NBME OBGYN Form 4

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1) A 37-year-old primigravid woman at 35 weeks’ gestation comes to the physician for a routine prenatal visit. She has been receiving routine…

Placental dysfunction

• Primigravid woman at 35 weeks gestation with new onset hypertension and proteinuria (concerning for pre-eclampsia) found to have a oligohydramnios (low amniotic fluid levels) and intrauterine growth restriction (weight < 10th percentile) most consistent with uteroplacental insufficiency
• Key idea: Next best step is often umbilical artery doppler ultrasound to assess placental perfusion given high risk of intrauterine demise
• Key idea: Definition of oligohydramnios is single deepest pocket < 2 cm OR Amniotic fluid index < 5 cm

2) A 32-year-old woman, gravida 2, para 1, at 27 weeks’ gestation is brought to the emergency department because of a 3-hour history of…

Pyelonephritis

• Woman at 27 weeks’ gestation with positive urine culture that was never treated who presents with fever, costovertebral angle tenderness and early labor most consistent with pyelonephritis complicated by preterm labor
• Key idea: Infection is associated with preterm labor in 40% of cases
• Key idea: Pregnant woman are at increased risk for UTI and pyelonephritis due to distorted urinary structures and high progesterone and estrogen leading to relaxed sphincters –> easier ascent of bacteria into bladder and kidneys

3) Three months after an uncomplicated vaginal delivery of a newborn at term, a 24-year-old woman, gravida 2, para 2, comes to the physician…

Recommendation for use of lubricant

• Mother who gave birth 3 months ago and is currently breastfeeding presents with dyspareunia, most likely due to increased prolactin –> inhibition of GnRH –> Decreased LH/FSH –> Decreased estrogen production by ovaries –> Vaginal dryness
• No signs of vaginosis (vaginal discharge/itchiness) or UTI (suprapubic tenderness, painful urination, etc.)

4) A previously healthy 5-year-old girl is brought to the physician because of a 2-day history of a foul-smelling, yellow discharge and…

Vaginal foreign body

• Key idea: Most common cause of malodorous discharge in a pre-pubertal girl is foreign body (most commonly toilet paper) and it should be managed with warm irrigation
• Rhabdomyosarcoma –> Looks like a “bundle of grapes”
• Candidal vaginitis –> White, cottage-cheese like discharge with cervical erythema and hyphae on microscopy

5) Two days after a cesarean delivery for fetal distress, a 27-year-old woman has temperatures to 38.2 C (100.8 F). She had an 8-hour…

Atelectasis

• Young woman two days post-op after a C-section who presents with fever and decreased breath sounds at both lung bases with a negative work-up for other causes of a fever (UTI, endometritis, etc.), most consistent with atelectasis
• Key idea: Most common of a fever within several days of delivery is endometritis, but that is not the diagnosis in this case because the patient lacks uterine tenderness
• Key idea: A way to remember causes/timing of post-op fever is with imagery of a hurricane
  • First there is wind (atelectasis and pneumonia in first 1-2 days post-op), then there is water (UTI on day 3 post-op), then sheltering in place (DVT/PE on day 5) followed by running for you life and falling down (cellulitis on day 7) and then not obtaining medical advice and getting an abscess (day 11)
• Note: Research has asserted that atelectasis causing post-op fever is actually a myth, but for the purposes of the NBME consider it as a cause
  • https://pubmed.ncbi.nlm.nih.gov/21527508/#:~:text=Conclusion%3A%20The%20available%20evidence%20regarding,atelectasis%20causes%20fever%20at%20all.

6) An asymptomatic 52-year-old nulligravid woman comes to the physician for a routine health maintenance examination. Her last visit…

Colonoscopy

• Key idea: Patients should receive a colonoscopy every 10 years beginning at age 50 regardless of gender (recommendation recently changed to 45 years old)
• Key idea: Bone density scan often indicated for women over 65 or men over 70, but should be considered in adults 50-69 with risk factors for bone loss (using corticosteroids, low body weight, breaking bone in minor accident, smoking, etc.) [https://www.choosingwisely.org/patient-resources/bone-density-tests/]

7) An 18-year-old primigravid woman at 39 weeks’ gestation delivers a newborn 2 days after developing chickenpox. The pregnancy…

Varicella-zoster immune globulin therapy

• If a mother develops chickenpox less than 5 days before delivery or less than 2 days after delivery, the newborn should receive varicella-zoster immunoglobulin therapy prophylaxis
• Note: If the infant starts to show signs/symptoms of chickenpox, then you would begin treatment with acyclovir
• Key idea: Babies <1 year of age have an undeveloped immune system and therefore are ineligible to receive live attenuated vaccines (such as VZV)

8) A 42-year-old woman, gravida 5, para 5, comes to the physician requesting advice regarding contraception. Menses occur at regular…

Placement of an IUD

• Key idea: The most effective contraceptive is often an IUD, especially in this setting because you don’t need to remember to take a medication every day
• Contraindications to IUD placement:
  • Pregnancy
  • Distorted uterine anatomy
  • ONGOING pelvic infection (not history of Chlamydia infection 20+ years ago)
  • Abnormal uterine bleeding of unknown origin
• Key idea: Barrier contraceptives are much less effective relative to hormonal/Copper contraceptives and therefore are RARELY the answer on NBME exams

9) A 42-year-old woman, gravida 2, para 1, at 20 weeks’ gestation comes to the physician for a routine prenatal visit. She has tested positive for…

Previous cesarean delivery

• Risk factors for Placenta Previa: Prior C-section, multiple gestation, prior placenta previa
• Key idea: Prior C-section risk factor for placenta previa, uterine rupture and placenta acreta/increta/percreta
• Note: Placenta previa managed with C-section at 36-37 weeks gestation
• Increased maternal age –> Increased risk of Trisomy 21

10) A 22-year-old woman, gravida 2, para 1, at 38 weeks’ gestation comes to the physician for a routine prenatal visit. She feels well…

Normal labor

• Key idea: True labor requires contractions AND cervical change
• True contractions: Come at regular times and get closer together, not affected by rest/movement, get steadily stronger and usually start in the back and then move to the front
• Braxton-Hicks contractions (fake contractions): Do not come regularly or get closer together, may improve/change with exercise or rest, usually felt ONLY in the front

11) A 17-year-old primigravid patient comes to the physician because she has had decreased fetal movement over the past 2 days…

Down syndrome

• Key idea: Down syndrome associated with duodenal atresia (which would lead to a duodenal bubble –> “double bubble” sign) and infants with down syndrome often have decreased tone
• Features associated with down syndrome: Flat face, slanted palpebral fissures, transverse palmar crease, small low-set ears, large “sandal gap” area between first 2 toes

12. A 32-year-old woman, gravida 1, para 1, at 34 weeks’ gestation is admitted to the hospital in labor. Pregnancy has been complicated…

Fetal growth restriction

• Pregnant woman presenting in 3rd trimester with new hypertension, proteinuria, edema and blurred vision concerning for pre-eclampsia with severe features
• Pre-eclampsia –> Maternal vascular malperfusion of placental beds –> Uteroplacental insufficiency –> Fetal growth restriction (“head-sparing”)
• Key idea: Pre-eclampsia without severe features managed with antihypertensives, magnesium sulfate and delivery at 37 weeks
• Pre-eclampsia with severe features should be delivered at 34 weeks, with criteria meeting severe features being:
  • Visual or cerebral symptoms
  • Increased creatinine
  • Increased LFTs (often in setting of HELLP)
  • Pulmonary edema
  • Thrombocytopenia (often in setting of HELLP)
  • Blood pressure > 180/110
• Gestational diabetes –> Macrosomia –> Brachial plexus injury
• Alpha thalassemia, Parvovirus B19, Rh alloimmunization, fetal aneuploidy –> Hydrops fetalis

13. Five weeks after the uncomplicated delivery of her newborn, a 25-year-old woman, gravida 1, para 1, comes to the physician with concerns…

Arrange for an immediate psychiatric evaluation

• Mother with signs of postpartum depression with thoughts of harming herself/baby who needs to be managed with immediate psychiatric evaluation and hospitalization
• Postpartum blues: Onset 2-3 days after delivery with mild depressive symptoms that resolve within 14 days –> Managed with reassurance
• Postpartum depression: Onset within 4-6 weeks of delivery with symptoms that will meet criteria for MDD (SIG E CAPS) and needs to be managed with antidepressants and psychotherapy
• Postpartum psychosis: Onset within days-weeks of delivery with symptoms of psychosis (delusions, hallucinations, thought disorganization, etc.) that should be managed with immediate hospitalization and psychiatric evaluation due to risk of infanticide

14) A 27-year-old primigravid woman at 30 weeks’ gestation comes to the physician because of a 3-week history of pain in her arms…

Carpal tunnel syndrome

• Carpal tunnel syndrome symptoms: Sensory problems to the palmar aspect of the thumb, 2nd finger, 3rd finger and half of the 4th finger /// Weakness in flexion of the same fingers and weakness in thumb opposition/abduction (thenar eminence muscles)
• Carpal tunnel syndrome seen with conditions that lead to swelling/thickening of tissues in the wrist, including pregnancy, hypothyroidism, diabetes, rheumatoid arthritis, end-stage renal disease, acromegaly and gout
• Key idea: Carpal tunnel syndrome often presents at night while patient is sleeping because people often sleep with their hand folded beneath/beside their head
• Note: Common wrist problem in patients after giving birth is De Quervain’s Tenosynovitis which leads to pain at the base of the thumb that is worse with thumb abduction

15) A 27-year-old primigravid woman at 7 weeks’ gestation comes to the physician for her first prenatal visit. She has no history of serious illness…

Hemoglobin electrophoresis

• Pregnant woman with microcytic anemia with normal iron/ferritin levels most concerning for some form of thalassemia –> Work-up first with hemoglobin electrophoresis
• Key idea: Patients typically need to have hemoglobin electrophoresis and iron studies performed BEFORE preceding to genetic testing for alpha-thalassemia (which would not show up on hemoglobin electrophoresis because alpha globin contributes to all hemoglobin types and hemoglobin electrophoresis looks at relative amounts of globins rather than absolute quantity of globins)

16) A 19-year-old woman comes to the emergency department because of moderate lower abdominal pain and vaginal spotting that began…

Chlamydia trachomatis infection

• Key idea: Cervicitis –> Cervical friability –> Cervical bleeding, especially post-coital bleeding
• Key idea: Cervical motion tenderness is most strongly associated with pelvic inflammatory disease, but note that it can also be seen in ectopic pregnancy (negative pregnancy test in this case) and endometriosis (no dyschezia, dyspareunia, dysmenorrhea, fixed uterus, etc.)
• Test-taking tip: If patient is sexually active and on OCPs on the NBME, that implies that they do NOT use barrier protection and are therefore at risk for STIs

17) A 20-year-old woman comes to the physician because of a 1-week history of vaginal discharge. She is sexually active with one partner…

Condyloma acuminata

• Young patient with high-risk sexual partner who presents with abnormal Pap findings and verrucous lesions in vagina consistent with condyloma acuminata
• Verrucous = Warty lesion = Some form of HPV-related disease (condyloma acuminata, cervical/vaginal/vulvar/penile/anal cancer)
• Condyloma acuminata treated with trichloroacetic acid, cryotherapy, laser therapy or Imiquimod (boosts immune response)
• General principle for the NBME: Just because a patient is monogamous or has healthy sexual practices does NOT eliminate chance that they obtain a sexually transmitted infection
• Bacterial vaginosis –> Gray, fishy-smelling vaginal discharge
• Herpes simplex –> Painful, vesicular rash

18) A 57-year-old woman, gravida 6, para 6, comes to the physician because of a 6-month history of immediate loss of urine when she coughs…

Stress incontinence

• Key idea: If a patient has incontinence that is brought on by exercise, coughing, sneezing, laughing, etc. then they must have some component of stress incontinence
• Key idea: A main risk factor for stress incontinence is history of multiple vaginal deliveries
• Note: In my opinion this question is slightly tricky because a urethrocele can be associated with abnormal downward mobility of urethra and can lead to stress incontinence
• Detrusor instability –> Urge incontinence (incontinence associated with strong urge to use restroom, often a diagnosis of exclusion on the NBME)

19) A 52-year-old postmenopausal woman comes to the physician for a health maintenance examination. She does not…

Breast cancer

• Key idea: Most common cancer in women is breast cancer, with patients receiving progestin-estrogen hormone replacement therapy having an even higher rate of breast cancer (https://www.cancer.org/cancer/cancer-causes/medical-treatments/menopausal-hormone-replacement-therapy-and-cancer-risk.html)
• Risk factors for cervical cancer –> HPV (many sexual partners, unsafe sexual practices), immunosuppression, smoking
• Risk factors for endometrial cancer –> Increased burden of unopposed estrogen (obesity, PCOS, etc.)
• Risk factors for ovarian cancer –> BRCA mutation, Lynch syndrome

20) A widowed 37-year-old woman, gravida 3, para 3, whose youngest child is 10 years old, has had increasingly heavy but regular…

Pedunculated submucous leiomyoma uteri

• 37 year old woman with chronic history of increasingly heavy periods presents with acute labor-like pain found to have beefy red tissue sticking out of the cervical os most consistent with a Prolapsed submucosal fibroid
• Key idea: Submucosal fibroids most commonly associated with heavier menstrual periods and if they prolapse it is as if the woman is delivering the fibroid so makes sense that it would lead to labor-like pain
• Increasingly heavy periods in a woman ~ 40 years old concerning for:
  • Endometrial hyperplasia/carcinoma (obesity, Lynch syndrome, etc.)
  • Fibroids (Irregular enlarged uterus, African-American)
  • Adenomyosis (Globular enlarged uterus, multiparous)
• Note: Since her last period was 2.5 weeks ago, would not have enough time for an abortion or ectopic pregnancy

21) A 42-year-old woman comes to the physician because of a 1-year history of vaginal bleeding for 2 to 5 days every 2 weeks…

Hysterectomy

• Young woman with family history of colon cancer and breast cancer (concerning for Peutz-Jeghers syndrome potentially) presenting with abnormal uterine bleeding found to have endometrial adenocarcinoma on endometrial biopsy, which should be treated with a hysterectomy
• Endometrial ablation –> Outpatient medical treatment to remove endometrial lining in women with heavy menstrual bleeding who have failed medical management AND do NOT wish to have any more children AND do not want to have a hysterectomy

22) A 25-year-old primigravid woman is admitted in labor at 39 weeks’ gestation. The cervix is 6 cm dilated and 100% effaced…

Ultrasonography

• Key idea: Ultrasonography useful for determining fetal position when unable to palpate presenting fetal part
• Amniotomy –> Would not want to perform without knowing the orientation of the baby
• Active stage of labor (6 cm to 10 cm) → Cervical dilation of at least 1 cm every 2 hours
  • Indications for C-section
    • Category 3 fetal HR tracingAbsent variability and recurrent late decelerations
      • Absent variability and recurrent variable decelerations
      • Absent variability and fetal bradycardia
      • Sinusoidal pattern
    • Active phase arrest with no cervical change for 4 hours with adequate contractions (>200 MV units) or 6 hours with inadequate contractions

23) A 28-year-old nulligravid woman has had increasingly severe dysmenorrhea over the past 2 years and dyspareunia and pain with defecation…

Endometriosis

• Key idea: Endometriosis classically leads to 3 D’s of Dysmenorrhea (painful menstruation), Dyspareunia (painful intercourse) and Dyschezia (painful defecation)
• Key idea: Other signs of endometriosis includes a fixed uterus (due to endometrial tissue on ligaments connecting to uterus), infertility, cervical motion tenderness (due to endometrial tissue on cervix) and a homogenous mass on the ovary (“chocolate cyst” = endometrioma)

24) A 27-year-old woman, gravida 3, para 3, had the sudden onset of severe, sharp pain in the right lower quadrant of the abdomen, pain in the…

Ruptured corpus luteum cyst

• Young woman with lower quadrant pain:
  • Appendicitis: Epigastric pain that migrates to RLQ pain, fever, leukocytosis –> No mention of fever in vignette
  • Ectopic pregnancy: Lower quadrant pain with vaginal bleeding and a positive pregnancy test or without a recent menses –> Negative pregnancy test
  • Pelvic inflammatory disease: Fever, Lower quadrant pain, cervical motion tenderness, risky sexual behaviors –> No fever or mention of cervical discharge in vignette
  • Mittelschmerz: Cyclical pain around day 14 of menstrual cycle (due to inflammation associated with ovulation event) –> Pain on day 24 of menstrual cycle
  • Ruptured ovarian cyst: Sudden onset pain with fluid in the adnexal area +/- signs of peritonitis –> Checks out!

25) A 30-year-old woman, gravida 3, para 2, at 10 weeks’ gestation has had fever, minimal vaginal bleeding, and severe pelvic pain for 36 hours…

Septic abortion

• Young woman with unintended pregnancy presenting with fever, pelvic pain, foul-smelling vaginal discharge, uterine tenderness and a leukocytosis most consistent with septic abortion
• Unintended pregnancy + Cervical laceration = Unsterile technique to cause an abortion –> Risk factor for septic abortion
• Key idea: Treated with sharp dilation and curettage + broad-spectrum antibiotics (gentamicin + ampicillin)

26) A 32-year-old primigravid woman at 10 weeks’ gestation comes for her first prenatal visit. She has a history of two to three seizures…

Increasing her current anticonvulsant medication

• Medicine is all about risk-reward and in this case the reward of improved maternal or fetal morbidity through less seizures outweighs the potential fetal risks of phenytoin (Ebstein anomaly, Fetal hydantoin syndrome, etc.), especially in this patient who is past the 8 week mark of her pregnancy (most teratogenic effects occur between 3-8 weeks of gestation because that is when organogenesis occurs)
• Key idea: Carbamazepine and Valproate are associated with neural tube defects and are therefore contraindicated in pregnancy

27) A previously healthy 37-year-old woman comes to the physician because of a 5-week history of bloody nipple discharge from the left breast…

Intraductal papilloma

• Key idea: Most common cause of unilateral, isolated (normal mammography) bloody nipple discharge is intraductal papilloma

28) A 32-year-old woman, gravida 5, para 4, at 40 weeks’ gestation is brought to the emergency department because of bright red vaginal…

Ask the patient to convene a meeting of the church elders to discuss cesarean delivery

• Key idea: Autonomy of the mother is basically prioritized over all else, even if her decisions may not be the best decision for the baby
• Would be inappropriate to transfer care just because you disagree with patient’s decision and patients have the right to refuse emergency surgery

29) A previously healthy 39-year-old woman at 37 weeks’ gestation comes to the emergency department 2 hours after the onset…

Pulmonary embolus

• Young woman in her 3rd trimester who develops sudden, pleuritic chest pain with an A-a gradient indicative of V/Q mismatch most concerning for pulmonary embolus
• Key idea: Pregnancy is a prothrombotic state to decrease likelihood of mother bleeding out during delivery
• Pleuritic chest pain differential
  • Pulmonary embolism
  • Pleuritis (often post-viral or post-pneumonia)
  • Pneumothorax
  • Pericarditis
• PAO2 = 150 – (PaCO2 / 0.8) = 150 – (35 / 0.8) = 150 – 44 = 106
• PaO2 = 70
• Normal A-a gradient < (Age/4) = 10
• A-a gradient = 106 – 70 = 36 > 10 –> indicative of V/Q mismatch

30) A 42-year-old woman comes to the physician because of a 3-month history of urinary urgency and frequency and occasional incontinence…

Detrusor hyperreflexia

• Young woman with relapsing-remitting multiple sclerosis with neuro symptoms including numbness below the week who has increased urinary frequency with intermittent incontinence and a normal post-void residual most consistent with urge incontinence due to detrusor overactivity
• Key idea: Normal post-void residual is <50 mL, so in this case we know that bladder hypotonia is not at play
• External sphincter incompetence –> Stress incontinence (loss of urine with coughing, laughing, exercise, etc.)

31. A 21-year-old primigravid woman at 8 weeks’ gestation comes to the physician for her first prenatal visit. She has sickle cell disease and is concerned…

50%

• Mother has sickle cell disease (almost all of hemoglobin is Hgb S) so we know that she is homozygous for the sickle cell mutation
• The husband has ~ equal levels of Hemoglobin A and Hemoglobin S, so we know that he has sickle cell trait and is heterozygous for the sickle cell mutation
• Therefore, all of their children will get at least one sickle cell mutation from the mother and the father will pass the mutation to 50% of their children
• Key idea: In most people, Hemoglobin A (2 alpha chains, 2 beta chains) comprises ~97-98% of their hemoglobin levels

32) A 15-year-old girl is brought to the physician because of a 1-week history of constant severe abdominal pain. During the past year…

Transvaginal incision and drainage

• A 15-year-old girl with normal pubertal development except for absence of known menses presents with intermittent, monthly abdominal pain, a palpable suprapubic mass and inability to visualize the vagina due to a bluish bulge most consistent with imperforate hymen –> Hematocolpos
• Key idea: Primary amenorrhea diagnosed in girls who have not had secondary sexual changes (breast development) by 13 or who have not had menarche by 15

33) A 25-year-old woman comes to the physician because of a 4-week history of right-sided pelvic pain. She has been sexually active with one partner for 3 years…

Cystic teratoma

• Key idea: Cystic teratoma is the most common cause of a complex ovarian mass in a child or young person
• Key idea: Cystic teratomas are an important risk factor for ovarian torsion because they are often unbalanced masses due to calcifications
• Ultrasound findings of ovarian mass:
  • Cystic teratoma –> Calcified mass with complex and cystic components (remember that teratomas often have hair and teeth, with teeth being calcified)
  • Endometrioma (“chocolate cyst”) –> Homogenous cystic mass without solid components
  • Follicular cyst –> Simple, small, thin-walled cyst with free fluid

34) A 27-year-old primigravid woman at 37 weeks’ gestation is admitted to the hospital in labor after an uncomplicated pregnancy. Fetal heart…

Vasa previa

• Woman during 3rd trimester presenting with bloody rupture of membranes + persistent fetal bradycardia concerning for vasa previa
• Key idea: Vasa previa is a very serious condition because it pertains to bleeding from the baby and the baby has very low blood folume (total blood volume of ~ 1 cup), so they can undergo rapid exsanguination and death within minutes even in setting of minimal vaginal bleeding –> Therefore, treatment involves emergency cesarean delivery

35) A 14-year-old girl is brought to the physician because of painful episodes of menstrual cramping over the past 5 months…

Prostaglandin production

• Key idea: Primary dysmenorrhea often seen in young girls (up to 90% of adolescents) and leads to painful menses especially during first 2-3 days related to excessive prostaglandin production
• Key idea: Treated with NSAIDs (to decrease prostaglandin production) or combined oral contraceptives
• Endometriosis –> Dysmenorrhea, Dyschezia, Dyspareunia
• Ovarian torsion –> Acute onset lower abdominal pain

36) A 21-year-old primigravid woman at 41 weeks’ gestation is admitted to the hospital in labor. Her pregnancy has been uncomplicated. Contractions…

Amnioinfusion

• By thinning/diluting the meconium-stained fluid, amnioinfusion may improve outcomes in setting of meconium-stained amniotic fluid, where you are principally worried about meconium aspiration syndrome –> persistent pulmonary hypertension of the newborn
  • Note: Not strongly supported by more recent data, but initially hypothesized to provide a benefit (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920933/)
• Key idea: Operative vaginal delivery (second stage) or C-section (active stage) would be indicated if patient had recurrent variable decelerations AND loss of variability
• External cephalic version used if patient is in breech position at 36-37 weeks (at 41 weeks baby would occupy too much of uterine cavity to be turned)

37) A 32-year-old woman comes to the physician because of a 3-year history of increasingly irregular menses. Menses had occurred…

Testosterone

• Heavy woman with menstrual irregularity and signs of insulin resistance (acanthosis nigricans), most concerning for polycystic ovary disease (PCOS)
• Diagnosis of PCOS requires at least 2 of the 3 following criteria:
  • Irregular menses (anovulation)
  • Polycystic ovaries on ultrasound
  • Clinical (acne, hirsutism) or laboratory (elevated testosterone) signs of hyperandrogenism
• Key idea: While insulin resistance is often a component of PCOS, it is NOT part of the diagnostic criteria
• Key idea: Patients with PCOS at increased risk for endometrial hyperplasia/carcinoma because they have high levels of androgens that is readily aromatized to estrogen due to elevated fat levels (aromatization primarily takes place in fat cells)

38) A 27-year-old woman who is a long-distance runner comes to the physician because of a 1-month history of postcoital spotting lasting…

Cervicitis

• Young woman with a new sexual partner who presents with postcoital spotting, most consistent with cervicitis (makes the cervix more friable/fragile –> postcoital bleeding)
• Menses have occurred at regular intervals –> Rules out PCOS, functional hypothalamic amenorrhea and primary ovarian failure
• Young patient with no mention of abdominal bloating or adnexal mass –> Rules out ovarian cancer
• No excessive bleeding or irregularly enlarged uterus –> Rules out fibroids (leiomyoma uteri)
• Bilateral tubal ligation –> Decreases risk of pregnancy
• No mention of anemia, excessive bleeding or abnormal labs –> Less likely blood cell dyscrasia

39) A 57-year-old woman, gravida 3, para 3, comes to the physician because of loss of urine for 2 weeks. She now wears an absorbent…

Vesicovaginal fistula

• Key idea: Vesicovaginal fistula most commonly seen in setting of pelvic surgery, childbirth trauma and/or genitourinary malignancy
• Key idea: Vesicovaginal fluid leads to painless, continuous leakage of urine FROM THE VAGINA
• Stress incontinence –> Loss of urine associated with exercise, laughing, coughing, etc.
• Overactive bladder –> Urge incontinence –> Loss of urine associated with strong urge to use restroom and low volume voids

40) A 34-year-old woman, gravida 4, para 3, at 40 weeks’ gestation is admitted because of a blood pressure of 160/95 Hg. She has chronic hypertension…

Uteroplacental insufficiency

• Woman in her 3rd trimester with chronic hypertension and baby with fetal growth restriction who has a fetal heart tracing showing recurrent late decelerations (nadir of deceleration falls AFTER peak of contraction) concerning for uteroplacental insufficiency
• Umbilical cord compression –> Variable decelerations (not necessarily associated with contractions, <30 seconds from onset to nadir)
• Pressure on fetal head –> Early decelerations (mirror image of the contractions)
• Key idea: Global fetal growth restriction often seen in 1st trimester and due to congenital infection or genetic defect, whereas Head-sparing fetal growth restriction often seen in 2nd/3rd trimester and most commonly due to uteroplacental insufficiency or maternal malnutrition
• Key idea: A normal fetal heart tracing will have all of the following features:
  • Rate: 110-160 beats/min
  • Variability: Moderate (not flat line, not crazy zig-zag)
  • Accelerations: 15/15 2:20 meaning an acceleration is counted if the heart rate increases by at least 15 units and if it lasts for at least 15 seconds and you want to see at least 2 accelerations every 20 minutes
  • Decelerations: None +/- early decelerations

41) A 36-year-old woman, gravida 1, para 1, has been unable to conceive for 1 year. Her vaginal delivery 2 years ago was complicated…

Uterine synechiae

• Young woman with a history of postpartum hemorrhage treated with D&C who ever since has been amenorrheic with infertility and cyclical abdominal pain concerning for intrauterine adhesions (Asherman’s syndrome)
• Intrauterine adhesions (Asherman’s syndrome) often presents with infertility, light/absent periods and cyclical cramping pain
• Key idea: The majority of cases of intrauterine adhesions (Asherman’s syndrome) is due to scar tissue from uterine surgery (commonly D&C procedures)

42) A moderately obese 27-year-old woman, gravida 1, para 1, comes to the physician because of pain and tenderness in her left thigh…

Duplex venous ultrasonography

• Postpartum patient with pain/tenderness of left thigh/calf with a positive Homan’s sign (increased pain with foot dorsiflexion) most concerning for deep vein thrombosis –> Work-up with a compression ultrasound
• Key idea: Pregnancy is a hypercoagulable state which makes sense because over the course of human history one of the major causes of mortality has been excessive bleeding in setting of childbirth so we have adapted to be more prone to clotting to decrease risk of excessive bleeding

43) A 27-year-old woman, gravida 2, para 1, aborta 1, comes to the physician because of a 3-day history of increasing abdominal pain and a 1-day history…

Amenorrhea

• Young woman with septic abortion (fever and uterine tenderness after an abortion) treated with dilation and sharp curettage –> Puts patients at increased risk for Asherman’s syndrome (uterine adhesions) –> Amenorrhea, cyclical abdominal pain, infertility
• Key idea: Endometrial lining composed of the underlying stratum basalis (stem cells) and stratum functionalis (grows and is shed cyclically as part of menses), with overly aggressive D&C leading to loss of stratum basalis –> Loss of stem cells means the body can only respond to trauma through production of scar tissue
• Premature ovarian failure associated with pelvic radiation and autoimmune disease

44) A 15-year-old girl is brought to the physician because of a 3-day history of fever, abdominal pain, and nausea. She also has had a thick…

Increased cervical cell vulnerability to infections

• Sexually active adolescent presents with thick vaginal discharge, fever, cervical motion tenderness, an adnexal mass and a Gram stain showing gram-negative diplococci most consistent with N. gonorrhea leading to pelvic inflammatory disease complicated by tubo-ovarian abscess formation
• Key idea: Adolescents are more likely to have increased cervical ectopy (columnar cells located on outer surface of the cervix), with the columnar cells being more prone to infection relative to squamous cells
• https://www.cdc.gov/std/stats18/adolescents.htm#:~:text=For%20some%20STDs%2C%20such%20as,outer%20surface%20of%20the%20cervix.

45) A 36-year-old woman, gravida 2, para 1, at 41 weeks’ gestation has had ruptured membranes without contractions for 8 hours. Her first infant…

Oxytocin administration

• Excessive oxytocin administration –> Excessive uterine contractions –> Interrupted intervillous blood flow with each contraction –> Uteroplacental insufficiency –> Recurrent late decelerations
• Key idea: Uterine tachysystole defined as 5+ contractions in a 10 minute period and is most commonly seen in setting of:
  • Oxytocin administration or vaginally-administered prostaglandins
  • Placental abruption (particularly useful with concealed abruption)
• Key idea: Managed by discontinuing uterotonic agents and implementing supportive measures (maternal repositioning, etc.)

46) A 23-year-old primigravid woman at 33 weeks’ gestation is admitted to the hospital because she has not felt fetal movement for 2 days…

Uteroplacental artery

• Key idea: Thrombosis of uteroplacental artery –> Insufficient blood flow to placenta/fetus –> Insufficient oxygen/nutrient delivery and waste removal –> Fetal hypoxia and acidosis –> Increased risk of fetal demise
• Note: Uteroplacental artery = Spiral arteries
• Key idea: Factor V Leiden mutation makes Factor Va resistant to cleavage by Activated Protein C –> Excessive coagulation factor –> Pro-thrombotic state
• Key idea: Recurrent pregnancy loss should often make you consider antiphospholipid syndrome (3+ consecutive fetal losses before 10th week OR 1+ unexplained fetal losses after 10th week AND positive antibody test (lupus anticoagulant, anti-cardiolipin, anti-beta-2)

47) A 22-year-old woman comes to the physician because of a 2-week history of increasingly severe vaginal burning and discharge…

Vaginal metronidazole gel

• Young woman presenting with vaginal itching with gray discharge with a pH = 5.0 and Clue cells on microscopy (squamous cells coated with bacteria) most consistent with bacterial vaginosis –> Treat with metronidazole or clindamycin
• 3 main forms of vaginal infection and definitive features include:
  • (1) Bacterial vaginosis: Gray fishy discharge, pH > 4.5, no cervical/vaginal erythema, clue cells, treat with metronidazole or clindamycin
  • (2) Candidal vaginitis: White cottage cheese discharge, pH < 4.5, cervical/vaginal erythema, pseudohyphae and budding yeast, treat with oral or topical -azole drugs
  • (3) Trichomonal vaginitis: Greenish-yellowish discharge, pH > 4.5, cervical/vaginal erythema, motile trichomonads, treat with metronidazole

48) A 22-year-old primigravid woman at 39 weeks’ gestation has had ruptured membranes for 5 hours without contractions…

Fetal sleep state

• Fetal heart tracing has normal rate with minimal variability, with causes of decreasedvariability being:
  • Maternal ingestion of CNS depressants (alcohol, etc.)
  • Prematurity
  • Fetal hypoxia
  • Temporary fetal sleep
• Key idea: A common cause is fetal sleep, which could be investigated by repeating the stress test after applying vibroacoustic stimulation to the abdomen
• Key idea: A normal fetal heart tracing will have all of the following features:
  • Rate: 110-160 beats/min
  • Variability: Moderate (not flat line, not crazy zig-zag)
  • Accelerations: 15/15 2:20 meaning an acceleration is counted if the heart rate increases by at least 15 units and if it lasts for at least 15 seconds and you want to see at least 2 accelerations every 20 minutes
  • Decelerations: None +/- early decelerations

49) A 32-year-old primigravid woman at term has a cervix that has remained 5 cm dilated over the past 4 hours despite the administration…

Arrest of active phase

• Young woman in labor (contractions + cervical change) who is currently 5 cm dilated and has had no cervical change in past 4 hours despite adequate contractions (3.33 X 60 = 200 Montevideo units) concerning for active phase arrest
• KEY IDEA: WHEN THIS QUESTION WAS WRITTEN, ACTIVE STAGE BEGAN AT 4 CM BUT NOW IT BEGINS AT 6 CM
• Latent stage of labor (0 cm to 6 cm) –> No normal/pre-determined rate of cervical dilation (can take days)
• Active stage of labor (6 cm to 10 cm) → Cervical dilation of at least 1 cm every 2 hours
  • Indications for C-section
    • Category 3 fetal HR tracing
      • Absent variability and recurrent late decelerations
      • Absent variability and recurrent variable decelerations
      • Absent variability and fetal bradycardia
      • Sinusoidal pattern
    • Active phase arrest with no cervical change for 4 hours with adequate contractions (>200 MV units) or 6 hours with inadequate contractions
• Second stage of labor (10 cm to delivery) → Fetal descent every 3 hours if nulliparous vs every 2 hours if multiparous
  • Indications for operative vaginal delivery (forceps)
    • Second stage arrest
    • Maternal exhaustion
    • Fetal distress
      • Absent variability and recurrent late decelerations
      • Absent variability and recurrent variable decelerations
      • Absent variability and fetal bradycardia
      • Sinusoidal pattern

50) A 52-year-old woman comes to the physician for a routine examination. She has mild hypothyroidism well controlled with levothyroxine. Five years…

BMI

• Key idea: Most important risk factors for osteoporosis are low body weight, being postmenopausal (low estrogen) and advanced age
• Major modifiable risk factors for osteoporosis: Excessive alcohol intake, sedentary lifestyle, smoking, corticosteroid use
• Major non-modifiable risk factors for osteoporosis: Advanced age, postmenopausal woman, low body weight

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