NBME OBGYN Form 3

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1: A 35-year-old woman, gravida 2, para 1, with chronic hypertension has spontaneous onset of labor at…

Amniotic fluid embolism

• Previously healthy woman who in the immediate postpartum setting develops respiratory distress, hypotension and DIC most consistent with amniotic fluid embolism
• Main causes of severe/acute illness immediately postpartum:
  • Amniotic fluid embolism: Respiratory distress, neurologic symptoms (confusion, seizures), hypotension, DIC
  • Pure DIC: Bleeding from venipuncture sites and hypertension often in a patient with a predisposing factor (placental abruption, acute fatty liver of pregnancy, etc.)
  • Eclampsia: Seizures in a patient with pre-eclampsia (3rd trimester HTN, proteinuria, edema, etc.)

2. A 26-year-old nulligravid woman has had infertility for 2 years. Menses occur at regular 25-day intervals. Serum progesterone…

Secretory endometrium

• Key idea: Progesterone will be elevated in the luteal phase of the ovarian cycle (corpus luteum produces progesterone after ovulation), and the luteal phase of the ovarian cycle corresponds with the secretory phase of the uterine cycle (progesterone stimulates endometrial cells to prepare for implantation of blastocyst)
• Key idea: Infertility not always due to endometrial factors (anovulation, etc.), which is especially true in this patient with regular 25-day menstrual cycle

3. A 27-year-old woman, gravida 2, para 1, at 30 weeks’ gestation comes to the physician because of…

Folic acid deficiency

• Young pregnant woman at 30 weeks gestation presents with chronic fatigue and pallor and is found to have severe anemia with a macrocytosis most consistent with folic acid deficiency
• Four general causes of folic acid deficiency:
  • Malnutrition (alcoholics)
  • Malabsorption (Tropical sprue)
  • Drugs (Methotrexate, phenytoin, etc.)
  • Increased requirement (pregnancy, hemolytic anemias [sickle cell disease, hereditary spherocytosis, etc.])
• Bone marrow hypoplasia –> More severe thrombocytopenia and leukopenia
• Vitamin B12 deficiency –> Neurologic symptoms (paresthesias, weakness, etc.), often in an alcoholic, elderly (malnourished) or vegan patient

4. A 37-year-old woman, gravida 1, para 1, with recently diagnosed breast cancer comes to the physician for advice…

Placement of a copper IUD

• Woman with breast cancer (who therefore cannot receive hormonal contraception) who wants contraception, with a copper IUD being the safest and most effective option
• Key idea: Breast cancer is an absolute contraindication to hormonal contraception (remember that some breast cancers can be Estrogen Receptor (ER) and/or Progesterone Receptor (PR) positive)
• Contraindications to combined contraception includes (1) Women > 35 yo who smoke (which is case with this patient) (2) Migraines with aura (3) Hypercoagulable risk factors (<3 weeks postpartum, prolonged immobilization, history of DVT/PE, blood disorders [factor V leiden, etc.]) (4) Active breast cancer (5) Liver disease (liver involved in metabolizing estrogen)

5. A 37-year-old woman, gravida 1, para 1, comes to the physician for a follow-up examination. Six weeks ago, a Pap smear showed low-grade…

Cone biopsy of the cervix

• Young woman with recent concerning Pap smear who on colposcopy had definite ectocervical disease with inability to fully evaluate the squamocolumnar junction, and should therefore receive a cone biopsy to evaluate for endocervical disease
• Local ectocervical disease could be treated with cryotherapy or loop electrosurgical excision procedure (LEEP), but in this case would be inappropriate because we have not fully ruled out endocervical disease
• Key idea: In setting of abnormal Pap test, next step is colposcopy
• Key idea: Dysplastic areas will turn white when stained with acetic acid on colposcopy

6. A sexually active 21-year-old college student requests an oral contraceptive. There are no contraindications based on her medical…

Test for Chlamydia trachomatis

• Key idea: USPSTF recommends chlamydia screening in ALL sexually active women 24 years or younger (even if they are monogamous and have extremely safe sexual practices!) but recommends AGAINST screening women 25 years or older if they are not at increased risk due to sexual practices
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening

7. A 37-year-old primigravid woman at 31 weeks’ gestation comes to the physician for a routine prenatal visit…

Antenatal testing

• Primigravid woman at 31 weeks gestation presenting with difficulty breathing in the setting of an increased fundal height and polyhydramnios with a fetal ultrasound showing a normal fetus, most consistent with idiopathic polyhydramnios that can be managed expectantly
• Key idea: Most cases of polyhydramnios are idiopathic and the mothers are typically asymptomatic (although they can sometimes develop orthopnea due to their enlarged abdomen making it hard for diaphragm to work properly)
• Key idea: Formal diagnosis of polyhydramnios is amniotic fluid index greater than or equal to 24 or single deepest pocket greater than or equal to 8
• Key idea: 2 general causes of polyhydramnios are (1) Impaired fetal swallowing (tracheoesophageal fistula, anencephaly) and (2) Increased fetal urination (maternal diabetes, high cardiac output due to anemia or twin-twin transfusion syndrome)

8. A 26-year-old woman, gravida 3, para 2, comes for her first prenatal visit at 11 weeks’ gestation…

Indirect antiglobulin (Coombs) test

• Key idea: Direct Coombs is testing whether antibodies are bound to the patient’s RBCs (useful for distinguishing autoimmune hemolytic anemia from hereditary spherocytosis, etc.) whereas Indirect Coombs is testing whether patient has antibodies against specific antigens (such as Rh antigen) within their serum
• Note: Kleihauer-Betke acid elution test is used to measure the amount of fetal hemoglobin within the mother’s circulation after delivery or another procedure in order to determine how much Rh immunoglobulin the mother should receive

9. A 23-year-old woman comes to the physician because of a 3-day history of pain and burning with urination. Two years ago, she had similar…

Voiding immediately after coitus

• In all honesty, this is somewhat of a flawed question because
• Key idea: Recurrent UTIs defined by repeated UTIs at a frequency of 2+ in the last 6 months or 3+ in the last 12 months and are often managed with continuous or post-coital antimicrobial prophylaxis (TMP-SMX, Nitrofurantoin, Cephalexin, etc.)
• https://www.aafp.org/afp/2010/0915/p638.html#:~:text=Women%20with%20recurrent%20symptomatic%20urinary,cranberry%20products%2C%20and%20behavioral%20modification.

10. A 47-year-old nulligravid woman comes to the physician because of heavy menstrual flow during the past 3 months…

Endometrial biopsy

• Obese middle-aged woman with abnormal uterine bleeding and atypical glandular cells on Pap smear who has multiple indications for Endometrial biopsy to rule-out endometrial hyperplasia/carcinoma
• Key idea: Endometrial tissue is stimulated by estrogen, with obese patients having higher rates of aromatization of testosterone –> estrogen –> excessive endometrial stimulation
• Indications for endometrial biopsy:
  • Age > 45 with post-menopausal bleeding or abnormal uterine bleeding (heavy or prolonged)
  • Age < 45 with abnormal uterine bleeding AND at least one of following:
    • Unopposed estrogen (obesity, anovulation)
    • Lynch syndrome (familial syndrome associated with colon, endometrial, and ovarian cancer)
    • Failed medical management (refractory to OCPs)
  • Age > 35 with Atypical glandular cells on Pap smear

11. A 42-year-old woman with systemic lupus erythematosus comes to the physician for a follow-up examination. Two weeks ago, prednisone…

Alendronate now

• Young patient who has used multiple courses of corticosteroid therapy that will put her at risk for osteoporosis and therefore should be given an oral bisphosphonate to reduce risk of osteoporosis
• Key idea: First-line treatment for osteoporosis treatment is almost always a bisphosphonate
• https://ard.bmj.com/content/64/2/176

12. A 27-year-old primigravid woman at 19 weeks’ gestation comes for a routine prenatal visit…

Parvovirus B19 infection

• Causes of fetal hydrops:
  • Rh alloimmunization: Positive Indirect Coombs test, immigrant Rh negative patient who has had previous pregnancies
  • Parvovirus B19: Patient who experienced cold symptoms or joint pains during pregnancy or patient who has been exposed to children who are more likely to pass on Parvovirus B19 (teacher, daycare, etc.)
  • Severe alpha thalassemia [Hb Barts]: Mother is Asian or African American and likely has microcytic anemia with low red cell distribution width, normal iron studies, etc.
  • Fetal aneuploidy: Growth restriction, limb abnormalities, facial dysmorphia

13. A 19-year-old primigravid woman comes to the emergency department because of vaginal bleeding, abdominal…

Cocaine use

• Young primigravid woman in her third trimester who presents with painful vaginal bleeding (AKA placental abruption) who is found to have tachycardia and hypertension most consistent with cocaine-induced placental abruption
• Key idea: 3rd trimester painful vaginal bleeding = placental abruption
• Causes/Risk factors for placental abruption:
  • Maternal hypertension
  • Pre-eclampsia or eclampsia
  • Cocaine and tobacco use
  • Abdominal trauma (motor vehicle accident, etc.)
• Note: Commonly leads to uterine tachysystole and a firm, tender uterus

14. A 22-year-old primigravid woman at 24 weeks’ gestation has had fullness in the lower pelvic area for 12 hours…

Incompetent cervix

• Young primigravid woman at 24 weeks’ gestation presenting with fetus in breech position in the vagina without contractions, most consistent with cervical incompetence
• Key idea: Common predisposing risk factor for cervical incompetence is previous LEEP procedures

15. A 32-year-old woman with type 1 diabetes mellitus has had increasingly severe perineal pain over the past 3 days. Her temperature…

Necrotizing fasciitis

• Young patient with type 1 diabetes who presents with fever and a physical exam consistent with with bartholin gland abscess complicated by cellulitis who is therefore at risk for Fournier gangrene (form of necrotizing fasciitis)
• Key idea: Patients with necrotizing fasciitis (including Fourier gangrene) should be taken immediately to the OR (surgical emergency!)
• Signs pointing to necrotizing fasciitis over cellulitis: (1) Pain out of proportion to examine (extreme pain > tenderness) (2) Rapid progression of symptoms (3) Severe systematic features (fever, chills, hypotension) (4) Crepitus or free air (5) Bullae (6) Purulent, cloudy discharge (7) Violaceous appearance of lesion (8) Paresthesia/Anesthesia at edge of lesion

16. A 32-year-old woman, gravida 2, para 1, at 18 weeks’ gestation comes for a routine prenatal visit…

Premature labor

• Common risk factors for preterm labor:
  • History of preterm labor
  • Short cervix (often < 2.5 cm in patient without history)
  • Multiple gestations
• Risk factors for placental abruption: Cocaine, tobacco, hypertension, pre-eclampsia, abdominal trauma
• Oligohydramnios: Placental insufficiency (hypertension, pre-eclampsia, etc.), bladder outlet obstruction (posterior urethral valves, etc.)
• Placenta previa: Previous C-sections
• Polyhydramnios: Impaired fetal swallowing (tracheoesophageal fistula) or increased fetal urine production (maternal diabetes)

17. A 32-year-old primigravid woman comes to the physician at 30 weeks’ gestation because of a 10-day history of decreased…

Intrahepatic cholestasis

• Primigravid woman at 30 weeks gestation presenting with generalized itching, normal blood pressure and mildly cholestatic transaminitis (Alkaline phosphatase > AST/ALT) most consistent with intrahepatic cholestasis
• Pathophysiology: Estrogen and progesterone lead to hepatobiliary tract stasis and decreased bile excretion
• Management: Ursodeoxycholic acid + Antihistamines + Delivery at 37 weeks (because it is associated with morbid obstetric risks)
• HELLP syndrome: Hemolytic anemia, Elevated Liver enzymes, Low Platelets and hypertension
• Acute fatty liver of pregnancy: Elevated liver enzymes with progressive jaundice, hypoglycemia, hypofibrinogenemia, prolonged INR, etc.

18. A 52-year-old woman comes to the physician because of a 6-month history of urinary urgency. She often has a strong urge to void…

Estrogen deficiency

• Middle-aged woman who is perimenopausal who comes to the office because she sometimes has a sudden strong urge to void with intermittent incontinence with physical exam showing vaginal atrophy most consistent with Genitourinary syndrome of menopause –> Urgency incontinence
• Menopause –> Decreased estrogen –> Atrophic vaginitis –> Urogenital atrophy (decreased collagen, blood flow and elasticity of estrogen-responsive urethral tissue) –> Urgency incontinence
• Key idea: Genitourinary syndrome of menopause treated with topical vaginal estrogen and vaginal lubricant
• Atonic bladder –> Often seen in setting of neurological disorder (diabetic neuropathy, multiple sclerosis) and would lead to increased post-void residual
• UTI –> Suprapubic tenderness
• Trichomoniasis –> Vaginal itching with greenish discharge and cervical inflammation

19. A 47-year-old woman comes to the physician for a follow-up examination. Six weeks ago, she underwent an abdominal hysterectomy…

No longer indicated

• Patients can stop Pap testing once they meet ALL OF the following conditions:
  • Age 65 or hysterectomy
  • No history of CIN 2 or higher
  • 3 consecutive negative Pap tests OR 2 consecutive negative co-testing results

20. A previously healthy 32-year-old woman comes to the physician because of a 2-day history of vaginal bleeding…

Ectopic pregnancy

• Young woman with lower quadrant abdominal pain + vaginal bleeding + elevated beta-hCG that is not increasing by >50% every 48 hours most consistent with ectopic pregnancy
• Young woman with lower quadrant pain:
  • Appendicitis: Epigastric pain that migrates to RLQ pain, fever, leukocytosis
  • Ectopic pregnancy: Lower quadrant pain with vaginal bleeding and a positive pregnancy test or without a recent menses
  • Pelvic inflammatory disease: Fever, Lower quadrant pain, cervical motion tenderness, risky sexual behaviors
  • Mittelschmerz: Cyclical pain around day 14 of menstrual cycle (due to inflammation associated with ovulation event)
  • Ruptured ovarian cyst: Sudden onset pain with fluid in the adnexal area +/- signs of peritonitis
• Key idea: In a normal pregnancy, we would expect beta-hCG levels to increased by at least 50% every 48 hours during the first trimester
• Key idea: Cervical motion tenderness can be seen in both ectopic pregnancy and pelvic inflammatory disease

21. A 16-year-old girl is brought to the physician by her mother because she has never had a menstrual period. She also has had moderate…

Imperforate hymen

• 16-year-old girl with primary amenorrhea with normal breast and pubic hair development whose vaginal canal cannot be visualized and who has a tender mass anterior to the rectum (vagina is anterior to the rectum) 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
• First step in primary amenorrhea work-up: Determine if uterus is present (physical exam, imaging) because if it is ABSENT then the patient either has Mullerian agenesis (XX, normal breast and pubic/axillary hair development) or Androgen Insensitivity Syndrome (XY, absent pubic/axillary hair with normal breast development)
• Second step in primary amenorrhea work-up: If patient with primary amenorrhea has a uterus, then next step is an FSH level because a low FSH tells you the pituitary/hypothalamus is dysfunctional (prolactinoma, hypothyroidism, functional hypothalamic amenorrhea), a normal FSH tells you they have a functional defect (imperforate hymen), and an elevated FSH tells you the ovaries are dysfunctional and can’t be stimulated (Turner syndrome, Primary ovarian failure)

22. A 19-year-old primigravid woman comes to the emergency department because of a 1-week history of nausea…

Hydatidiform mole

• Young primigravid woman presenting with signs of hyperemesis gravidarum (nausea and persistent vomiting), pre-eclampsia (hypertension, proteinuria, edema), enlarged uterine size (20>15) who is found to have multilocular ovarian cysts and echogenic structures in the uterus most consistent with a hydatidiform mole
• Key idea: Early onset pre-eclampsia (before 20 weeks) almost always due to hydatidiform moles
• Hydatidiform mole –> Very elevated beta-hCG –> hyperemesis gravidarum
• Hydatidiform mole –> Very elevated beta-hCG –> hCG shares same alpha subunit as TSH, LH and FSH and therefore can lead to hyperthyroidism and bilateral ovarian theca-lutein cysts
• Management: Dilation and curretage + methotrexate + monitor beta-hCG for several months (to monitor for development of choriocarcinoma)

23. A 27-year-old primigravid woman at 38 weeks’ gestation is admitted to the hospital in labor. She had…

Polymicrobial infection

• Key idea: Postpartum endometritis is the most likely cause of postpartum fever, often follows a prolonged labor (>18 hours), C-section or chorioamnionitis (which this patient likely has due to fetal tachycardia + maternal fever + purulent cervical discharge before delivery), leads to diffuse abdominal pain + maternal fever in the post-partum period and is most likely caused by a polymicrobial infection
• Normal fetal heart rate: 110-160 bpm
• Treatment: Ampicillin + Gentamicin + Clindamycin
• Septic pelvic thrombophlebitis: Fever and pelvic pain in the postpartum period that is refractory to antibiotics
• C. trachomatis and N. gonorrhoeae –> Pelvic inflammatory disease
• E. coli –> UTI, pyelonephritis

24. A 21-year-old primigravid woman at 10 weeks’ gestation has had severe nausea and has been unable…

Measurement of urinary ketones

• Pregnant woman at 10 weeks’ gestation presenting with severe nausea and inability to keep food/liquids down for 48 hours concerning for hyperemesis gravidarum, which classically leads to urinary ketones with low glucose (starvation ketoacidosis)
• Risk factors for hyperemesis gravidarum:
  • Hydatidiform mole
  • Multifetal gestation
  • Key idea: All women with hyperemesis gravidarum undergo a screening ultrasound to look for either of these risk factors
• Potential clinical features of hyperemesis gravidarum:
  • Severe persistent nausea
  • Dehydration, orthostatic hypotension
  • >5% loss in pre-pregnancy weight
• Key idea: Hyperemesis gravidarum classically leads to ketonuria with low glucose (starvation ketoacidosis) and hypochloremic hypokalemia metabolic alkalosis (as with all types of vomiting)
• Management: Hospital admission with IV antiemetics and IV fluids (patients are often hemodynamically unstable and cannot take oral antiemetics due to persistent nausea/vomiting)

25. A 50-year-old woman, gravida 3, para 2, aborta 1, has had loss of urine with coughing, straining or lifting since the birth of her child…

Urethrocele

• Middle-aged woman with signs of stress incontinence (loss of urine with increased abdominal pressure) and a relatively benign physical exam, with the only answer that could explain that presentation being a urethrocele –> Stress incontinence
• Key idea: Any incontinence in the setting of coughing, laughing, exercise, etc. is indicative of some degree of stress incontinence
• Key idea: Q-tip test with > 30 degrees of motion is indicative of stress incontinence with poor support and abnormal descent of the bladder neck, which can also be seen in a urethrocele

26. A 37-year-old woman, gravida 2, para 1, at 36 weeks’ gestation is admitted to the hospital after she was found to have fetal…

Doppler ultrasonography of the umbilical artery

• Woman at 36 weeks’ gestation presents with fetal growth restriction (estimated fetal weight < 10th percentile), more specifically head-sparing growth restriction (fetal head relatively normal with small body) which should prompt concern for uteroplacental insufficiency that would be worked-up with doppler ultrasound of the umbilical artery to assess placental perfusion
• 2 major types of growth restriction include:
  • Asymmetric (head-sparing lag): Head remains normal size but body is small; often seen in 2nd/3rd trimester due to uteroplacental insufficiency (maternal hypertension, pre-eclampsia, etc.)
  • Symmetric (global growth lag): Body AND head are small; often presents early in pregnancy and is due to TORCHES infections or genetic abnormalities
• Key idea: Fetal growth restriction defined as fetal weight < 10th percentile for gestational age and these patients should receive serial growth ultrasounds and serial umbilical artery doppler ultrasounds (to assess placental perfusion)
• Fetal fibronectin test –> Assesses risk of preterm labor in a patient presenting with signs concerning for preterm labor
• Determination of nuchal thickness –> Part of routine ultrasound screenings to assess for risk of down syndrome and other genetic abnormalities
• Glucose tolerance test –> Performed in all pregnant woman ~24-28 weeks pregnancy to assess for gestational diabetes

27. A 77-year-old woman, gravida 2, para 2, comes to the physician because of a 1-month history of intermittent episodes of vaginal…

Squamous cell carcinoma

• Elderly woman with significant smoking history presents with intermittent episodes of vaginal bleeding found to have an exophytic cervical lesion most consistent with cervical cancer (squamous cell > adenocarcinoma)
• Key idea: For cervical cancer, Squamous cell carcinoma (~85%) is more common than Adenocarcinoma (~15%) and they have similar risk factors
• Risk factors for cervical cancer: HPV infection, immunosuppression, oral contraceptive use, tobacco use
• Feared complication of cervical carcinoma is post-renal AKI due to lateral invasion of cervical cancer to ureters
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376844/

28. A previously healthy 42-year-old woman comes to the physician because of irregular menses during the past 7 months. She has also…

Pregnancy test

• Key idea: In a woman in her 40’s who begins to show signs of menopause (irregular menses, hot flashes, mood changes), you always need to rule out pregnancy because it can lead to a similar presentation
• Key idea: Best lab test to specifically investigate menopause is Follicle stimulating hormone (FSH), will be elevated in setting of menopause (ovaries not producing as much estrogen –> less negative feedback on hypothalamus/anterior pituitary –> Increased FSH)
• Endometrial biopsy primarily indicated in setting of post-menopausal bleeding or abnormal uterine bleeding with risk factors

29. An otherwise healthy 27-year-old woman comes to the physician 2 weeks after noticing a tender mass in her left breast during breast…

Fibrocystic changes of the breast

• Young woman presenting with bilateral, soft, mobile, tender breast masses (“lumpy bumpy”) most consistent with fibrocystic changes of the breast
• Note: Definitely possible that the 3-cm mass is a fibroadenoma but importantly the answer of fibroadenoma would not explain the entire picture
• Key idea: Fibrocystic changes often associated with painful breast tissue before menses, whereas fibroadenomas often grow in size during menses

30. A 32-year-old woman, gravida 3, para 2, at 30 weeks’ gestation is brought to the emergency department because of pain…

Surgical exploration

• Pregnant woman at 30 weeks’ gestation presents with fever + RLQ abdominal pain + leukocytosis + fluid in right paracolic gutter most consistent with acute appendicitis –> Surgical exploration
• Key idea: Appendicitis is a clinical diagnosis and classically does not need imaging prior to proceeding to surgery (although recent guidelines are suggesting otherwise)
• Key idea: Appendicitis is a relatively common condition seen in pregnancy and while it can present similarly to typical appendicitis you may also see signs of uterine irritability, fetal tachycardia and pain that is not exactly localized to RLQ due to enlarged uterus pushing other structures around

31. A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive for 3 years. Menses occur at irregular…

Clomiphene

• Young women with infertility (unable to conceive >12 months) who has oligomenorrhea (irregular periods) with no evidence of structural problems, endometriosis, adenomyosis/fibroids or male reasons, and therefore is most likely dealing with some form of anovulation (most common cause of infertility and most often due to PCOS)
• Key idea: Patients with PCOS/anovulation who do NOT wish to become pregnant should be treated with combined OCPs, whereas patients who DO wish to become pregnant should be treated with Clomiphene (selective estrogen receptor modulator leading to reduced negative feedback on hypothalamus –> Increased GnRH release –> Increased LH/FSH –> Increased chance of successful ovulation)
• Danazol –> Partial agonist at androgen receptors that can be used in endometriosis
• Leuprolide –> GnRH agonist when used in a pulsatile manner but GnRH antagonist when given continuously

32. A 32-year-old woman, gravida 3, para 2, comes to the physician for her first prenatal visit. Her last…

Ultrasonography

• Key idea: Causes of an increased AFP include incorrect fetal dating, neural tube defects, abdominal wall defects (gastroschisis, omphalocele) and multiple gestations, all of which could be picked up on ultrasound (which is why ultrasound is indicated in setting of increased AFP)

33. A 24-year-old primigravid woman at 42 weeks’ gestation is admitted to the hospital for labor induction…

Administer a prostaglandin

• Post-term pregnant woman presents with normal vitals, normal nonstress fetal testing and oligohydramnios (which is commonly seen in post-term pregnancies) who should be induced to deliver before 43 weeks
• Key idea: Late-term pregnancy defined as lasting >41 weeks, whereas post-term pregnancy defined as lasting >42 weeks
• Key idea: Post-term pregnancy can be associated with oligohydramnios (as is seen in this patient) and fetal demise secondary to uteroplacental insufficiency, and therefore patients should be delivered prior to 43 weeks gestation
• Administer betamethasone –> Preterm labor before 34 weeks labor and sometimes preterm labor before 37 weeks gestation if lung maturation is in question
• Begin amnioinfusion –> Main indications include recurrent variable decelerations (to increase amniotic fluid and decrease umbilical cord compression) and in setting of meconium-stained amniotic fluid (old studies found it to improve outcomes in this situation)
• Immediate delivery: Eclampsia, fetal instability, etc.

34. An 18-year-old woman comes to the physician because of irregular menses over the past 3 months; menses occur at 14- to 40-day intervals…

Cyclic progesterone therapy

• Primary dysmenorrhea: Painful menses seen in young women due to excessive prostaglandin production
• Managed with NSAIDs or combined OCPs, and in this case given the irregular menses (likely due to an immature HPG axis in a young woman) we would probably opt for OCPs
• Note: Basically will NEVER give isolated estrogen without progesterone (conjugated estrogen therapy) due to risk of endometrial hyperplasia/carcinoma

35. A 47-year-old woman comes to the emergency department because of a 4-day history of increasing pain with urination. Five days…

Herpes simplex virus 1

• Painful genital ulcers: (1) Herpes simplex virus: Small vesicles/ulcers on erythematous base with mild lymphadenopathy (2) Chancroid (H. ducreyi): Large, deep ulcers with a soft, friable base and severe suppurative lymphadenopathy
• Painless genital ulcers: (1) Syphilis: Single ulcer with regular borders and hard base (chancre) (2) Lymphogranuloma venereum (Chylamydia trachomatis): Painless, shallow ulcers with painful fluctuant lymphadenopathy (buboes) (3) Condyloma acuminata: Painless, verrucous lesions associated with HPV infection
• Key idea: Once a patient is infected with genital herpes they will be infected for life and will tend to have flares during stressful periods

36. A 62-year-old woman comes to the physician because of two episodes of vaginal bleeding during the past 3 weeks. Menopause occurred…

Granulosa cell tumor

• Post-menopausal, non-obese woman presenting with signs of estrogen excess (vaginal bleeding and endometrial hyperplasia) and an ovarian mass most consistent with an estrogen-secreting granulosa cell tumor
• Sertoli-Leydig cell tumor –> Signs of androgen excess, which can be either hirsuitism (hair in androgen-sensitive areas) or virilization (voice deepening, increased muscle mass, cliteromegaly, male-pattern baldness)
• Note: Ovarian fibroma associated with Meigs syndrome (triad of ovarian fibroma, ascites and pleural effusion)

37. A 23-year-old woman, gravida 3, para 2, at 26 weeks’ gestation comes to the physician for a follow-up examination…

Parvovirus B19

• Causes of fetal hydrops:
  • Rh alloimmunization: Positive Indirect Coombs test, immigrant Rh negative patient who has had previous pregnancies
  • Parvovirus B19: Patient who experienced cold symptoms or joint pains during pregnancy or patient who has been exposed to children who are more likely to pass on Parvovirus B19 (teacher, daycare, etc.)
  • Severe alpha thalassemia [Hb Barts]: Mother is Asian or African American and likely has microcytic anemia with low red cell distribution width, normal iron studies, etc.
  • Fetal aneuploidy: Growth restriction, limb abnormalities, facial dysmorphia

38. At 37 weeks’ gestation, a 28-year-old woman with gestational diabetes delivers a 4500-g (10-lb) newborn who develops…

Insulin

• 3 factors associated with higher rates of neonatal respiratory distress syndrome:
  • Prematurity: Adequate surfactant production begins at 28 weeks and is reached at ~34 weeks
  • C-section delivery: Less stressful delivery for baby –> Less stress-induced steroids –> Less surfactant synthesis (reason why we use betamethasone, a steroid, to stimulate fetal lung development)
  • Maternal diabetes: Insulin decreases surfactant production
• Key idea: Babies born to women with gestational diabetes are at increased risk for hypoglycemia after delivery because they are cut off from their mother’s glucose but their pancreas continues to pump out insulin at higher rates (babies have to make their own insulin in utero because insulin CANNOT cross the placenta)
• Human placental lactogen –> Works against insulin in pregnancy so that mother’s blood has higher levels of sugar and amino acids that can pass through the placenta to the developing fetus

39. A 17-year old girl is brought to the physician by her mother because she has never had a menstrual period. She is otherwise healthy…

Karyotype analysis

• 17-year old girl with primary amenorrhea without secondary sexual development (pubic hair, breasts) and an elevated FSH level concerning for some form of ovarian dysfunction that has prevented production of estrogen, most likely Turner syndrome vs Primary ovarian failure –> Can differentiate between them using a Karyotype
• 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
• First step in primary amenorrhea work-up: Determine if uterus is present (physical exam, imaging) because if it is ABSENT then the patient either has Mullerian agenesis (XX, normal breast and pubic/axillary hair development) or Androgen Insensitivity Syndrome (XY, absent pubic/axillary hair with normal breast development)
• Second step in primary amenorrhea work-up: If patient with primary amenorrhea has a uterus, then next step is an FSH level because a low FSH tells you the pituitary/hypothalamus is dysfunctional (prolactinoma, hypothyroidism, functional hypothalamic amenorrhea), a normal FSH tells you they have a functional defect (imperforate hymen), and an elevated FSH tells you the ovaries are dysfunctional and can’t be stimulated (Turner syndrome, Primary ovarian failure)

40. A 28-year-old woman, gravida 1, para 1, has been amenorrheic and has had hot flashes for the past 6 months. She takes thyroid…

Autoimmune ovarian failure

• Young woman with autoimmune history coming in with amenorrhea and hot flashes found to have a low estrogen level and increased FSH level, most consistent with primary ovarian failure (menopause before age 40)
• Key idea: Primary ovarian failure often associated with autoimmune disease, history of pelvic radiation (past leukemia) or Fragile X syndrome
• Key idea: Patients with one autoimmune disease (Hashimoto thyroiditis, Vitiligo, Type 1 diabetes, etc.) are at high risk for other autoimmune diseases
• Key idea: Best lab test to specifically investigate menopause or primary ovarian failure is Follicle stimulating hormone (FSH), which will be elevated in those conditions (ovaries not producing as much estrogen –> less negative feedback on hypothalamus/anterior pituitary –> Increased FSH)

41. A 21-year-old woman comes to the physician because of a 2-week history of a small amount of vaginal discharge and itching…

Candida albicans

• 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
• Key idea: Recent antibiotic use (such as in this patient) can predispose to candidal vaginosis by disrupting normal vaginal flora
• “Addition of KOH to the discharge produces no odor” –> Negative whiff sign –> Rules out Bacterial vaginosis
• “A wet mount shows no motile organisms” –> Rules out Trichomonal vaginitis

42. A 12 1/2-old girl is brought to the physician because she has not had a menstrual period for 5 months. Menarche was at the age…

Normal development

• Key idea: Normal for girls to have irregular periods early in life due to immaturity of the HPG axis
• Athletic amenorrhea = Functional hypothalamic amenorrhea –> Patient would likely be low weight or participate in a particularly rigorous sport (cross country, gymnastics, etc.)

43. A 37-year-old woman, gravida 7, para 4, aborta 2, at 40 weeks’ gestation is admitted to the hospital in labor…

Uterine rupture

• Multigravid woman with history of C-section presenting at 40 weeks’ gestation with rupture of membranes accompanied by severe abdominal pain + decreased fundal height + fetal small parts above the fundus most concerning for uterine rupture
• Key idea: Uterine rupture clasically leads to abdominal pain + loss of fetal station + palpable fetal parts on abdominal exam
• Risk factors for uterine rupture: Previous C-section, fetal macrosomia
• Management: Laparotomy for delivery and repair of the uterus
• Placental abruption –> PAINFUL third trimester bleeding associated with drugs, trauma or HTN/pre-eclampsia
• Placenta previa –> PAINLESS third trimester bleeding often in a patient with a previous C-section
• Umbilical cord prolapse –> Umbilical cord passes into the vagina prematurely, emergency that should be managed by elevating fetal head (to avoid umbilical cord compression) and immediate C-section delivery

44. One month after an uncomplicated vaginal delivery of a 3400-g (7-lb 8-oz) newborn, a 32-year-old woman, gravida 2, para 2, comes to the…

Galactocele

• Breastfeeding mother presents with a focal tender mass in her breast without warmth, erythema or fever most consistent with galactocele or a plugged duct
• Note: UWorld says that galactocele should be nontender, but for this question we could rule out mastitis/abscess because of the lack of fever or other signs of inflammation and we could rule out engorgement because disease was unilateral
• Galactocele: Subareolar, mobile, nontender mass with no fever
• Mastitis: Tenderness/erythema of the breast + Fever
• Plugged duct: Focal tenderness, firmness and erythema with no fever
• Breast Engorgement: Bilateral symmetric fullness, tenderness and warmth of the breasts

45. A 27-year-old woman comes to the physician because of painful vulvar swelling for 2 days. She has had three episodes…

Bartholin duct abscess

• Young woman with multiple episodes of Neisseria gonorrhoeae infection who comes into the office with tender fluctuant mass of the labium majus most consistent with Bartholin duct abscess
• “Fluctuant mass” = Abscess
• Note: Although Bartholin gland cyst/abscess is associated with Neisseria gonorrhoeae infection, the infection itself is almost always polymicrobial

46. A 20-year-old woman, gravida 2, para 1, at 42 weeks’ gestation is admitted to the hospital in labor. She reports severe abdominal pain…

Injury to the fifth and sixth cervical roots

• Newborn with a difficult delivery who is unable to move their arm and has it adducted, extended and internally rotated, most consistent with an Erb palsy (damage to C5 and C6 nerve roots)
• Lateral traction on the neck during delivery can lead to Erb palsy (damage to C5 and C6) leading to dysfunction of deltoid/supraspinatus (loss of shoulder abduction), infraspinatus (loss of external rotation of shoulder) and biceps (loss of forearm flexion), leading to a waiter’s tip position
• Clavicular fracture –> Pain with movement of arm + crepitus of clavicle
• Hypoxic injury –> Cerebral palsy –> Abnormal tone
• Partial dislocation (Nursemaid’s elbow) seen after a young child has his/her arm tugged and patient will present with arm flexed and up against body
• Injury to C8 and T1 –> Klumpe palsy –> Total claw hand

47. A 38-year-old woman, gravida 3, para 1, aborta 1, is admitted to the hospital at 33 weeks’ gestation because of suspected pyelonephritis…

Maternal fever

• Fetal tachycardia: Heart rate > 160 beats/min
• Causes of fetal tachycardia
  • Maternal fever
  • Medications (stimulants)
  • Fetal hyperthyroidism
  • Fetal tachyarrhythmia
• 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

48. A 27-year-old woman comes to the physician because of a 4-month history of increasingly severe pain during her menstrual periods…

Cervical stenosis

• Young woman who received a LEEP and then shortly after developed progressive pain during menstrual periods with low amounts of flow found to have a small, scarred cervix and an enlarged, tender uterus most consistent with cervical stenosis
• Key idea: Cervical stenosis can lead to cyclical pain due to blood being trapped in the uterus
• Endometritis often seen in the postpartum period (fever and lower abdominal pain)
• Premenstrual syndrome –> Often seen in young girls beginning to have period, so would be strange to develop in mid-late 20’s

49. A 37-year-old woman, gravida 5, para 3, aborta 1, at 40 weeks’ gestation is admitted in labor. Contractions began 2 hours ago. She has not had…

Ultrasonography

• Key idea: Ultrasonography useful for determining fetal position when unable to palpate presenting fetal part
• Fetal scalp stimulation –> often used to assess fetal well-being in setting of decreased movement or abnormal fetal heart tracing (neither of which this patient has)
• Amniotomy –> Would not want to perform without knowing the orientation of the baby
• Indications for C-section in early labor:
  • Category 3 fetal heart tracings:
    • Fetal bradycardia (<110 beats/min) with absent variability
    • Recurrent late decelerations with absent variability
    • Recurrent variable decelerations with absent variability
    • Sinusoidal pattern (sign of fetal anemia)
  • Failure to progress

50. A 47-year-old woman has had increasing fatigue, constipation, night sweats, anxiety, and mood lability over the past year. Her…

Follicle-stimulating hormone

• Woman around menopausal age who has secondary amenorrhea and signs concerning for menopause (fatigue, night sweats, mood swings) and therefore should have her FSH level measured (increased in setting of menopause)
• Key idea: Best lab test to specifically investigate menopause is Follicle stimulating hormone (FSH), will be elevated in setting of menopause (ovaries not producing as much estrogen –> less negative feedback on hypothalamus/anterior pituitary –> Increased FSH)
• Key idea: Average age of menopause is 52