm labor has been arrested, the patient can be switched to oral magnesium sulfate. A minor side effect of magnesium sulfate is warmth or flushing with the first administration. Respiratory depression can occur with levels of 12 to 15 mg/dL, and cardiac effects may occur with higher levels. With magnesium sulfate administration the fetus (if delivered) may show signs of decreased muscle tone and drowsiness, resulting in lower Apgar scores. These effects are often prolonged in premature infants because of decreased renal clearance.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:290–291.
177. Which of the following fetal presentations should always be delivered via cesarean section?
A) Complete breech
B) Footling breech
C) Frank breech
D) Vertex presentation
View Answer
Answer and Discussion
The answer is B. Three types of vaginal breech delivery are performed:
· Spontaneous breech delivery: The fetus is delivered spontaneously without manipulation by the physician other than support of the fetus.
· Partial (or assisted) breech extraction: The fetus is delivered spontaneously until the umbilicus is at the introitus, at which point the fetus is extracted.
· Total breech extraction: The physician extracts the entire body of the fetus.
Incomplete or footling breech presentations should be delivered via cesarean section because the risk of cord prolapse is greater and entrapment of the fetus by the cervix is greater.
The risk of birth trauma is greater with breech deliveries, particularly brachial plexus injuries, if the fetus weighs >3,600 g. In many communities the standard of care is cesarean section for breech presentation; however, this is controversial. Premature infants are generally delivered by cesarean section because of the disparity between head and body size.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:369–376.
178. Which of the following is a contraindication for external cephalic version?
A) 36 weeks' gestation
B) Maternal age of 35
C) Polyhydramnios
D) Maternal diabetes
E) Obesity
View Answer
Answer and Discussion
The answer is A. External cephalic version can be attempted on fetuses that are detected before the onset of labor and after 37 weeks' gestation. A tocolytic medication is delivered, and abdominal manipulation is performed under ultrasound guidance. Version before 37 weeks is not recommended because of the risk that the fetus may revert to a breech presentation before delivery and the risk of delivery of a premature infant. The success rate is approximately 75%. The procedure should be performed in the hospital so that cesarean section can be done if complications arise. The most common complications are placental abruption and cord compression. Contraindications for external cephalic version include uteroplacental insufficiency, hypertension, intrauterine growth retardation, oligohydramnios, or history of prior uterine surgery.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:378–379.
179. Which of the following is not an acceptable test for the detection of chlamydia and gonorrhea?
A) Polymerase chain reaction (PCR) on urine samples in women.
B) Transcription-mediated amplification on urine samples in men.
C) Strand displacement amplification on urine samples in women.
D) Polymerase chain reaction (PCR) on urine samples in men.
E) Transcription-mediated amplification on urine samples in women.
View Answer
Answer and Discussion
The answer is A. Until recently, testing patients for chlamydia and gonorrhea involved collecting samples from the cervix or urethra and sending them for cultures. The discomfort and embarrassment associated with sampling these sites may deter some high-risk patients from seeking testing for these infections. An alternative to cervical or urethral cultures is nucleic acid amplification tests (NAATs) that can be performed on urine samples. Three types of NAAT are commercially available: polymerase chain reaction (PCR), transcription-mediated amplification, and strand displacement amplification. With the exception of PCR for detection of gonorrhea in women, urine samples perform as well as samples collected from other sites.
Cook RL, Hutchison SL, Ostergaard L. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005;142:914–925.
180. Which of the following is used infrequently in the treatment of pubic lice because of concerns of neurotoxicity, resistence, and slow killing time?
A) Malathion
B) Permethrin
C) Pyrethrum
D) Lindane
View Answer
Answer and Discussion
The answer is D. Pubic lice are readily transmitted sexually. There is some evidence that occasionally they may be transmitted through contaminated clothing or towels, although this is controversial. The presence of pubic lice should prompt an evaluation for other common sexually transmitted diseases, such as chlamydial infection and gonorrhea. Treatment is the same as for head lice. Sexual contacts also should be treated if infested. Recent evidence-based reviews found that malathion, permethrin, and pyrethrum insecticides were equally effective in treating head lice infestations. A 1% lindane shampoo is also used to treat resistant lice infestations. However, lindane shampoo is used infrequently now because of concerns about neurotoxicity, resistance, and slow killing time.
Flinders DC, De Schweinitz P. Pediculosis and scabies. Am Fam Physician. 2004;69:341–348, 349–350.
181. Which of the following ultrasound parameters is best used for estimating gestational age during the first trimester?
A) Crown–rump length
B) Biparietal diameter
C) Femur length
D) Head–foot length
E) Estimated weight
View Answer
Answer and Discussion
The answer is A. The practice of performing routine ultrasound examinations to confirm accurate dates is controversial. Many advocate no testing, whereas others believe that an ultrasound at 14 to 20 weeks helps to confirm dates and looks for fetal abnormalities or perhaps twins. The ultrasound can be used to measure crown–rump length, biparietal diameter, and femur length, all of which can be used to confirm dates. The crown–rump length is more accurate during the first trimester, whereas the biparietal diameter and femur length are used more during the second trimester. The ultrasound is best used in the first trimester for estimating age of the fetus. As pregnancy progresses estimation of age is more difficult to assess using ultrasound examination.
DeCherney AH, Nathan L. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed. New York: Lange/McGraw-Hill; 2003:266.
182. The maximum acceptable cumulative dose of ionizing radiation during pregnancy is
A) 100 rads
B) 50 rads
C) 10 rads
D) 5 rads
E) 1 rad
View Answer
Answer and Discussion
The answer is D. The accepted cumulative dose of ionizing radiation during pregnancy is 5 rads, and no single diagnostic study exceeds this maximum. The amount of exposure to the fetus from a two-view chest x-ray of the mother is only 0.00007 rads. The most sensitive time period for central nervous system teratogenesis is between 10 and 17 weeks of gestation. The fetal malformations that are most commonly caused by high-dose radiation are central nervous system changes, especially microcephaly and mental retardation. Nonurgent radiologic testing should be avoided during this time. Rare consequences of prenatal radiation exposure also include a slight increase in the incidence of childhood leukemia and, possibly, a very small change in the frequency of genetic mutations. Such exposure is not an indication for pregnancy termination. Appropriate counseling of patients before radiologic studies are performed is critical. Physicians should carefully weigh the risks and benefits of any radiographic study and include the mother in the decision-making process whenever possible.
Toppenberg KS, Hill DA, Miller DP. Safety of radiographic imaging during pregnancy. Am Fam Physician. 1999;59: 1813–1818.
183. Which of the following statements regarding ectopic pregnancy is correct?
A) The number of ectopic pregnancies has decreased significantly over the last few decades.
B) Symptoms are rarely present.
C) Diagnosis should be suspected if there is no gestational sac and the β-hCG level is >1,500 mIU/mL (1,500 IU/L).
D) Methotrexate is best for large ectopic pregnancies that have ruptured the fallopian tube.
E) Symptoms are usually delayed for 10 to 12 weeks.
View Answer
Answer and Discussion
The answer is C. The number of ectopic pregnancies has increased dramatically in the past few decades. Ectopic pregnancy is more often detected in women older than 35 years of age and in non-White ethnic groups. The hallmark symptoms of ectopic pregnancy are abdominal pain with spotting, usually occurring 6 to 8 weeks after the last normal menstrual period. This remains the most common presentation of tubal pregnancy in symptomatic patients. Other presentations depend on the location of the ectopic pregnancy. Less commonly, ectopic pregnancy presents with pain that radiates to the shoulder, vaginal bleeding, syncope, and/or hypovolemic shock. The condition should be suspected if a transvaginal ultrasound shows no intrauterine gestational sac when the β-hCG level is >1,500 mIU/mL (1,500 IU/L). If the β-hCG level plateaus or fails to double in 48 hours and the ultrasound examination fails to identify an intrauterine gestational sac, uterine curettage may determine the presence or absence of chorionic villi. Although past treatment consisted of an open laparotomy and salpingectomy, current laparoscopic techniques for unruptured ectopic pregnancy emphasize tubal preservation. Other treatment options include the use of methotrexate therapy for small, unruptured ectopic pregnancies in hemodynamically stable patients. Expectant management may have a role when β-hCG levels are low and declining.
Tenore JL. Ectopic pregnancy. Am Fam Physician. 2000; 61: 1080–1088.
The hallmark symptoms of ectopic pregnancy are abdominal pain with spotting, usually occurring 6 to 8 weeks after the last normal menstrual period.
184. In premenopausal women the best time to perform a clinical breast examination (CBE) is
A) 1 week prior to menses
B) 1 week after menses
C) during menses
D) at the time of ovulation
E) 1 day prior to menses
View Answer
Answer and Discussion
The answer is B. A CBE includes an assessment of both breasts and the chest, axillae, and regional lymphatics. In premenopausal women, the CBE is best done the week following menses, when breast tissue is least engorged. With the patient in an upright position, the physician visually inspects the breasts, noting asymmetry, nipple discharge, obvious masses, and skin changes, such as dimpling, inflammation, rashes, and unilateral nipple retraction or inversion.
Klein S. Evaluation of palpable breast masses. Am Fam Physician. 2005;71:1731–1738.
Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA. 1999;282:1270–1280.
185. Which of the following statements regarding breast conservation therapy is true?
A) The risk of recurrent cancer is higher.
B) The fear of recurrence is higher in these women.
C) Women have more depression with breast conservative therapy.
D) Women have more anxiety with breast conservative therapy.
E) Women have fewer episodes of insomnia with breast conservative therapy.
View Answer
Answer and Discussion
The answer is E. The patient's desires should always be considered when deciding breast cancer treatment. For most patients, mastectomy does not influence the likelihood of survival, but may have an impact on quality of life. Women whose breasts are preserved have fewer episodes of depression, anxiety, and insomnia. A recent study of patients with early-stage breast cancer found women who undergo breast conservation therapy have improved body image, higher satisfaction with treatment, and no more fear of recurrence compared with women treated with mastectomy.
McArdle JM, Hughson AV, McArdle CS. Reduced psychological morbidity after breast conservation. Br J Surg. 1990;77:1221–1223.
Curran D, van Dongen JP, Aaronson NK, et al. Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC Trial 10801. Eur J Cancer. 1998;34:307–314.
186. The most common cause of neonatal sepsis in the United States is
A) Staphylococcus aureus
B) Streptococcus pneumoniae
C) Group B Streptococcus
D) Escherichia coli
E) Haemophilus influenzae
View Answer
Answer and Discussion
The answer is C. Group B Streptococcus is considered part of the normal flora of humans. The majority of the bacteria exist in the gastrointestinal tract; however, the bacteria may also be found in the vagina, cervix, throat skin, urethra, and urine of healthy individuals. The organism affects as many as 40% of pregnant or sexually active women. The diagnosis is made by culture or rapid assays that are now available. Transmission to the fetus at the time of birth ranges from 35% to 70%, with the highest rates associated with heavy vaginal colonization. Risk factors for transmission include preterm labor or delivery, premature rupture of membranes, low birth weight, prolonged rupture of membranes (>12–18 hours), intrapartum fever, and a history of delivering an infected infant. Group B Streptococcus is the most common cause of neonatal sepsis in the United States. It is the second-most common cause of bacteriuria in pregnancy. Affected children may experience respiratory distress, pneumonia, and meningitis (30%). Septicemia, shock, and death may occur despite the use of antibiotics. Treating carriers in labor reduces the rate of transmission to the infant. All women should be tested at 35 to 37 weeks. Empiric treatment in during labor and subsequent delivery is recommended. Treatment usually consists of ampicillin, penicillin, and clindamycin for those with penicillin allergies.
Cunningham FG, Gant NF, Leveno KJ, et al. Williams Obstetrics, 21st ed. New York: McGraw-Hill; 2001:1472–1473.
187. Which of the following statements regarding vasectomy is true?
A) Vasectomy requires surgical intervention and has many risks that prevent it from being a cost-effective birth control method.
B) Patients should be monitored in a controlled setting for 2 days following a vasectomy.
C) Sperm analysis should be performed twice to confirm azoospermia before the discontinuation of alternative birth control methods.
D) After vasectomy the patient should be counseled not to lift heavy objects for 4 weeks.
E) Intercourse should be avoided for 4 to 6 weeks after vasectomy.
View Answer
Answer and Discussion
The answer is C. Vasectomy is among the most dependable and cost-effective methods of contraception. Family physicians perform approximately 15% of the estimated 500,000 vasectomies that are done each year in the United States. Vasectomy can be performed using various techniques, although each requires isolation and division of the vas and operative management of the vasal ends. Removal of at least 15 mm vas is recommended. Division of the vas without removal of a segment is effective if the technique is combined with other methods for treating the vasal ends, such as thermal luminal fulguration and proximal fascial interposition. Ligation of the ends without the aid of surgical clips may result in necrosis and sloughing of the ends, which may cause early failure. Leaving the testicular end of the vas open has been shown to be effective and to result in a lower incidence of epididymal congestion and sperm granuloma. The no-scalpel technique offers shorter operating time, less pain and swelling, and faster recovery. Appropriate postoperative recommendations include intermittent ice applications to the scrotum for 8 hours, bed rest and scrotal support for 48 hours, and avoidance of heavy exertion for 1 week. Acetaminophen usually produces sufficient analgesia, although occasionally narcotic analgesics are necessary. Sexual activity should be avoided for 1 week. Another method of contraception should be used until semen analysis has confirmed azoospermia on two separate occasions. The possible link with vasectomy and coronary artery disease has not been proven to exist by large studies.
Clenney TL, Higgins JC. Vasectomy techniques. Am Fam Physician. 1999;60:137–152.
188. Which of the following tests is most useful in diagnosing cystic breast masses?
A) Mammograms
B) Ultrasound
C) Fine-needle biopsy
D) Magnetic resonance imaging (MRI)
E) Computed tomography (CT)
View Answer
Answer and Discussion
The answer is B. Approximately 180,000 new cases of breast cancer are diagnosed annually, accounting for about 48,000 deaths/year in the United States. Although somewhat controversial, annual mammograms and clinical breast examinations are recommended for women older than 40 years. Women older than 20 years should be encouraged to do monthly breast self-examinations, and women between 20 and 39 years of age should have a clinical breast examination every 3 years. Screening guidelines are modified for women with risk factors. Risk factors include increasing age and female sex. Family history is highly significant in a first-degree relative (e.g., mother, sister, daughter), especially if the cancer has been diagnosed premenopausally. Women who have premenopausal first-degree relatives with breast cancer have a three- to fourfold increased risk of developing breast cancer than women who do not. Important to note is that most women with breast cancer have no identifiable risk factors. Approximately 8% of all cases of breast cancer are hereditary. About one-half of these cases are attributed to mutations in two breast cancer susceptibility genes, BRCA1 and BRCA2. Hereditary breast cancer commonly occurs in premenopausal women and is more frequently bilateral than is nonhereditary breast cancer. Several family members are affected over three generations or more and can include women from the paternal side of the family. Screening tests are available that detect BRCA mutations. Abnormal breast examinations and mammograms should be further evaluated. Ultrasonographic studies are most useful to evaluate cystic breast masses. For solid masses, diagnostic biopsy techniques include fine-needle aspiration, core biopsy, and excisional biopsy.
Apantaku LM. Breast cancer diagnosis and screening. Am Fam Physician. 2000;62:596–602, 605–606.
189. A 43-year-old woman is diagnosed with stage II breast cancer. One year later she is asymptomatic. Appropriate follow up consists of
A) at least yearly mammograms
B) bone scan to rule out metastatic disease
C) CT of the head to rule out metastatic disease
D) liver function test every 6 months to rule out metastatic disease
E) serial calcium levels to monitor for metatstatic disease
View Answer
Answer and Discussion
The answer is A. A baseline mammogram should be obtained approximately 6 months after tumor excision and the completion of all treatments. Mammography should then be done at least annually. Other imaging studies may be necessary in symptomatic patients. Patients with bone pain should be screened by bone scan for bone secondaries. Detailed laboratory follow-up is expensive and has not been shown to improve survival. Randomized control trials have not shown survival benefit from the routine use of bone scan and computed tomographic scan for asymptomatic patients with stage I or stage II breast cancer.
Cady B, Bland K, Copeland E. Choice of operations for early breast cancer: an expanding role for breast conservation instead of mastectomy. In: Bland KI, Copeland EM, eds. The breast: comprehensive management of benign and malignant diseases. 2nd ed. Philadelphia: WB Saunders; 1998:1130–1152.
190. Which of the following HPV subtypes is most associated with the development of cervical cancer?
A) Types 43 and 54
B) Types 7 and 9
C) Types 16 and 18
D) Types 24 and 28
E) Types 33 and 40
View Answer
Answer and Discussion
The answer is C. A preponderance of evidence suggests a causal link between HPV infection and cervical neoplasia. This link is strongest for certain HPV types, particularly types 16 and 18.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1652.
A preponderance of evidence suggests a causal link between HPV infection types 16 and 18 and cervical neoplasia.