Obstetrics And Gynecology PreTest Self-Assessment And Review [13th ed.] 978-0071761260

Table of contents :
Introduction......Page 8
Obstetrics......Page 9
Questions......Page 10
Answers......Page 18
Questions......Page 23
Answers......Page 25
Questions......Page 27
Answers......Page 33
Questions......Page 37
Answers......Page 42
Questions......Page 47
Answers......Page 51
Questions......Page 56
Answers......Page 60
Questions......Page 64
Answers......Page 68
Gynecology......Page 73
Questions......Page 74
Answers......Page 77
Questions......Page 80
Answers......Page 88
Questions......Page 94
Answers......Page 102
Questions......Page 109
Answers......Page 113
Questions......Page 116
Answers......Page 120
Questions......Page 124
Answers......Page 126
Questions......Page 129
Answers......Page 130
Bibliography......Page 132
Index......Page 133

Citation preview

Notice Medi ci ne i s a n ever-cha ngi ng s ci ence. As new res ea rch a nd cl i ni ca l experi ence broa den our knowl edge, cha nges i n trea tment a nd drug thera py a re requi red. The a uthors a nd the publ i s her of thi s work ha ve checked wi th s ources bel i eved to be rel i a bl e i n thei r efforts to provi de i nforma on tha t i s compl ete a nd genera l l y i n a ccord wi th the s ta nda rds a ccepted a t the me of publ i ca on. However, i n vi ew of the pos s i bi l i ty of huma n error or cha nges i n medi ca l s ci ences , nei ther the a uthors nor the publ i s her nor a ny other pa rty who ha s been i nvol ved i n the prepa ra on or publ i ca on of thi s work wa rra nts tha t the i nforma on conta i ned herei n i s i n every res pect a ccura te or compl ete, a nd they di s cl a i m a l l res pons i bi l i ty for a ny errors or omi s s i ons or for the res ul ts obta i ned from us e of the i nforma on conta i ned i n thi s work. Rea ders a re encoura ged to confirm the i nforma on conta i ned herei n wi th other s ources . For exa mpl e a nd i n pa r cul a r, rea ders a re a dvi s ed to check the product i nforma on s heet i ncl uded i n the pa cka ge of ea ch drug they pl a n to a dmi ni s ter to be certa i n tha t the i nforma on conta i ned i n thi s work i s a ccura te a nd tha t cha nges ha ve not been ma de i n the recommended dos e or i n the contra i ndi ca ons for a dmi ni s tra on. Thi s recommenda on i s of pa r cul a r i mporta nce i n connecti on wi th new or i nfrequentl y us ed drugs .

Copyri ght © 2012 by The McGra w-Hi l l Compa ni es , Inc. Al l ri ghts res erved. Except a s permi ed under the Uni ted Sta tes Copyri ght Act of 1976, no pa rt of thi s publ i ca on ma y be reproduced or di s tri buted i n a ny form or by a ny mea ns , or s tored i n a da ta ba s e or retri eva l s ys tem, wi thout the pri or wri tten permi s s i on of the publ i s her. ISBN: 978-0-07-176127-7 MHID: 0-07-176127-6 The ma teri a l i n thi s eBook a l s o a ppea rs i n the pri nt vers i on of thi s ti tl e: ISBN: 978-0-07-176126-0, MHID: 0-07-176126-8. Al l tra dema rks a re tra dema rks of thei r res pec ve owners . Ra ther tha n put a tra dema rk s ymbol a er every occurrence of a tra dema rked na me, we us e na mes i n a n edi tori a l fa s hi on onl y, a nd to the benefit of the tra dema rk owner, wi th no i nten on of i nfri ngement of the tra dema rk. Where s uch des i gna ti ons a ppea r i n thi s book, they ha ve been pri nted wi th i ni ti a l ca ps . McGra w-Hi l l eBooks a re a va i l a bl e a t s peci a l qua n ty di s counts to us e a s premi ums a nd s a l es promo ons , or for us e i n corpora te tra i ni ng progra ms . To conta ct a repres enta ti ve pl ea s e e-ma i l us a t bul ks a l es @mcgra w-hi l l .com. TERMS OF USE Thi s i s a copyri ghted work a nd The McGra w-Hi l l Compa ni es , Inc. (“McGra w-Hi l l ”) a nd i ts l i cens ors res erve a l l ri ghts i n a nd to the work. Us e of thi s work i s s ubject to thes e terms . Except a s permi ed under the Copyri ght Act of 1976 a nd the ri ght to s tore a nd retri eve one copy of the work, you ma y not decompi l e, di s a s s embl e, revers e engi neer, reproduce, modi fy, crea te deri va ve works ba s ed upon, tra ns mi t, di s tri bute, di s s emi na te, s el l , publ i s h or s ubl i cens e the work or a ny pa rt of i t wi thout McGra w-Hi l l ’s pri or cons ent. You ma y us e the work for your own noncommerci a l a nd pers ona l us e; a ny other us e of the work i s s tri ctl y prohi bi ted. Your ri ght to us e the work ma y be termi na ted i f you fa i l to compl y wi th thes e terms . THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGra w-Hi l l a nd i ts l i cens ors do not wa rra nt or gua ra ntee tha t the func ons conta i ned i n the work wi l l meet your requi rements or tha t i ts opera on wi l l be uni nterrupted or error free. Nei ther McGra w-Hi l l nor i ts l i cens ors s ha l l be l i a bl e to you or a nyone el s e for a ny i na ccura cy, error or omi s s i on, rega rdl es s of ca us e, i n the work or for a ny da ma ges res ul ng therefrom. McGra w-Hi l l ha s no res pons i bi l i ty for the content of a ny i nforma on a cces s ed through the work. Under no ci rcums ta nces s ha l l McGra w-Hi l l a nd/or i ts l i cens ors be l i a bl e for a ny i ndi rect, i nci denta l , s peci a l , puni ve, cons equen a l or s i mi l a r da ma ges tha t res ul t from the us e of or i na bi l i ty to us e the work, even i f a ny of them ha s been a dvi s ed of the pos s i bi l i ty of s uch da ma ges . Thi s l i mi ta ti on of l i a bi l i ty s ha l l a ppl y to a ny cl a i m or ca us e wha ts oever whether s uch cl a i m or ca us e a ri s es i n contra ct, tort or otherwi s e.

Student Reviewers Nisha David Thi rd-Yea r Medi ca l Student Uni vers i ty of Roches ter Cl a s s of 2011 Kay-Yoon Flannery Thi rd-Yea r Medi ca l Student UMDNJ School of Os teopa thi c Medi ci ne Cl a s s of 2011 Stephanie Henderson Fourth-Yea r Medi ca l Student Uni vers i ty of Roches ter Cl a s s of 2011 Svjetlana Lozo, MD PGY-2 ObGyn Res i dent St George’s School of Medi ci ne Cl a s s of 2009 Abigail Whetstone Fourth-Yea r Medi ca l Student UMDNJ School of Os teopa thi c Medi ci ne Cl a s s of 2012

Contents Introduction Obstetrics Preconception Counseling, Genetics, and Prenatal Diagnosis Questions Answers Maternal-Fetal Physiology and Placentation Questions Answers Antepartum Care and Fetal Surveillance Questions Answers Obstetrical Complications of Pregnancy Questions Answers Medical and Surgical Complications of Pregnancy Questions Answers Normal and Abnormal Labor and Delivery Questions Answers The Puerperium, Lactation, and Immediate Care of the Newborn Questions Answers Gynecology Preventive Care and Health Maintenance Questions Answers Benign and Malignant Disorders of the Breast and Pelvis Questions Answers Infertility, Endocrinology, and Menstrual Dysfunction Questions Answers Pelvic Relaxation and Urology Questions Answers Human Sexuality and Contraception Questions Answers Sexual Abuse and Domestic Violence Questions Answers

Ethical and Legal Issues in Obstetrics and Gynecology Questions Answers

Bibliography Index

Introduction Obstetrics and Gynecology: PreTest ™ Self-Assessment and Review, 13th Edi on, i s i ntended to provi de medi ca l s tudents , a s wel l a s phys i ci a ns , wi th a conveni ent tool for a s s es s i ng a nd i mprovi ng thei r knowl edge of obs tetri cs a nd gynecol ogy. The 502 ques ons i n thi s book a re s i mi l a r i n forma t a nd compl exi ty to thos e i ncl uded i n Step 2 of the Uni ted Sta tes Medi ca l Li cens i ng Exa mi na on (USMLE). They ma y a l s o be a us eful s tudy tool for Step 3. Ea ch ques on i n thi s book ha s a corres pondi ng a ns wer, a reference to a text tha t provi des ba ckground for the a ns wer, a nd a s hort di s cus s i on of va ri ous i s s ues ra i s ed by the ques on a nd i ts a ns wer. A l i s ng of references for the en re book fol l ows the l a s t cha pter. For mul pl e-choi ce ques ons , the one best res pons e to ea ch ques on s houl d be s el ected. For ma tchi ng s ets , a group of ques ons wi l l be preceded by a l i s t of l ettered opti ons . For ea ch ques ti on i n the ma tchi ng s et, s el ect one l ettered opti on tha t i s most cl os el y a s s oci a ted wi th the ques ti on. To s i mul a te the me cons tra i nts i mpos ed by the qua l i fyi ng exa mi na ons for whi ch thi s book i s i ntended a s a pra c ce gui de, the s tudent or phys i ci a n s houl d a l l ot a bout 1 mi nute for ea ch ques on. A er a ns weri ng a l l ques ons i n a cha pter, a s much me a s neces s a ry s houl d be s pent revi ewi ng the expl a na ons for ea ch ques on a t the end of the cha pter. A en on s houl d be gi ven to a l l expl a na ons , even i f the exa mi nee a ns wered the ques on correctl y. Thos e s eeki ng more i nforma on on a s ubject s houl d refer to the reference ma teri a l s l i s ted or to other s ta nda rd texts i n medi ci ne.

Obstetrics

Preconception Counseling, Genetics, and Prenatal Diagnosis Questions 1. A er a n i ni a l pregna ncy res ul ted i n a s ponta neous l os s i n the firs t tri mes ter, your pa ent i s concerned a bout the pos s i bi l i ty of thi s recurri ng. Whi ch of the fol l owi ng i s the mos t a ppropri a te a ns wer rega rdi ng the cha nce of recurrence? a . It depends on the geneti c ma keup of the pri or a bortus . b. It i s no di fferent tha n i t wa s pri or to the mi s ca rri a ge. c. It ha s i ncrea s ed to a pproxi ma tel y 50%. d. It ha s i ncrea s ed mos t l i kel y to grea ter tha n 50%. e. It depends on the s ex of the pri or a borted fetus . 2. A 24-yea r-ol d woma n ha s ha d three firs t-tri mes ter s ponta neous a bor ons . Whi ch of the fol l owi ng s ta tements concerni ng chromos oma l a berra ti ons i n a borti ons i s true? a . 45 X i s more preva l ent i n chromos oma l l y a bnorma l term ba bi es tha n i n s ponta neous l y a borted pregna nci es . b. Approxi ma tel y 20% of fi rs t-tri mes ter s ponta neous a borti ons ha ve chromos oma l a bnorma l i ti es . c. Tri s omy 21 i s the mos t common tri s omy i n a bortus es . d. Des pi te the rel a ti vel y hi gh frequency of Down s yndrome a t term, mos t Down fetus es a bort s ponta neous l y. e. Sti l l bi rths ha ve twi ce the i nci dence of chromos oma l a bnorma l i ti es a s l i ve bi rths . 3. A 29-yea r-ol d G3P0 pres ents to your office for preconcep on couns el i ng. Al l of her pregna nci es were l os t i n the firs t tri mes ter. She ha s no s i gni fica nt pa s t medi ca l or s urgi ca l hi s tory. She s houl d be couns el ed tha t wi thout eva l ua on a nd trea tment her cha nce of ha vi ng a l i ve bi rth i s whi ch of the fol l owi ng? a . 85% 4. A 26-yea r-ol d G3P0030 ha s ha d three cons ecuti ve s ponta neous a borti ons i n the fi rs t tri mes ter. As pa rt of a n eva l ua ti on for thi s probl em, whi ch of the fol l owi ng tes ts i s mos t a ppropri a te i n the eva l ua ti on of thi s pa ti ent? a . Hys teros a l pi ngogra m b. Chromos oma l a na l ys i s of the coupl e c. Endometri a l bi ops y i n the l utea l pha s e d. Pos tcoi ta l tes t e. Cervi ca l l ength by ul tra s onogra phy 5. A 30-yea r-ol d G1P0 a t 8 weeks ges ta on pres ents for her firs t prena ta l vi s i t. She ha s no s i gni fica nt pa s t medi ca l or s urgi ca l hi s tory. A 29-yea r-ol d fri end of hers jus t ha d a ba by wi th Down s yndrome a nd s he i s concerned a bout her ri s k of ha vi ng a ba by wi th the s a me probl em. The pa ent deni es a ny fa mi l y hi s tory of gene c di s orders or bi rth defects . You s houl d tel l her tha t s he ha s a n i ncrea s ed ri s k of ha vi ng a ba by wi th Down s yndrome i n whi ch of the fol l owi ng ci rcums ta nces ? a . The a ge of the fa ther of the ba by i s 40 yea rs or ol der. b. Her pregna ncy wa s a chi eved by i nducti on of ovul a ti on a nd a rti fi ci a l i ns emi na ti on. c. She ha s a n i ncompetent cervi x. d. She ha s a l utea l pha s e defect. e. She ha s ha d three fi rs t-tri mes ter s ponta neous a borti ons . 6. A 20-yea r-ol d woma n pres ents to your office for rou ne wel l -woma n exa mi na on. She ha s a hi s tory of a cne, for whi ch s he ta kes mi nocycl i ne a nd i s otre noi n on a da i l y ba s i s . She ha s a hi s tory of epi l eps y tha t i s wel l -control l ed on va l proi c a ci d. She a l s o ta kes a combi ned ora l contra cep ve bi rth control pi l l conta i ni ng norethi ndrone a ceta te a nd ethi nyl es tra di ol . She i s a nons moker but dri nks a l cohol on a da i l y ba s i s . She i s concerned a bout the effec venes s of her bi rth control pi l l , gi ven a l l the medi ca ons tha t s he ta kes . She i s pa r cul a rl y worri ed a bout the effects of her medi ca ons on a devel opi ng fetus i n the event of a n uni ntended pregna ncy. Whi ch of the fol l owi ng s ubs ta nces tha t s he i nges ts ha s the l owes t potenti a l to ca us e bi rth defects ? a . Al cohol b. Is otreti noi n (Accuta ne) c. Tetra cycl i nes d. Proges terone e. Va l proi c a ci d (Depa kote) 7. A 24-yea r-ol d woma n i s i n a ca r a cci dent a nd i s ta ken to a n emergency room, where s he recei ves x-ra y exa mi na ons of her neck, ches t, a nd l ower s pi ne. It i s l a ter di s covered tha t s he i s 10-weeks pregna nt. Whi ch of the fol l owi ng i s the mos t a ppropri a te s ta tement to ma ke to the pa ti ent? a . The fetus ha s recei ved 50 ra ds of x-ra y expos ure a nd wi l l l i kel y a bort. b. Ei ther chori oni c vi l l us s a mpl i ng (CVS) or a mni ocentes i s i s a dvi s a bl e to check for feta l chromos oma l a bnorma l i ti es . c. At 10 weeks , the fetus i s pa rti cul a rl y s us cepti bl e to dera ngements of the centra l nervous s ys tem (CNS). d. The fetus ha s recei ved l es s tha n the a s s umed thres hol d for ra di a ti on da ma ge. e. The ri s k tha t thi s fetus wi l l devel op l eukemi a a s a chi l d i s ra i s ed. 8. A 25-yea r-ol d G0 pres ents to your office for preconcep on couns el i ng. She i s a l ong-di s ta nce runner a nd wa nts to con nue to tra i n s houl d s he concei ve. She wa nts to know whether there a re a ny poten a l a dvers e effects to a devel opi ng fetus i f s he were to purs ue a progra m of regul a r

exerci s e duri ng her pregna ncy. You a dvi s e her of whi ch of the fol l owi ng true s ta tements rega rdi ng exerci s e a nd pregna ncy? a . Duri ng pregna ncy, s he s houl d s top exerci s i ng beca us e s uch a cti vi ty i s commonl y a s s oci a ted wi th i ntra uteri ne growth reta rda ti on i n the fetus . b. She s houl d perform exerci s es i n the s upi ne pos i ti on to ma xi mi ze venous return a nd ca rdi a c output. c. She ma y conti nue to exerci s e throughout pregna ncy a s l ong a s her hea rt ra te does not exceed 160. d. She s houl d onl y perform non-wei ght-bea ri ng exerci s es beca us e they mi ni mi ze the ri s ks of ma terna l a nd feta l i njuri es . e. She s houl d reduce her da i l y exerci s e rou ne by one-ha l f duri ng the pregna ncy but fol l owi ng del i very, s he ma y res ume her a c vi es to prepregna ncy l evel s . 9. A 47-yea r-ol d woma n ha s a chi eved a pregna ncy vi a i n vi tro fer l i za on (IVF) us i ng donor eggs from a 21-yea r-ol d woma n a nd s perm from her 46yea r-ol d hus ba nd. She ha s a s onogra m performed a t 6 weeks ges ta ona l a ge tha t s hows a twi n pregna ncy. A s ubs equent s onogra m a t 12 weeks s hows a 5-mm nucha l fol d i s di s covered i n one of the embryos . Impl i ca ti ons of thi s i ncl ude whi ch of the fol l owi ng? a . The embryo ha s a hi gh ri s k of a neura l tube defect. b. The embryo ha s a hi gh ri s k of a ca rdi a c ma l forma ti on. c. Such a nucha l fol d i s norma l a nd there a re no i mpl i ca ti ons to the fetus . d. If the nucha l tra ns l ucency res ol ves , the ri s k of a chromos ome a bnorma l i ty i s compa ra bl e to tha t of other embryos . e. The embryo ha s a n a bnorma l ka ryotype wi th the mos t l i kel y di a gnos i s of Turner s yndrome. 10. Your pa ent pres ents for her firs t prena ta l vi s i t. She i s 27-yea r-ol d a nd thi s i s her firs t pregna ncy. She i s a n a chondropl a s c dwa rf. Her hus ba nd i s of norma l s ta ture. Whi ch of the fol l owi ng s ta tements s houl d you tel l her rega rdi ng a chondropl a s i a ? a . The i nheri ta nce pa ttern i s a utos oma l reces s i ve therefore there i s a one-i n-four cha nce tha t her chi l d wi l l be a ffected. b. Achondropl a s i a i s ca us ed by a new geneti c muta ti on therefore i t ca nnot be pa s s ed on to her chi l d. c. Beca us e s he ha s a chondropl a s i a s he ha s a l ow ri s k of ces a rea n s ecti on for del i very. d. She i s fortuna te to ha ve l i ved to reproducti ve a ge. e. She l i kel y ha s s ome degree of s pi na l s tenos i s whi ch coul d pres ent a di ffi cul ty wi th s pi na l or epi dura l a nes thes i a . 11. A 25-yea r-ol d G3P0 pres ents for preconcep on couns el i ng. She ha s ha d three firs t-tri mes ter pregna ncy l os s es . As pa rt of her eva l ua on for recurrent a bor on, s he ha d ka ryotypi ng done on hers el f a nd her hus ba nd. Her hus ba nd i s 46, XY. She ca rri es a ba l a nced 13;13 tra ns l oca on. Wha t i s the l i kel i hood tha t her next ba by wi l l ha ve a n a bnorma l ka ryotype? a . 3 cm) between funda l . Therefore, the pa ent does not need to be i nduced. Si nce the pa ent ha s been repor ng good feta l movement a nd i s not pos t-term, there i s no i ndi ca on to do a ntepa rtum tes ng s uch a s a n NST. A fern tes t i s not i ndi ca ted s i nce the pa ent ha s not reported l ea ka ge of flui d. An a s s es s ment of a mni o c flui d to detect ol i gohydra mni os i s not i ndi ca ted s i nce the funda l hei ght i s a ppropri a te for the pa ti ent’s ges ta ti ona l a ge. 87. The answer is d. (Cunningham, p 200.) Va gi na l ul tra s ound ca n detect feta l hea rt a c on a s ea rl y a s 5 weeks of a menorrhea . Wi th a tra di ona l , nonel ectri c feta l s tethos cope, hea rt tones ca n be hea rd a er 19 to 20 weeks ges ta ona l a ge. Wi th a Doppl er s tethos cope, feta l hea rt tones ca n be

us ua l l y be detected by 10 weeks ges ta ti ona l a ge. 88. The answer is d. (Cunningham, pp 530-532, 539-542.) The pa ent who ha s a fetus wi th a breech pres enta on ha s the op on of s chedul i ng a n externa l cepha l i c vers i on, a n el ec ve ces a rea n s ec on a t or a er 39 weeks , or ca n el ect to ha ve a va gi na l breech del i very i f certa i n condi ons a re met. It i s i na ppropri a te to el ec vel y del i ver a ny pa ent pri or to 39 weeks wi thout a documenta on of feta l l ung ma turi ty beca us e of the ri s k of neona ta l res pi ra tory di s tres s s yndrome (RDS). Therefore, i f a pa ent decl i nes to undergo a va gi na l breech del i very, a n el ec ve ces a rea n s houl d be s chedul ed a t or a er 39 weeks ges ta ona l a ge to a voi d RDS. If a pa ent woul d l i ke to a voi d a ces a rea n s ec on but does not wa nt to undergo a va gi na l breech del i very, then a n externa l cepha l i c vers i on i s a n a ppropri a te ma na gement pl a n. Externa l cepha l i c vers i on (ECV) i s a procedure where the breech fetus i s ma ni pul a ted through the a bdomi na l wa l l to cha nge the pres enta on to vertex. Studi es i ndi ca te tha t i f a n ECV i s not performed, 80% of breech pres enta ons wi l l pers i s t a t term vers us onl y 30% i f a s ucces s ful vers i on i s performed. ECV ha s a n a vera ge s ucces s ra te of a bout 60%; i t i s mos t s ucces s ful i n pa rous women wi th a n unenga ged breech a nd a norma l a mount of a mni o c flui d (a l l condi ons tha t exi s t i n the pa ent des cri bed). A tri a l of l a bor for a pregna nt woma n wi th a fetus i n the breech pres enta on i s a ppropri a te i f the fetus i s fra nk breech, ha s a flexed hea d, ha s a norma l a mount of a mni o c flui d, a nd ha s a n es ma ted wei ght between 2500 a nd 3800 g. In a ddi on, the pel vi s s houl d be a dequa te a s a s s es s ed wi th x-ra y pel vi metry or a hi s tory of del i very of a previ ous ba by of bi gger s i ze. A fetus wi th a hyperextended, or “s ta rga zer,” hea d ha s a hi gher ri s k of s pi na l cord i njury duri ng va gi na l breech del i very; therefore del i very s houl d be by ces a rea n del i very. The bes t cours e of ma na gement i n thi s ca s e i s externa l cepha l i c vers i on. 89. The answer is d. (Cunningham, pp 832-841.) Pos erm or prol onged pregna nci es a re thos e pregna nci es tha t ha ve gone beyond 42 compl eted weeks of ges ta on. In genera l , obs tetri ci a ns do not a l l ow pregna nci es to pers i s t a er 42 weeks beca us e of the s i gni fica ntl y i ncrea s ed i nci dence of peri na ta l morbi di ty a nd morta l i ty. If a pa ent ha s a fa vora bl e cervi x, i t i s rea s ona bl e to i nduce the pa ent a t 41 weeks beca us e the cha nce of ha vi ng a s ucces s ful va gi na l del i very i s very hi gh. On the other ha nd, i f the pa ent ha s a n unfa vora bl e cervi x, i t i s genera l l y recommended tha t s he con nue wi th the pregna ncy. Al terna vel y, a pa ent ca n be i nduced a t 41 weeks wi th a n unfa vora bl e cervi x i f cervi ca l ri peni ng a gents a re us ed. If a pa ent wa i ts un l 42 weeks a nd s l l ha s a n unfa vora bl e cervi x, then a dmi s s i on wi th a dmi ni s tra on of cervi ca l ri peni ng a gents pri or to Pi toci n i nducti on i s recommended to i mprove the l i kel i hood of a s ucces s ful va gi na l del i very.

The Bi s hop s core i s a method to document the fa vora bi l i ty of the cervi x to i nduc on. The el ements of the Bi s hop s core i ncl ude effa cement, di l a on, s ta on, cons i s tency, a nd pos i on of the cervi x (s ee ta bl e). Poi nts a re a s s i gned for ea ch el ement, a nd then tota l ed to gi ve the Bi s hop s core. Induc on to a c ve l a bor i s us ua l l y s ucces s ful wi th a Bi s hop s core of 9 or grea ter. In the s cena ri o des cri bed here, the pa ent ha s a Bi s hop s core of 4, whi ch i s unfa vora bl e for i nduc on. Therefore, expecta nt ma na gement i s a rea s ona bl e ma na gement pl a n to try to gi ve the cervi x me to ri pen to a voi d a ces a rea n s ec on. It i s not recommended to perform a n el ec ve s ec on wi thout a tri a l of l a bor beca us e of the ri s ks of ma jor s urgery. 90. The answer is c. (Cunningham, pp 832-841.) As di s cus s ed i n ques on 89, pa ents a t 41 to 42 weeks ges ta on wi th good da ng cri teri a a nd a fa vora bl e cervi x s houl d undergo i nduc on of l a bor. If the cervi x i s unfa vora bl e, feta l wel l -bei ng s houl d be a s s es s ed pri or to a l l owi ng the pregna ncy to con nue. Pa ent s el f-a s s es s ment by mea s urement of feta l ki ck counts , NST, contra c on s tres s tes ng, a nd bi ophys i ca l profil e (BPP) ma y be us ed to a s s es s feta l wel l -bei ng. The BPP, whi ch a s s es s es the feta l hea rt ra te tra ci ng, feta l tone, feta l brea thi ng, feta l movement a nd the a mni o c flui d l evel , i s the next bes t s tep i n the ma na gement of thi s pa ent. Induc on of l a bor i s recommended a t 42 weeks rega rdl es s of the fa vora bi l i ty of the cervi x beca us e of the i ncrea s ed ri s k of peri na ta l morbi di ty a er tha t ges ta ona l a ge. As noted a bove, i t i s not recommended to perform a n el ecti ve s ecti on wi thout a tri a l of l a bor beca us e of the ri s ks of ma jor s urgery. 91. The answer is b. (Cunningham, pp 495-498, 501-505. ACOG, Practice Bulletin 10.) Pa ti ents wi th ol i gohydra mni os a t term s houl d be del i vered. If there i s no contra i ndi ca on to va gi na l del i very, the pa ent s houl d be i nduced. The pa ent wi th a n unfa vora bl e cervi x ma y undergo cervi ca l ri peni ng a er a s s es s ment of feta l wel l -bei ng. If feta l tes ng i s rea s s uri ng, the unfa vora bl e cervi x ca n be ri pened wi th a va ri ety of mecha ni ca l a nd pha rma col ogi c a gents pri or to i ni a ng Pi toci n. Pha rma col ogi c a gents i ncl ude pros ta gl a ndi n E 2 prepa ra ons a va i l a bl e a s a va gi na l /cervi ca l gel (Prepi di l ) or va gi na l i ns ert (Cervi di l ). Mi s opros tol , a s ynthe c PGE1 a na l ogue, ha s been us ed off-l a bel for pre-i nduc on cervi ca l ri peni ng a nd l a bor i nduc on. It ca n be a dmi ni s tered vi a the ora l or va gi na l route. Mecha ni ca l ri peni ng of the cervi x ca n be a chi eved wi th l a mi na ri a , whi ch i s a hygros copi c di l a tor tha t i s pl a ced i n the cervi ca l ca na l a nd a bs orbs wa ter from the s urroundi ng cervi ca l s s ue. Pi toci n i s not cons i dered a cervi ca l ri peni ng a gent but a l a bor-i nduci ng a gent. In pa ents wi th ol i gohydra mni os , cervi ca l ri peni ng s houl d be performed i n the hos pi ta l under conti nuous feta l moni tori ng. 92. The answer is a. (Cunningham, pp 429, 432-433. ACOG, Technical Bulle n 207.) A feta l hea rt ra te tra ci ng i ndi ca ng ta chyca rdi a , decrea s ed or a bs ent va ri a bi l i ty, a nd pers i s tent l a te decel era ons i s i ndi ca ve of feta l meta bol i c a ci dos i s a nd hypoxi a . Prompt i nterven on a nd del i very i s i ndi ca ted. There i s no i ndi ca on for a dmi ni s teri ng MgSO 4 s i nce the pa ent i s not preecl a mp c; her bl ood pres s ure i s not el eva ted a nd s he does not ha ve protei nuri a . Si nce i mmi nent del i very of the fetus i s i ndi ca ted by the nonre-a s s uri ng feta l hea rt ra te pa ern, there i s no rol e for a dmi ni s teri ng cervi ca l ri peni ng a gents or Pi toci n. 93. The answer is e. (Cunningham, pp 335-336. ACOG, Prac ce Bulle n 9.) Ma terna l percep on of decrea s ed feta l movement ma y precede feta l dea th i n utero. Therefore, ki ck counts ha ve been empl oyed a s a method of a ntepa rtum a s s es s ment. The op ma l number of feta l movements tha t s houl d be percei ved per hour ha s not been determi ned. However, s tudi es i ndi ca te tha t the percep on of 10 di s nct movements i n a peri od of up to 2 hours i s rea s s uri ng. Si nce thi s pa ent i s experi enci ng onl y one movement per hour, a nd thi s movement i s decrea s ed from her previ ous ba s el i ne, further a ntepa rtum tes ti ng i s i ndi ca ted. A nons tres s tes t i s the preferred moda l i ty. A contra cti on s tres s tes t i nvol ves provoki ng uteri ne contra cti ons a nd eva l ua ng the res pons e of the feta l hea rt ra te tra ci ng to contra c ons . As thi s pa ent i s preterm, provoki ng contra c ons s houl d be a voi ded. Del i very i s not i ndi ca ted unti l nonrea s s uri ng feta l s ta tus ca n be documented.

94. The answer is b. (Cunningham, pp 341-342. ACOG, Practice Bulletin 9.) The BPP cons i s ts of fi ve components : 1. Nons tres s tes t 2. Feta l brea thi ng movements —one or more epi s odes of feta l brea thi ng movements of 30 s econds or more wi thi n 30 mi nutes 3. Feta l movement—three or more di s crete body or l i mb movements wi thi n 30 mi nutes 4. Feta l tone—one or more epi s odes of extens i on of a feta l extremi ty wi th return to fl exi on, or openi ng or cl os i ng of a ha nd 5. Determi na ti on of a mni oti c fl ui d vol ume—a s i ngl e verti ca l pocket of a mni oti c fl ui d exceedi ng 2 cm Ea ch of thes e components i s a s s i gned a s core of 2 (norma l ) or 0 (a bnorma l or a bs ent). In the modi fied BPP, onl y the NST a nd determi na on of a mni oti c fl ui d vol ume a re a s s es s ed. 95. The answer is c. (Cunningham, pp 341-342. ACOG, Prac ce Bulle n 9.) A BPP s core of 8 or 10 i s norma l . A s core of 0 to 2 di cta tes i mmi nent del i very, beca us e feta l a s phyxi a i s proba bl e. Scores of 4 to 6 requi re repea t tes ti ng a nd del i very i f pers i s tent. 96. The answer is b. (Cunningham, pp 78, 195.) The expected da te of del i very ca n be es ma ted by us i ng Na egel e’s rul e. To do thi s , count ba ck 3 months a nd then a dd 7 da ys to the da te of the fi rs t da y of the l a s t norma l mens trua l peri od. 97. The answer is e. (Cunningham, pp 199-200, 257-259.) At 11 weeks of ges ta on, the uterus i s s l l wi thi n the pel vi s a nd s houl d not be pa l pa bl e a bove the s ymphys i s pubi s . A uterus tha t i s pa l pa bl e mi dwa y between the s ymphys i s pubi s a nd the umbi l i cus i s 14 to 16 weeks i n s i ze. The feta l hea rt tones a re a udi bl e i n mos t pa ents a t 10 weeks . If no feta l hea rt tones a re a udi bl e by Doppl er a us cul ta on a nd the pa ent i s 10 weeks or more, a n ul tra s ound of the pregna ncy s houl d be ordered. Mol a r pregna ncy, twi n ges ta on, i ncorrect da tes , a nd uteri ne fibroi ds a re a l l pos s i bl e di a gnos es when the uterus i s l a rge for da tes ; therefore, ul tra s onogra phy i s the firs t s tep i n the eva l ua on of s i ze/da te di s crepa ncy. Al though mol a r pregna ncy i s a n i ndi ca on for di l a on a nd cure a ge, the procedure i s not i ndi ca ted before eva l ua on of the pa ent wi th ul tra s onogra phy. Thi s pa ent i s of a dva nced ma terna l a ge (>35 yea rs of a ge a t the me of del i very), however, gene c a mni ocentes i s s houl d not be performed wi thout fi rs t knowi ng the ges ta ti ona l a ge a nd vi a bi l i ty of the pregna ncy. 98. The answer is e. (Cunningham, pp 567-571.) The des i re for s teri l i za on i s not a n i ndi ca on for a n el ec ve repea t ces a rea n s ec on. The morbi di ty of repea t ces a rea n s ec on i s grea ter tha n tha t of va gi na l bi rth wi th pos tpa rtum tuba l l i ga on. The ri s k of uteri ne rupture i n a woma n who undergoes a tri a l of l a bor a nd ha s ha d one pri or ces a rea n s ec on i s a pproxi ma tel y 0.6%. Wi th a hi s tory of two pri or ces a rea n s ec ons , the ri s k of uteri ne rupture i s a bout 1.8%. The ri s k of uteri ne rupture i n s omeone who ha s ha d a cl a s s i ca l or T-s ha ped uteri ne i nci s i on i s 4% to 6%. The s ucces s ra te for a tri a l of l a bor i s genera l l y a bout 60% to 80%. Succes s ra tes a re hi gher when the ori gi na l ces a rea n s ec on wa s performed for breech or a nonrea s s uri ng feta l hea rt ra te tra ci ng ra ther tha n dys toci a . Induc on of l a bor s houl d not be performed wi thout a n obs tetri ca l i ndi ca ti on (eg, preecl a mps i a ) a t l es s tha n 39 weeks . 99. The answer is e. (Cunningham, pp 707, 729-733, 992.) Hypertens i on i s di a gnos ed i n pregna ncy when the res ng bl ood pres s ure i s 140/90 mm Hg or grea ter. The pa ent ma y ha ve a hi s tory of chroni c hypertens i on. Ges ta ona l hypertens i on i s di a gnos ed i f the pa ent devel ops hypertens i on wi thout protei nuri a duri ng the pregna ncy. Preecl a mps i a i s di a gnos ed when the hypertens i on i s a s s oci a ted wi th protei nuri a of grea ter tha n 300 mg i n a 24 hour col l ec on or pers i s tent 1+ protei nuri a i n ra ndom uri ne s a mpl i ng. The trea tment for ges ta ona l hypertens i on a nd preecl a mps i a i s del i very. Sel ect preterm pa ents ma y be ma na ged cons erva vel y a t home or i n the hos pi ta l dependi ng upon the s everi ty of the hypertens i on. BPP tes ng i s us eful when fol l owi ng the pa ent cons erva vel y. Al though bed res t ma y tra ns i entl y i mprove el eva ted bl ood pres s ure, a pa ent a t ful l term s houl d be del i vered. Ba s ed on the s everi ty of thi s pa ent’s bl ood pres s ure a nd the 4+ protei nuri a , s he ha s s evere preecl a ms i a a nd s he s houl d be del i vered. Si nce thi s pa ent’s fetus i s breech, ces a rea n del i very ra ther tha n i nduc on of l a bor i s the next bes t s tep i n her ma na gement. Di ure cs s houl d not be us ed i n the ma na gement of preecl a mps i a , a s they depl ete the ma terna l i ntra va s cul a r vol ume a nd ma y compromi s e pl a centa l perfus i on. 100. The answer is b. (Cunningham, p 210.) Lower ba ck pa i n i s a common compl a i nt i n pregna ncy a nd i s reported by a bout 50% of pregna nt women. It i s ca us ed by s tres s pl a ced on the l ower s pi ne a nd a s s oci a ted mus cl es a nd l i ga ments by the gra vi d uterus , es peci a l l y i n l a te pregna ncy. The pa i n ca n be exa cerba ted wi th exces s i ve bendi ng a nd l i i ng. In a ddi on, obes i ty predi s pos es the pa ent to l ower ba ck pa i n i n pregna ncy. Trea tment op ons i ncl ude hea t, ma s s a ge, a nd a na l ges i a . Thi s pa ent ha s no evi dence of l a bor s i nce s he i s l a cki ng regul a r uteri ne contra c ons a nd cervi ca l cha nge. Wi thout a ny uri na ry s ymptoms or a uri na l ys i s s ugges ve of i nfec on, a uri na ry tra ct i nfec on i s unl i kel y. The di a gnos i s of chori oa mni oni s does not fit s i nce the pa ent ha s i nta ct membra nes , no fever, a nd a nontender uterus . Round l i ga ment pa i n i s cha ra cteri zed by s ha rp groi n pa i n. 101 to 105. The answers are 101-a, 102-e, 103-b, 104-d, 105-c. (Cunningham, pp 412-436.) Feta l hea rt ra te tra ci ngs a re obta i ned i n mos t pregna nci es i n the Uni ted Sta tes through the us e of el ectroni c feta l moni tori ng equi pment. Accura te i nterpreta on of thes e tra ci ngs wi th res ul ta nt a c on to expedi te del i very i n fetus es threa tened by hypoxi a ha s i mproved neona ta l outcome. El ectroni c feta l moni tori ng ha s ha d very l i l e effect on the overa l l i nci dence of cerebra l pa l s y whi ch s eems mos t o en to ha ve i ts e ol ogy remote from the me of l a bor. Tra ci ng a s hows a cl a s s i c hypers mul a on pa ern, wi th a toni c contra c on l a s ng s evera l mi nutes wi th di s nctl y ra i s ed i ntra uteri ne pres s ure a nd a cons equent fa l l i n feta l hea rt ra te. Des pi te the i ncrea s ed uteri ne pres s ure, there rema i ns good bea t-to-bea t va ri a bi l i ty, whi ch s ugges ts tha t the fetus i s wi ths ta ndi ng the s tres s . Tra ci ng b s hows feta l hea rt ra te a ccel era ons occurri ng s ponta neous l y both before a nd a er contra c ons , wi th good bea t-to-bea t va ri a bi l i ty, a nd i s repres enta ve of a hea l thy fetus . Tra ci ng c s hows l a te decel era ons fol l owi ng two cons ecu ve contra c ons . The ba s el i ne va ri a bi l i ty i s s i gni fica ntl y reduced. Thi s pa ern i s ca us ed by uteropl a centa l i ns uffici ency. Tra ci ng d s hows va ri a bl e decel era ons i n whi ch the cl a s s i c V-s ha ped pi cture of a va ri a bl e decel era on i s ma i nta i ned. Such decel era ons a re a norma l , reflex res pons e to umbi l i ca l cord compres s i on.

Obstetrical Complications of Pregnancy Question 106. A 29-yea r-ol d G3P2 pres ents to the emergency center wi th compl a i nts of a bdomi na l di s comfort for 2 weeks . Her vi ta l s i gns a re: bl ood pres s ure 120/70 mm Hg, pul s e 90 bea ts per mi nute, tempera ture 36.9°C, res pi ra tory ra te 18 brea ths per mi nute. A pregna ncy tes t i s pos i ve a nd a n ul tra s ound of the a bdomen a nd pel vi s revea l s a vi a bl e 16-week ges ta on l oca ted behi nd a norma l -a ppea ri ng 10 × 6 × 5.5 cm uterus . Both ova ri es a ppea r norma l . No free fl ui d i s noted. Whi ch of the fol l owi ng i s the mos t l i kel y ca us e of thes e fi ndi ngs ? a . Ectopi c ova ri a n ti s s ue b. Fi s tul a between the peri toneum a nd uteri ne ca vi ty c. Pri ma ry peri tonea l i mpl a nta ti on of the ferti l i zed ovum d. Tuba l a borti on e. Uteri ne rupture of pri or ces a rea n s ecti on s ca r 107. A 32-yea r-ol d G2P1 a t 28 weeks ges ta on pres ents to l a bor a nd del i very wi th the compl a i nt of va gi na l bl eedi ng. Her vi ta l s i gns a re: bl ood pres s ure 115/67 mm Hg, pul s e 87 bea ts per mi nute, tempera ture 37.0°C, res pi ra tory ra te 18 brea ths per mi nute. She deni es a ny contra c on a nd s ta tes tha t the ba by i s movi ng norma l l y. On ul tra s ound the pl a centa i s a nteri orl y l oca ted a nd compl etel y covers the i nterna l cervi ca l os . Whi ch of the fol l owi ng woul d mos t i ncrea s e her ri s k for hys terectomy? a . Des i re for s teri l i za ti on b. Devel opment of di s s emi na ted i ntra va s cul a r coa gul opa thy (DIC) c. Pl a centa a ccreta d. Pri or va gi na l del i very e. Smoki ng 108. A pa ent a t 17 weeks ges ta on i s di a gnos ed a s ha vi ng a n i ntra uteri ne feta l demi s e. She returns to your office 5 weeks l a ter a nd her vi ta l s i gns a re: bl ood pres s ure 110/72 mm Hg, pul s e 93 bea ts per mi nute, tempera ture 36.38°C, res pi ra tory ra te 16 brea ths per mi nute. She ha s not ha d a mi s ca rri a ge, a l though s he ha s ha d s ome occa s i ona l s po ng. Her cervi x i s cl os ed on exa mi na on. Thi s pa ent i s a t i ncrea s ed ri s k for whi ch of the fol l owi ng? a . Septi c a borti on b. Recurrent a borti on c. Cons umpti ve coa gul opa thy d. Future i nferti l i ty e. Ectopi c pregna nci es 109. A 24-yea r-ol d pres ents a t 30 weeks wi th a funda l hei ght of 50 cm. Whi ch of the fol l owi ng s ta tements concerni ng pol yhydra mni os i s true? a . Acute pol yhydra mni os ra rel y l ea ds to l a bor pri or to 28 weeks . b. The i nci dence of a s s oci a ted ma l forma ti ons i s a pproxi ma tel y 3%. c. Ma terna l edema , es peci a l l y of the l ower extremi ti es a nd vul va , i s ra re. d. Es opha gea l a tres i a i s a ccompa ni ed by pol yhydra mni os i n nea rl y 10% of ca s es . e. Compl i ca ti ons i ncl ude pl a centa l a brupti on, uteri ne dys functi on, a nd pos tpa rtum hemorrha ge. 110. A 20-yea r-ol d G1 a t 32 weeks pres ents for her rou ne obs tetri c (OB) vi s i t. She ha s no medi ca l probl ems . She i s noted to ha ve a bl ood pres s ure of 150/96 mm Hg, a nd her uri ne di p s hows 1+ protei n. She compl a i ns of a cons ta nt hea da che a nd vi s i on cha nges tha t a re not rel i eved wi th res t or a pa i n rel i ever. The pa ent i s s ent to the hos pi ta l for further ma na gement. At the hos pi ta l , her bl ood pres s ure i s 158/98 mm Hg a nd s he i s noted to ha ve toni c-cl oni c s ei zure. Whi ch of the fol l owi ng i s i ndi ca ted i n the ma na gement of thi s pa ti ent? a . Low-dos e a s pi ri n b. Di l a nti n (phenytoi n) c. Anti hypertens i ve thera py d. Ma gnes i um s ul fa te e. Ces a rea n del i very 111. Duri ng rou ne ul tra s ound s urvei l l a nce of a twi n pregna ncy, twi n A wei ghs 1200 g a nd twi n B wei ghs 750 g. Hydra mni os i s noted a round twi n A, whi l e twi n B ha s ol i gohydra mni os . Whi ch s ta tement concerni ng the ul tra s ound fi ndi ngs i n thi s twi n pregna ncy i s true? a . The donor twi n devel ops hydra mni os more often tha n does the reci pi ent twi n. b. Gros s di fferences ma y be obs erved between donor a nd reci pi ent pl a centa s . c. The donor twi n us ua l l y s uffers from a hemol yti c a nemi a . d. The donor twi n i s more l i kel y to devel op wi des prea d thrombos es . e. The donor twi n often devel ops pol ycythemi a . 112. A 32-yea r-ol d G5P1 pres ents for her firs t prena ta l vi s i t. A compl ete obs tetri ca l , gynecol ogi ca l , a nd medi ca l hi s tory a nd phys i ca l exa mi na on i s done. Whi ch of the fol l owi ng woul d be a n i ndi ca ti on for el ecti ve cercl a ge pl a cement? a . Three s ponta neous fi rs t-tri mes ter a borti ons b. Twi n pregna ncy c. Three s econd-tri mes ter pregna ncy l os s es wi thout evi dence of l a bor or a brupti on d. Hi s tory of l oop el ectros urgi ca l exci s i on procedure for cervi ca l dys pl a s i a e. Cervi ca l l ength of 35 mm by ul tra s ound a t 18 weeks

Questions 113 to 117 Ma tch ea ch des cri pti on wi th the correct type of a borti on. Ea ch l ettered opti on ma y be us ed once, more tha n once, or not a t a l l .

a . Compl ete a borti on b. Incompl ete a borti on c. Threa tened a borti on d. Mi s s ed a borti on e. Inevi ta bl e a borti on 113. Uteri ne bl eedi ng a t 12 weeks ges ta ti on a ccompa ni ed by cervi ca l di l a ti on wi thout pa s s a ge of ti s s ue. 114. Pa s s a ge of s ome but not a l l pl a centa l ti s s ue through the cervi x a t 9 weeks ges ta ti on. 115. Feta l dea th a t 15 weeks ges ta ti on wi thout expul s i on of a ny feta l or ma terna l ti s s ue for a t l ea s t 8 weeks . 116. Uteri ne bl eedi ng a t 7 weeks ges ta ti on wi thout a ny cervi ca l di l a ti on. 117. Expul s i on of a l l feta l a nd pl a centa l ti s s ue from the uteri ne ca vi ty a t 10 weeks ges ta ti on. 118. A 19-yea r-ol d pri mi gra vi da i s 12 weeks pregna nt by da tes . She ha s va gi na l bl eedi ng a nd a n enl a rged-for-da tes uterus . In a ddi on, no feta l hea rt s ounds a re hea rd. The ul tra s ound s hown bel ow i s obta i ned. Whi ch of the fol l owi ng i s true rega rdi ng the pa ti ent’s di a gnos i s ?

a . The mos t common chromos oma l ma keup of a pa rti a l or i ncompl ete mol e i s 46, XX, of pa terna l ori gi n. b. Ol der ma terna l a ge i s not a ri s k fa ctor for hyda ti di form mol e. c. Pa rti a l or i ncompl ete hyda ti di form mol e ha s a hi gher ri s k of devel opi ng i nto chori oca rci noma tha n compl ete mol e. d. Va gi na l bl eedi ng i s a common s ymptom of hyda ti di form mol e. e. Hys terectomy i s contra i ndi ca ted a s pri ma ry thera py for mol a r pregna ncy i n women who ha ve compl eted chi l dbea ri ng. 119. A 20-yea r-ol d G1P0 pres ents to your cl i ni c for fol l ow-up for a s uc on di l a on a nd cure a ge for a n i ncompl ete a bor on. She i s a s ymptoma c wi thout a ny va gi na l bl eedi ng, fever, or chi l l s . Her exa mi na on i s norma l . The pa thol ogy report revea l s trophobl a s c prol i fera on a nd hydropi c degenera on wi th the a bs ence of va s cul a ture; no feta l s s ue i s i den fied. A ches t x-ra y i s nega ve for a ny evi dence of meta s ta c di s ea s e. Whi ch of the fol l owi ng i s the bes t next s tep i n her ma na gement? a . Weekl y huma n chori oni c gona dotropi n (hCG) ti ters b. Hys terectomy c. Si ngl e-a gent chemothera py d. Combi na ti on chemothera py e. Ra di a ti on thera py 120. A 22-yea r-ol d G1P0 pres ents to your cl i ni c for fol l ow-up of eva cua on of a compl ete hyda di form mol e. She i s a s ymptoma c a nd her exa mi na ti on i s norma l . Whi ch of the fol l owi ng woul d be a n i ndi ca ti on to s ta rt s i ngl e-a gent chemothera py? a . A ri s e i n hCG ti ters b. A pl a tea u of hCG ti ters for 1 week c. Return of hCG ti ter to norma l a t 6 weeks a fter eva cua ti on d. Appea ra nce of l i ver meta s ta s i s e. Appea ra nce of bra i n meta s ta s i s 121. A 32-yea r-ol d woma n pres ents to the emergency depa rtment wi th a bdomi na l pa i n a nd va gi na l bl eedi ng. Her l a s t mens trua l peri od wa s 8 weeks a go a nd her pregna ncy tes t i s pos i ve. On exa mi na on s he i s ta chyca rdi c a nd hypotens i ve a nd her a bdomi na l exa mi na on findi ngs revea l peri tonea l s i gns , a beds i de a bdomi na l ul tra s ound s hows free flui d wi thi n the a bdomi na l ca vi ty. The deci s i on i s ma de to ta ke the pa ent to the opera ti ng room for emergency expl ora tory l a pa rotomy. Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Ruptured ectopi c pregna ncy b. Hyda ti di form mol e c. Incompl ete a borti on d. Mi s s ed a borti on e. Tors ed ova ri a n corpus l utea l cys t 122. A 19-yea r-ol d woma n comes to the emergency depa rtment a nd reports tha t s he fa i nted a t work ea rl i er i n the da y. She ha s mi l d va gi na l

bl eedi ng. Her a bdomen i s di ffus el y tender a nd di s tended. In a ddi on, s he compl a i ns of s houl der a nd a bdomi na l pa i n. Her tempera ture i s 37.2°C, pul s e ra te i s 120 bea ts per mi nute, a nd bl ood pres s ure i s 80/42 mm Hg. Whi ch of the fol l owi ng i s the bes t di a gnos c procedure to qui ckl y confirm your di a gnos i s ? a . Computed tomogra phy of the a bdomen a nd pel vi s b. Cul docentes i s c. Di l a ti on a nd curetta ge d. Pos teri or col potomy e. Qua nti ta ti ve β-huma n chori oni c gona dotropi n (β-hCG) 123. An 18-yea r-ol d G2P1 pres ents to the emergency depa rtment wi th a bdomi na l pa i n a nd va gi na l bl eedi ng for the pa s t da y. Her l a s t mens trua l peri od wa s 7 weeks a go. On exa mi na on s he i s a febri l e wi th norma l bl ood pres s ure a nd pul s e. Her a bdomen i s tender i n the l e l ower qua dra nt wi th vol unta ry gua rdi ng. On pel vi c exa mi na on, s he ha s a s ma l l a nteverted uterus , no a dnexa l ma s s es , mi l d l e a dnexa l tendernes s , a nd mi l d cervi ca l mo on tendernes s . La bs revea l a norma l whi te count, hemogl obi n of 10.5, a nd a qua n ta ve β-hCG of 2342. Ul tra s ound revea l s a 10 × 5 × 6 cm uterus wi th a norma l -a ppea ri ng 1-cm s tri pe a nd no ges ta on s a c or feta l pol e. A 2.8-cm compl ex a dnexa l ma s s i s noted on the l e . In the trea tment of thi s pa ti ent, l a pa ros copy ha s wha t a dva nta ge over l a pa rotomy? a . Decrea s ed hos pi ta l s ta ys b. Lower ferti l i ty ra te c. Lower repea t ectopi c pregna ncy ra te d. Compa ra bl e pers i s tent ectopi c ti s s ue ra te e. Grea ter s ca r forma ti on 124. A 27-yea r-ol d ha s jus t ha d a n ectopi c pregna ncy. Whi ch of the fol l owi ng events woul d be mos t l i kel y to predi s pos e to ectopi c pregna ncy? a . Previ ous cervi ca l coni za ti on b. Pel vi c i nfl a mma tory di s ea s e (PID) c. Us e of a contra cepti ve uteri ne devi ce (IUD) d. Inducti on of ovul a ti on e. Expos ure i n utero to di ethyl s ti l bes trol (DES) 125. An 18-yea r-ol d G1 a t 8 weeks ges ta on compl a i ns of na us ea a nd vomi ng over the pa s t week occurri ng on a da i l y ba s i s . Na us ea a nd emes i s a re a common s ymptom i n ea rl y pregna ncy. Whi ch of the fol l owi ng s i gns or s ymptoms woul d i ndi ca te a more s eri ous di a gnos i s of hyperemes i s gra vi da rum? a . Hypothyroi di s m b. Hypoka l emi a c. Wei ght ga i n d. Protei nuri a e. Di a rrhea 126. A 32-yea r-ol d G2P0101 pres ents to l a bor a nd del i very a t 34 weeks of ges ta on, compl a i ni ng of regul a r uteri ne contra c ons a bout every 5 mi nutes for the pa s t s evera l hours . She ha s a l s o no ced the pa s s a ge of a cl ea r flui d from va gi na . A nurs e pl a ces the pa ent on a n externa l feta l moni tor a nd ca l l s you to eva l ua te her s ta tus . The externa l feta l moni tor demons tra tes a rea c ve feta l hea rt ra te tra ci ng, wi th regul a r uteri ne contra cti ons occurri ng a bout every 3 to 4 mi nutes . On s teri l e s pecul um exa mi na ti on, the cervi x i s vi s ua l l y cl os ed. A s a mpl e of pool ed a mni oti c fl ui d s een i n the va gi na l va ul t i s fern a nd ni tra zi ne-pos i ti ve. The pa ti ent ha s a tempera ture of 38.8°C, pul s e 102 bea ts per mi nute, bl ood pres s ure 100/60 mm Hg, a nd her fundus i s tender to deep pa l pa on. Her a dmi s s i on bl ood work comes ba ck i ndi ca ng a WBC of 19,000. The pa ent i s very concerned beca us e s he ha d previ ous l y del i vered a ba by a t 35 weeks who s uffered from res pi ra tory di s tres s s yndrome (RDS). You perform a beds i de s onogra m, whi ch i ndi ca tes ol i gohydra mni os a nd a fetus whos e s i ze i s a ppropri a te for ges ta ona l a ge a nd wi th a cepha l i c pres enta on. Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent? a . Admi ni s ter beta metha s one. b. Admi ni s ter tocol yti cs . c. Pl a ce a cervi ca l cercl a ge. d. Admi ni s ter a nti bi oti cs . e. Perform emergent ces a rea n s ecti on. 127. A 30-yea r-ol d G1P0 wi th a twi n ges ta on a t 25 weeks pres ents to l a bor a nd del i very compl a i ni ng of i rregul a r uteri ne contra c ons a nd ba ck pa i n. She reports a n i ncrea s e i n the a mount of her va gi na l di s cha rge, but deni es a ny rupture of membra nes . She reports tha t ea rl i er i n the da y s he ha d s ome very l i ght va gi na l bl eedi ng, whi ch ha s now res ol ved. On a rri va l to l a bor a nd del i very, s he i s pl a ced on a n externa l feta l moni tor, whi ch i ndi ca tes uteri ne contra c ons every 2 to 4 mi nutes . She i s a febri l e a nd her vi ta l s i gns a re a l l norma l . Her gra vi d uterus i s nontender. The nurs e ca l l s you to eva l ua te the pa ti ent. Whi ch of the fol l owi ng i s the mos t a ppropri a te fi rs t s tep i n the eva l ua ti on of va gi na l bl eedi ng i n thi s pa ti ent? a . Va gi na l exa mi na ti on to determi ne cervi ca l di l a ti on b. Ul tra s ound to check pl a centa l l oca ti on c. Uri ne cul ture to check for uri na ry tra ct i nfecti on d. La bs to eva l ua te for di s s emi na ted i ntra va s cul a r coa gul opa thy e. Apt tes t to determi ne i f bl ood i s from the fetus 128. A 30-yea r-ol d G1 wi th twi n ges ta on a t 28 weeks i s bei ng eva l ua ted for va gi na l bl eedi ng a nd uteri ne contra c ons . A beds i de ul tra s ound exa mi na on rul es out the pres ence of a pl a centa previ a . Feta l hea rt ra te tra ci ng i s rea c ve on both twi ns , a nd the uteri ne contra c ons a re every 2 to 3 mi nutes a nd l a s t 60 s econds . A s teri l e s pecul um exa mi na on i s nega ve for rupture membra nes . A di gi ta l exa mi na on i ndi ca tes tha t the cervi x i s 2 to 3 cm di l a ted a nd 50% effa ced, a nd the pres enti ng pa rt i s a t —3 s ta ti on. Tocol ys i s wi th ma gnes i um s ul fa te i s i ni ti a ted a nd i ntra venous a n bi o cs a re s ta rted for group B s treptococcus prophyl a xi s . Beta metha s one, a cor cos teroi d, i s a l s o a dmi ni s tered. Whi ch of the fol l owi ng s ta tements rega rdi ng the us e of beta metha s one i n the trea tment of preterm l a bor i s true? a . Beta metha s one enha nces the tocol yti c effect of ma gnes i um s ul fa te a nd decrea s es the ri s k of preterm del i very. b. Beta metha s one ha s been s hown to decrea s e i ntra a mni oti c i nfecti ons . c. Beta metha s one promotes feta l l ung ma turi ty a nd decrea s es the ri s k of res pi ra tory di s tres s s yndrome. d. The a nti -i nfl a mma tory effect of beta metha s one decrea s es the ri s k of GBS s eps i s i n the newborn. e. Beta metha s one i s the onl y corti cos teroi d proven to cros s the pl a centa .

129. A ma terna l feta l medi ci ne s peci a l i s t i s cons ul ted a nd performs a n i n-depth s onogra m on a 30-yea r-ol d G1 a t 28 weeks wi th a twi n ges ta on. The s onogra m i ndi ca tes tha t the fetus es a re both ma l e, a nd the chori oni ci ty i s di a mni o c a nd monochori oni c. Twi n B i s noted to ha ve ol i gohydra mni os a nd to be much s ma l l er tha n twi n A. Whi ch of the fol l owi ng woul d be a fi ndi ng mos t l i kel y a s s oci a ted wi th twi n A? a . Conges ti ve hea rt fa i l ure b. Anemi a c. Hypovol emi a d. Hypotens i on e. Low a mni oti c fl ui d l evel 130. A 30-yea r-ol d G1 a t 28 weeks ges ta on wi th a twi n pregna ncy i s a dmi ed to the hos pi ta l for preterm l a bor wi th regul a r pa i nful contra c ons every 2 mi nutes . She i s 3 cm di l a ted wi th membra nes i nta ct a nd a s ma l l a mount of bl oody s how. Ul tra s ound revea l s growth res tri c on of twi n A a nd ol i gohydra mni os , otherwi s e norma l a na tomy. Twi n B ha s norma l a na tomy a nd ha s a ppropri a te-for-ges ta ona l -a ge wei ght. Whi ch of the fol l owi ng i s a contra i ndi ca ti on to the us e of i ndometha ci n a s a tocol yti c i n thi s pa ti ent? a . Twi n ges ta ti on b. Ges ta ti ona l a ge grea ter tha n 26 weeks c. Va gi na l bl eedi ng d. Ol i gohydra mni os e. Feta l growth res tri cti on 131. A hea l thy 32-yea r-ol d G2P1001 pres ents to l a bor a nd del i very a t 30 weeks ges ta on compl a i ni ng of a s ma l l a mount of bri ght red bl ood per va gi na whi ch occurred s hortl y a er i ntercours e. It s ta rted off a s s po ng a nd then progres s ed to a l i ght bl eedi ng. By the me the pa ent a rri ved a t l a bor a nd del i very, the bl eedi ng ha d compl etel y res ol ved. The pa ent deni es a ny regul a r uteri ne contra c ons , but a dmi ts to occa s i ona l a bdomi na l cra mpi ng. She reports no pregna ncy compl i ca ons a nd s he ha s ha d norma l ul tra s ounds done a t 18 weeks of ges ta on. Her obs tetri ca l hi s tory i s s i gni fica nt for a previ ous l ow tra ns vers e ces a rea n s ec on a t term. Vi ta l s i gns a re norma l . Tocometer s hows contra c ons every 8 to 10 mi nutes , a nd the feta l hea rt ra te tra ci ng i s rea cti ve. Whi ch of the fol l owi ng ca n be rul ed out a s a ca us e for her va gi na l bl eedi ng? a . Cervi ci ti s b. Preterm l a bor c. Pl a centa l a brupti on d. Pl a centa previ a e. Va s a previ a 132. A 34-yea r-ol d G2P1 a t 31 weeks ges ta on pres ents to l a bor a nd del i very wi th compl a i nts of va gi na l bl eedi ng ea rl i er i n the da y tha t res ol ved on i ts own. She deni es a ny l ea ka ge of flui d or uteri ne contra c ons . She reports good feta l movement. In her l a s t pregna ncy, s he ha d a l ow tra ns vers e ces a rea n del i very for breech pres enta on a t term. She deni es a ny medi ca l probl ems . Her vi ta l s i gns a re norma l a nd el ectroni c externa l moni tori ng revea l s a rea c ve feta l hea rt ra te tra ci ng a nd no uteri ne contra c ons . Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent? a . Send her home, s i nce the bl eedi ng ha s compl etel y res ol ved a nd s he i s experi enci ng good feta l movements . b. Perform a s teri l e di gi ta l exa mi na ti on. c. Perform a n a mni ocentes i s to rul e out i nfecti on. d. Perform a s teri l e s pecul um exa mi na ti on. e. Perform a n ul tra s ound exa mi na ti on. 133. A 34-yea r-ol d G2P1 a t 31 weeks ges ta on wi th a known pl a centa previ a pres ents to the hos pi ta l wi th va gi na l bl eedi ng. On a s s es s ment, s he ha s norma l vi ta l s i gns a nd the feta l hea rt ra te tra ci ng i s 140 bea ts per mi nute wi th a ccel era ons a nd no decel era ons . No uteri ne contra c ons a re demons tra ted on externa l tocometer. Hea vy va gi na l bl eedi ng i s noted. Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent? a . Admi ni s ter i ntra mus cul a r terbuta l i ne. b. Admi ni s ter methyl ergonovi ne. c. Admi t a nd s ta bi l i ze the pa ti ent. d. Perform ces a rea n del i very. e. Induce l a bor. 134. A 34-yea r-ol d G2P1 a t 31 weeks ges ta on wi th a known pl a centa previ a i s a dmi ed to the hos pi ta l for va gi na l bl eedi ng. The pa ent con nues to bl eed hea vi l y a nd you obs erve pers i s tent l a te decel era ons on the feta l hea rt moni tor wi th l os s of va ri a bi l i ty i n the ba s el i ne. Her bl ood pres s ure a nd pul s e a re norma l . You expl a i n to the pa ent tha t s he needs to be del i vered. The pa ent i s del i vered by ces a rea n s ec on under genera l a nes thes i a . The ba by a nd pl a centa a re ea s i l y del i vered, but the uterus i s noted to be boggy a nd a toni c des pi te i ntra venous i nfus i on of Pi toci n. Whi ch of the fol l owi ng i s contra i ndi ca ted i n thi s pa ti ent for the trea tment of uteri ne a tony? a . Methyl ergonovi ne (Methergi ne) a dmi ni s tered i ntra mus cul a rl y b. Pros ta gl a ndi n F 2 α (Hema ba te) s uppos i tori es c. Mi s opros tol (Cytotec) s uppos i tori es d. Terbuta l i ne a dmi ni s tered i ntra venous l y e. Pros ta gl a ndi n E2 s uppos i tori es 135. A 20-yea r-ol d G2P1 a t 30 weeks ges ta on wi th a known pl a centa previ a i s del i vered by ces a rea n s ec on under genera l a nes thes i a for va gi na l bl eedi ng a nd nonrea s s uri ng feta l hea rt ra te tra ci ng. The ba by i s ea s i l y del i vered, but the pl a centa i s a dherent to the uterus a nd ca nnot be compl etel y removed, a nd hea vy uteri ne bl eedi ng i s noted. Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent? a . Admi ni s ter methyl ergonovi ne (Methergi ne) i ntra mus cul a rl y. b. Admi ni s ter mi s opros tol (Cytotec) s uppos i tori es per rectum. c. Admi ni s ter pros ta gl a ndi n F 2 α (Hema ba te) i ntra mus cul a rl y. d. Perform hys terectomy. e. Cl os e the uteri ne i nci s i on a nd perform curetta ge. 136. A 39-yea r-ol d G2P1001 pres ents to your office for a rou ne OB vi s i t a t 30 weeks ges ta ona l a ge. Her firs t pregna ncy wa s del i vered 10 yea rs a go a nd wa s uncompl i ca ted. She ha d a norma l va gi na l del i very a t 40 weeks a nd the ba by wei ghed 6 l b. Duri ng thi s pres ent pregna ncy, s he ha s not ha d a ny compl i ca ons , a nd s he reports no s i gni fica nt medi ca l hi s tory. She wei ghed 95 l b pri or to pregna ncy a nd s he ha s ga i ned 20 l b to da te. She i s a

non-s moker a nd deni es i l l i ci t drug us e. Her a na tomy s ca n wa s norma l a nd her firs t tri mes ter s creen di d not s how a n i ncrea s ed ri s k of chromos oma l a neupl oi di es . Her bl ood pres s ure ra nge ha s been 100 to 120/60 to 70 mm Hg. Duri ng her exa mi na on, you note tha t her funda l hei ght mea s ures onl y 26 cm. Whi ch of the fol l owi ng i s a mos t l i kel y expl a na ti on for thi s pa ti ent’s decrea s ed funda l hei ght? a . Autos oma l tri s omy b. Cons ti tuti ona l l y s ma l l mother c. Poor wei ght ga i n d. Soci a l depri va ti on e. Uteropl a centa l i ns uffi ci ency 137. A 38-yea r-ol d G4P3 a t 33 weeks ges ta on i s noted to ha ve a funda l hei ght of 29 cm on rou ne obs tetri ca l vi s i t. An ul tra s ound i s performed by the ma terna l -feta l medi ci ne s peci a l i s t. The es ma ted feta l wei ght i s determi ned to be i n the fi h percen l e for the es ma ted ges ta ona l a ge. The bi pa ri eta l di a meter a nd a bdomi na l ci rcumference a re concorda nt i n s i ze. Whi ch of the fol l owi ng i s a s s oci a ted wi th s ymmetri c growth res tri cti on? a . Nutri ti ona l defi ci enci es b. Chromos ome a bnorma l i ti es c. Hypertens i on d. Uteropl a centa l i ns uffi ci ency e. Ges ta ti ona l di a betes 138. A 37-yea r-ol d G4P2 pres ents to your office for new OB vi s i t a t 8 weeks . In a pri or pregna ncy, the fetus ha d mul pl e congeni ta l a noma l i es cons i s tent wi th tri s omy 18, a nd the ba by di ed s hortl y a er bi rth. The mother i s worri ed tha t the current pregna ncy wi l l end the s a me wa y, a nd s he wa nts tes ti ng performed to s ee whether thi s ba by i s a ffected. Whi ch of the fol l owi ng ca n be us ed for chromos ome a na l ys i s of the fetus ? a . Bi ophys i ca l profi l e b. Chori oni c vi l l us s a mpl i ng c. Feta l umbi l i ca l Doppl er vel oci metry d. Ma terna l s erum s creen e. Nucha l tra ns l ucency 139. A 26-yea r-ol d G1 a t 37 weeks pres ents to the hos pi ta l i n a c ve l a bor. She ha s no medi ca l probl ems a nd ha s a norma l prena ta l cours e except for feta l growth res tri c on. She undergoes a n uncompl i ca ted va gi na l del i very of a fema l e i nfa nt wei ghi ng 1950 g. The i nfa nt i s a t ri s k for whi ch of the fol l owi ng compl i ca ti ons ? a . Hypergl ycemi a b. Fever c. Hypertens i on d. Anemi a e. Hypoxi a 140. A 38-yea r-ol d G1P1 comes to s ee you for her firs t prena ta l vi s i t a t 10 weeks ges ta ona l a ge. She ha d a previ ous term va gi na l del i very wi thout a ny compl i ca ons . You detect feta l hea rt tones a t thi s vi s i t, a nd her uteri ne s i ze i s cons i s tent wi th da tes . You a l s o dra w her prena ta l l a bs a t thi s vi s i t a nd tel l her to fol l ow up i n 4 weeks for a return OB vi s i t. Two weeks l a ter, the res ul ts of the pa ent’s prena ta l l a bs come ba ck. Her bl ood type i s A–, wi th a n a nti -D a nti body ti ter of 1:4. Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent? a . Schedul e a n a mni ocentes i s for a mni oti c fl ui d bi l i rubi n a t 16 weeks . b. Repea t the ti ter i n 4 weeks . c. Repea t the ti ter a t 28 weeks . d. Schedul e Percuta neous Umbi l i ca l Bl ood Sa mpl i ng (PUBS) to determi ne feta l hema tocri t a t 20 weeks . e. Schedul e PUBS a s s oon a s pos s i bl e to determi ne feta l bl ood type. 141. A 23-yea r-ol d G3P1011 a t 6 weeks pres ents for rou ne prena ta l ca re. She ha d a ces a rea n del i very 3 yea rs a go for breech pres enta on a er a fa i l ed externa l cepha l i c vers i on. Her da ughter i s Rh-nega ti ve. She a l s o ha d a n el ecti ve termi na ti on of pregna ncy 1 yea r a go. She i s Rh-nega ti ve a nd i s found to ha ve a pos i ve a n -D ter of 1:8 on rou ne prena ta l l a bs . Fa i l ure to a dmi ni s ter RhoGAM a t whi ch me i s the mos t l i kel y ca us e of her s ens i ti za ti on? a . After el ecti ve termi na ti on b. At the ti me of ces a rea n del i very c. At the ti me of externa l cepha l i c vers i on d. Wi thi n 3 da ys of del i veri ng a n Rh-nega ti ve fetus e. At 28 weeks i n the pregna ncy for whi ch s he ha d a ces a rea n del i very 142. A 27-yea r-ol d G2P1 a t 29 weeks ges ta ona l a ge, who i s bei ng fol l owed for Rh i s oi mmuni za on pres ents for her OB vi s i t. The funda l hei ght i s noted to be 33 cm. An ul tra s ound revea l s feta l a s ci tes a nd a peri ca rdi a l effus i on. Whi ch of the fol l owi ng ca n be a nother fi ndi ng i n feta l hydrops ? a . Ol i gohydra mni os b. Hydrocepha l us c. Hydronephros i s d. Subcuta neous edema e. Over-di s tended feta l bl a dder 143. A 39-yea r-ol d G1P0 a t 39 weeks ges ta ona l a ge i s s ent to l a bor a nd del i very from her obs tetri ci a n’s office beca us e of a bl ood pres s ure rea di ng of 150/100 mm Hg obta i ned duri ng a rou ne OB vi s i t. Her ba s el i ne bl ood pres s ures duri ng the pregna ncy were 100 to 120/60 to 70. On a rri va l to l a bor a nd del i very, the pa ent deni es a ny hea da che, vi s ua l cha nges , na us ea , vomi ng, or a bdomi na l pa i n. The hea rt ra te s tri p i s rea c ve a nd the tocodyna mometer i ndi ca tes i rregul a r uteri ne contra c ons . The pa ent’s cervi x i s 3 cm di l a ted. Her repea t bl ood pres s ure i s 160/90 mm Hg. Hema tocri t i s 34.0, pl a tel ets a re 160,000, SGOT i s 22, SGPT i s 15, a nd uri na l ys i s i s nega ve for protei n. Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Preecl a mps i a b. Chroni c hypertens i on c. Chroni c hypertens i on wi th s uperi mpos ed preecl a mps i a d. Ecl a mps i a

e. Ges ta ti ona l hypertens i on 144. A 20-yea r-ol d G1 a t 36 weeks i s bei ng moni tored for preecl a mps i a ; s he ri ngs the bel l for the nurs e beca us e s he i s devel opi ng a hea da che a nd feel s funny. As you a nd the nurs e enter the room, you wi tnes s the pa ent undergoi ng a toni c-cl oni c s ei zure. You s ecure the pa ent’s a i rwa y, a nd wi thi n a few mi nutes the s ei zure i s over. The pa ent’s bl ood pres s ure moni tor i ndi ca tes a pres s ure of 160/110 mm Hg. Whi ch of the fol l owi ng medi ca ti ons i s recommended for the preventi on of a recurrent ecl a mpti c s ei zure? a . Hydra l a zi ne b. Ma gnes i um s ul fa te c. La beta l ol d. Pi toci n e. Ni fedi pi ne 145. You a re doi ng pos tpa rtum rounds on a 22-yea r-ol d G1P1, who va gi na l l y del i vered a n i nfa nt ma l e a t 36 weeks a er a n i nduc on for s evere preecl a mps i a . Duri ng her l a bor s he requi red hydra l a zi ne to control her bl ood pres s ures . She i s on ma gnes i um s ul fa te for s ei zure prophyl a xi s . Her vi ta l s i gns a re: bl ood pres s ure 154/98 mm Hg, pul s e 93 bea ts per mi nute, res pi ra tory ra te 24 brea ths per mi nute, a nd tempera ture 37.3°C. She ha s a dequa te uri ne output a t grea ter tha n 40 cc/h. On exa mi na on, s he i s ori ented to me a nd pl a ce, but s he i s s omnol ent a nd her s peech i s s l urred. She ha s good movement a nd s trength of her extremi es , but her deep tendon reflexes a re a bs ent. Whi ch of the fol l owi ng i s the mos t l i kel y ca us e of her s ymptoms ? a . Advers e rea cti on to hydra l a zi ne b. Hypertens i ve s troke c. Ma gnes i um toxi ci ty d. Si nus venous thrombos i s e. Tra ns i ent i s chemi c a tta ck

Obstetrical Complications of Pregnancy Answers 106. The answer is d. (Cunningham, pp 249-251.) Al mos t a l l ca s es of a bdomi na l pregna ncy fol l ow ea rl y rupture or a bor on of a tuba l pregna ncy. Women wi th a bdomi na l pregna ncy a re l i kel y to be uncomforta bl e, but wi th va gue ga s troi ntes na l s ymptoms s uch a s na us ea , vomi ng, fla tul ence, cons pa on, a nd di a rrhea . Feta l s urvi va l i s preca ri ous wi th a peri na ta l l os s of 75%. Feta l ma l forma ons a nd deformi es , s uch a s cra ni ofa ci a l a s ymmetry, l i mb defici enci es , a nd joi nt a bnorma l i es , a re pres ent i n 20% of fetus es . Expecta nt ma na gement ca rri es the ri s k of s udden l i fethrea teni ng hemorrha ge a nd i s ra rel y i f ever i ndi ca ted i f the di a gnos i s of a bdomi na l pregna ncy i s ma de. Surgery i s the us ua l trea tment of a bdomi na l pregna ncy, but ma s s i ve hemorrha ge ma y ens ue wi th s epa ra on a nd remova l of the pl a centa . In genera l , the fetus s houl d be del i vered, the cord s evered cl os e to the pl a centa , a nd the a bdomen cl os ed. Lea vi ng the pl a centa i n s i tu ca n ca us e i nfec ous a bs ces s forma on, a dhes i ons , a nd i ntes na l obs truc on. The us e of methotrexa te to ha s ten pl a centa l i nvol u on i s controvers i a l . Ma terna l morta l i ty i s i ncrea s ed s ubs ta nti vel y compa red wi th norma l pregna ncy. 107. The answer is c. (Cunningham, pp 769-780.) Pri or ces a rea n del i very a nd pl a centa previ a , es peci a l l y a n a nteri orl y l oca ted pl a centa , i ncrea s e your ri s k of pl a centa a ccreta , i ncreta , a nd percreta . Pl a centa a ccreta , i ncreta , or percreta a re trea ted wi th hys terectomy. Adva nci ng ma terna l a ge, mul pa ri ty, pri or ces a rea n del i very, a nd s moki ng a re a s s oci a ted wi th previ a . Pa i nl es s bl eedi ng i s the mos t common s ymptom, a nd i s ra rel y fa ta l . Va gi na l exa mi na on to eva l ua te for pl a centa previ a i s never permi s s i bl e unl es s the woma n i s i n the opera ng room prepa red for i mmedi a te ces a rea n del i very, beca us e even the mos t gentl e exa mi na on ca n ca us e torren a l hemorrha ge. Thes e “doubl e s etup” exa mi na ons a re ra rel y neces s a ry beca us e ul tra s ound i s us ua l l y rea di l y a va i l a bl e to ma ke the di a gnos i s of pl a centa previ a . Ces a rea n del i very i s neces s a ry i n pra c ca l l y a l l ca s es of previ a . Beca us e of the poor contra c l e na ture of the l ower uteri ne s egment, uncontrol l a bl e hemorrha ge ma y fol l ow remova l of the pl a centa . Hys terectomy ma y be i ndi ca ted i f cons erva ti ve methods to control hemorrha ge fa i l . Res us ci ta ti on wi th bl ood products i s the trea tment of di s s emi na ted i ntra va s cul a r coa gul opa thy, not hys terectomy. Steri l i za on i ts el f i s not a n i ndi ca on for hys terectomy a t the me of ces a rea n del i very, beca us e the compl i ca ti ons of s urgery a re much i ncrea s ed wi th a ces a rea n hys terectomy. 108. The answer is c. (Cunningham, p 787.) In women wi th i ntra uteri ne feta l demi s e, l a bor us ua l l y occurs wi thi n 2 weeks . If the fetus i s reta i ned l onger tha n 1 month, 25% of women ca n devel op coa gul opa thy whi ch i s ma ni fes ted by decrea s ed fibri nogen, el eva ted fibri n degra da on products a nd decrea s ed pl a tel ets . Sep c a bor ons were more frequentl y s een duri ng the era of i l l ega l a bor ons , a l though occa s i ona l l y s eps i s ca n occur i f there i s i ncompl ete eva cua on of the products of concep on i n ei ther a thera peu c or s ponta neous a bor on. However, s i nce her cervi x i s cl os ed a nd no s s ue ha s pa s s ed, s ep c a bor on i s unl i kel y. Intra uteri ne feta l demi s e ha s no i mpa ct on future i nfer l i ty or a s s oci a on wi th ectopi c pregna nci es . 109. The answer is e. (Cunningham, pp 491-494.) Pol yhydra mni os i s a n exces s i ve qua n ty of a mni o c flui d. The frequency of di a gnos i s va ri es , but pol yhydra mni os s uffici ent to ca us e cl i ni ca l s ymptoms proba bl y occurs i n 1 of 1000 pregna nci es , excl us i ve of twi ns . The i nci dence of a s s oci a ted ma l forma ons i s a bout 20%, wi th CNS a nd GI a bnorma l i es bei ng pa r cul a rl y common. For exa mpl e, pol yhydra mni os a ccompa ni es a bout ha l f of ca s es of a nencepha l y a nd nea rl y a l l ca s es of es opha gea l a tres i a . Edema of the l ower extremi es , vul va , a nd a bdomi na l wa l l res ul ts from compres s i on of ma jor venous s ys tems . Acute hydra mni os tends to occur ea rl y i n pregna ncy a nd, a s a rul e, l ea ds to l a bor before the 28th week. The mos t frequent ma terna l compl i ca ti ons a re pl a centa l a brupti on, uteri ne dys functi on, a nd pos tpa rtum hemorrha ge. 110. The answer is d. (Cunningham, pp 706-709, 728-747.) Ecl a mps i a i s the pres ence of new-ons et gra nd ma l s ei zures i n a woma n wi th preecl a mps i a . She requi res del i very. Ces a rea n del i very i s not a l wa ys neces s a ry. Ma gnes i um s ul fa te i s gi ven for prophyl a xi s a ga i ns t recurrent s ei zure. Ma gnes i um s ul fa te ha s been s hown i n ra ndomi zed control tri a l s to be be er tha n phenytoi n or di a zepa m a t preven ng s ei zures . Low-dos e a s pi ri n a nd ca l ci um s uppl ementa on ha ve not been s hown to be benefici a l i n preven ng preecl a mps i a . Women wi th ecl a mps i a s houl d be s ta bi l i zed qui ckl y; ma gnes i um s ul fa te s houl d be s ta rted to prevent further s ei zures ; a nd a n hypertens i ves s houl d be us ed to control bl ood pres s ure. The pa ent s houl d be del i vered i n a mel y fa s hi on, a nd the method of del i very s houl d depend on fa ctors s uch a s ges ta ona l a ge, feta l pres enta on, a nd cervi ca l exa mi na on. An hypertens i ve thera py i s us ua l l y i ni a ted for s ys tol i c bl ood pres s ure grea ter tha n 160 or di a s tol i c bl ood pres s ure grea ter

tha n 110. The i nci dence of preecl a mps i a i s 5% to 8% a nd pri ma ri l y occurs i n firs t pregna nci es . Ri s k fa ctors i ncl ude preecl a mps i a i n previ ous pregna ncy, chroni c hypertens i on, preges ta ona l di a betes , mul feta l ges ta ons , va s cul a r a nd connec ve s s ue di s ea s e, nephropa thy, a nti phos phol i pi d s yndrome, obes i ty, ol der a ge, a nd Afri ca n Ameri ca n ra ce. Diagnosis of Hypertension in Pregnancy Gestational hypertension: Sys tol i c or di a s tol i c mm Hg for the fi rs t ti me i n pregna ncy No protei nuri a BP returns to norma l before 12 weeks pos tpa rtum Fi na l di a gnos i s onl y ma de pos tpa rtum Ma y ha ve other s i gns or s ymptoms of preecl a mps i a , i e, epi ga s tri c di s comfort or thrombocytopeni a Preeclampsia: Hypertens i on a fter 20 weeks of ges ta ti on wi th protei nuri a .

Eclampsia: Sei zures tha t ca nnot be a ttri buted to other ca us es i n a woma n wi th preecl a mps i a . 111. The answer is b. (Cunningham, pp 874-876.) In the twi n-to-twi n tra ns fus i on s yndrome, the donor twi n i s a l wa ys a nemi c, owi ng not to a hemol y c proces s but to the di rect tra ns fer of bl ood to the reci pi ent twi n, who becomes pol ycythemi c. The reci pi ent ma y s uffer thrombos es s econda ry to hypertra ns fus i on a nd s ubs equent hemoconcentra on. Al though the donor pl a centa i s us ua l l y pa l e a nd s omewha t a trophi ed, tha t of the reci pi ent i s conges ted a nd enl a rged. Hydra mni os ca n devel op i n ei ther twi n, but i s more frequent i n the reci pi ent beca us e of ci rcul a tory overl oa d. When hydra mni os occurs i n the donor, i t i s owi ng to conges ti ve hea rt fa i l ure ca us ed by s evere a nemi a . 112. The answer is c. (ACOG, Prac ce Bulle n No. 48. Cunningham pp 218-221.) The di a gnos i s of cervi ca l i ns uffici ency or i ncompetence i s ba s ed on the pres ence of pa i nl es s cervi ca l di l a on wi th a hi s tory of pregna ncy l os s i n the s econd tri mes ter or ea rl y-thi rd-tri mes ter preterm del i very. A pa ent wi th a hi s tory of three or more mi dtri mes ter pregna ncy l os s es or ea rl y preterm del i veri es i s a ca ndi da te for a cercl a ge. Cercl a ge i s not i ndi ca ted for the preven on of firs t-tri mes ter l os s es . Cercl a ge ha s not been s hown to i mprove the preterm del i very ra te or neona ta l outcome i n twi n ges ta ons . A s i mpl e punch bi ops y or l oop el ectros urgi ca l exci s i on procedure of the cervi x i s unl i kel y to di s rupt func ona l s tructure of the cervi x a nd prophyl a c c cercl a ge i s not wa rra nted. Seri a l tra ns va gi na l ul tra s ound eva l ua on of cervi ca l l ength ca n be cons i dered i n women wi th a hi s tory of s econd a nd ea rl y-thi rd-tri mes ter del i veri es . A cervi ca l l ength l es s tha n 25 mm or funnel i ng of more tha n 25% or both i s a s s oci a ted wi th a n i ncrea s ed ri s k of preterm del i very. 113 to 117. The answers are 113-e, 114-b, 115-d, 116-c, 117-a. (Cunningham, pp 220-223.) Bl eedi ng occurs i n a bout 30% to 40% of huma n ges ta ons before 20 weeks of pregna ncy, wi th a bout ha l f of thes e pregna nci es endi ng i n s ponta neous a bor on. A threa tened a bor on ta kes pl a ce when thi s uteri ne bl eedi ng occurs wi thout a ny cervi ca l di l a on or effa cement. In a pa ent bl eedi ng duri ng the firs t ha l f of pregna ncy, the di a gnos i s of i nevi ta bl e a bor on i s s trengthened i f the bl eedi ng i s profus e a nd a s s oci a ted wi th uteri ne cra mpi ng pa i ns . If cervi ca l di l a on ha s occurred, wi th or wi thout rupture of membra nes , the a bor on i s i nevi ta bl e. If onl y a por on of the products of concep on ha s been expel l ed a nd the cervi x rema i ns di l a ted, a di a gnos i s of i ncompl ete a bor on i s ma de. However, i f a l l feta l a nd pl a centa l s s ue ha s been expel l ed, the cervi x i s cl os ed, bl eedi ng from the ca na l i s mi ni ma l or decrea s i ng, a nd uteri ne cra mps ha ve cea s ed, a di a gnos i s of compl ete a bor on ca n be ma de. The di a gnos i s of mi s s ed a bor on i s s us pected when the uterus fa i l s to con nue to enl a rge wi th or wi thout uteri ne bl eedi ng or s po ng. A mi s s ed a bor on i s one i n whi ch feta l dea th occurs before 20 weeks ges ta on wi thout expul s i on of a ny feta l or ma terna l s s ue for a t l ea s t 8 weeks therea er. When a fetus i s reta i ned i n the uterus beyond 5 weeks a fter feta l dea th, cons umpti ve coa gul a bi l i ty wi th hypofi brogenemi a ma y occur. Thi s i s uncommon, however, i n ges ta ti ons of l es s tha n 14 weeks i n dura ti on. 118. The answer is d. (Cunningham, pp 257-261.) The hi s tory, cl i ni ca l pi cture, a nd ul tra s ound of the woma n i n the ques on a re cha ra cteri s c of hyda di form mol e. The mos t common chromos oma l ma keup for pa r a l mol e i s 69, XXX, or 69, XXY, a nd for compl ete mol e i s 46, XX. The mos t common i ni a l s ymptoms i ncl ude a n enl a rged-for-da tes uterus a nd con nuous or i ntermi ent bl eedi ng i n the firs t two tri mes ters . Other

s ymptoms i ncl ude hypertens i on, protei nuri a , a nd hyperthyroi di s m. Hyda di form mol e i s 10 mes a s common i n the Fa r Ea s t a s i n North Ameri ca , a nd i t occurs more frequentl y i n women ol der tha n 45 yea rs of a ge. A s s ue s a mpl e woul d s how a vi l l us wi th hydropi c cha nges a nd no ves s el s . Gros s l y, thes e l es i ons a ppea r a s s ma l l , cl ea r cl us ters of gra pel i ke ves i cl es , the pa s s a ge of whi ch confirms the di a gnos i s . Hys terectomy ma y be cons i dered a s pri ma ry thera py for mol a r pregna ncy i n women who ha ve compl eted chi l dbea ri ng. 119. The answer is a. (Cunningham, pp 257-264.) The condi on of women who ha ve hyda di form mol es but no evi dence of meta s ta c di s ea s e s houl d be fol l owed routi nel y by hCG ti ters a fter uteri ne eva cua ti on. Mos t a uthori ti es a gree tha t prophyl a cti c chemothera py s houl d not be empl oyed i n the rou ne ma na gement of women ha vi ng hyda di form mol es beca us e 85% to 90% of a ffected pa ents wi l l requi re no further trea tment. For a young woma n i n whom pres erva ti on of reproducti ve functi on i s i mporta nt, s urgery i s not routi nel y i ndi ca ted. 120. The answer is a. (Cunningham, pp 257-264.) Si ngl e-a gent chemothera py i s us ua l l y i ns tuted i f l evel s of hCG rema i n el eva ted 8 weeks a er eva cua on of a hyda di form mol e. Approxi ma tel y 50% of the pa ents who ha ve pers i s tentl y hi gh hCG ters wi l l devel op ma l i gna nt s equel a e. If hCG ters ri s e or rea ch a pl a tea u for 2 to 3 s ucces s i ve weeks fol l owi ng mol a r eva cua on, a s i ngl e-a gent chemothera py s houl d be i ns tuted, provi ded tha t the trophobl a s c di s ea s e ha s not meta s ta s i zed to the l i ver or bra i n. The pres ence of s uch meta s ta s es us ua l l y requi res i ni a on of combi na ti on chemothera py. 121. The answer is a. (Cunningham, pp 238-256.) The di a gnos i s i s ectopi c pregna ncy. Mol a r pregna ncy, i ncompl ete a bor on, a nd mi s s ed a bor on ca n a l s o be a s s oci a ted wi th a bdomi na l pa i n a nd va gi na l bl eedi ng, but woul d not be a s s oci a ted wi th free flui d (bl ood) wi thi n the a bdomi na l ca vi ty. A tors ed ova ri a n cys t woul d pres ent wi th i ntermi ent a bdomi na l pa i n. The ul tra s ound woul d s how a pel vi c ma s s wi th no flow to the ova ry, not free fl ui d. 122. The answer is b. (Cunningham, pp 238-256.) The cl i ni ca l hi s tory pres ented i n thi s ques on i s cl a s s i c for a ruptured tuba l pregna ncy a ccompa ni ed by hemoperi toneum. A CT s ca n of the a bdomen a nd pel vi s woul d not produce a qui ck di a gnos i s . Though o en underu l i zed, cul docentes i s i s a ra pi d, nons urgi ca l method to confirm the pres ence of uncl o ed i ntra a bdomi na l bl ood from a ruptured tuba l pregna ncy. Cul docentes i s , however, i s a l s o not perfect, a nd a nega ve cul docentes i s s houl d not be us ed a s the s ol e cri teri on for whether or not to opera te on a pa ent. Di l a on a nd cure a ge woul d not permi t ra pi d enough di a gnos i s , a nd the res ul ts obta i ned by thi s procedure a re va ri a bl e. Pos teri or col potomy requi res a n opera ng room, s urgi ca l a nes thes i a , a nd a n experi enced opera tor wi th a s crubbed a nd gowned a s s oci a te. Whi l e a qua n ta ve β-HCG confirms pregna ncy, i t woul d ta ke over a n hour to perform i n the l a b a nd i t does not confi rm the di a gnos i s of hemoperi toneum. A uri ne pregna ncy tes t coul d be done more qui ckl y. 123. The answer is a. (Cunningham, pp 238-251.) Cons erva ve l a pa ros copi c trea tment of ectopi c pregna ncy i s now commonpl a ce. Recent s tudi es s ugges t tha t the fer l i ty ra tes for l a pa ros copy a nd l a pa rotomy a re compa ra bl e, a s a re the i mpl i ca ons of repea t ectopi c pregna nci es . Certa i nl y l a pa ros copy, beca us e of i ts s ma l l i nci s i on, res ul ts i n fewer brea kdowns a nd s horter hos pi ta l s ta ys , but wi th l a pa ros copi c s a l pi ngos tomy the i nci dence of reta i ned/pers i s tent ectopi c pregna ncy i s hi gher. 124. The answer is b. (Cunningham, pp 238-241, 898.) Any fa ctor del a yi ng tra ns i t of the ovum through the fa l l opi a n tube ma y predi s pos e a pa ent to ectopi c pregna ncy. The ma jor predi s pos i ng fa ctor i n the devel opment of ectopi c pregna ncy i s pel vi c i nfla mma tory di s ea s e. Ni ne percent of women a fter one epi s ode of s a l pi ngi ti s wi l l ha ve a n ectopi c pregna ncy. However, a ny opera ti ve procedure on the fa l l opi a n tubes , s uch a s tuba l l i ga ti on or s urgery to rel i eve i nfer l i ty or previ ous ectopi c, i ncrea s e a pa ent’s ri s k. It a ppea rs tha t tuba l s teri l i za ons wi th l a pa ros copi c ful gura on ha ve a hi gher ra te of ectopi c pregna ncy tha n tuba l l i ga ons performed wi th cl i ps or ri ngs . Women who ha ve ha d one ectopi c pregna ncy a re a t i ncrea s ed ri s k of ha vi ng a s econd. DES (di ethyl s l bes trol ) expos ure, us e of a s s i s ted reproduc ve technol ogy (ART), a nd IUD us e i ncrea s e the pos s i bi l i ty of ectopi c pregna ncy. 125. The answer is b. (Cunninham, pp 1050-1052.) Hyperemes i s gra vi da rum i s i ntra cta bl e vomi ng of pregna ncy a nd i s a s s oci a ted wi th di s turbed nutri on. Ea rl y s i gns of the di s order i ncl ude wei ght l os s (up to 5% of body wei ght) a nd ketonuri a . El ectrol yte a bnorma l i es ca n a l s o be pres ent. Beca us e vomi ng ca us es pota s s i um l os s , el ectroca rdi ogra phi c evi dence of pota s s i um depl e on, s uch a s i nverted T wa ves a nd prol onged QT a nd PR i nterva l s , i s us ua l l y a l a ter findi ng. Ja undi ce a l s o i s a l a ter findi ng a nd i s proba bl y ca us ed by fa y i nfil tra on of the l i ver; occa s i ona l l y, a cute hepa c necros i s occurs . Meta bol i c a ci dos i s i s ra re. Hypoka l emi c nephropa thy wi th i s os thenuri a ma y occur l a te. Hypoprotei nemi a a l s o ma y res ul t, ca us ed by poor di et a s wel l a s by a l bumi nuri a . Pa ents who ha ve hyperemes i s gra vi da rum a re bes t trea ted (i f the di s ea s e i s ea rl y i n i ts cours e) wi th pa rentera l fl ui ds a nd el ectrol ytes , s eda ti on, res t, vi ta mi ns , a nd a nti emeti cs i f neces s a ry. In s ome ca s es , i s ol a ti on of the pa ti ent i s neces s a ry. Very s l ow rei ns tu on of ora l feedi ng i s permi ed a er dehydra on a nd el ectrol yte di s turba nces a re corrected. Thera peu c a bor on ma y be neces s a ry i n ra re i ns ta nces ; however, the di s ea s e us ua l l y i mproves s ponta neous l y a s pregna ncy progres s es . 126. The answer is d. (ACOG, Prac ce Bulle n 80. Cunningham, pp 818-820.) Thi s pa ent wi th prema ture rupture of membra nes (PROM) ha s a phys i ca l exa mi na on cons i s tent wi th a n i ntra uteri ne i nfec on or chori oa mni oni s . Chori oa mni oni s ca n be di a gnos ed cl i ni ca l l y by the pres ence of ma terna l fever, ta chyca rdi a , a nd uteri ne tendernes s . Leukocyte counts a re a nons peci fic i ndi ca tor of i nfec on beca us e they ca n be el eva ted wi th l a bor a nd the us e of cor cos teroi ds . When chori oa mni oni s i s di a gnos ed, feta l a nd ma terna l morbi di ty i ncrea s es a nd del i very i s i ndi ca ted rega rdl es s of the fetus ’s ges ta ona l a ge. In the ca s e des cri bed, a n bi o cs need to be a dmi ni s tered to a voi d neona ta l s eps i s . Ampi ci l l i n i s the drug of choi ce to trea t group B s treptococca l i nfec on. Si nce the feta l hea rt ra te i s rea c ve, there i s no i ndi ca on for ces a rea n s ec on. Augmenta on wi th Pi toci n s houl d be i ns tuted a s i ndi ca ted. There i s no rol e for tocol ys i s i n the s e ng of chori oa mni oni s , s i nce del i very i s the goa l . There i s a l s o no rol e for the a dmi ni s tra on of s teroi ds , s i nce del i very i s i mmi nent. In a ddi on, s teroi ds a re i ndi ca ted a t 32 weeks ges ta ona l a ge or l es s onl y wi th PROM. A cercl a ge (cervi ca l s tch) woul d be pl a ced i n a pre-vi a bl e pregna ncy where a n i ncompetent cervi x i s di a gnos ed i n the a bs ence of ruptured membra nes . 127. The answer is b. (Cunningham, pp 810-817.) The concern wi th thi s pa ent who pres ents wi th a twi n ges ta on a nd s ymptoms of bl eedi ng, cra mpi ng, a nd i ncrea s ed va gi na l di s cha rge i s preterm l a bor. Intra venous hydra on i s a ppropri a te beca us e dehydra on ca n be a ca us e of prema ture contra c ons a nd uteri ne i rri ta bi l i ty. Uri na ry i nfec ons ca n be a s s oci a ted wi th uteri ne contra c ons , a nd therefore a uri na l ys i s a nd uri ne cul ture s houl d be obta i ned. Infec on ca us ed by group B s treptococci ca n be a s s oci a ted wi th preterm l a bor, s o a cul ture to detect thi s orga ni s m s houl d be obta i ned. Before performi ng a di gi ta l exa mi na on on thi s pa ent to determi ne her cervi ca l s ta tus , a n ul tra s ound s houl d be performed to rul e out pl a centa previ a i n l i ght of the hi s tory of va gi na l bl eedi ng. 128. The answer is c. (Cunningham, pp 810-817.) The pa ent i s i n pre-term l a bor, beca us e s he ha s a di l a ted a nd effa ced cervi x i n the pres ence of regul a r uteri ne contra c ons . Therefore, trea tment i s a i med a t del a yi ng del i very to a l l ow con nued feta l growth a nd ma turi ty. The a dmi ni s tra on of tocol y c thera py to trea t the preterm contra c ons i s i ndi ca ted. In a ddi on, from 24 to 34 weeks , ma na gement a l s o i ncl udes the a dmi ni s tra on of s teroi ds , s uch a s beta metha s one, to promote feta l l ung ma turi ty. Res pi ra tory di s tres s s yndrome i s a s equel a of preterm neona tes a nd occurs l es s o en i n i nfa nts gi ven beta metha s one i n utero. If del i very s eems l i kel y, i ntra venous a n bi o cs a re a dmi ni s tered to prevent pos s i bl e

neona ta l s eps i s . If the pa ent’s contra c ons s ubs i de a nd there i s no evi dence of i nfec on, then the a n bi o cs ca n be di s con nued. It i s a dva nta geous to obta i n a neona tol ogy cons ul t on a ny pa ent who a ppea rs to be i n preterm l a bor s o the pa rents know wha t to expect i f they gi ve bi rth to preterm i nfa nts . There i s no need to prepa re for a ces a rea n s ec on i n thi s pa ent. A empts a re ma de to s top the l a bor firs t. If the pa ent conti nues to progres s , then a va gi na l del i very i s preferred s i nce the twi ns do not ha ve a ma l pres enta ti on. 129. The answer is a. (Cunningham, pp 874-876.) In twi n ges ta ti ons where monochori oni c pl a centa s exi s t, twi n-to-twi n tra ns fus i on s yndrome ca n occur. In thi s s yndrome, there a re va s cul a r communi ca ons or a na s tomos es between the twi ns . There i s bl ood flow or tra ns fus i on from one twi n to a nother. The donor twi n becomes a nemi c a nd ma y s uffer growth reta rda on a nd ol i gohydra mni os . The reci pi ent twi n ma y devel op hydra mni os , hypervol emi a , hypertens i on, pol ycythemi a , a nd conges ti ve hea rt fa i l ure. 130. The answer is d. (Cunningham, pp 821-827.) Indometha ci n woul d not be a n a ppropri a te tocol y c a gent i n thi s pa ent. Indoci n i s a pros ta gl a ndi n s yntheta s e i nhi bi tor tha t ca n decrea s e feta l uri ne produc on a nd ca us e ol i gohydra mni os . Si nce twi n B a l rea dy ha s ol i gohydra mni os s econda ry to twi n-to-twi n tra ns fus i on s yndrome, i t i s bes t to a voi d thi s thera py. Ni fedi pi ne i s us ed for tocol ys i s a nd i s thought to work by preven ng entry of ca l ci um i nto mus cl e cel l s . It ca n be a s s oci a ted wi th hypotens i on, s o bl ood pres s ure mus t be fol l owed ca reful l y. Ri todri ne a nd terbuta l i ne a re tocol y c a gents tha t a re β-a drenergi c a gents . They work by i ncrea s i ng cAMP i n cel l s , whi ch decrea s es free ca l ci um. Thes e a gents ca n be a s s oci a ted wi th ta chyca rdi a , hypotens i on, a nd pul mona ry edema . Ma gnes i um s ul fa te i s a tocol y c a gent tha t works by compe ng wi th ca l ci um for entry i nto cel l s . At hi gh l evel s , i t ca n ca us e res pi ra tory a nd ca rdi a c depres s i on. 131. The answer is e. (Cunningham, pp 583-584, 758-759.) Va s a previ a occurs when feta l ves s el s overl i e the cervi ca l os from vel a mentous i ns er on of the umbi l i ca l cord. They a re s us cep bl e to compres s i on a nd l a cera on wi th rupture of membra nes . Bl eedi ng from a va s a previ a ca us es feta l exs a ngui na on a nd s i nce onl y a s ma l l a mount of bl eedi ng i s neces s a ry to ki l l a fetus , dea th i s a l mos t i ns ta nta neous i f i t goes unrecogni zed. Si nce the feta l hea rt tones a re norma l , va s a previ a ca n be rul ed out. Cervi ca l i nfla mma on (cervi ci s ) ca n render the cervi x fri a bl e a nd a bl e to bl eed ea s i l y, es peci a l l y a er i ntercours e. Pl a centa l a brup on occurs when there i s a prema ture s epa ra on of the pl a centa from the uteri ne wa l l . Whi l e va gi na l bl eedi ng ca n be obs erved, the hemorrha ge ca n be compl etel y concea l ed, wi th the bl ood bei ng tra pped between the deta ched pl a centa a nd the uteri ne wa l l . La bor ca n be a s s oci a ted wi th va gi na l bl eedi ng ca us ed by cervi ca l di l a on. Pl a centa previ a occurs when the pl a centa i s l oca ted over or i n cl os e proxi mi ty to the i nterna l os of the cervi x. When the l ower uteri ne s egment i s formed or cervi ca l di l a on occurs i n the pres ence of pl a centa previ a , a certa i n degree of s ponta neous pl a centa l s epa ra on a nd hemorrha ge from di s rupted bl ood ves s el s wi l l occur. 132. The answer is e. (Cunningham, pp 758-759.) Any pa ent who gi ves a hi s tory of va gi na l bl eedi ng i n the thi rd tri mes ter s houl d undergo a n ul tra s ound exa mi na on a s the firs t s tep i n eva l ua on to rul e out the pres ence of a pl a centa previ a . A di gi ta l cervi ca l exa mi na on performed i n the pres ence of a pl a centa previ a ca n preci pi ta te a hemorrha ge. Vi s ua l i za on of the cervi x through a s pecul um a l l ows for the i den fica on of the bl eedi ng s ource, but every effort s houl d be ma de to i den fy pl a centa l l oca on. There i s no i ndi ca on to work the pa ent up for i nfec on i n the ca s e des cri bed here; therefore, a n a mni ocentes i s i s not i ndi ca ted. She s houl d not be s ent home even though the bl eedi ng ha s res ol ved. She firs t needs to undergo a n ul tra s ound a nd s houl d be moni tored for uteri ne contra cti ons a nd further bl eedi ng pri or to bei ng di s cha rged. 133. The answer is c. (Cunningham, pp 772-773, 791-795.) In thi s pa ent who i s s ta r ng to hemorrha ge from a pl a centa previ a , s teps s houl d be ta ken to s ta bi l i ze the pa ent a nd prepa re for pos s i bl e emergent ces a rea n s ec on. The pa ent i s not contra c ng, a nd therefore there i s no rol e for tocol ys i s . In a ddi on, terbuta l i ne s houl d never be us ed i n a pa ent who i s a c vel y bl eedi ng beca us e i t i s a s s oci a ted wi th ma terna l ta chyca rdi a a nd va s odi l a on. The a c vel y bl eedi ng pa ent s houl d be res us ci ta ted wi th i ntra venous flui ds whi l e bl ood i s bei ng cros s -ma tched for pos s i bl e tra ns fus i on. A Fol ey ca theter s houl d be pl a ced beca us e uri na ry output i s a reflec on of the pa ent’s vol ume s ta tus . Fi na l l y, a nes thes i a s houl d be noti fi ed beca us e the pa ti ent ma y requi re i mmi nent del i very. 134. The answer is d. (Cunningham, pp 775-776.) Methyl ergonovi ne, pros ta gl a ndi n F 2 α, pros ta gl a ndi n E1 (Mi s opros tol ), a nd pros ta gl a ndi n E2 a re a l l uterotoni c a gents tha t ca n be us ed i n s i tua ons where there i s a pos tpa rtum hemorrha ge ca us ed by uteri ne a tony. Terbuta l i ne woul d be contra i ndi ca ted i n thi s s i tua ti on beca us e i t i s a tocol yti c tha t i s us ed to promote uteri ne rel a xa ti on. 135. The answer is d. (Cunningham, pp 776-780.) Women who ha ve a pl a centa previ a ha ve a bout a 10% ri s k of a l s o ha vi ng a pl a centa a ccreta . The ri s k of pl a centa a ccreta i s even grea ter i n women who ha ve a hi s tory of a previ ous ces a rea n s ec on (es ma ted to be between 14% a nd 24%). The i nci dence of pl a centa a ccreta con nues to i ncrea s e a s the numbers of pri or ces a rea n s ec ons i ncrea s e. If a pl a centa a ccreta i ndeed exi s ts , a hys terectomy i s i ndi ca ted. 136. The answer is b. (Cunningham, pp 846-849.) In a norma l s i ngl eton pregna ncy from a bout 18 to 36 weeks , the number of weeks of ges ta on s houl d a pproxi ma te the funda l hei ght mea s urement. A funda l hei ght mea s urement tha t i s 2 to >3 cm l es s tha n expected, or s ma l l for da tes , s ugges ts the pos s i bi l i ty tha t the pa ent’s da tes a re i ncorrect, tha t ol i gohydra mni os i s pres ent, or tha t the fetus ha s growth res tri c on or ha s undergone demi s e. The pa ent ha s hea rt tones s o the pregna ncy i s s l l vi a bl e a nd the pa ent ha d a firs t tri mes ter ul tra s ound s o the da tes a re correct. She ha s not gi ven a hi s tory of l ea ka ge of flui d nor does s he ha ve a ny ri s k fa ctors for ol i gohydra mni os . She i s cons tu ona l l y s ma l l a nd mothers who wei gh l es s tha n 100 l b pri or to pregna ncy ha ve a two-fol d i ncrea s ed ri s k of ha vi ng a s ma l l -for-ges ta ona l a ge (SGA) i nfa nt. Whi l e poor ma terna l wei ght ga i n, es peci a l l y i n the s econd tri mes ter, i s a s s oci a ted wi th feta l growth res tri c on, the pa ent ha s ga i ned 20 l b to da te, whi ch i s a dequa te. Soci a l depri va on s uch a s s moki ng, a l cohol or drug us e i s a l s o a s s oci a ted wi th SGA, but not for thi s mother ba s ed on hi s tory. Fetus es wi th chromos oma l a neupl oi di es s uch a s tri s omy 13, 16, 18 or 21 a re a s s oci a ted wi th SGA but the pa ent ha s ha d a norma l firs t tri mes ter s creen a nd a na tomy s ca n. Chroni c pl a centa hypoxi a or uteropl a centa l i ns uffici ency a re typi ca l l y a s s oci a ted wi th ma terna l condi ons s uch a s va s cul a r di s ea s e, chroni c rena l i ns uffi ci ency, preges ta ti ona l di a betes , chroni c hypertens i on, s moki ng, or preecl a mps i a . 137. The answer is b. (Cunningham, pp 843-853) Intra uteri ne growth res tri c on (IUGR) i s di a gnos ed when the es ma ted wei ght of the fetus fa l l s bel ow the tenth percen l e for a gi ven a ge. By the us e of ul tra s onogra phy, IUGR ca n be cl a s s i fied a s ei ther s ymmetri c or a s ymmetri c. In a s ymmetri c IUGR, the a bdomi na l ci rcumference i s l ow, but the bi pa ri eta l di a meter ma y be a t or nea r norma l . In ca s es of s ymmetri c IUGR, a l l feta l s tructures (i ncl udi ng both hea d a nd body s i ze) a re propor ona tel y di mi ni s hed i n s i ze. Feta l i nfec ons , chromos ome a bnorma l i es , a nd congeni ta l a noma l i es us ua l l y res ul t i n s ymmetri c IUGR. As ymmetri c IUGR i s s een i n ca s es where feta l a cces s to nutri ents i s compromi s ed, s uch a s wi th s evere ma terna l nutri ti ona l defi ci enci es or hypertens i on. 138. The answer is b. (Cunningham, pp 299-302.) Feta l s s ue for chromos ome a na l ys i s ca n be obta i ned vi a a mni ocentes i s , chori oni c vi l l us s a mpl i ng (CVS), percuta neous umbi l i ca l bl ood s a mpl i ng, or di rect bi ops y of feta l mus cl e or s ki n. Amni ocentes i s , whi ch i s typi ca l l y done from 15 to 20 weeks , i nvol ves obta i ni ng a s a mpl e of a mni o c flui d, whi ch conta i ns feta l fibrobl a s ts . Chori oni c vi l l us s a mpl i ng, whi ch i s bes t done from 10 to 13 weeks , i nvol ves ta ki ng a bi ops y of the pl a centa . In the ca s e of PUBS, the umbi l i ca l vei n i s punctured under di rect ul tra s ound gui da nce nea r the pl a centa l

ori gi n a nd bl ood i s obta i ned for gene c a na l ys i s . Doppl er vel oci metry i s a n ul tra s ound techni que us ed to exa mi ne bl ood flow through the umbi l i ca l a rtery. IUGR ha s been a s s oci a ted wi th a bnorma l umbi l i ca l a rtery Doppl er vel oci metry. Therefore, thi s techni que i s us ed wi th other moda l i ti es s uch a s BPP a nd NSTS to moni tor feta l wel l -bei ng. 139. The answer is e. (Cunningham, p 845.) Fetus es tha t a re growth-res tri cted o en ha ve di fficul ty tra ns i oni ng to the extra uteri ne envi ronment. Therefore, i t i s cri ca l tha t neona tol ogi s ts be pres ent a t s uch del i veri es . Growth-res tri cted fetus es more commonl y pa s s meconi um; therefore a s pi ra on i s a concern a t the me of del i very. In a ddi on, growth-res tri cted fetus es compens a te for poor pl a centa l oxygen tra ns fer by ha vi ng a pol ycythemi a tha t ca n then res ul t i n mul orga n thrombos i s a t or a er bi rth. At the me of del i very, s uch i nfa nts ma y s uffer from hypoxi a ca us ed by pl a centa l i ns uffici ency. Infa nts wi th IUGR ha ve l es s s ubcuta neous fa t depos i on; therefore, hypothermi a a nd hypogl ycemi a a re a poten a l concern. 140. The answer is b. (Cunningham, pp 618-619.) Duri ng the firs t prena ta l vi s i t, a l l pregna nt women a re s creened for the ABO bl ood group a nd the Rh group, whi ch i ncl udes the D a n gen. If the woma n i s Rh-nega ve, a n body s creeni ng i s performed. If the a n body D ter i s pos i ve, the woma n i s cons i dered s ens i zed beca us e s he ha s produced a n bodi es a ga i ns t the D a n gen. Sens i za on occurs a s a res ul t of expos ure to bl ood from a n Rh-pos i ve fetus i n a pri or pregna ncy. A fetus tha t i s Rh-pos i ve pos s es s es red bl ood cel l s tha t expres s the D a n gen. Therefore, the ma terna l a n -D a n bodi es ca n cros s the pl a centa a nd ca us e feta l hemol ys i s . Once the a n body s creen i s pos i ve for i s oi mmuni za on, the ter s houl d be fol l owed a t regul a r i nterva l s (a bout every 4 weeks ). A ter of 1:16 or grea ter i s us ua l l y i ndi ca ve of the pos s i bi l i ty of s evere hemol y c di s ea s e of the fetus . Once the cri ca l ter i s rea ched, further eva l ua on i s done by a mni o c flui d a s s es s ment or a na l ys i s of feta l bl ood vi a PUBS. In the pres ence of feta l hemol ys i s , the a mni o c flui d conta i ns el eva ted l evel s of bi l i rubi n tha t ca n be determi ned vi a s pectrophotometri c a na l ys i s . Cordocentes i s , or percuta neous umbi l i ca l bl ood s a mpl i ng, i nvol ves obta i ni ng a bl ood s a mpl e from the umbi l i ca l cord under ul tra s ound gui da nce. The feta l bl ood s a mpl e ca n then be a na l yzed for Hct a nd determi na on of feta l bl ood type. Cordocentes i s a l s o a l l ows the fetus wi th a nemi a to undergo a bl ood tra ns fus i on. 141. The answer is a. (ACOG, Prac ce Bulle n 4. Cunningham, pp 624-625.) To prevent ma terna l Rh s ens i za on, pregna nt women who a re Rh-nega ve s houl d recei ve RhoGAM or Rh i mmune gl obul i n (a n body to the D a n gen) i n the fol l owi ng s i tua ons : a er a s ponta neous or i nduced a bor on, a er a n ectopi c pregna ncy, a t the me of a n a mni ocentes i s /CVS/PUBS, a t 28 weeks ges ta ona l a ge, wi thi n 3 da ys of a del i very of a n Rh-pos i ve fetus , a t the ti me of externa l cepha l i c vers i on, wi th s econd-or thi rd-tri mes ter a ntena ta l bl eedi ng, a nd i n the s etti ng of a bdomi na l tra uma . 142. The answer is d. (Cunningham, pp 620-622.) Cha ra cteri s cs of feta l hydrops i ncl ude a bnorma l flui d i n two or more s i tes s uch a s the thora x, a bdomen, a nd s ki n. Feta l hydrops occurs a s a res ul t of exces s i ve a nd prol onged hemol ys i s whi ch ca us es a nemi a , whi ch s mul a tes erythroi d hyper-pl a s i a of the bone ma rrow a nd extra medul l a ry hema topoi es i s i n the l i ver a nd s pl een. The pl a centa i s a l s o ma rkedl y erythema tous , enl a rged, a nd boggy. Hydrothora x ma y be s o s evere tha t i t ma y res tri ct l ung devel opment a nd ca us e pul mona ry compromi s e a er del i very. As ci tes , hepa tomega l y, a nd s pl enomega l y ma y l ea d to s evere dys toci a . Hydropi c cha nges a re ea s i l y s een on feta l ul tra s ound. 143. The answer is e. (Cunningham, pp 706-709.) Hypertens i on i n pregna ncy i s defined a s bl ood pres s ure of 140/90 mm Hg or grea ter on a t l ea s t two s epa ra te occa s i ons tha t a re 6 hours or more a pa rt. The pres ence of edema i s no l onger us ed a s a di a gnos c cri teri a beca us e i t i s s o preva l ent i n norma l pregna nt women. A ri s e i n s ys tol i c bl ood pres s ure of 30 mm Hg a nd a ri s e i n di a s tol i c bl ood pres s ure of 15 mm Hg i s no l onger us ed, beca us e women mee ng thi s cri teri a a re not l i kel y to s uffer a dvers e pregna ncy outcomes i f thei r a bs ol ute bl ood pres s ure i s bel ow 140/90 mm Hg. In ges ta ona l hypertens i on, ma terna l bl ood pres s ure rea ches 140/90 mm Hg or grea ter for the firs t me duri ng pregna ncy, a nd protei nuri a i s not pres ent. In preecl a mps i a , bl ood pres s ure i ncrea s es to 140/90 mm Hg a er 20 weeks ges ta on a nd protei nuri a i s pres ent (300 mg i n 24 hour or 1+ protei n or grea ter on di ps ck). Ecl a mps i a i s pres ent when women wi th preecl a mps i a devel op s ei zures . Chroni c hypertens i on exi s ts when a woma n ha s a bl ood pres s ure of 140/90 mm Hg or grea ter pri or to the pregna ncy or before 20 weeks ges ta on. A woma n wi th hypertens i on who devel ops preecl a mps i a i s des cri bed a s ha vi ng chroni c hypertens i on wi th s uperi mpos ed preecl a mps i a . 144. The answer is b. (Cunningham, pp 728-748.) Women who ha ve s uffered a n ecl a mp c s ei zure need to ha ve thei r bl ood pres s ure control l ed wi th a n hypertens i ve medi ca ons i f the di a s tol i c i s i ncrea s ed a bove 105 to 110 mm Hg. The purpos e of a n hypertens i ve thera py i s to a voi d a ma terna l s troke. Hydra l a zi ne, ni fedi pi ne, a nd l a beta l ol a re commonl y us ed i n a cute hypertens i ve cri s es . Ma gnes i um s ul fa te i s a dmi ni s tered a s a l oa di ng dos e a nd then a s a con nuous i nfus i on to prevent further s ei zures . Steps to effect a va gi na l del i very s houl d then be underta ken. To a voi d ma terna l ri s ks from s urgery, ces a rea n s ec on s houl d be a voi ded. In the ca s e pres ented here, the bra dyca rdi a s een i n the fetus i s tra ns i ent a nd i s ca us ed by the ma terna l hypoxi a tha t ha s occurred wi th the s ei zure. Del i very duri ng a bra dyca rdi c epi s ode woul d i mpos e unneces s a ry ri s k for the fetus a nd s houl d be a voi ded. In the ca s e pres ented here, the pa ent ha s a ri pe cervi x a nd l a bor s houl d be i nduced wi th a mni otomy a nd Pi toci n. A Fol ey ca theter s houl d be pl a ced to keep tra ck of ma terna l rena l functi on. 145. The answer is c. (Cunningham, pp 736-739.) The thera peu c ra nge of s erum ma gnes i um to prevent s ei zures i s 4 to 7 mg/dL. At l evel s between 8 a nd 12 mg/dL, pa tel l a r reflexes a re l os t. At 10 to 12 mg/dL, s omnol ence a nd s l urred s peech commonl y occur. Mus cl e pa ra l ys i s a nd res pi ra tory di ffi cul ty occur a t 15 to 17 mg/dL, a nd ca rdi a c a rres t occurs a t l evel s grea ter tha n 30 mg/dL.

Medical and Surgical Complications of Pregnancy Question 146. A 33-yea r-ol d G3P2 a t 38 weeks ges ta on devel ops flu-l i ke i l l nes s a nd brea ks out wi th a pruri c, ves i cul a r l es i ons a l l over her body. Three da ys l a ter s he goes i nto s ponta neous l a bor a nd del i vers a hea l thy a ppea ri ng ma l e i nfa nt vi a va gi na l del i very. Her l es i ons a re begi nni ng to hea l a nd s he feel s wel l . Wha t i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent a nd her ba by? a . Admi ni s ter i ntra venous a cycl ovi r to the mother. b. Admi ni s ter i ntra venous a cycl ovi r to the ba by. c. Admi ni s ter va ri cel l a -zos ter i mmune gl obul i n to the ba by. d. Admi ni s ter Va ri va x (va ri cel l a va cci ne) to the ba by. e. Admi ni s ter Zos ta va x (herpes zos ter va cci ne) to the mother. 147. A 22-yea r-ol d G1 a t 14 weeks ges ta on pres ents to your office wi th a hi s tory of recent expos ure to her 3-yea r-ol d nephew who ha d a rubel l a vi ra l i nfecti on. In whi ch ti me peri od does ma terna l i nfecti on wi th rubel l a vi rus ca rry the grea tes t ri s k for congeni ta l rubel l a s yndrome i n the fetus ? a . Preconcepti on b. Fi rs t tri mes ter c. Second tri mes ter d. Thi rd tri mes ter e. Pos tpa rtum 148. A pregna nt woma n i s di s covered to be a n a s ymptoma c ca rri er of Neisseria gonorrhoeae. A yea r a go, s he wa s trea ted wi th peni ci l l i n for a gonococca l i nfecti on a nd devel oped a s evere a l l ergi c rea cti on. Whi ch of the fol l owi ng i s the trea tment of choi ce a t thi s ti me? a . Tetra cycl i ne b. Ampi ci l l i n c. Specti nomyci n d. Chl ora mpheni col e. Peni ci l l i n 149. A 22-yea r-ol d ha s jus t been di a gnos ed wi th toxopl a s mos i s . You try to determi ne wha t her ri s k fa ctors were. The hi ghes t ri s k a s s oci a on i s whi ch of the fol l owi ng? a . Ea ti ng ra w mea t b. Ea ti ng ra w fi s h c. Owni ng a dog d. Engl i s h na ti ona l i ty e. Ha vi ng vi ra l i nfecti ons i n ea rl y pregna ncy 150. A 17-yea r-ol d woma n a t 22 weeks ges ta on pres ents to the emergency center wi th a 3-da y hi s tory of na us ea , vomi ng, a nd a bdomi na l pa i n. The pa i n s ta rted i n the mi ddl e of the a bdomen a nd i s now l oca ted a l ong her mi d to upper ri ght s i de. She i s noted to ha ve a tempera ture of 38.4°C (101.1°F). She deni es a ny pa s t medi ca l probl ems or s urgeri es . How does pregna ncy a l ter the di a gnos i s a nd trea tment of the di s ea s e? a . Owi ng to a na tomi ca l a nd phys i ol ogi ca l cha nges i n pregna ncy, di a gnos i s i s ea s i er to ma ke. b. Surgi ca l trea tment s houl d be del a yed s i nce the pa ti ent i s pregna nt. c. Feta l outcome i s i mproved wi th del a yed di a gnos i s . d. The i nci dence i s uncha nged i n pregna ncy. e. The i nci dence i s hi gher i n pregna ncy. 151. A 24-yea r-ol d woma n a ppea rs a t 8 weeks of pregna ncy a nd revea l s a hi s tory of pul mona ry embol i s m 7 yea rs a go duri ng her firs t pregna ncy. She wa s trea ted wi th i ntra venous hepa ri n fol l owed by s evera l months of ora l wa rfa ri n (Couma di n) a nd ha s ha d no further evi dence of thromboembol i c di s ea s e for more tha n 6 yea rs . Whi ch of the fol l owi ng s ta tements a bout her current condi ti on i s true? a . Ha vi ng no evi dence of di s ea s e for more tha n 5 yea rs mea ns tha t the ri s k of thromboembol i s m i s not grea ter tha n norma l . b. Impeda nce pl ethys mogra phy i s a us eful s tudy to eva l ua te for deep-venous thrombos i s i n pregna ncy. c. Doppl er ul tra s onogra phy i s not a us eful techni que to eva l ua te for deep-venous thrombos i s i n pregna ncy. d. The pa ti ent s houl d be pl a ced on l ow-dos e hepa ri n thera py throughout pregna ncy a nd puerperi um. e. The pa ti ent i s a t hi ghes t ri s k for recurrent thromboembol i s m duri ng the s econd tri mes ter of pregna ncy. 152. A 29-yea r-ol d G3P2 bl a ck woma n i n the thi rty-thi rd week of ges ta on i s a dmi ed to the emergency room beca us e of a cute a bdomi na l pa i n tha t ha s been i ncrea s i ng duri ng the pa s t 24 hours . The pa i n i s s evere a nd i s ra di a ng from the epi ga s tri um to the ba ck. The pa ent ha s vomi ted a few mes a nd ha s not ea ten or ha d a bowel movement s i nce the pa i n s ta rted. On exa mi na on, you obs erve a n a cutel y i l l pa ent l yi ng on the bed wi th her knees dra wn up. Her bl ood pres s ure i s 100/70 mm Hg, her pul s e i s 110 bea ts per mi nute, a nd her tempera ture i s 38.8°C (101.8°F). On pa l pa on, the a bdomen i s s omewha t di s tended a nd tender, ma i nl y i n the epi ga s tri c a rea , a nd the uteri ne fundus rea ches 31 cm a bove the s ymphys i s . Hypotoni c bowel s ounds a re noted. Feta l moni tori ng revea l s a norma l pa ern of feta l hea rt ra te (FHR) wi thout uteri ne contra c ons . On ul tra s onogra phy, the fetus i s i n vertex pres enta on a nd a ppropri a te i n s i ze for ges ta ona l a ge; feta l brea thi ng a nd trunk movements a re noted, a nd the vol ume of a mni o c flui d i s norma l . The pl a centa i s l oca ted on the a nteri or uteri ne wa l l a nd no previ a i s s een. La bora tory va l ues s how mi l d l eukocytos i s (12,000 cel l s per mL); a hema tocri t of 43; mi l dl y el eva ted s erum gl uta mi coxa l oa ce c tra ns a mi na s e (SGOT), s erum gl uta mi cpyruvi c tra ns a mi na s e (SGPT), a nd bi l i rubi n; a nd s erum a myl a s e of 180 U/dL. Uri na l ys i s i s norma l . Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Acute degenera ti on of uteri ne l ei omyoma b. Acute chol ecys ti ti s c. Acute pa ncrea ti ti s d. Acute a ppendi ci ti s e. Severe preecl a mpti c toxemi a

153. An 18-yea r-ol d G1 ha s a s ymptoma c ba cteri uri a (ASB) a t her firs t prena ta l vi s i t a t 15 weeks ges ta on. Whi ch of the fol l owi ng s ta tements i s true? a . The preva l ence of ASB duri ng pregna ncy ma y be a s grea t a s 30%. b. There i s a decrea s ed i nci dence of ASB i n women wi th s i ckl e cel l tra i t. c. Fi fteen percent of women devel op a uri na ry tra ct i nfecti on a fter a n i ni ti a l nega ti ve uri ne cul ture. d. Twenty-five percent of women wi th ASB s ubs equentl y devel op a n a cute s ymptoma c uri na ry i nfec on duri ng the s a me pregna ncy a nd s houl d be trea ted wi th a nti bi oti cs . e. ASB i s hi ghl y a s s oci a ted wi th a dvers e pregna ncy outcomes . 154. A 20-yea r-ol d gra vi d 1 a t 18 weeks of ges ta on i s hos pi ta l i zed for i ntra venous a n bi o cs for the trea tment of a cute pyel onephri s . She devel ops s hortnes s of brea th a nd i s found to ha ve ta chypnea a nd decrea s ed oxygen s a tura on. Ches t x-ra y revea l s pul mona ry i nfil tra tes cons i s tent wi th pul mona ry edema . Wha t i s the mos t l i kel y ca us e of thi s compl i ca ti on? a . Acute rena l fa i l ure b. Al l ergi c rea cti on c. Ba cteremi a d. Endotoxi n rel ea s e e. Intra venous hydra ti on 155. A 30-yea r-ol d gra vi da 1 a t 6 weeks by l a s t mens trua l peri od pres ents for prena ta l ca re. She ha s ha d type 1 di a betes s i nce the a ge of 14. She a l s o reports a hi s tory of di a be c nephropa thy a nd prol i fera ve re nopa thy. She i s concerned a bout the effects of di a betes on her ba by. Whi ch of the fol l owi ng s ta tements a bout di a betes i n pregna ncy i s true? a . Di a beti c ketoa ci dos i s i s a common compl i ca ti on duri ng the fi rs t tri mes ter. b. Protei nuri a over 300 mg/d i s a s s oci a ted wi th i ncrea s ed ri s k of preecl a mps i a . c. Prol i fera ti ve reti nopa thy i mproves i n pregna ncy. d. Gl ycos yl a ted hemogl obi n l evel s a re poor predi ctors of the ri s k of congeni ta l ma l forma ti ons . e. The ri s k of feta l chromos oma l a bnorma l i ti es i s i ncrea s ed. 156. You a re ca l l ed i n to eva l ua te the hea rt of a 19-yea r-ol d pri mi gra vi da a t term. Li s teni ng ca reful l y to the hea rt, you determi ne tha t there i s a s pl i t S 1 , norma l S 2 , S 3 ea s i l y a udi bl e wi th a 2/6 s ys tol i c ejec on murmur grea ter duri ng i ns pi ra on, a nd a s o di a s tol i c murmur. You i mmedi a tel y recogni ze whi ch of the fol l owi ng? a . The pres ence of the S 3 i s a bnorma l . b. The s ys tol i c ejecti on murmur i s unus ua l i n a pregna nt woma n a t term. c. Di a s tol i c murmurs a re ra re i n pregna nt women. d. The combi na ti on of a promi nent S 3 a nd s oft di a s tol i c murmur i s a s i gni fi ca nt a bnorma l i ty. e. Al l fi ndi ngs recorded a re norma l cha nges i n pregna ncy. 157. A 21-yea r-ol d ha s a pos i ve puri fied protei n deri va ve (PPD) a nd i s a bout to be trea ted wi th ri fa mpi n, i s oni a zi d, a nd pyri doxi ne for tubercul os i s . She ca n be rea s s ured tha t her ri s k of whi ch of the fol l owi ng i s mi ni ma l ? a . A fl ul i ke s yndrome ca us ed by ri fa mpi n b. A peri phera l neuropa thy ca us ed by i s oni a zi d c. Opti c neuri ti s ca us ed by i s oni a zi d d. Ototoxi ci ty a s a s i de effect of s treptomyci n e. A pos i ti ve a nti nucl ea r a nti body (ANA) ti ter wi th INH thera py 158. A 33-yea r-ol d woma n a t 10 weeks pres ents for her firs t prena ta l exa mi na on. Rou ne l a bs a re dra wn a nd her hepa s B s urfa ce a n gen i s pos i ve. Li ver func on tes ts a re norma l a nd her hepa s B core a nd s urfa ce a n body tes ts a re nega ve. Whi ch of the fol l owi ng i s the bes t wa y to prevent neona ta l i nfecti on? a . Provi de i mmune gl obul i n to the mother. b. Provi de hepa ti ti s B va cci ne to the mother. c. Perform a ces a rea n del i very a t term. d. Provi de hepa ti ti s B va cci ne to the neona te. e. Provi de i mmune gl obul i n a nd the hepa ti ti s B va cci ne to the neona te. 159. A 38-yea r-ol d G1P0 pres ents to the obs tetri ci a n’s office a t 37 weeks ges ta ona l a ge compl a i ni ng of a ra s h on her a bdomen tha t i s becomi ng i ncrea s i ngl y pruri c. The ra s h s ta rted on her a bdomen, a nd the pa ent notes tha t i t i s s ta r ng to s prea d downwa rd to her thi ghs . The pa ent reports no previ ous hi s tory of a ny s ki n di s orders or probl ems . She deni es a ny ma l a i s e or fever. On phys i ca l exa mi na on, s he i s a febri l e a nd her phys i ci a n notes tha t her a bdomen, a nd mos t nota bl y her s tretch ma rks , i s covered wi th red pa pul es a nd pl a ques . No excori a ons or bul l a e a re pres ent. The pa ti ent’s fa ce, a rms , a nd l egs a re una ffected by the ra s h. Whi ch of the fol l owi ng i s thi s pa ti ent’s mos t l i kel y di a gnos i s ? a . Herpes ges ta ti oni s b. Pruri ti c urti ca ri a l pa pul es a nd pl a ques of pregna ncy c. Pruri go gra vi da rum d. Intra hepa ti c chol es ta s i s of pregna ncy e. Impeti go herpeti formi s 160. A 25-yea r-ol d G2P0 a t 30 weeks ges ta on pres ents wi th the compl a i nt of a new ra s h a nd i tchi ng on her a bdomen over the l a s t few weeks . She deni es a ny cons tu ona l s ymptoms or a ny new l o ons , s oa ps , or detergents . On exa mi na on s he i s a febri l e wi th a s ma l l , pa pul a r ra s h on her trunk a nd forea rms . Excori a ti ons from s cra tchi ng a re a l s o noted. Whi ch of the fol l owi ng i s the recommended fi rs t-l i ne trea tment for thi s pa ti ent? a . Del i very b. Chol es tyra mi ne c. Topi ca l s teroi ds a nd ora l a nti hi s ta mi nes d. Ora l s teroi ds e. Anti bi oti c thera py 161. A 23-yea r-ol d G3P2002 pres ents for a rou ne obs tetri c (OB) vi s i t a t 34 weeks . She reports a hi s tory of geni ta l herpes for 5 yea rs . She reports tha t s he ha s ha d onl y two outbrea ks duri ng the pregna ncy, but i s very concerned a bout the pos s i bi l i ty of tra ns mi ng thi s i nfec on to her ba by.

Whi ch of the fol l owi ng s ta tements i s a ccura te rega rdi ng how thi s pa ti ent s houl d be couns el ed? a . There i s no ri s k of neona ta l i nfecti on duri ng a va gi na l del i very i f no l es i ons a re pres ent a t the ti me the pa ti ent goes i nto l a bor. b. The pa ti ent s houl d be s chedul ed for a n el ecti ve ces a rea n s ecti on a t 39 weeks of ges ta ti on to a voi d neona ta l i nfecti on. c. Sta rti ng a t 36 weeks , weekl y geni ta l herpes cul tures s houl d be done. d. The herpes vi rus i s commonl y tra ns mi tted a cros s the pl a centa i n a pa ti ent wi th a hi s tory of herpes . e. Suppres s i ve a nti vi ra l thera py ca n be s ta rted a t 36 weeks to hel p prevent a n outbrea k from occurri ng a t the ti me of del i very. 162. A 28-yea r-ol d G1 pres ents to your office a t 8 weeks ges ta on. She ha s a hi s tory of di a betes s i nce the a ge of 14. She us es i ns ul i n a nd deni es a ny compl i ca ti ons rel a ted to her di a betes . Whi ch of the fol l owi ng i s the mos t common bi rth defect a s s oci a ted wi th di a betes ? a . Anencepha l y b. Encepha l ocel e c. Meni ngomyel ocel e d. Sa cra l a genes i s e. Ventri cul a r s epta l defect 163. A 32-yea r-ol d G1 a t 10 weeks ges ta on pres ents for her rou ne OB vi s i t. She i s worri ed a bout her pregna ncy beca us e s he ha s a hi s tory of i ns ul i n-dependent di a betes s i nce the a ge of 18. Pri or to becomi ng pregna nt, her endocri nol ogi s t di a gnos ed her wi th mi croa l bumi nuri a . She ha s ha d photo l a s er a bl a ti on of reti nopa thy i n the pa s t. Whi ch di a beti c compl i ca ti on i s mos t l i kel y to be wors ened by pregna ncy? a . Beni gn reti nopa thy b. Ga s tropa res i s c. Nephropa thy d. Neuropa thy e. Prol i fera ti ve reti nopa thy 164. A 37-yea r-ol d G3P2 pres ents to your office for her firs t OB vi s i t a t 10 weeks ges ta on. She ha s a hi s tory of Gra ves di s ea s e a nd ha s been ma i nta i ned on propyl thi oura ci l (PTU) a s trea tment for her hyperthyroi di s m. She i s currentl y euthyroi d but a s ks you i f her condi on pos es a ny probl ems for the pregna ncy. Whi ch of the fol l owi ng s ta tements s houl d be i ncl uded i n your couns el i ng s es s i on wi th the pa ti ent? a . She ma y need to di s conti nue the us e of the thi ona mi de drug beca us e i t i s commonl y a s s oci a ted wi th l eukopeni a . b. Infa nts born to mothers on PTU ma y devel op a goi ter a nd be cl i ni ca l l y hypothyroi d. c. Propyl thi oura ci l does not cros s the pl a centa . d. Pregna nt hyperthyroi d women, even when a ppropri a tel y trea ted, ha ve a n i ncrea s ed ri s k of devel opi ng preecl a mps i a . e. Thyroi d s torm i s a common compl i ca ti on i n pregna nt women wi th Gra ves di s ea s e. 165. A 40-yea r-ol d G3P2 obes e pa ent a t 37 weeks pres ents for her rou ne OB vi s i t. She ha s ges ta ona l di a betes tha t i s control l ed wi th di et. She reports tha t her fa s ng a nd pos tpra ndi a l s uga rs ha ve a l l been wi thi n the norma l ra nge. Her fetus ha s a n es ma ted feta l wei ght of 6½ l b by Leopol d ma neuvers . Whi ch of the fol l owi ng i s the bes t next s tep i n her ma na gement? a . Admi ni s tra ti on of i ns ul i n to prevent ma cros omi a b. Ces a rea n del i very a t 39 weeks to prevent s houl der dys toci a c. Inducti on of l a bor a t 38 weeks d. Ki ck counts a nd routi ne return OB vi s i t i n 1 week e. Weekl y bi ophys i ca l profi l e 166. A 36-yea r-ol d G1P0 a t 35 weeks ges ta on pres ents to l a bor a nd del i very compl a i ni ng of a s evera l -da y hi s tory of genera l i zed ma l a i s e, a norexi a , na us ea , a nd emes i s . She deni es a ny hea da che or vi s ua l cha nges . Her feta l movement ha s been good, a nd s he deni es a ny regul a r uteri ne contra c ons , va gi na l bl eedi ng, or rupture of membra nes . On phys i ca l exa mi na on, you no ce tha t s he i s mi l dl y ja undi ced a nd a ppea rs to be a l i l e confus ed. Her vi ta l s i gns i ndi ca te a tempera ture of 37.7°C (99.9°F), pul s e of 70 bea ts per mi nute, a nd bl ood pres s ure of 100/62 mm Hg. Bl ood i s dra wn a nd the fol l owi ng res ul ts a re obta i ned: ,

,

, ,

,

, s,

s erum

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a mmoni a

. Uri na l ys i s i s pos i ti ve for 3+ protei n a nd l a rge ketones . Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Hepa ti ti s B b. Acute fa tty l i ver of pregna ncy c. Intra hepa ti c chol es ta s i s of pregna ncy d. Severe preecl a mps i a e. Hyperemes i s gra vi da rum 167. A 27-yea r-ol d G1P0 a t 34 weeks ges ta on pres ents to your office compl a i ni ng of a 2-da y hi s tory of na us ea a nd emes i s . On phys i ca l exa mi na on, you no ce tha t s he i s i cteri c s cl era a nd s ki n. Her vi ta l s i gns i ndi ca te a tempera ture of 37.2°C (99°F), pul s e of 102 bea ts per mi nute, a nd bl ood pres s ure of 130/84 mm Hg. She i s s ent to l a bor a nd del i very for a ddi ona l eva l ua on. In l a bor a nd del i very, the feta l hea rt ra te i s i n the 160s wi th good va ri a bi l i ty, but nonrea c ve. Bl ood i s dra wn a nd the fol l owi ng res ul ts a re obta i ned: ,

,

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, s,

(nl 11-35). Uri na l ys i s i s pos i ve for 3+ protei n a nd l a rge ketones . Whi ch of the fol l owi ng i s the recommended trea tment for thi s pa ti ent? a . Immedi a te del i very b. Chol ecys tectomy c. Intra venous di phenhydra mi ne d. MgSO4 thera py e. Bed res t a nd s upporti ve mea s ures s i nce thi s condi ti on i s s el f-l i mi ted 168. A 32-yea r-ol d G1P0 reports to your office for a rou ne OB vi s i t a t 14 weeks ges ta ona l a ge. La bs dra wn a t her firs t prena ta l vi s i t 4 weeks a go revea l a pl a tel et count of 60,000, a norma l PT, PTT a nd bl eedi ng me. Al l her other l a bs were wi thi n norma l l i mi ts . Duri ng the pres ent vi s i t, the pa ent ha s a bl ood pres s ure of 120/70 mm Hg. Her uri ne di p revea l s the pres ence of tra ce protei n. The pa ent deni es a ny compl a i nts . The onl y medi ca on s he i s currentl y ta ki ng i s a prena ta l vi ta mi n. On ta ki ng a more i n-depth hi s tory you l ea rn tha t, pri or to pregna ncy, your pa ent ha d a

hi s tory of occa s i ona l nos e a nd gum bl eeds , but no s eri ous bl eedi ng epi s odes . She ha s cons i dered hers el f to be a pers on who jus t brui s es ea s i l y. Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Al l oi mmune thrombocytopeni a b. Ges ta ti ona l thrombocytopeni a c. Idi opa thi c thrombocytopeni c purpura d. HELLP s yndrome e. Pregna ncy-i nduced hypertens i on 169. A 23-yea r-ol d G1P0 reports to your office for a rou ne OB vi s i t a t 28 weeks ges ta ona l a ge. La bs dra wn a t her prena ta l vi s i t 2 weeks a go revea l a 1-hour gl ucos e tes t of 128, hemogl obi n of 10.8, a nd a pl a tel et count of 80,000. Al l her other l a bs were wi thi n norma l l i mi ts . Duri ng the pres ent vi s i t, the pa ent ha s a bl ood pres s ure of 120/70 mm Hg. Her uri ne di p i s nega ve for protei n, gl ucos e, a nd bl ood. The pa ent deni es a ny compl a i nts . The onl y medi ca on s he i s currentl y ta ki ng i s a prena ta l vi ta mi n. She does report a hi s tory of epi s ta xi s on occa s i on, but no other bl eedi ng. Whi ch of the fol l owi ng medi ca l trea tments s houl d you recommend to trea t the thrombocytopeni a ? a . No trea tment i s neces s a ry. b. Stop prena ta l vi ta mi ns . c. Ora l corti cos teroi d thera py. d. Intra venous i mmune gl obul i n. e. Spl enectomy. 170. A 21-yea r-ol d G2P1 a t 25 weeks ges ta on pres ents to the emergency room compl a i ni ng of s hortnes s of brea th. She reports a hi s tory of a s thma a nd s ta tes her pea k expi ra tory flow ra te (PEFR) wi th good control i s us ua l l y a round 400. Duri ng s pea ki ng the pa ent ha s to s top to ca tch her brea th between words ; her PEFR i s 210. An a rteri a l bl ood ga s i s dra wn a nd oxygen thera py i s i ni a ted. She i s a febri l e a nd on phys i ca l exa mi na on expi ra tory wheezes a re hea rd i n a l l l ung fi el ds . Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n her ma na gement? a . Anti bi oti cs b. Ches t x-ra y c. Inha l ed β-a goni s t d. Intra venous corti cos teroi ds e. Theophyl l i ne 171. One of your obs tetri c pa ents pres ents to the office a t 25 weeks compl a i ni ng of s evere l e ca l f pa i n a nd s wel l i ng. The a rea of concern i s s l i ghtl y edema tous , but no erythema i s a ppa rent. The pa ent demons tra tes a pos i ve Homa ns s i gn, a nd you a re concerned tha t s he ma y ha ve a deep vei n thrombos i s . Whi ch of the fol l owi ng di a gnos ti c moda l i ti es s houl d you order? a . MRI b. Computed tomogra phi c s ca nni ng c. Venogra phy d. Compres s i on ul tra s onogra phy e. X-ra y of l ower extremi ty 172. A 20-yea r-ol d G1 pa ent del i vers a l i ve-born i nfa nt wi th cuta neous l es i ons , l i mb defects , cerebra l cor ca l a trophy, a nd chori ore ni s . Her pregna ncy wa s compl i ca ted by pneumoni a a t 18 weeks . Wha t i s the mos t l i kel y ca us a ti ve a gent? a . Cytomega l ovi rus b. Group B s treptococcus c. Rubel l a vi rus d. Treponemal pallidum e. Va ri cel l a zos ter 173. A 34-yea r-ol d G2 a t 36 weeks del i vers a growth-res tri cted i nfa nt wi th ca ta ra cts , a nemi a , pa tent ductus a rteri os us , a nd s ens ori neura l dea fnes s . She ha s a hi s tory of chroni c hypertens i on, whi ch wa s wel l control l ed wi th methyl dopa duri ng pregna ncy. She ha d a vi ra l s yndrome wi th ra s h i n ea rl y pregna ncy. Wha t i s the mos t l i kel y ca us a ti ve a gent? a . Pa rvovi rus b. Rubel l a vi rus c. Rubeol a d. Toxoplasma gondii e. T pallidum 174. A 25-yea r-ol d G3 a t 39 weeks del i vers a s ma l l -for-ges ta ona l -a ge i nfa nt wi th chori ore ni s , i ntra cra ni a l ca l ci fica ons , ja undi ce, hepa tos pl enomega l y, a nd a nemi a . The i nfa nt di s pl a ys poor feedi ng a nd tone i n the nurs ery. The pa ent deni es ea ng a ny ra w or undercooked mea t a nd does not ha ve a ny ca ts l i vi ng a t home wi th her. She works a s a nurs e i n the pedi a tri c i ntens i ve ca re uni t a t the l oca l hos pi ta l . Wha t i s the mos t l i kel y ca us a ti ve a gent? a . Cytomega l ovi rus b. Group B s treptococcus c. Hepa ti ti s B d. Pa rvovi rus e. Toxoplasmosis gondii 175. A 23-yea r-ol d G1 wi th a hi s tory of a flul i ke i l l nes s , fever, mya l gi a s , a nd l ympha denopa thy duri ng her ea rl y thi rd tri mes ter del i vers a growthres tri cted i nfa nt wi th s ei zures , i ntra cra ni a l ca l ci fi ca ti ons , hepa tos pl enomega l y, ja undi ce, a nd a nemi a . Wha t i s the mos t l i kel y ca us a ti ve a gent? a . Cytomega l ovi rus b. Hepa ti ti s B c. Infl uenza A d. Pa rvovi rus e. Toxoplasmosis gondii 176. A 32-yea r-ol d G5 del i vers a s l l born fetus a t 34 weeks . The pl a centa i s noted to be much l a rger tha n norma l . The fetus a ppea red hydropi c a nd ha d petechi a e over much of the s ki n. Wha t i s the mos t l i kel y ca us a ti ve a gent?

a . Herpes s i mpl ex b. Pa rvovi rus c. Rubel l a vi rus d. T pallidum e. Va ri cel l a zos ter 177. A 38-yea r-woma n a t 39 weeks del i vers a 7-l b i nfa nt fema l e wi thout compl i ca ons . At 2 weeks of l i fe, the i nfa nt devel ops ful mi na nt l i ver fa i l ure a nd di es . Wha t i s the mos t l i kel y ca us a ti ve vi rus ? a . Cytomega l ovi rus b. Hepa ti ti s B c. Herpes s i mpl ex d. Pa rvovi rus e. Rubeol a 178. A 20-yea r-ol d woma n who works a s a ki nderga rten tea cher pres ents for her rou ne vi s i t a t 32 weeks . Her funda l hei ght mea s ures 40 cm. An ul tra s ound revea l s pol yhydra mni os , a n a ppropri a tel y grown fetus wi th a s ci tes a nd s ca l p edema . The pa ent deni es a ny recent i l l nes s es , but s ome of the chi l dren a t her s chool ha ve been s i ck recentl y. Wha t i s the mos t l i kel y ca us e of the feta l fi ndi ngs ? a . Cytomega l ovi rus b. Hepa ti ti s B c. Infl uenza A d. Pa rvovi rus e. T gondii 179. A 25-yea r-ol d woma n i n her firs t pregna ncy del i vers a 6-l b ma l e i nfa nt a t 38 weeks . The i nfa nt devel ops fever, ves i cul a r ra s h, poor feedi ng, a nd l i s tl es s nes s a t 1 week of a ge. Wha t i s the mos t l i kel y ca us e of the i nfa nt’s s i gns a nd s ymptoms ? a . Cytomega l ovi rus b. Group B s treptococcus c. Hepa ti ti s B d. Herpes s i mpl ex e. Listeria monocytogenes 180. A 22-yea r-ol d woma n del i vers a 7-l b ma l e i nfa nt a t 40 weeks wi thout a ny compl i ca ons . On da y 3 of l i fe, the i nfa nt devel ops res pi ra tory di s tres s , hypotens i on, ta chyca rdi a , l i s tl es s nes s , a nd ol i guri a . Wha t i s the mos t l i kel y ca us e of the i nfa nt’s i l l nes s ? a . Cytomega l ovi rus b. Group B s treptococcus c. Hepa ti ti s B d. Herpes s i mpl ex e. L monocytogenes

Medical and Surgical Complications of Pregnancy Answers 146. The answer is c. (Cunningham, pp 1211-1212.) Peri na ta l expos ure to va ri cel l a pri or to the devel opment of ma terna l a n bodi es i s a grea t threa t to newborns . Neona ta l morta l i ty ra tes a re cl os e to 25%. Therefore i f a mother ha s cl i ni ca l evi dence of va ri cel l a i nfec on 5 da ys before or up to 2 da ys a er del i very, the newborn s houl d recei ve va ri cel l a -zos ter i mmune gl obul i n. Typi ca l l y va ri cel l a i nfec on i n the mother onl y requi res s uppor ve thera py, but pregna nt women ha ve a hi gher a nd morta l i ty rel a ted to devel opment of pneumoni a . If pneumoni a i s di a gnos ed, i ntra venous a cycl ovi r s houl d be gi ven. The newborn s houl d be i s ol a ted from the mother i f s he i s i nfec ve, a nd i f the neona te devel ops s i gns or s ymptoms of va ri cel l a i nfec on then i ntra venous a cycl ovi r woul d be a dmi ni s tered. Va ri va x, the l i ve-a enua ted va ri cel l a va cci ne recommended for hea l thy chi l dren a er 12 months of a ge a nd i t i s contra i ndi ca ted i n pregna nt women. Zos ta va x the va cci ne for the preven on of herpes zos ter i s not recommended for i ndi vi dua l s under the a ge of 60. 147. The answer is b. (Cunningham, p 1282.) Rubel l a i s one of the mos t tera togeni c a gents known. Ri s k of congeni ta l rubel l a i nfec on i n the fetus i s 80% when the mother ha s a rubel l a i nfecti on i n the fi rs t tri mes ter. Thi s ri s k decrea s es to 25% by the end of the s econd tri mes ter. 148. The answer is c. (Cunningham, pp 1239-1240.) Spec nomyci n i s the trea tment of choi ce for pregna nt women who ha ve a s ymptoma c N gonorrhoeae i nfec ons a nd who a re a l l ergi c to peni ci l l i n. Erythromyci n i s a nother drug tha t i s effec ve i n trea ng a s ymptoma c gonorrhea . Al though tetra cycl i ne i s a n effec ve a l terna ve to peni ci l l i n, i ts us e i s genera l l y contra i ndi ca ted i n pregna ncy. Admi ni s tra on of chl ora mpheni col i s not recommended to trea t women, pregna nt or not, who ha ve cervi ca l gonorrhea , a nd the us e of a mpi ci l l i n or peni ci l l i n a na l ogues i s contra i ndi ca ted for peni ci l l i n-a l l ergi c pa ti ents . 149. The answer is a. (Cunningham, pp 1226-1227.) Toxopl a s mos i s , a protozoa l i nfec on ca us ed by T gondii, ca n res ul t from i nges on of ra w or undercooked mea t i nfected by the orga ni s m or from conta ct wi th i nfected ca t feces . The French, beca us e thei r di et i ncl udes ra w mea t, ha ve a hi gh i nci dence. The i nci dence of toxopl a s mos i s i n pregna nt women i s es ma ted to be 1 i n every 150 to 700 pregna nci es . Infec on ea rl y i n pregna ncy ma y ca us e a bor on; l a ter i n pregna ncy, the fetus ma y become i nfected. A s ma l l number of i nfected i nfa nts devel op i nvol vement of the centra l nervous s ys tem or the eye; mos t i nfa nts who ha ve the di s ea s e, however, es ca pe s eri ous cl i ni ca l probl ems . 150. The answer is d. (Cunningham, pp 1058-1059.) The i nci dence of a ppendi ci s i n pregna ncy i s 1 i n 2000, the s a me a s tha t i n the nonpregna nt popul a on. The di a gnos i s i s very di fficul t i n pregna ncy beca us e l eukocytos i s , na us ea , a nd vomi ng a re common i n pregna ncy a nd the upwa rd di s pl a cement of the a ppendi x by the uterus ma y ca us e a ppendi ci s to s i mul a te chol ecys s , pyel onephri s , ga s tri s , or degenera ng myoma s . Surgery i s neces s a ry even i f the di a gnos i s i s not certa i n. Del a ys i n s urgery owi ng to di fficul ty i n di a gnos i s a s the a ppendi x moves up a re proba bl y

the ca us e of i ncrea s i ng ma terna l morta l i ty wi th i ncrea s i ng ges ta ona l a ge. Prema ture bi rth a nd a bor on a ccount for a ra te of feta l l os s cl os e to 15%. 151. The answer is d. (Cunningham, pp 1019-1028.) Pa ents wi th a hi s tory of thromboembol i c di s ea s e i n pregna ncy a re a t hi gh ri s k of devel opi ng i t i n s ubs equent pregna nci es . Impeda nce pl ethys mogra phy ha s l i mi ted us e i n pregna ncy due to a hi gher fa l s e-pos i ve ra te beca us e of decrea s ed venous return i n the l ower extremi es duri ng pregna ncy. Compres s i on ul tra -s onogra phy i s the mos t-us ed firs t-l i ne s tudy to di a gnos e venous thrombos i s . Pregna nt pa ents wi th a hi s tory of venothromboembol i s m s houl d be trea ted prophyl a c ca l l y wi th l ow-dos e hepa ri n thera py through the pos tpa rtum peri od a s thi s i s the ti me of hi ghes t ri s k of thi s di s ea s e. 152. The answer is c. (Cunningham, pp 1074-1075.) The mos t proba bl e di a gnos i s i n thi s ca s e i s a cute pa ncrea s . The pa i n ca us ed by a myoma i n degenera on i s more l oca l i zed to the uteri ne wa l l . Low-gra de fever a nd mi l d l eukocytos i s ma y a ppea r wi th a degenera ng myoma , but l i ver func on tes ts a re us ua l l y norma l . The other obs tetri ca l ca us es of epi ga s tri c pa i n, s uch a s preecl a mps i a ma y exhi bi t di s turbed l i ver func on (s ome mes a s s oci a ted wi th the HELLP s yndrome [hemol ys i s , el eva ted l i ver enzymes , l ow pl a tel ets ]), but thi s pa ent ha s onl y mi l d el eva on of bl ood pres s ure a nd no protei nuri a . Acute a ppendi ci ti s i n pregna ncy i s one of the more common nonobs tetri c ca us es of a bdomi na l pa i n. Symptoms of a cute a ppendi ci s i n pregna ncy a re s i mi l a r to thos e i n nonpregna nt pa ents , but the pa i n i s more va gue a nd poorl y l oca l i zed a nd the poi nt of ma xi ma l tendernes s moves to the ri ght upper qua dra nt wi th a dva nci ng ges ta on. Li ver func on tes ts a re norma l wi th a cute a ppendi ci s . Acute chol ecys s ma y ca us e fever, l eukocytos i s , a nd pa i n of the ri ght upper qua dra nt wi th a bnorma l l i ver func on tes ts , but a myl a s e l evel s woul d be el eva ted onl y mi l dl y, i f a t a l l , a nd pa i n woul d be l es s s evere tha n des cri bed i n thi s pa ti ent. The di a gnos i s tha t fi ts the cl i ni ca l des cri pti on a nd the l a bora tory findi ngs i s a cute pa ncrea s . Thi s di s order ma y be more common duri ng pregna ncy, wi th a n i nci dence of 1 i n 100 to 1 i n 10,000 pregna nci es . Chol el i thi a s i s , chroni c a l cohol i s m, i nfec on, a bdomi na l tra uma , s ome medi ca ons , a nd pregna ncy-i nduced hypertens i on a re known predi s pos i ng fa ctors . Leukocytos i s , hemoconcentra on, a nd a bnorma l l i ver func on tes ts a re common l a bora tory findi ngs i n a cute pa ncrea s . However, the mos t i mporta nt l a bora tory findi ng i s a n el eva on of s erum a myl a s e l evel s , whi ch a ppea rs 12 to 24 hours a er ons et of cl i ni ca l di s ea s e. Va l ues ma y exceed 200 U/dL (norma l va l ues a re 50 to 160 U/dL). Trea tment cons i dera ons for the pregna nt pa ent wi th a cute pa ncrea s a re s i mi l a r to thos e i n nonpregna nt pa ents . Intra venous hydra on, na s oga s tri c s uc on, enteri c res t, a nd correc on of el ectrol yte i mba l a nce a nd of hypergl ycemi a a re the ma i ns ta ys of thera py. 153. The answer is d. (Cunningham, pp 1034-1036.) The term asymptomatic bacteriuria i s us ed to i ndi ca te pers i s ng, a c vel y mul pl yi ng ba cteri a wi thi n the uri na ry tra ct wi thout s ymptoms of a uri na ry i nfec on. The reported preva l ence duri ng pregna ncy va ri es from 2% to 7%. The hi ghes t i nci dence ha s been reported i n bl a ck mul pa ra s wi th s i ckl e cel l tra i t a nd the l owes t i nci dence a mong whi te women of l ow pa ri ty. In women who demons tra te ASB, the ba cteri uri a i s typi ca l l y pres ent a t the me of the firs t prena ta l vi s i t; a er a n i ni a l nega ve cul ture of the uri ne, fewer tha n 1% devel op a uri na ry i nfec on. If ASB i s not trea ted duri ng pregna ncy, 25% of i nfected women devel op a n a cute i nfec on. ASB ha s very l i l e, i f a ny, effect on pregna ncy outcomes , except for s eri ous uri na ry tra ct i nfec ons . Pyel onephri s i s the mos t common s eri ous medi ca l compl i ca on of pregna ncy. 154. The answer is d. (Cunningham, pp 1036-1037.) Endotoxi n rel ea s e ca n ca us e a l veol a r i njury a nd l ea d to pul mona ry edema a nd a cute res pi ra tory di s tres s . Endotoxi n rel ea s e ca n a l s o ca us e rena l dys func on ma ni fes ted a s i ncrea s e s erum crea ni ne, but thi s effect i s us ua l l y revers i bl e wi th flui d res us ci ta on. Uteri ne contra c ons a nd hemol y c a nemi a a re a l s o effects of endotoxi n rel ea s e. Ba cteremi a ca n be found i n up to 20% of women wi th pyel onephri s , but i t i s the endotoxi n rel ea s e tha t l ea ds to a l veol a r da ma ge. Whi l e a l l ergi c rea c ons to a n bi o cs ca n ca us e res pi ra tory s ymptoms , they do s o by ca us i ng bronchocons tri c on. Intra venous hydra on to ens ure a dequa te uri na ry ouput (>50 mL/h) i s the ma i ns ta y of thera py. Ca reful moni tori ng of the i nput a nd output of the pa ent i s neces s a ry s o tha t flui d overl oa d wi l l not compound the pul mona ry effects of the endotoxi n. 155. The answer is b. (Cunningham, pp 1106-1113.) Ma terna l di a betes mel l i tus ca n a ffect a pregna nt woma n a nd her fetus i n ma ny wa ys . Di a be c women wi th rena l i nvol vement ha ve i ncrea s ed ri s k of preecl a mps i a a nd i ndi ca ted preterm del i very. Di a be c ketoa ci dos i s i s a s eri ous compl i ca on tha t ca n devel op wi th hyperemes i s gra vi da rum i n the firs t tri mes ter but i t onl y a ffects a bout 1% of di a be c pregna nci es . Type 1 di a be cs ha ve a 5% i nci dence of ma jor congeni ta l ma l forma ons , but the ri s k of chromos oma l a bnorma l i es i s not i ncrea s ed. Pregna ncy i s a s s oci a ted wi th progres s i on of prol i fera ve re nopa thy. Op ma l gl ycemi c control pri or to pregna ncy i s the bes t wa y to mi ni mi ze congeni ta l ma l forma ons a nd gl ycos yl a ted hemogl obi n i s a us eful wa y to a s s es s control . The hi gher the va l ue i n the firs t tri mes ter the hi gher the ri s k of ma l forma ti ons . • Ges ta ti ona l di a betes —when a mother who does not ha ve di a betes devel ops a res i s ta nce to i ns ul i n beca us e of the hormones of pregna ncy • Noni ns ul i n dependent—Cl a s s A1 • Ins ul i n dependent—Cl a s s A2 • Preexi s ti ng di a betes —women who a l rea dy ha ve i ns ul i n dependent di a betes a nd become pregna nt • Cl a s s B—di a betes devel oped a fter a ge 20; ha ve ha d the di s ea s e l es s tha n 10 yea rs ; no va s cul a r compl i ca ti ons • Cl a s s C—di a betes devel oped between a ges 10 a nd 19 or ha ve ha d the di s ea s e for 10 to 19 yea rs ; no va s cul a r compl i ca ti ons • Cl a s s D—di a betes devel oped before a ge 10; ha ve ha d the di s ea s e more tha n 20 yea rs ; va s cul a r compl i ca ti ons a re pres ent • Cl a s s F—di a beti c women wi th ki dney di s ea s e ca l l ed nephropa thy • Cl a s s R—di a beti c women wi th reti nopa thy (reti na l da ma ge) • Cl a s s T—di a beti c women who ha ve undergone ki dney tra ns pl a nt • Cl a s s H—di a beti c women wi th corona ry a rtery or other hea rt di s ea s e 156. The answer is e. (Cunningham, pp 118-121.) Numerous cha nges occur i n the ca rdi ova s cul a r s ys tem duri ng pregna ncy. Hea rt ra te i ncrea s es by a bout 10 to 15 bea ts per mi nute. Bl ood vol ume a nd ca rdi a c output i ncrea s e s i gni fica ntl y. Al l the findi ngs l i s ted i n the ques on a re norma l . An exa ggera ted s pl i ng for the firs t hea rt s ound occurs wi th i ncrea s ed l oudnes s of both components . Al s o a l oud thi rd hea rt s ound ca n be ea s i l y hea rd. Ni nety percent of pregna nt women ha ve s ys tol i c ejec on murmurs . In a pproxi ma tel y 20% of women, a s o di a s tol i c murmur ca n be hea rd. Ten percent of women ma y ha ve a conti nuous murmur a ri s i ng from the brea s t va s cul a ture. 157. The answer is c. (Cunningham, pp 320, 1006, 1083.) Ri fa mpi n ha s occa s i ona l l y been known to ca us e a flul i ke s yndrome, a bdomi na l pa i n, a cute rena l fa i l ure, a nd thrombocytopeni a . It ma y a l s o res embl e hepa s a nd ca n ca us e ora nge uri ne, s wea t, a nd tea rs . INH ha s been a s s oci a ted wi th hepa s , hypers ens i vi ty rea c ons , a nd peri phera l neuropa thi es . The neuropa thy ca n be prevented by the a dmi ni s tra on of pyri doxi ne, es peci a l l y i n the pregna nt pa ent, where pyri doxi ne requi rements a re i ncrea s ed. INH ma y a l s o ca us e a ra s h, a fever, a nd a l upus l i ke s yndrome wi th a pos i ve ANA ter. Streptomyci n ha s a poten a l for ototoxi ci ty i n both the mother a nd the fetus . The mos t commonl y s een feta l s i de effects i ncl ude mi nor ves bul a r i mpa i rment, a udi tory i mpa i rment, or both. Ca s es of s evere a nd bi l a tera l hea ri ng l os s a nd ma rked ves bul a r

a bnorma l i es ha ve been reported wi th s treptomyci n us e. Op c neuri s i s a wel l -des cri bed s i de effect of etha mbutol , a l though i t i s ra re a t the us ua l pres cri bed dos es . 158. The answer is e. (Cunningham, p 1070.) Infec on of the newborn whos e mother chroni ca l l y ca rri es the hepa s B vi rus ca n us ua l l y be prevented by the a dmi ni s tra ti on of hepa ti ti s B i mmune gl obul i n very s oon a fter bi rth, fol l owed promptl y by the hepa ti ti s B va cci ne. 159. The answer is b. (Cunningham, pp 1186-1189.) Pruri c ur ca ri a l pa pul es a nd pl a ques of pregna ncy (PUPPP) i s the mos t common derma tol ogi c condi on of pregna ncy. It i s more common i n nul l i pa rous women a nd occurs mos t o en i n the s econd a nd thi rd tri mes ters of pregna ncy. PUPPP i s cha ra cteri zed by erythema tous pa pul es a nd pl a ques tha t a re i ntens el y pruri c a nd a ppea r firs t on the a bdomen. The l es i ons then commonl y s prea d to the bu ocks , thi ghs , a nd extremi es wi th s pa ri ng of the fa ce. Herpes ges ta oni s i s a bl i s teri ng s ki n erup on tha t occurs more commonl y i n mul pa rous pa ents i n the s econd or thi rd tri mes ter of pregna ncy. The pres ence of ves i cl es a nd bul l a e hel p di fferen a te thi s s ki n condi on from PUPPP. Pruri go ges ta oni s i s a very ra re derma tos i s of pregna ncy tha t i s cha ra cteri zed by s ma l l , pruri c excori a ted l es i ons tha t occur between 25 a nd 30 weeks . The l es i ons firs t a ppea r on the trunk a nd forea rms a nd ca n s prea d throughout the body a s wel l . In ca s es of i ntra hepa c chol es ta s i s of pregna ncy, bi l e a ci ds a re cl ea red i ncompl etel y a nd a ccumul a te i n the dermi s , whi ch ca us es i ntens e i tchi ng. Thes e pa ents devel op pruri tus i n l a te pregna ncy; there a re no cha ra cteri s c s ki n cha nges or ra s hes except i n women who devel op excori a ons from s cra tchi ng. Impe go herpe formi s i s a ra re pus tul a r erup on tha t forms a l ong the ma rgi ns of erythema tous pa tches . Thi s s ki n condi on us ua l l y occurs i n l a te pregna ncy. The s ki n l es i ons us ua l l y begi n a t poi nts of flexure a nd extend peri phera l l y; mucous membra nes a re commonl y i nvol ved. Pa ents wi th i mpe go herpe formi s us ua l l y do not ha ve i ntens e pruri tus , but more commonl y ha ve s ys temi c s ymptoms of na us ea , vomi ng, di a rrhea , chi l l s , a nd fever. 160. The answer is c. (Cunningham, pp 1188-1189.) The firs t-l i ne trea tment for pruri go ges ta oni s a nd pa pul a r derma s i s ora l a n hi s ta mi nes a nd topi ca l cor cos teroi ds . If thes e trea tments do not gi ve rel i ef, ora l s teroi ds s houl d be a dmi ni s tered. The ra s h wi l l res ol ve qui ckl y fol l owi ng del i very, but del i very woul d not be the firs t-l i ne trea tment. Chol es tyra mi ne i s o en us ed i n ca s es of chol es ta s i s of pregna ncy to l ower s erum bi l e s a l ts a nd decrea s e pruri tus . There i s no rol e for a nti bi oti c thera py i n the trea tment s i nce no ba cteri a l eti ol ogy ha s been i denti fi ed. 161. The answer is e. (Cunningham, pp 1241-1245.) A ma terna l HSV i nfec on ca n be pa s s ed to the fetus vi a ver ca l tra ns mi s s i on. If a pregna nt woma n wi th a hi s tory of herpes ha s no l es i ons pres ent a t the me s he goes i nto l a bor, va gi na l del i very i s permi ed. If l es i ons a re pres ent a t the me of l a bor, then there i s a 3% to 5% ri s k of tra ns mi ng the i nfec on to the fetus , a nd ces a rea n del i very i s recommended. Vi ra l s heddi ng ca n occur wi thout the pres ence of a l es i on. It i s not recommended tha t a pa ent wi th a hi s tory of herpes be s chedul ed for a n el ec ve ces a rea n s ec on. It i s not recommended tha t weekl y geni ta l vi ra l cul tures be performed beca us e s uch cul tures do not predi ct whether a pa ent wi l l be s heddi ng the vi rus a t the me of del i very. For pa ents a t or beyond 36 weeks ges ta on, da i l y s uppres s i ve thera py wi th a n a n vi ra l medi ca on s uch a s a cycl ovi r ca n be us ed to try to decrea s e the ri s k of vi ra l s heddi ng a nd outbrea ks a nd the l i kel i hood of a ces a rea n s ecti on. 162. The answer is e. (Cunningham, pp 1113-1119.) The i nci dence of ma jor ma l forma ons i n women wi th di a betes i s 5% to 10%. It i s bel i eved tha t they a re a cons equence of poorl y control l ed di a betes i n the preconcep on a nd ea rl y pregna ncy peri od. Gl ycos yl a ted hemogl obi n (Hgb A 1c) l evel correl a tes to gl ycemi c control a nd the hi gher the l evel of Hgb A1c, the poorer the control a nd the grea ter the ri s k for ma jor congeni ta l a noma l i es . A hemogl obi n A1c l evel grea ter tha n 10.6 ha s a 25% ri s k of feta l ma l forma ons . The mos t common s i ngl e orga n s ys tem a noma l i es a re ca rdi a c (38%), mus cul os kel eta l (15%), a nd centra l nervous s ys tem (10%). Sa cra l a genes i s i s a ra re ma l forma ti on s een commonl y i n s everel y di a beti c women. 163. The answer is e. (Cunningham, pp 1116-1119.) The i nci dence of rena l fa i l ure i s a l mos t 30% i n type 1 di a be cs a nd 4% to 20% i n type 2 di a be cs . Pregna ncy ha s not been found to exa cerba te or modi fy di a be c nephropa thy. Di a be c neuropa thy a nd ga s tropa res i s ma y compl i ca te s ome pregna nci es , but pregna ncy does not a ffect the overa l l di s ea s e proces s . Prol i fera ve re nopa thy i s the one di a be c compl i ca on tha t pregna ncy i s thought to wors en. 164. The answer is b. (Cunningham, pp 1127-1130.) Hyperthyroi di s m i n pregna ncy i s trea ted wi th thi ona mi des , na mel y, propyl thi oura ci l (PTU) a nd methi ma zol e. Tra ns i ent l eukopeni a occurs i n a bout 10% of pa ents ta ki ng thi ona mi de drugs , but does not neces s i ta te s toppi ng the medi ca on. Agra nul ocytos i s whi ch i s a ra re compl i ca on neces s i ta tes di s con nua on of the drug. Feta l expos ure to thi ona mi des , whi ch ca n cros s the pl a centa , ma y ca s e goi terous hypothyroi di s m. Women who rema i n hyperthyroi d des pi te thera py ha ve a hi gher i nci dence of preecl a mps i a a nd hea rt fa i l ure. Thyroi d s torm occurs onl y ra rel y i n untrea ted women wi th Gra ves di s ea s e. Thi s emergent medi ca l condi on i nvol ves thyrotoxi cos i s , whi ch i s cha ra cteri zed by fever, ta chyca rdi a , a l tered menta l s ta tus , vomi ti ng, di a rrhea , a nd ca rdi a c a rrhythmi a . 165. The answer is d. (Cunningham, pp 1110-1112.) In genera l , women wi th ges ta ona l di a betes , who do not requi re i ns ul i n, s el dom need ea rl y del i very or other i nterven ons . There i s no cons ens us on whether a ntepa rtum feta l tes ng i s neces s a ry i n women wi th wel l -control l ed ges ta ona l di a betes . Antepa rtum feta l tes ng i s recommended for women wi th preexi s ng di a betes mel l i tus a nd thos e who requi re i ns ul i n thera py. There i s no good evi dence to s upport rou ne del i very before 40 weeks when gl ucos e control i s good a nd no other compl i ca ons s upervene. Ces a rea n del i very ma y be cons i dered i n women wi th ges ta ona l di a betes i f the es ma ted feta l wei ght i s 4500 g or more. Ins ul i n thera py i s i ndi ca ted i f di et ca nnot keep fa s ti ng gl ucos e bel ow 105 a nd 2-hour va l ues bel ow 120. 166. The answer is b. (Cunningham, pp 1065-1067.) Acute fa y l i ver of pregna ncy i s a ra re compl i ca on of pregna ncy. Es ma tes of i ts i nci dence ra nge from 1 i n 7000 to 1 i n 15,000 pregna nci es . Thi s di s order i s us ua l l y fa ta l for both mother a nd ba by. Recentl y, i t ha s been s ugges ted tha t reces s i vel y i nheri ted mi tochondri a l a bnorma l i es of fa y a ci d oxi da on predi s pos e a woma n to fa y l i ver i n pregna ncy. Thi s di s order us ua l l y ma ni fes ts i ts el f l a te i n pregna ncy a nd i s more common i n nul l i pa rous women. Typi ca l l y, a pa ent wi l l pres ent wi th a s evera l -da y or -week hi s tory of genera l ma l a i s e, a norexi a , na us ea , emes i s , a nd ja undi ce. Li ver enzymes a re us ua l l y not el eva ted a bove 500. Indi ca ons of l i ver fa i l ure a re pres ent, ma ni fes ted by el eva ted PT/PTT, bi l i rubi n, a nd a mmoni a l evel s . In a ddi ti on, there i s ma rked hypogl ycemi a . Low fi bri nogen a nd pl a tel et l evel s occur s econda ry to a cons ump ve coa gul opa thy. In ca s es of vi ra l hepa s , s erum tra ns a mi na s e l evel s a re us ua l l y much hi gher a nd ma rked hypogl ycemi a or el eva ted s erum a mmoni a l evel s woul d not be s een. Some mes the HELLP s yndrome ca n i ni a l l y be di fficul t to di fferen a te from a cute fa y l i ver, but i n thi s ca s e the pa ent ha s a norma l bl ood pres s ure. In a ddi on, hepa c fa i l ure i s not cha ra cteri s c of s evere preecl a mps i a . Hyperemes i s gra vi da rum i s cha ra cteri zed by na us ea a nd vomi ng unres pons i ve to s i mpl e thera py. It us ua l l y occurs ea rl y i n the firs t tri mes ter a nd res ol ves by a bout 16 weeks . In s ome ca s es , there ca n be a tra ns i ent hepa c dys func on. Intra hepa c chol es ta s i s of pregna ncy i s cha ra cteri zed by pruri tus a nd/or i cterus . Some women devel op chol es ta s i s i n the thi rd tri mes ter s econda ry to es trogen-i nduced cha nges . There i s a n a ccumul a on of s erum bi l e s a l ts , whi ch ca us es pruri tus . Li ver enzymes a re s el dom el eva ted a bove 250 U/L. 167. The answer is a. (Cunningham, pp 1065-1067.) Acute fa y l i ver res ol ves s ponta neous l y a er del i very. Del a yed di a gnos i s a nd movement towa rd del i very ca n res ul t i n ri s k of coma a nd dea th from s evere hepa c fa i l ure. In a ddi on, procra s na on ca n res ul t i n s evere hemorrha ge a nd rena l fa i l ure. Bed res t a nd s uppor ve thera py woul d be the trea tment for vi ra l hepa s . Bena dryl trea tment woul d a ppl y to thera py for chol es ta s i s of

pregna ncy. MgSO4 thera py woul d be a ppl i ca bl e to ca s es of the HELLP s yndrome. 168. The answer is c. (Cunningham, p 1092-1094.) Immune thrombocytopeni c purpura (ITP) typi ca l l y occurs i n the s econd or thi rd deca de of l i fe a nd i s more common i n women tha n i n men. The di a gnos i s of ITP i s one of excl us i on, beca us e there a re no pa thognomoni c s i gns , s ymptoms , or di a gnos c tes ts . Tra di ona l l y, ITP i s a s s oci a ted wi th a pers i s tent pl a tel et count of l es s tha n 100,000 i n the a bs ence of s pl enomega l y. Mos t women ha ve a hi s tory of ea s y brui s i ng a nd nos e a nd gum bl eeds tha t precede pregna ncy. If the pl a tel et count i s ma i nta i ned a bove 20,000, hemorrha gi c epi s odes ra rel y occur. In ca s es of ITP, the pa ent produces IgG a n pl a tel et a n bodi es tha t i ncrea s e pl a tel et cons ump on i n the s pl een a nd i n other s i tes . Ges ta ona l thrombocytopeni a occurs i n up to 8% of pregna nci es . Affected women a re us ua l l y a s ymptoma c, ha ve no pri or hi s tory of bl eedi ng, a nd us ua l l y ma i nta i n pl a tel et counts a bove 70,000. In ges ta ona l thrombocytopeni a , pl a tel et counts us ua l l y return to norma l i n a bout 3 months . The ca us e of ges ta ona l thrombocytopeni a ha s not been cl ea rl y el uci da ted. HELLP s yndrome of s evere preecl a mps i a i s a s s oci a ted wi th thrombocytopeni a , but thi s condi on occurs i n the thi rd tri mes ter a nd i s a s s oci a ted wi th hypertens i on. In neona ta l a l l oi mmune thrombocytopeni a , there i s a ma terna l a l l oi mmuni za on to feta l pl a tel et a n gens . The mother i s hea l thy a nd ha s a norma l pl a tel et count, but produces a nti bodi es tha t cros s the pl a centa a nd des troy feta l /neona ta l pl a tel ets . 169. The answer is a. (Cunningham, p 1094.) As ymptoma c pregna nt women wi th pl a tel et counts a bove 50,000 do not need to be trea ted, beca us e the count i s s uffici ent to prevent bl eedi ng compl i ca ons . For s everel y l ow pl a tel et counts , thera py ca n i ncl ude predni s one, i ntra venous i mmune gl obul i n, a nd s pl enectomy. 170. The answer is c. (Cunningham, pp 996-1001.) Inha l ed β-a goni s ts a re the pri ma ry trea tment for a n a cute a s thma exa cerba on. Intra venous s teroi ds s houl d be gi ven i f the exa cerba on i s s evere, i f the pa ent i s currentl y ta ki ng ora l s teroi ds , or i f the res pons e to bronchodi l a tor thera py i s i ncompl ete or poor. An bi o cs a re us ed for pa ents wi th fever, l eukocytos i s , or evi dence of i nfec on. A febri l e pa ent s houl d ha ve a ches t x-ra y to rul e out pneumoni a . Methyl xa nthi nes a re not us ed for a cute a s thma exa cerba ti ons . 171. The answer is d. (Cunningham, pp 1019-1020.) Noni nva s i ve moda l i es a re currentl y the preferred tes ts for di a gnos i ng venous thromboembol i . Venogra phy i s s l l the gol d s ta nda rd, but i t i s not commonl y us ed beca us e i t i s cumbers ome to perform a nd expens i ve a nd ha s s eri ous compl i ca ons . Compres s i on ul tra s onogra phy or col or Doppl er ul tra s ound i s the procedure of choi ce to detect proxi ma l deep vei n thrombos i s . MRI a nd CT s ca nni ng a re us ed i n s peci fi c ca s es when ul tra s ound fi ndi ngs a re equi voca l . 172. The answer is e. (Cunningham, pp 1211-1221.) Ma terna l i nfec on wi th vi rus es a nd ba cteri a duri ng pregna ncy ca n ca us e a n a rra y of feta l effects from none to congeni ta l ma l forma ons a nd dea th. Ma terna l i nfec on wi th va ri cel l a -zos ter duri ng the firs t ha l f of pregna ncy ca n ca us e ma l forma ons s uch a s cuta neous a nd bony defects , chori ore ni s , cerebra l cor ca l a trophy, a nd hydronephros i s . Adul ts wi th va ri cel l a i nfec on fa re much wors e tha n chi l dren; a bout 10% wi l l devel op a pneumoni ti s , a nd s ome of thes e wi l l requi re venti l a tory s upport. 173. The answer is b. (Cunningham, pp 1213-1216, 1226-1227, 1235-1239.) Rubel l a i s one of the mos t tera togeni c a gents known. Feta l ma ni fes ta ons of i nfec on correl a te wi th me of ma terna l i nfec on a nd feta l orga n devel opment. If i nfec on occurs i n the firs t 12 weeks , 80% of fetus es ma ni fes t congeni ta l rubel l a s yndrome, whi l e onl y 25% i f occurs a t the end of the s econd tri mes ter. Congeni ta l rubel l a s yndrome i ncl udes one or more of the fol l owi ng: eye l es i ons , ca rdi a c di s ea s e, s ens ori neura l dea fnes s , CNS defects , growth res tri c on, thrombocytopeni a , a nemi a , l i ver dys func on, i nters ti ti a l pneumoni ti s , a nd os s eous cha nges . Rubeol a (mea s l es ) vi rus does not a ppea r to ha ve a ny tera togeni c effect on the fetus . 174. The answer is a. (Cunningham, pp 1069-1070, 1215-1221, 1226-1227.) Cytomega l ovi rus i n the mother i s us ua l l y a s ymptoma c, but 15% of a dul ts wi l l ha ve a mononucl eos i s -l i ke s yndrome. Ma terna l i mmuni ty does not prevent recurrence or congeni ta l i nfec on. Congeni ta l i nfec on i ncl udes l ow bi rth wei ght, mi crocepha l y, i ntra cra ni a l ca l ci fica ons , chori ore ni s , menta l a nd motor reta rda on, s ens ori neura l defici ts , hepa tos pl enomega l y, ja undi ce, a nemi a , a nd thrombocytopeni c purpura . The vi rus i s s hed i n the s ecre ons of a ffected i ndi vi dua l s . Cytomega l ovi rus i s common i n da y ca re centers a nd by a ge 2 or three chi l dren us ua l l y a cqui re the i nfecti on from one a nother a nd tra ns mi t i t to thei r pa rents . 175. The answer is e. (Cunningham, pp 1069-1070, 1212-1221, 1226-1227.) T. gondii i s tra ns mi ed by ea ng i nfected ra w or undercooked mea t a nd conta ct wi th i nfected ca t feces . Ma terna l i mmuni ty a ppea rs to protect a ga i ns t feta l i nfec on, a nd up to one-thi rd of Ameri ca n women a re i mmune pri or to pregna ncy. Acute i nfec on i n the mother i s o en s ubcl i ni ca l , but s ymptoms ca n i ncl ude fa gue, l ympha denopa thy, a nd mya l gi a s . Feta l i nfec on i s more common when di s ea s e i s a cqui red l a ter i n pregna ncy (60% i n thi rd tri mes ter vs 10% i n firs t tri mes ter). Congeni ta l di s ea s e cons i s ts of l ow bi rth wei ght, hepa tos pl enomega l y, ja undi ce, a nemi a , neurol ogi ca l di s ea s e wi th s ei zures , i ntra cra ni a l ca l ci fica ons , a nd menta l reta rda ti on. Infl uenza does not ca us e a ny feta l effects . 176. The answer is d. (Cunningham, pp 1211-1221, 1241-1245.) In the pa s t, s yphi l i s a ccounted for a bout one-thi rd of a l l s l l bi rths . Tra ns pl a centa l i nfec on ca n occur wi th a ny s ta ge of s yphi l i s , but the hi ghes t i nci dence of congeni ta l i nfec on occurs i n women wi th pri ma ry or s econda ry di s ea s e. The feta l a nd neona ta l effects i ncl ude hepa tos pl enomega l y, edema , a s ci tes , hydrops , petechi a e or purpuri c s ki n l es i ons , os teochondri s , l ympha denopa thy, rhi ni s , pneumoni a , myoca rdi s , a nd nephros i s . The pl a centa i s enl a rged, s ome mes wei ghi ng a s much a s the fetus . Whi l e pa rvovi rus ca n ca us e s ti l l bi rth a nd feta l hydrops , i t i s not a s s oci a ted wi th s ki n l es i ons or pl a centa l hypertrophy. 177. The answer is b. (Cunningham, pp 1069-1070, 1213-1218, 1241-1245.) Tra ns pl a centa l tra ns fer of hepa s B from the mother to fetus occurs wi th a cute hepa s , not chroni c s eropos i vi ty. Acute i nfec on i n firs t tri mes ter i nfects 10% of fetus es , a nd i n thi rd tri mes ter 80% to 90% a re a ffected. Peri na ta l tra ns mi s s i on occurs by i nges on of i nfected ma teri a l duri ng del i very or expos ure s ubs equent to bi rth i n mothers who a re chroni c ca rri ers . Some i nfected i nfa nts ma y be a s ymptoma c, a nd others devel op ful mi na nt hepa c di s ea s e. Admi ni s tra on of hepa s B i mmune gl obul i n a fter bi rth, fol l owed by the va cci ne, ca n prevent di s ea s e i n i nfa nts born to mothers who a re chroni c ca rri ers . 178. The answer is d. (Cunningham, pp 1069-1070, 1212-1221, 1226-1227.) Pa rvovi rus i s trophi c for erythroi d cel l s a nd ca n ca us e feta l a nemi a . Ma terna l i nfec on ca n l ea d to feta l hydrops , a bor on, or s l l bi rth. In s us cep bl e a dul ts 20% to 30% wi l l a cqui re di s ea s e duri ng s chool outbrea ks . If a pregna nt woma n ha s di a gnos i s confirmed wi th IgM a n bodi es , ul tra s ound i s done for feta l s urvei l l a nce. If hydrops i s di a gnos ed, feta l tra ns fus i on ca n be offered. One-thi rd of fetus es wi l l ha ve s ponta neous res ol u on of hydrops , a nd 85% of fetus es who recei ve tra ns fus i on wi l l s urvi ve. 179. The answer is d. (Cunningham, pp 1069-1070, 1216-1225, 1241-1245.) Neona ta l herpes i nfec on ha s three forms : di s s emi na ted wi th i nvol vement of ma jor orga ns ; l oca l i zed, wi th i nvol vement confined to the centra l nervous s ys tem; a nd a s ymptoma c. A 50% ri s k of neona ta l i nfec on occurs wi th pri ma ry ma terna l i nfec on, but onl y 4% to 5% ri s k wi th recurrent outbrea ks . Pos tna ta l i nfec on ca n occur through conta ct wi th ora l a nd s ki n l es i ons . Neona ta l i nfec on pres enta on i s nons peci fic, wi th s i gns a nd s ymptoms s uch a s i rri ta bi l i ty, l etha rgy, fever, a nd poor feedi ng. Les s tha n 50% of i nfa nts do not ha ve s ki n l es i ons .

180. The answer is b. (Cunningham, pp 1069-1070, 1216-1225, 1241-1245.) Ea rl y-ons et group B s treptococcus di s ea s e occurs wi thi n 1 week of bi rth. Si gns of the di s ea s e i ncl ude res pi ra tory di s tres s , a pnea , a nd s hock. La te-ons et di s ea s e us ua l l y occurs a er 7 da ys a nd ma ni fes ts a s meni ngi s . Li s teri os i s duri ng pregna ncy ca n be a s ymptoma c or ca us e a febri l e i l l nes s tha t i s confus ed wi th i nfluenza , pyel onephri s , or meni ngi s . Listeria monocytogenes, the ca us a ve ba cteri a i s us ua l l y a cqui red through food-borne tra ns mi s s i on from ma nure-conta mi na ted ca bba ge, pa s teuri zed mi l k, a nd fres h Mexi ca n-s tyl e chees es . Feta l i nfec on i s cha ra cteri zed by gra nul oma tous l es i ons wi th mi croa bs ces s es . Ea rl y ons et neona ta l s eps i s i s a common ma ni fes ta on of l i s teri os i s duri ng pregna ncy, a nd l a te ons et l i s teri os i s occurs a er 3 to 4 weeks a s meni ngi s , whi ch i s s i mi l a r to group B s treptococci . However, l i s teri os i s i nfecti on i s much l es s common.

Normal and Abnormal Labor and Delivery Questions 181. A 20-yea r-ol d G1 a t 38 weeks ges ta on pres ents wi th regul a r pa i nful contra c ons every 3 to 4 mi nutes l a s ng 60 s econds . On pel vi c exa mi na on, s he i s 3 cm di l a ted a nd 90% effa ced; a n a mni otomy i s performed a nd cl ea r flui d i s noted. The pa ent recei ves epi dura l a na l ges i a for pa i n ma na gement. The feta l hea rt ra te tra ci ng i s rea c ve. One hour l a ter on repea t exa mi na on, her cervi x i s 5 cm di l a ted a nd 100% effa ced. Whi ch of the fol l owi ng i s the bes t next s tep i n her ma na gement? a . Begi n pus hi ng. b. Ini ti a te Pi toci n a ugmenta ti on for protra cted l a bor. c. No i nterventi on; l a bor i s progres s i ng norma l l y. d. Perform ces a rea n del i very for i na dequa te cervi ca l effa cement. e. Stop epi dura l i nfus i on to enha nce contra cti ons a nd cervi ca l cha nge. 182. A 30-yea r-ol d G2P0 a t 39 weeks i s a dmi ed i n a c ve l a bor wi th s ponta neous rupture of membra nes occurri ng 2 hours pri or to a dmi s s i on. The pa ent noted cl ea r flui d a t the me. On exa mi na on, her cervi x i s 4 cm di l a ted a nd compl etel y effa ced. The feta l hea d i s a t 0 s ta on a nd the feta l hea rt ra te tra ci ng i s rea c ve. Two hours l a ter on repea t exa mi na on her cervi x i s 5 cm di l a ted a nd the feta l hea d i s a t +1 s ta on. Ea rl y decel era ti ons a re noted on the feta l hea rt ra te tra ci ng. Whi ch of the fol l owi ng i s the bes t next s tep i n her l a bor ma na gement? a . Admi ni s ter terbuta l i ne. b. Ini ti a te a mni oi nfus i on. c. Ini ti a te Pi toci n a ugmenta ti on. d. Perform ces a rea n del i very for a rres t of des cent. e. Perform ces a rea n del i very of ea rl y decel era ti ons . 183. A 32-yea r-ol d G1 a t 39 weeks ges ta on i s a dmi ed i n l a bor a t 4 cm di l a ted a nd compl etel y effa ced; the feta l hea d i s a t 0 s ta on. You perform cl i ni ca l pel vi metry a nd find the fol l owi ng: the di a gona l conjuga te i s 10 cm, the i nteri s chi a l s pi ne di s ta nce i s 11 cm wi th non convergent s i de wa l l s , a nd the i ntertuberous di s ta nce i s 9 cm. Thos e mea s urements des cri be whi ch of the fol l owi ng types of pel vi s ? a . Norma l pel vi s b. Contra cted pel vi c i nl et c. Contra cted mi dpel vi s d. Contra cted pel vi c outl et e. Genera l l y contra cted pel vi s 184. A 27-yea r-ol d G2P1 a t 38 weeks ges ta on wa s a dmi ed i n a c ve l a bor a t 4 cm di l a ted; s ponta neous rupture of membra nes occurred pri or to a dmi s s i on. She ha s ha d one pri or uncompl i ca ted va gi na l del i very a nd deni es a ny medi ca l probl ems or pa s t s urgery. She reports a n a l l ergy to s ul fa drugs . Currentl y, her vi ta l s i gns a re norma l a nd the feta l hea rt ra te tra ci ng i s rea c ve. Her prena ta l record i ndi ca tes tha t her group B s treptococcus (GBS) cul ture a t 36 weeks wa s pos i ti ve. Wha t i s the recommended a nti bi oti c for prophyl a xi s duri ng l a bor? a . Cefa zol i n b. Cl i nda myci n c. Erythromyci n d. Peni ci l l i n e. Va ncomyci n 185. A 38-yea r-ol d G6P4 undergoes a pri ma ry ces a rea n del i very under regi ona l a na l ges i a for ma l pres enta on of twi ns a t 37 weeks . Immedi a tel y a er the del i very of the pl a centa , the a nes thes i ol ogi s t notes ma terna l s ei zure a c vi ty wi th profound hypoxi a a nd hypotens i on a nd i ntuba tes the pa ent a nd provi des ci rcul a tory s upport wi th va s opres s ors . Ma s s i ve hemorrha ge from the s urgi ca l s i te ens ues a nd the pa ent i s gi ven uterotoni c a gents a nd bl ood products . Whi ch of the fol l owi ng i s mos t l i kel y ca us e of her hemorrha ge? a . Amni oti c fl ui d embol i s m b. Ha l ogena ted a nes thes ti c a gent c. Pl a centa a ccreta d. Severe preecl a mps i a wi th HELLP e. Uteri ne a tony from overdi s tended uterus 186. A 23-yea r-ol d G1 a t 38 weeks ges ta on pres ents i n a c ve l a bor a t 6 cm di l a ted wi th ruptured membra nes . On cervi ca l exa mi na on the feta l nos e, eyes , a nd l i ps ca n be pa l pa ted. The feta l hea rt ra te tra ci ng i s 140 bea ts per mi nute wi th a ccel era ons a nd no decel era ons . The pa ent’s pel vi s i s a dequa te. Whi ch of the fol l owi ng i s the mos t a ppropri a te ma na gement for thi s pa ti ent? a . Perform i mmedi a te ces a rea n s ecti on wi thout l a bor. b. Al l ow s ponta neous l a bor wi th va gi na l del i very. c. Perform forceps rota ti on i n the s econd s ta ge of l a bor to convert mentum pos teri or to mentum a nteri or a nd to a l l ow va gi na l del i very. d. Al l ow pa ent to l a bor s ponta neous l y un l compl ete cervi ca l di l a on i s a chi eved a nd then perform a n i nterna l poda l i c vers i on wi th breech extra cti on. e. Attempt ma nua l convers i on of the fa ce to vertex i n the s econd s ta ge of l a bor. 187. A 32-yea r-ol d G3P2 a t 39 weeks ges ta on pres ented to the hos pi ta l wi th ruptured membra nes a nd 4 cm di l a ted. She ha s a hi s tory of two pri or va gi na l del i veri es , wi th her l a rges t chi l d wei ghi ng 3800 g a t bi rth. Over the next 2 hours s he progres s es to 7 cm di l a ted. Two hours l a ter, s he rema i ns 7 cm di l a ted. The es ti ma ted feta l wei ght by ul tra s ound i s 3200 g. Whi ch of the fol l owi ng l a bor a bnorma l i ti es bes t des cri bes thi s pa ti ent? a . Prol onged l a tent pha s e b. Protra cted a cti ve-pha s e di l a ti on c. Hypertoni c dys functi on d. Seconda ry a rres t of di l a ti on

e. Pri ma ry dys functi on 188. You a re fol l owi ng a 38-yea r-ol d G2P1 a t 39 weeks i n l a bor. She ha s ha d one pri or va gi na l del i very of a 3800-g i nfa nt. One week a go, the es ma ted feta l wei ght wa s 3200 g by ul tra s ound. Over the pa s t 3 hours her cervi ca l exa mi na on rema i ns uncha nged a t 6 cm. Feta l hea rt ra te tra ci ng i s rea c ve. An i ntra uteri ne pres s ure ca theter (IUPC) revea l s two contra c ons i n 10 mi nutes wi th a mpl i tude of 40 mm Hg ea ch. Whi ch of the fol l owi ng i s the bes t ma na gement for thi s pa ti ent? a . Ambul a ti on b. Seda ti on c. Admi ni s tra ti on of oxytoci n d. Ces a rea n s ecti on e. Expecta nt 189. A pri mi pa ra i s i n the s econd s ta ge of l a bor a nd a n epi s i otomy i s a bout to be cut. Compa red wi th a mi dl i ne epi s i otomy, whi ch of the fol l owi ng i s a n a dva nta ge of medi ol a tera l epi s i otomy? a . Ea s e of repa i r b. Fewer brea kdowns c. Les s bl ood l os s d. Les s dys pa reuni a e. Les s extens i on of the i nci s i on 190. A 27-yea r-ol d woma n (G3P2) comes to the del i very floor a t 37 weeks ges ta on. She ha s ha d no prena ta l ca re. She compl a i ns tha t, on bendi ng down to pi ck up her 2-yea r-ol d chi l d, s he experi enced s udden, s evere ba ck pa i n tha t now ha s pers i s ted for 2 hours . Approxi ma tel y 30 mi nutes a go s he noted bri ght red bl ood comi ng from her va gi na . By the me s he a rri ves a t the del i very floor, s he i s contra c ng s trongl y every 3 mi nutes ; the uterus i s qui te firm even between contra c ons . By a bdomi na l pa l pa on, the fetus i s vertex wi th the hea d deepl y enga ged. Feta l hea rt ra te i s 130 bea ts per mi nutes . The fundus i s 38 cm a bove the s ymphys i s . Bl ood for cl o ng i s dra wn, a nd a cl ot forms i n 4 mi nutes . Cl o ng s tudi es a re s ent to the l a bora tory. Whi ch of the fol l owi ng a cti ons ca n mos t l i kel y wa i t unti l the pa ti ent i s s ta bi l i zed? a . Sta bi l i zi ng ma terna l ci rcul a ti on b. Atta chi ng a feta l el ectroni c moni tor c. Ins erti ng a n i ntra uteri ne pres s ure ca theter d. Admi ni s teri ng oxytoci n e. Prepa ri ng for ces a rea n s ecti on

Questions 191 to 193 For ea ch cl i ni ca l des cri pti on, s el ect the mos t a ppropri a te procedure. Ea ch l ettered opti on ma y be us ed once, more tha n once, or not a t a l l . a . Externa l vers i on b. Interna l vers i on c. Mi dforceps rota ti on d. Low tra ns vers e ces a rea n s ecti on e. Cl a s s i c ces a rea n s ecti on 191. A 24-yea r-ol d pri mi gra vi d woma n, a t term, ha s been i n l a bor for 16 hours a nd ha s been di l a ted to 9 cm for 3 hours . The feta l vertex i s i n the ri ght occi put pos teri or pos i on, a t +1 s ta on, a nd mol ded. There ha ve been mi l d l a te decel era ons for the pa s t 30 mi nutes . Twenty mi nutes a go, the feta l s ca l p pH wa s 7.27; i t i s now 7.20. 192. You ha ve jus t del i vered a n i nfa nt wei ghi ng 2.5 kg (5.5 l b) a t 39 weeks ges ta on. Beca us e the uterus s l l feel s l a rge, you do a va gi na l exa mi na on. A s econd s et of membra nes i s bul gi ng through a ful l y di l a ted cervi x, a nd you feel a s ma l l pa rt pres en ng i n the s a c. A feta l hea rt i s a us cul ta ted a t 60 bea ts per mi nute. 193. A 24-yea r-ol d woma n (G3P2) i s a t 37 weeks ges ta ti on. The feta l pres enta ti on i s a tra ns vers e l i e by ul tra s ound.

Questions 194 to 196 Sel ect the mos t a ppropri a te trea tment for ea ch cl i ni ca l s i tua ti on. Ea ch l ettered opti on ma y be us ed once, more tha n once, or not a t a l l . a . Epi dura l bl ock b. Meperi di ne (Demerol ) 100 mg i ntra mus cul a rl y c. Oxytoci n i ntra venous l y d. Mi dforceps del i very e. Ces a rea n s ecti on 194. A mul pa rous woma n ha s ha d pa i nful uteri ne contra c ons every 2 to 4 mi nutes for the pa s t 17 hours . The cervi x i s di l a ted to 2 to 3 cm a nd effa ced 50%; i t ha s not cha nged s i nce a dmi s s i on. 195. A nul l i pa rous woma n i s i n a c ve l a bor (cervi ca l di l a on 5 cm wi th compl ete effa cement, vertex a t 0 s ta on); the l a bor curve s hows protra cted progres s i on wi thout des cent fol l owi ng the a dmi ni s tra on of a n epi dura l bl ock. An IUPC s hows contra c ons every 4 to 5 mi nutes , pea ki ng a t 40 mm Hg. 196. A nul l i pa rous woma n ha s a n a rres t of des cent for the pa s t 2 hours a nd a rres t of di l a on for the pa s t 3 hours . The cervi x i s di l a ted to 7 cm a nd the vertex i s a t +1 s ta ti on. Moni tori ng s hows a norma l pa ttern a nd a dequa te contra cti ons . Feta l wei ght i s es ti ma ted a t 7.5 l b.

Questions 197 to 200 Ma tch ea ch des cri p on wi th the mos t a ppropri a te type of obs tetri c a nes thes i a . Ea ch l e ered op on ma y be us ed once, more tha n once, or not a t all. a . Intra venous meperi di ne

b. Pudenda l bl ock c. Spi na l bl ock d. Epi dura l bl ock 197. Appea rs to l engthen the s econd s ta ge of l a bor 198. Is a s s oci a ted wi th feta l s eda ti on 199. Ma y be compl i ca ted by profound hypotens i on 200. Ma y be a s s oci a ted wi th i ncrea s ed need for a ugmenta ti on of l a bor wi th oxytoci n a nd for i ns trument-a s s i s ted del i very 201. A 23-yea r-ol d G1 a t 40 weeks ges ta on pres ents to the hos pi ta l wi th the compl a i nt of contra c ons . She s ta tes they a re occurri ng every 4 to 8 mi nutes a nd ea ch l a s ts a pproxi ma tel y 1 mi nute. She reports good feta l movement a nd deni es a ny l ea ka ge of flui d or va gi na l bl eedi ng. The nurs e pl a ces a n externa l tocometer a nd feta l moni tor a nd reports tha t the pa ent i s ha vi ng contra c ons every 2 to 10 mi nutes . The nurs e s ta tes tha t the contra c ons a re mi l d to pa l pa on. On exa mi na on the cervi x i s 2 cm di l a ted, 50% effa ced, a nd the vertex i s a t –1 s ta on. The pa ent ha d the s a me cervi ca l exa mi na on i n your office l a s t week. The feta l hea rt ra te tra ci ng i s 140 bea ts per mi nute wi th a ccel era ons a nd no decel era ons . Whi ch of the fol l owi ng s ta ges of l a bor i s thi s pa ti ent i n? a . Acti ve l a bor b. La tent l a bor c. Fa l s e l a bor d. Sta ge 1 of l a bor e. Sta ge 2 of l a bor 202. A 19-yea r-ol d G1 a t 40 weeks ges ta on pres ents to the hos pi ta l wi th the compl a i nt of contra c ons . She s ta tes they a re very pa i nful a nd occurri ng every 3 to 5 mi nutes . She reports good feta l movement a nd deni es a ny l ea ka ge of flui d or va gi na l bl eedi ng. The nurs e pl a ces a n externa l tocometer a nd feta l moni tor a nd reports tha t the pa ent i s ha vi ng contra c ons every 4 to 12 mi nutes . The nurs e s ta tes tha t the contra c ons a re mi l d to modera te to pa l pa on. On exa mi na on the cervi x i s 1 cm di l a ted, 60% effa ced, a nd the vertex i s a t –1 s ta on. The pa ent ha d the s a me cervi ca l exa mi na on i n your office l a s t week. The feta l hea rt ra te tra ci ng i s 140 bea ts per mi nute wi th a ccel era ons a nd no decel era ons . Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent? a . Send her home. b. Admi t her for a n epi dura l for pa i n control . c. Rupture membra nes . d. Admi ni s ter terbuta l i ne. e. Augment l a bor wi th Pi toci n. 203. A 38-yea r-ol d G3P2 a t 40 weeks ges ta on pres ents to l a bor a nd del i very wi th gros s rupture of membra nes occurri ng 1 hour pri or to a rri va l . The pa ent i s ha vi ng contra c on every 3 to 4 mi nutes on the externa l tocometer, a nd ea ch contra c on l a s ts 60 s econds . The feta l hea rt ra te tra ci ng i s 120 bea ts per mi nute wi th a ccel era ons a nd no decel era ons . The pa ent ha s a hi s tory of ra pi d va gi na l del i veri es , a nd her l a rges t ba by wa s 3200 g. On cervi ca l exa mi na on s he i s 5 cm di l a ted a nd compl etel y effa ced, wi th the vertex a t –2 s ta on. The es ma ted feta l wei ght i s 3300 g. The pa ti ent i s i n a l ot of pa i n a nd reques ti ng medi ca ti on. Whi ch of the fol l owi ng i s the mos t a ppropri a te method of pa i n control for thi s pa ti ent? a . Intra mus cul a r Meperi di ne b. Pudenda l bl ock c. Peri nea l bl ock d. Epi dura l a na l ges i a e. Genera l a nes thes i a 204. You a re fol l owi ng a 22-yea r-ol d G2P1 a t 39 weeks duri ng her l a bor. At 4 cm di l a ted s he i s gi ven a n epi dura l for pa i n ma na gement. Three hours a er a dmi ni s tra ng the pa i n medi ca on, the pa ent’s cervi ca l exa mi na on i s uncha nged. Her contra c ons a re now every 2 to 3 mi nutes , l a s ng 60 s econds . The feta l hea rt ra te tra ci ng i s 120 bea ts per mi nute wi th a ccel era ons a nd ea rl y decel era ons . Whi ch of the fol l owi ng i s the bes t next s tep i n ma na gement of thi s pa ti ent? a . Pl a ce a feta l s ca l p el ectrode. b. Rebol us the pa ti ent’s epi dura l . c. Pl a ce a n i ntra uteri ne pres s ure ca theter (IUPC). d. Prepa re for a ces a rea n s ecti on s econda ry to a di a gnos i s of s econda ry a rres t of l a bor. e. Admi ni s ter Pi toci n for a ugmenta ti on of l a bor. 205. A 25-yea r-ol d G3P2 a t 39 weeks i s a dmi ed i n l a bor a t 5 cm di l a ted. The feta l hea rt ra te tra ci ng i s rea c ve. Two hours l a ter, s he i s reexa mi ned a nd her cervi x i s uncha nged a t 5 cm di l a ted. An IUPC i s pl a ced a nd the pa ent i s noted to ha ve 280 Montevi deo uni ts (MUV) by the IUPC. A er a n a ddi ona l 2 hours of l a bor, the pa ent i s noted to s l l be 5 cm di l a ted. The feta l hea rt ra te tra ci ng rema i ns rea c ve. Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s l a bor? a . Perform a ces a rea n s ecti on. b. Conti nue to wa i t a nd obs erve the pa ti ent. c. Augment l a bor wi th Pi toci n. d. Attempt del i very vi a va cuum extra cti on. e. Perform a n opera ti ve del i very wi th forceps . 206. A 29-yea r-ol d G2P1 a t 40 weeks i s i n a cti ve l a bor. Her cervi x i s 5 cm di l a ted, compl etel y effa ced, a nd the vertex i s a t 0 s ta ti on. She i s on oxytoci n to a ugment her l a bor a nd s he ha s jus t recei ved a n epi dura l for pa i n ma na gement. The nurs e ca l l s you to the room beca us e the feta l hea rt ra te ha s been i n the 70 s econds for the pa s t 3 mi nutes . The contra c on pa ern i s noted to be every 3 mi nutes , ea ch l a s ng 60 s econds , wi th return to norma l tone i n between contra c ons . The pa ent’s vi ta l s i gns a re bl ood pres s ure 90/40 mm Hg, pul s e 105 bea ts per mi nute, res pi ra tory ra te 18 brea ths per mi nute, a nd tempera ture 36.1°C (97.6°F). On repea t cervi ca l exa mi na on, the vertex i s wel l a ppl i ed to the cervi x a nd the pa ent rema i ns 5 cm di l a ted a nd a t 0 s ta ti on, a nd no va gi na l bl eedi ng i s noted. Whi ch of the fol l owi ng i s the mos t l i kel y ca us e for the decel era ti on? a . Cord prol a ps e b. Epi dura l a na l ges i a c. Pi toci n

d. Pl a centa l a brupti on e. Uteri ne hypers ti mul a ti on 207. You a re del i veri ng a 26-yea r-ol d G3P2002 a t 40 weeks . She ha s a hi s tory of two previ ous uncompl i ca ted va gi na l del i veri es a nd ha s ha d no compl i ca ons i n thi s pregna ncy. A er 15 mi nutes of pus hi ng, the ba by’s hea d del i vers s ponta neous l y, but then retra cts ba ck a ga i ns t the peri neum. As you a ppl y gentl e downwa rd tra c on to the hea d, the ba by’s a nteri or s houl der fa i l s to del i ver. Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent? a . Ca l l for hel p. b. Cut a s ymphys i otomy. c. Ins truct the nurs e to a ppl y funda l pres s ure. d. Perform a Za va nel l i ma neuver. e. Pus h the ba by’s hea d ba ck i nto the pel vi s . 208. You a re del i veri ng a 33-yea r-ol d G3P2 a nd encounter a s houl der dys toci a . A er performi ng the a ppropri a te ma neuvers , the ba by fina l l y del i vers , a nd the pedi a tri ci a ns a endi ng the del i very note tha t the ri ght a rm i s ha ngi ng l i mpl y to the ba by’s s i de wi th the forea rm extended a nd i nterna l l y rota ted. Whi ch of the fol l owi ng i s the ba by’s mos t l i kel y di a gnos i s ? a . Erb pa l s y b. Kl umpke pa ra l ys i s c. Humera l fra cture d. Cl a vi cul a r fra cture e. Pa ra l ys i s from i ntra ventri cul a r bl eed 209. A 41-yea r-ol d G1P0 a t 39 weeks , who ha s been compl etel y di l a ted a nd pus hi ng for 3 hours , ha s a n epi dura l i n pl a ce a nd rema i ns undel i vered. She i s exha us ted a nd cryi ng a nd tel l s you tha t s he ca n no l onger pus h. Her tempera ture i s 38.3°C (101°F). The feta l hea rt ra te i s i n the 190 s econds wi th decrea s ed va ri a bi l i ty. The pa ent’s membra nes ha ve been ruptured for over 24 hours , a nd s he ha s been recei vi ng i ntra venous peni ci l l i n for a hi s tory of col oni za on wi th group B s treptococcus ba cteri a . The pa ent’s cervi x i s compl etel y di l a ted a nd effa ced a nd the feta l hea d i s i n the di rect OA pos i on a nd i s vi s i bl e a t the i ntroi tus between pus hes . Extens i ve ca put i s noted, but the feta l bones a re a t the +3 s ta on. Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent? a . Del i ver the pa ti ent by ces a rea n s ecti on. b. Encoura ge the pa ti ent to conti nue to pus h a fter a s hort res t. c. Attempt opera ti ve va gi na l del i very. d. Rebol us the pa ti ent’s epi dura l . e. Cut a fourth-degree epi s i otomy. 210. A 28-yea r-ol d G1 a t 38 weeks ha d a norma l progres s i on of her l a bor. She ha s a n epi dura l a nd ha s been pus hi ng for 2 hours . The feta l hea d i s di rect occi put a nteri or a t +3 s ta on. The feta l hea rt ra te tra ci ng i s 150 bea ts per mi nute wi th va ri a bl e decel era ons . Wi th the pa ent’s l a s t pus h the feta l hea rt ra te ha d a prol onged decel era on to the 80 s econds for 3 mi nutes . You recommend forceps to a s s i s t the del i very owi ng to the nonrea s s uri ng feta l hea rt ra te tra ci ng. Compa red to the us e of the va cuum extra ctor, forceps a re a s s oci a ted wi th a n i ncrea s ed ri s k of whi ch of the fol l owi ng neona ta l compl i ca ti ons ? a . Cepha l ohema toma b. Reti na l hemorrha ge c. Ja undi ce d. Intra cra ni a l hemorrha ge e. Cornea l a bra s i ons 211. You performed a forceps -a s s i s ted va gi na l del i very on a 20-yea r-ol d G1 a t 40 weeks for ma terna l exha us on. The pa ent ha d pus hed for 3 hours wi th a n epi dura l for pa i n ma na gement. A s econd-degree epi s i otomy wa s cut to fa ci l i ta te del i very. Ei ght hours a er del i very, you a re ca l l ed to s ee the pa ent beca us e s he i s una bl e to voi d a nd compl a i ns of s evere pa i n. On exa mi na on you note a l a rge fluctua nt purpl e ma s s i ns i de the va gi na . Wha t i s the bes t ma na gement for thi s pa ti ent? a . Appl y a n i ce pa ck to the peri neum. b. Embol i ze the i nterna l i l i a c a rtery. c. Inci s i on a nd eva cua ti on of the hema toma . d. Perform di l a ti on a nd curetta ge to remove reta i ned pl a centa . e. Pl a ce a va gi na l pa ck for 24 hours . 212. A 20-yea r-ol d G1 a t 41 weeks ha s been pus hi ng for 2½; hours . The feta l hea d i s a t the i ntroi tus a nd begi nni ng to crown. It i s neces s a ry to cut a n epi s i otomy. The tea r extends through the s phi ncter of the rectum, but the recta l mucos a i s i nta ct. How s houl d you cl a s s i fy thi s type of epi s i otomy? a . Fi rs t-degree b. Second-degree c. Thi rd-degree d. Fourth-degree e. Medi ol a tera l epi s i otomy 213. A 16-yea r-ol d G1P0 a t 38 weeks ges ta on comes to the l a bor a nd del i very s ui te for the s econd me duri ng the s a me weekend tha t you a re on ca l l . She i ni a l l y pres ented to l a bor a nd del i very a t 2:00 PM Sa turda y a ernoon compl a i ni ng of regul a r uteri ne contra c ons . Her cervi x wa s 1 cm di l a ted, 50% effa ced wi th the vertex a t –1 s ta on, a nd s he wa s s ent home a er wa l ki ng for 2 hours i n the hos pi ta l wi thout a ny cervi ca l cha nge. It i s now Sunda y ni ght a t 8:00 PM, a nd the pa ent returns to l a bor a nd del i very wi th i ncrea s i ng pa i n. She i s exha us ted beca us e s he di d not s l eep the ni ght before beca us e her contra c ons kept wa ki ng her up. The pa ent i s pl a ced on the externa l feta l moni tor. Her contra c ons a re occurri ng every 2 to 3 mi nutes . You reexa mi ne the pa ent a nd determi ne tha t her cervi x i s uncha nged. Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent? a . Perform a rti fi ci a l rupture of membra nes to i ni ti a te l a bor. b. Admi ni s ter a n epi dura l . c. Admi ni s ter Pi toci n to a ugment l a bor. d. Achi eve cervi ca l ri peni ng wi th pros ta gl a ndi n gel .

e. Admi ni s ter 10 mg i ntra mus cul a r morphi ne. 214. A 25-yea r-ol d G1P0 pa ent a t 41 weeks pres ents to l a bor a nd del i very compl a i ni ng of gros s rupture of membra nes a nd pa i nful uteri ne contra c ons every 2 to 3 mi nutes . On di gi ta l exa mi na on, her cervi x i s 3 cm di l a ted a nd compl etel y effa ced wi th feta l feet pa l pa bl e through the cervi x. The es ma ted wei ght of the fetus i s a bout 6 l b, a nd the feta l hea rt ra te tra ci ng i s rea c ve. Whi ch of the fol l owi ng i s the bes t method to a chi eve del i very? a . Del i ver the fetus va gi na l l y by breech extra cti on. b. Del i ver the ba by va gi na l l y a fter externa l cepha l i c vers i on. c. Perform a n emergent ces a rea n s ecti on. d. Perform a n i nterna l poda l i c vers i on. e. Perform a forceps -a s s i s ted va gi na l del i very. 215. A 25-yea r-ol d G1 a t 37 weeks pres ents to l a bor a nd del i very wi th gros s rupture of membra nes . The flui d i s noted to be cl ea r a nd the pa ent i s noted to ha ve regul a r pa i nful contra c ons every 2 to 3 mi nutes l a s ng for 60 s econds ea ch. The feta l hea rt ra te tra ci ng i s rea c ve. On cervi ca l exa mi na on s he i s noted to be 4 cm di l a ted, 90% effa ced wi th the pres en ng pa rt a −3 s ta on. The pres en ng pa rt i s s o a nd fel t to be the feta l bu ock. A qui ck beds i de ul tra s ound revea l s a breech pres enta on wi th both hi ps flexed a nd knees extended. Wha t type of breech pres enta on i s des cri bed? a . Fra nk b. Incompl ete, s i ngl e footl i ng c. Compl ete d. Doubl e footl i ng

Normal and Abnormal Labor and Delivery Answers 181. The answer is c. (Cunningham, pp 390-394, 456.) Pa ent ha s norma l a nd a dequa te l a bor; no i nterven on i s needed a t thi s me. The pa ent i s not compl etel y di l a ted, s o pus hi ng i s not wa rra nted a nd i t ca n ca us e cervi ca l l a cera ons a nd s wel l i ng. An epi dura l ca n prol ong the a c ve pha s e by one hour, however s toppi ng i t wi l l not ma ke l a bor progres s more qui ckl y. 182. The answer is c. (Cunningham, pp 432-433, 464-471.) The pa ent ha s a protra cted a c ve pha s e of l a bor (cervi ca l di l a on < 1.2 cm/h). Ei ther expecta nt ma na gement or Pi toci n a ugmenta on ma y be us ed for trea tment. There i s no a rres t of des cent a t thi s me, a nd ces a rea n del i very i s not wa rra nted. Amni oi nfus i on i s not i ndi ca ted for ea rl y decel era ons . It ma y decrea s e the need for ces a rea n del i very i n pa ents wi th va ri a bl e or prol onged decel era ti ons . Terbuta l i ne woul d ca us e uteri ne rel a xa ti on a nd i s not i ndi ca ted. 183. The answer is b. (Cunningham, pp 471-472.) The pel vi c i nl et i s cons i dered contra cted i f the a nteropos teri or di a meter i s l es s tha n 10 cm. The i nl et i s di gi ta l l y mea s ured by the di a gona l conjuga te whi ch i s typi ca l l y 1.5 cm grea ter tha n the i nl et, therefore a pel vi c i nl et contra c on i s defined a s a di a gona l conjuga te l es s tha n 11.5 cm. The mi dpel vi s extends from the i nferi or ma rgi n of the s ymphys i s to the i s chi a l s pi nes bi l a tera l l y to the s a crum nea r the junc on of the fourth a nd fi h vertebra e. The a vera ge mi d-pel vi s mea s urements i ncl ude: i nteri s chi a l s pi nous 10.5 cm, a nteropos teri or from s ymphys i s to s a crum 11.5 cm a nd pos teri or s a gi a l from mi dpoi nt of i nters pi nous l i ne to s a crum 5 cm. But there i s no preci s e ma nua l mea s urement of the mi dpel vi s but contra c on i s s ugges ted i f the s pi nes a re promi nent, the pel vi c s i dewa l l s converge or i f the s a cros ci a c notch i s na rrow. The contra cted outl et i s defined a s a i ntertuberous di a meter of 8 cm or l es s . Outl et contra c on wi thout concomi ta nt mi dpel vi s contra cti on i s ra re. A genera l l y contra cted pel vi s i s ca us ed by combi na ti ons of contra cti ons i n the i nl et, mi dpel vi s , a nd outl et. 184. The answer is d. (ACOG Commi ee Opinion 279.) Group B s treptococci (GBS), or Streptococcus agalac ae, ha s emerged a s a n i mporta nt ca us e of peri na ta l morbi di ty a nd morta l i ty. The gra m-pos i ve orga ni s m ca n col oni ze the l ower ga s troi ntes na l tra ct, a nd s econda ry s prea d to the geni touri na ry tra ct i s common. Between 10% a nd 30% of pregna nt women a re col oni zed wi th GBS i n the va gi na or rectum. Rou ne prena ta l s creeni ng i s recommended between 35 a nd 37 weeks . Peni ci l l i n rema i ns the a gent of choi ce for i ntra pa rtum prophyl a xi s . Ampi ci l l i n i s a n a ccepta bl e a l terna ve, but peni ci l l i n i s preferred. However, da ta a l s o s how tha t GBS i s ol a tes a re i ncrea s i ngl y res i s ta nt to s econd-l i ne thera pi es . Up to 15% of GBS i s ol a tes a re res i s ta nt to cl i nda myci n a nd 7% to 25% of i s ol a tes a re res i s ta nt to erythromyci n. Thi s pa ern of res i s ta nce ha s l ed to a cha nge i n the recommenda ons for s econd-l i ne thera pi es . If peni ci l l i n a l l ergi c, but not a t hi gh ri s k for a na phyl a xi s , cefa zol i n i s recommended. If peni ci l l i n a l l ergi c a nd hi gh ri s k for a na phyl a xi s , us e cl i nda myci n or erythromyci n i f i s ol a te i s s us cep bl e. If peni ci l l i n a l l ergi c a nd hi gh ri s k for a na phyl a xi s a nd GBS res i s ta nt to cl i nda myci n or erythromyci n, or s us cepti bi l i ti es not a va i l a bl e, us e va ncomyci n. 185. The answer is a. (Cunningham, pp 788-790.) Amni oni c flui d embol i s m i s compl ex di s order cha ra cteri zed by a brupt ons et of ma terna l hypoxi a , hypotens i on a nd di s s emi na ted i ntra va s cul a r coa gul opa thy. Amni oni c flui d enters the ma terna l ci rcul a on from brea ch i n the norma l ma terna l feta l phys i ol ogi ca l ba rri ers . Thi s typi ca l l y ha ppens wi th l a bor a nd del i very a nd ces a rea n del i very offers a mpl e opportuni ty. The typi ca l cl i ni ca l pres enta on i s dra ma c wi th a mother ei ther pos tdel i very or i n the l a te s ta ges of l a bor ga s pi ng for a i r, s ufferi ng s ei zures from hypoxi a then ca rdi opul mona ry col l a ps e fol l owed by ma s s i ve hemorrha ge from cons ump ve coa gul opa thy a nd ul ma tel y dea th gi ven the qui cknes s of events . Immedi a te s upport wi th oxygena on through i ntuba on a nd ci rcul a tory s upport a nd bl ood products i s vi ta l . Profound neurol ogi ca l i mpa i rment i s common i n s urvi vors . Whi l e ha l ogena ted a nes the c a gents a nd mul pl e ges ta on ca n ca us e uteri ne a tony l ea di ng to hemorrha ge a nd whi l e pl a centa a ccreta ca n a l s o be a ca us e of hemorrha ge, thes e a re not the cul pri ts i n thi s dra s ti c pres enta ti on. 186. The answer is b. (Cunningham, pp 474-476.) In the event of a fa ce pres enta ti on, s ucces s ful va gi na l del i very wi l l occur; the ma jori ty of the ti me wi th a n a dequa te pel vi s . Sponta neous i nterna l rota on duri ng l a bor i s requi red to bri ng the chi n to the a nteri or pos i on, whi ch a l l ows the neck to pa s s benea th the pubi s . Therefore, the pa ent i s a l l owed to l a bor s ponta neous l y; a ces a rea n s ec on i s empl oyed for fa i l ure to progres s or for feta l di s tres s . Ma nua l convers i on to vertex, forceps rota on, a nd i nterna l vers i on a re no l onger empl oyed i n obs tetri cs to del i ver the fa ce pres enta ti on beca us e of undue tra uma to both the mother a nd the fetus . 187. The answer is d. (Cunningham, pp 464-474.) The l a bor portra yed i s cha ra cteri s c of a s econda ry a rres t of di l a on. The woma n ha s entered the a c ve pha s e of l a bor, a s s he previ ous l y progres s ed from 4 to 7 cm i n l es s tha n 2 hours a nd then rema i ns 7 cm over a n a ddi ona l 2 hours . The

mul pa rous woma n norma l l y progres s es a t a ra te of a t l ea s t 1.5 cm/h (a nd the nul l i pa ra a t l ea s t 1.2 cm/h) i n the a c ve pha s e. Di l a on a t a s l ower ra te i s a protra c on di s order. Pri ma ry dys func on, prol onged l a tent pha s e, a nd hypertoni c dys func on occur pri or to the a c ve pha s e. The bes t evi dence a va i l a bl e i ndi ca tes tha t thi s l a bor i s hypotoni c. Si nce the ul tra s ound i ndi ca tes a fetus wi thout obvi ous a bnorma l i es , a nd s i nce the pa ent’s previ ous i nfa nts were l a rger tha n thi s one, we a s s ume the a bs ence of cepha l opel vi c di s propor on (CPD). Oxytoci n i s the trea tment of choi ce. If CPD were s us pected, then the trea tment preferred by ma ny obs tetri ci a ns woul d be ces a rea n s ecti on. 188. The answer is c. (Cunningham, pp 464-474.) The bes t evi dence a va i l a bl e i ndi ca tes tha t thi s l a bor i s hypotoni c a nd tha t the contra c ons a re i na dequa te. Two contra c ons of 40 mm Hg i ntens i ty duri ng a 10-mi nute peri od equa tes to 80 MUV. About 200 MUV a re needed to cons i der contra c ons to be a dequa te to effect del i very. Si nce the ul tra s ound i ndi ca tes a fetus wi thout obvi ous a bnorma l i es a nd s ma l l er tha n her firs t i nfa nt, we a s s ume the a bs ence of cepha l opel vi c di s propor on (CPD). Oxytoci n i s the trea tment of choi ce i n thi s s i tua on. If CPD were s us pected, then the trea tment preferred by ma ny obs tetri ci a ns woul d be ces a rea n s ecti on. 189. The answer is e. (Cunningham, p 401-402.) Mi dl i ne epi s i otomi es a re ea s i er to fix a nd ha ve a s ma l l er i nci dence of s urgi ca l brea kdown, l es s pa i n, a nd l ower bl ood l os s . The i nci dence of dys pa reuni a i s s omewha t l es s . However, the i nci dence of extens i ons of the i nci s i on to i ncl ude the rectum i s cons i dera bl y hi gher tha n wi th medi ol a tera l epi s i otomi es . Rega rdl es s of techni que, a en on to hemos ta s i s a nd a na tomi c res tora on i s the key el ement of a techni ca l l y a ppropri a te repa i r. 190. The answer is d. (Cunningham, pp 410-440, 764-766.) The pa ent des cri bed i n the ques on pres ents wi th a cl a s s i c hi s tory for a brup on— tha t i s , the s udden ons et of a bdomi na l pa i n a ccompa ni ed by bl eedi ng. Phys i ca l exa mi na on revea l s a firm, tender uterus wi th frequent contra c ons , whi ch confirms the di a gnos i s . The fa ct tha t a cl ot forms wi thi n 4 mi nutes s ugges ts tha t coa gul opa thy i s not pres ent. Beca us e a brup on i s o en a ccompa ni ed by hemorrha gi ng, i t i s i mporta nt tha t a ppropri a te flui ds (i e, l a cta ted Ri nger s ol u on a nd whol e bl ood) be a dmi ni s tered i mmedi a tel y to s ta bi l i ze the mother’s ci rcul a on. Ces a rea n s ec on ma y be neces s a ry i n the ca s e of a s evere a brup on, but onl y when feta l di s tres s i s evi dent or del i very i s unl i kel y to be a ccompl i s hed va gi na l l y. Interna l moni tori ng equi pment s houl d provi de a n ea rl y wa rni ng tha t the fetus i s compromi s ed. The i nterna l uteri ne ca theter provi des pres s ure recordi ngs , whi ch a re i mporta nt i f oxytoci n s mul a on i s neces s a ry. Genera l l y, however, pa ti ents wi th a brupti o pl a centa e a re contra cti ng vi gorous l y a nd do not need oxytoci n. 191 to 193. The answers are 191-d, 192-b, 193-a. (Cunningham, pp 464-470, 542, 546-551.) A woma n who ha s been di l a ted 9 cm for 3 hours i s experi enci ng a s econda ry a rres t of di l a on i n l a bor. The deteri ora ng feta l condi on (a s evi denced, eg, by l a te decel era ons a nd fa l l i ng s ca l p pH) di cta tes i mmedi a te del i very. A forceps rota on woul d be i na ppropri a te beca us e the cervi x i s not ful l y di l a ted. Ces a rea n s ec on woul d be the s a fes t a nd mos t expedi ous method. Cl a s s i c ces a rea n s ec on i s ra rel y us ed now beca us e of grea ter bl ood l os s a nd a hi gher i nci dence i n s ubs equent pregna nci es of rupture of the s ca r pri or to l a bor. The bes t procedure woul d be a l ow tra ns vers e ces a rea n s ec on. Accordi ng to s ome s tudi es , 25% of twi ns a re di a gnos ed a t the me of del i very. Al though s onogra phy or ra di ogra phy ca n di a gnos e mul pl e ges ta ons ea rl y i n pregna ncy, thes e methods a re not us ed rou nel y i n a l l medi ca l centers . The s econd twi n i s proba bl y the onl y rema i ni ng s i tua on where i nterna l vers i on i s permi s s i bl e. Al though s ome obs tetri ci a ns mi ght perform a ces a rea n s ec on for a s econd twi n pres en ng a s a footl i ng or s houl der, feta l bra dyca rdi a di cta tes tha t i mmedi a te del i very be done, a nd i nterna l poda l i c vers i on i s the qui ckes t procedure. A tra ns vers e l i e i s undel i vera bl e va gi na l l y. One trea tment op on i s to do nothi ng a nd hope tha t the l i e wi l l be l ongi tudi na l by the me l a bor commences . The onl y other a ppropri a te ma neuver woul d be to perform a n externa l cepha l i c vers i on. Thi s ma neuver s houl d be done i n the hos pi ta l , wi th moni tori ng of the feta l hea rt. If the vers i on i s s ucces s ful a nd the cervi x i s ri pe, i t mi ght be bes t to ta ke a dva nta ge of the fa vora bl e vertex pos i on by rupturi ng the membra nes a t tha t poi nt a nd i nduci ng l a bor. 194. The answer is b. (Cunningham, pp 464-466.) The mul pa rous pa ent i s i n prol onged l a tent pha s e, cha ra cteri zed by pa i nful uteri ne contra c ons wi thout s i gni fica nt progres s i on i n cervi ca l di l a on. Prol onga on of the l a tent pha s e i s defined a s 20 hour i n nul l i pa rous a nd 14 hour i n mul pa rous . The di a gnos i s of thi s ca tegory of uteri ne dys func on i s di fficul t a nd i s ma de i n ma ny ca s es onl y i n retros pect. Onl y ra rel y i s there need to res ort to oxytoci c a gents or to ces a rea n s ec on. The recommended ma na gement i s meperi di ne (Demerol ) 100 mg i ntra mus cul a rl y; thi s wi l l a l l ow mos t pa ents to res t a nd wa ke up i n a c ve l a bor. About 10% of pa ents wi l l wa ke up wi thout contra c ons a nd the di a gnos i s of fa l s e l a bor wi l l be ma de. Onl y a bout 5% of pa ents wi l l wa ke up a er meperi di ne i n the s a me s ta te of contra c ons wi thout progres s i on. Epi dura l bl ock ma y l ea d to a bnorma l l a bor pa tterns a nd to del a y of des cent of the pres enti ng pa rt. 195. The answer is c. (Cunningham, pp 464-470.) Thi s protra cted l a bor i s a s s oci a ted wi th hypotoni c uteri ne dys func on, a condi on tha t ma y ha ve been exa cerba ted by the epi dura l bl ock. If not contra i ndi ca ted by other fa ctors (eg, uteri ne s ca r), a ugmenta on of l a bor by i ntra venous oxytoci n i s the trea tment of choi ce i n thi s s i tua ti on. 196. The answer is e. (Cunningham, pp 464-474.) The pa ent wi th a rres t of des cent a nd s econda ry a rres t of di l a on ha s a dequa te uteri ne contra c ons . Thus there i s no rea s on to a empt to a ugment thes e contra c ons by oxytoci n. The s ma l l -fra med mother a nd the rel a vel y l a rge fetus ma y s ugges t cepha l opel vi c di s propor on (CPD). Arres t di s orders , common i n CPD, a nd the a bs ence of hea d enga gement des pi te cervi ca l di l a on a l s o s upport thi s di a gnos i s . The s a fes t wa y to del i ver s uch a ba by woul d be ces a rea n s ec on. Ea rl y decel era ons occur before the ons et of the contra cti on a nd repres ent a va ga l res pons e to i ncrea s ed i ntra cra ni a l pres s ure from uteri ne pres s ure on the feta l hea d. 197 to 200. The answers are 197-d, 198-a, 199-c, 200-d. (Cunningham, pp 444-461.) Pa rentera l na rco cs a re commonl y us ed for l a bor pa i n. Meperi di ne i s the mos t common opi oi d us ed for l a bor pa i n rel i ef. It ha s a depres s a nt effect on the fetus a nd ca n ca us e neona ta l s eda on, pudenda l bl ock i s s l l us ed for va gi na l del i very. It provi des a dequa te pa i n rel i ef for epi s i otomy, s ponta neous del i very, forceps del i very, or va cuum extra c on. The s ucces s of a pudenda l bl ock depends on a cl ea r unders ta ndi ng of the a na tomy of the pudenda l nerve a nd i ts s urroundi ngs . Compl i ca ons (va gi na l hema toma s , retrops oa s , or pel vi c a bs ces s es ) a re qui te ra re. Spi na l bl ock provi des prompt a nd a dequa te rel i ef for s ponta neous a nd i ns trument-a s s i s ted del i very. The l oca l a nes the c i s i njected a t the l evel of the L4-5 i nters pa ce wi th the pa ent s i ng. Al though thi s method i s i ntended to a nes the ze the s a ddl e a rea , the l evel of a nes thes i a ma y s ome mes rea ch a s hi gh a s T10. Hypotens i on a nd a decrea s e i n uteropl a centa l perfus i on a re common res ul ts of the profound s ympa the c bl ocka de ca us ed by s pi na l a nes thes i a . Epi dura l a nes thes i a provi des effec ve pa i n rel i ef for the firs t a nd s econd s ta ges of l a bor a nd for del i very. It ma y be a s s oci a ted wi th l a te decel era ons s ugges ve of uteropl a centa l i ns uffici ency i n a s ma ny a s 20% of ca s es , but the frequency of thi s compl i ca on ma y be reduced by prehydra on of the mother a nd by a voi di ng the s upi ne pos i on. Epi dura l bl ock a ppea rs to l engthen the s econd s ta ge of l a bor a nd i s a s s oci a ted wi th a n i ncrea s ed need for a ugmenta ti on of l a bor wi th oxytoci n a nd for i ns trument-a s s i s ted del i very. 201 and 202. The answers are 201-c, 202-a. (Cunningham, pp 382-389, 464-471.) Thi s pa ent i s mos t l i kel y experi enci ng fa l s e l a bor, or Bra xton-Hi cks contra c ons . Fa l s e l a bor i s cha ra cteri zed by contra c ons tha t a re i rregul a r i n mi ng a nd dura on a nd do not res ul t i n a ny cervi ca l di l a on. The i ntens i ty of fa l s e l a bor does not cha nge a nd the di s comfort i s ma i nl y fel t i n the l ower a bdomen a nd i s us ua l l y rel i eved by s eda on. In the ca s e of true l a bor, the uteri ne contra c ons occur a t regul a r i nterva l s a nd tend to become i ncrea s i ngl y more i ntens e wi th me. In true l a bor, the

contra c ons tend to be fel t i n the pa ent’s ba ck a nd a bdomen, a nd cervi ca l cha nge occurs over me. Seda on does not s top the di s comfort. Ac ve l a bor occurs when the cervi x ha s rea ched a bout 4 cm a nd there a re regul a r uteri ne contra c ons tha t ra pi dl y di l a te the cervi x wi th me. The firs t s ta ge of l a bor i s the i nterva l between the ons et of l a bor a nd ful l cervi ca l di l a on. The s econd s ta ge of l a bor begi ns wi th compl ete cervi ca l di l a on a nd ends wi th the del i very of the i nfa nt. The l a tent pha s e of l a bor i s pa rt of the firs t s ta ge of l a bor; i t encompa s s es cervi ca l effa cement a nd ea rl y di l a ti on. Si nce thi s pa ti ent i s not i n true l a bor, the bes t pl a n of ma na gement i s to s end her home. 203. The answer is d. (Cunningham, pp 444-461.) The mos t a ppropri a te moda l i ty for pa i n control i n thi s pa ent i s a dmi ni s tra on of a n epi dura l a na l ges i a . An epi dura l bl ock provi des rel i ef from the pa i n of uteri ne contra c ons a nd del i very. It i s a ccompl i s hed by i njec ng a l oca l a nes the c a gent i nto the epi dura l s pa ce a t the l evel of the l umba r i ntervertebra l s pa ce. An i ndwel l i ng ca theter ca n be l e i n pl a ce to provi de con nuous i nfus i on of a n a nes the c a gent throughout l a bor a nd del i very vi a a vol umetri c pump. In thi s pa ent, i ntra mus cul a r na rco cs s uch a s meperi di ne or morphi ne woul d not be preferred beca us e thes e a gents ca n ca us e res pi ra tory depres s i on i n the newborn i f del i very i s i mmi nent. A pudenda l bl ock i nvol ves l oca l i nfil tra on of the pudenda l nerve, whi ch provi des a nes thes i a to the peri neum for del i very but no pa i n rel i ef for uteri ne contra c ons . A l oca l peri nea l bl ock refers to i nfus i ng a l oca l a nes the c to the a rea of a n epi s i otomy. The i nha l a on of a nes the c ga s es (genera l a nes thes i a ) i s res erved pri ma ri l y for s i tua ons i nvol vi ng emergent ces a rea n s ec ons a nd di fficul t del i veri es . Al l a nes the c a gents tha t depres s the ma terna l CNS cros s the pl a centa a nd a ffect the fetus . In a ddi on, a ma jor compl i ca on of genera l a nes thes i a i s ma terna l a s pi ra on, whi ch ca n res ul t i n fa ta l a s pi ra ti on pneumoni ti s . 204. The answer is c. (Cunningham, pp 437-440, 464-474.) Arres t of l a bor ca nnot be di a gnos ed duri ng the fi rs t s ta ge of l a bor unti l the cervi x ha s rea ched 4 cm di l a on a nd un l a dequa te uteri ne contra c ons (both i n frequency a nd i ntens i ty) ha ve been documented. The a ctua l pres s ure wi thi n the uterus ca nnot be mea s ured vi a a n externa l tocodyna mometer; a n IUPC needs to be pl a ced. It i s genera l l y a ccepted tha t 200 MUV (number of contra c ons i n 10 mi nutes × a vera ge contra c on i ntens i ty i n mm Hg) a re requi red for norma l l a bor progres s . A feta l s ca l p el ectrode woul d need to be pl a ced i n ca s es where the feta l hea rt ra te tra ci ng i s di fficul t to moni tor externa l l y. A ces a rea n s ec on woul d need to be performed once a rres t of l a bor i s di a gnos ed. Augmenta on wi th Pi toci n woul d be i ndi ca ted i f i na dequa te uteri ne contra c ons a re di a gnos ed vi a the IUPC. The epi dura l woul d need to be rebol us ed i f the pa ti ent requi res a ddi ti ona l pa i n rel i ef. 205. The answer is a. (Cunningham, pp 437-440, 464-471, 511-524.) The pa ent i s ha vi ng a dequa te uteri ne contra c ons a s determi ned by the i ntra uteri ne pres s ure ca theter. Therefore, a ugmenta on wi th Pi toci n i s not i ndi ca ted. The pa ent’s di a gnos i s i s s econda ry a rres t of l a bor, whi ch requi res ces a rea n s ec on. In the a c ve pha s e of l a bor, a mul pa rous pa ent s houl d undergo di l a on of the cervi x a t a ra te of a t l ea s t 1.5 cm/h i f uteri ne contra c ons a re a dequa te. There i s no i ndi ca on for the us e of va cuum or forceps i n thi s pa ent beca us e the pa ent’s cervi x i s not compl etel y di l a ted a nd the hea d i s unenga ged. As s i s ted va gi na l del i very wi th va cuum or forceps i s i ndi ca ted when the pa ent i s compl etel y di l a ted, to a ugment ma terna l pus hi ng when ma terna l expul s i ve efforts a re i ns uffici ent to del i ver the fetus . It i s not recommended to con nue to a l l ow the pa ti ent to l a bor i f dys toci a i s di a gnos ed, beca us e uteri ne rupture i s a potenti a l compl i ca ti on. 206. The answer is b. (Cunningham, pp 410-440, 455.) Prol onged feta l hea rt ra te decel era ons a re i s ol a ted decel era ons l a s ng 2 mi nutes or l onger, but l es s tha n 10 mi nutes from ons et to return to ba s el i ne. Epi dura l a na l ges i a i s a very common ca us e of feta l hea rt ra te decel era ons beca us e i t ca n be a s s oci a ted wi th ma terna l hypotens i on a nd decrea s ed pl a centa l perfus i on. Therefore, ma terna l bl ood pres s ure s houl d a l wa ys be noted i n ca s es of feta l hea rt ra te decel era ons . If ma terna l bl ood pres s ure i s a bnorma l l y l ow, ephedri ne ca n be gi ven to correct the hypotens i on. Beca us e a n umbi l i ca l cord prol a ps e ca n be a s s oci a ted wi th decel era ons , the pa ent s houl d undergo a cervi ca l exa mi na on. In a ddi on, the Pi toci n i nfus i on s houl d be s topped beca us e hypers mul a on of the uterus ca n be a ca us e of feta l hypoxi a . The pa ent s houl d be turned to the l e l a tera l pos i on to decrea s e uteri ne pres s ure on the grea t ves s el s a nd enha nce uteropl a centa l flow. Suppl ementa l oxygen s houl d be gi ven to the pa ti ent i n a n a ttempt to i ncrea s e oxygen to the fetus . Onl y i f the hea rt ra te decel era ti on pers i s ts i s a ces a rea n s ecti on performed. 207. The answer is a. (Cunningham, pp 481-487.) In thi s cl i ni ca l s cena ri o, a s houl der dys toci a i s encountered. A s houl der dys toci a occurs when the feta l s houl ders fa i l to s ponta neous l y del i ver s econda ry to i mpa c on of the a nteri or s houl der a ga i ns t the pubi c bone a er del i very of the hea d ha s occurred. Shoul der dys toci a i s a n obs tetri c emergency a nd one s houl d a l wa ys ca l l for hel p when s uch a s i tua on i s encountered. A generous epi s i otomy s houl d a l wa ys be ma de to a l l ow the obs tetri ci a n to ha ve a dequa te room to perform a number of ma ni pul a ons to try to rel i eve the dys toci a . Such ma neuvers i ncl ude the fol l owi ng: s upra pubi c pres s ure, McRoberts ma neuver (flexi ng ma terna l l egs upon the a bdomen), Wood’s corks crew ma neuver (rota ng the pos teri or s houl der), a nd del i very of the pos teri or s houl der. There i s no rol e for funda l pres s ure beca us e thi s a c on further i mpa cts the s houl der a ga i ns t the pubi c bone a nd ma kes the s i tua on wors e. A Za va nel l i ma neuver i s repl a cement of the feta l hea d i nto the pel vi s s o tha t ces a rea n del i very ca n be performed. It s houl d onl y be a empted when a l l other methods ha ve fa i l ed. A s ymphys i otomy i nvol ves cutti ng the pubi c s ymphys i s a nd ha s a hi gh morbi di ty for the mother. 208. The answer is a. (Cunningham, pp 481-487.) Shoul der dys toci a s ca n be a s s oci a ted wi th s i gni fica nt feta l morbi di ty i ncl udi ng bra chi a l pl exus pa l s i es , cl a vi cul a r fra ctures , a nd humera l fra ctures . Fra ctures of the cl a vi cl e a nd humerus us ua l l y hea l ra pi dl y a nd a re cl i ni ca l l y i ns i gni fica nt. Injury to the bra chi a l pl exus ma y be l oca l i zed to the upper or l ower roots . In Erb (or Erb-Duchenne) pa l s y, the upper roots of the bra chi a l pl exus a re i njured (C5-6), res ul ng i n pa ra l ys i s of the s houl der a nd a rm mus cl es ; the a rm ha ngs l i mpl y to the s i de a nd i s extended a nd i nterna l l y rota ted. In the ca s e of Kl umpke pa ra l ys i s , the l ower nerves of the bra chi a l pl exus a re a ffected (C7-T1) a nd the ha nd i s pa ra l yzed. 209. The answer is c. (Cunningham, pp 511-524.) Indi ca ons for a n opera ve va gi na l del i very wi th a va cuum extra ctor or forceps occur i n s i tua ons where the feta l hea d i s enga ged, the cervi x i s compl etel y di l a ted, a nd there i s a prol onged s econd s ta ge, s us pi ci on of poten a l feta l compromi s e, or need to s horten the s econd s ta ge for ma terna l benefit. In thi s s i tua on, a l l the i ndi ca ons for opera ve del i very a ppl y. Thi s pa ent ha s been pus hi ng for 3 hours , whi ch i s the defini on for prol onged s econd s ta ge of l a bor i n a nul l i pa rous pa ent wi th a n epi dura l . In a ddi on, poten a l ma terna l a nd feta l compromi s e exi s ts s i nce the pa ent ha s the cl i ni ca l pi cture of chori oa mni oni s a nd the feta l hea rt ra te i s nonrea s s uri ng. It i s bes t to a voi d ces a rea n s ecti on s i nce i t woul d ta ke more ti me to a chi eve a nd s i nce the pa ti ent i s i nfected. 210. The answer is e. (Cunningham, pp 511-524.) Cornea l a bra s i ons a nd ocul a r tra uma a re more common wi th forceps vers us the va cuum unl es s the va cuum i s i na dvertentl y pl a ced over the eye. Va cuum del i veri es ha ve a hi gher ra te of neona ta l cepha l ohema toma s , re na l hemorrha ges , i ntra cra ni a l hemorrha ges , a nd ja undi ce. 211. The answer is c. (Cunningham, pp 783-784.) The des cri bed ma s s i s a va gi na l hema toma . A er del i very, the s ymptoms of s evere pa i n a nd uri na ry reten on s houl d l ea d to a va gi na l exa mi na on a nd the di s covery of fluctua nt tumor. Sma l l vul va r hema toma s di s covered a er l ea vi ng the del i very room ma y be trea ted expecta ntl y. If s evere pa i n occurs or i f the hema toma con nues to expa nd, the bes t trea tment i s i nci s i on a nd eva cua on of the bl ood cl ots wi th l i ga ti on of the bl eedi ng ves s el s i f they ca n be i denti fi ed. Often no s i tes of a cti ve bl eedi ng a re found, i n thi s ca s e the defect i s cl os ed a nd the va gi na pa cked for 12 to 24 hours . La pa rotomy ma y be i ndi ca ted i f the hema toma extends i nto the broa d l i ga ment. Embol i za on of the va gi na l bra nch of the i nterna l pudenda l a rtery, uteri ne a rtery, a nd i nterna l pudenda l a rtery ca n be performed i f bl eedi ng i s i ntra cta bl e.

212. The answer is c. (Cunningham, pp 400-404.) A firs t-degree tea r i nvol ves the va gi na l mucos a or peri nea l s ki n, but not the underl yi ng s s ue. In a s econd-degree epi s i otomy, the underl yi ng s ubcuta neous s s ue i s a l s o i nvol ved, but not the recta l s phi ncter or recta l mucos a . In a thi rd-degree tea r, the recta l s phi ncter i s a ffected. A fourth-degree epi s i otomy i nvol ves a tea r tha t extends i nto the recta l mucos a . 213. The answer is e. (Cunningham, pp 464-471.) Thi s pa ent i s ei ther experi enci ng prol onged l a tent l a bor or i s i n fa l s e l a bor. The l a tent pha s e of l a bor begi ns wi th the ons et of regul a r uteri ne contra c ons a nd i s a ccompa ni ed by progres s i ve but s l ow cervi ca l di l a on. The l a tent pha s e ends when the cervi ca l di l a ti on ra te rea ches a bout 1.2 cm/h i n nul l i pa rous pa ti ents a nd 1.5 cm/h i n mul ti pa rous pa ti ents ; thi s norma l l y occurs when the cervi x i s a bout 3 to 4 cm di l a ted. In nul l i pa rous pa ents , the l a tent pha s e of l a bor us ua l l y l a s ts l es s tha n 20 hours (i n mul pa rous pa ents , i t l a s ts > 14 hours ). To correct prol onged l a tent l a bor, i t i s genera l l y recommended tha t a s trong s eda ve s uch a s morphi ne be a dmi ni s tered to the pa ent. Thi s i s preferred over a ugmenta on wi th Pi toci n or performi ng a n a mni otomy, beca us e 10% of pa ents wi l l a ctua l l y ha ve been i n fa l s e l a bor a nd thes e pa ents wi l l s top contra c ng a er a dmi ni s tra on of morphi ne. If a pa ent trul y i s i n l a bor, then, a er the s eda ve wea rs off, s he wi l l ha ve undergone cervi ca l cha nge a nd wi l l ha ve benefited from the res t i n terms of ha vi ng a ddi ona l energy to proceed wi th l a bor. An epi dura l woul d not be recommended beca us e the pa ent ma y be i n fa l s e l a bor. There i s no rol e for cervi ca l ri peni ng i n thi s pa ent beca us e of the fa ct tha t s he mi ght be i n fa l s e l a bor a nd ca n go home a nd wa i t for na tura l cervi ca l ri peni ng i f her uteri ne contra c ons res ol ve wi th a thera peuti c res t wi th morphi ne. 214 and 215. The answers are 214-c, 215-a. (Cunningham, pp 527-542.) The pa ent des cri bed here ha s a fetus i n the doubl e footl i ng breech pres enta on. In ca s es of fra nk breech pres enta ons , the l ower extremi es a re flexed a t the hi ps a nd extended a t the knees s o tha t the feet l i e i n cl os e proxi mi ty to the hea d a nd the feta l bu ocks i s the pres en ng pa rt. Wi th a compl ete breech pres enta on, one or both knees a re flexed. In the ca s e of a n i ncompl ete breech pres enta on, s i ngl e footl i ng, one hi p i s not flexed a nd one foot or knee i s l owermos t i n the bi rth ca na l . Beca us e of the ri s k of a prol a ps ed cord, i t i s genera l l y recommended tha t fetus es wi th footl i ng breech pres enta ons undergo del i very by ces a rea n s ec on. Externa l cepha l i c vers i on i s a procedure whereby the pres enta on of the fetus i s cha nged from breech to cepha l i c by ma ni pul a ng the fetus externa l l y through the a bdomi na l wa l l . It i s not i ndi ca ted i n thi s pa ent beca us e the membra nes a re ruptured a nd the ri s k of cord prol a ps e i s grea t. In a ddi ti on, thi s procedure genera l l y requi res tha t the uterus be s oft a nd rel a xed, whi ch i s not the ca s e wi th thi s pa ti ent i n l a bor. Interna l poda l i c vers i on i s a procedure us ed i n the del i very of a s econd twi n. It i nvol ves turni ng the fetus by i ns er ng a ha nd i nto the uterus , gra bbi ng both feet, a nd del i veri ng the fetus by breech extra cti on.

The Puerperium, Lactation, and Immediate Care of the Newborn Questions 216. A 34-yea r-ol d G3P2 del i vers a ba by by s ponta neous va gi na l del i very. She ha d s ca nt prena ta l ca re a nd no ul tra s ound, s o s he i s a nxi ous to know the s ex of the ba by. At firs t gl a nce you no ce fema l e geni ta l i a , but on cl os er exa mi na on the geni ta l i a a re a mbi guous . Whi ch of the fol l owi ng i s the bes t next s tep i n the eva l ua ti on of thi s i nfa nt? a . Chromos oma l a na l ys i s b. Eva l ua ti on a t 1 month of a ge c. Pel vi c ul tra s ound d. Thorough phys i ca l exa mi na ti on e. La pa rotomy for gona dectomy 217. A 24-yea r-ol d pri mi gra vi d woma n, who i s i ntent on brea s t-feedi ng, deci des on a home del i very. Immedi a tel y a er the bi rth of a 4.1-kg (9-l b) i nfa nt, the pa ent bl eeds ma s s i vel y from extens i ve va gi na l a nd cervi ca l l a cera ons . She i s brought to the nea res t hos pi ta l i n s hock. Over 2 hours , 9 uni ts of bl ood a re tra ns fus ed, a nd the pa ent’s bl ood pres s ure returns to a rea s ona bl e l evel . A hemogl obi n va l ue the next da y i s 7.5 g/dL, a nd 3 uni ts of pa cked red bl ood cel l s a re gi ven. The mos t l i kel y l a te s equel a to cons i der i n thi s woma n i s whi ch of the fol l owi ng? a . Hemochroma tos i s b. Stei n-Leventha l s yndrome c. Sheeha n s yndrome d. Si mmonds s yndrome e. Cus hi ng s yndrome 218. A 27-yea r-ol d G4P3 a t 37 weeks pres ents to the hos pi ta l wi th hea vy va gi na l bl eedi ng a nd pa i nful uteri ne contra c ons . Qui ck beds i de ul tra s ound revea l s a funda l pl a centa . The pa ent’s vi ta l s i gns a re bl ood pres s ure 140/92 mm Hg, pul s e 118 bea ts per mi nute, res pi ra tory ra te 20 brea ths per mi nute, a nd tempera ture 37°C (98.6°F). The feta l hea rt ra te tra ci ng revea l s ta chyca rdi a wi th decrea s ed va ri a bi l i ty a nd a few l a te decel era ons . An emergency ces a rea n s ec on del i vers a ma l e i nfa nt wi th Apga r s cores of 4 a nd 9. Wi th del i very of the pl a centa , a l a rge retropl a centa l cl ot i s noted. The pa ent becomes hypotens i ve, a nd bl eedi ng i s noted from the wound edges a nd her IV ca theter s i tes . Whi ch of the fol l owi ng bl ood products wi l l mos t qui ckl y res ol ve her ca us e of hemorrha ge? a . Cryopreci pi ta te b. Fres h frozen pl a s ma c. Pa cked red bl ood cel l s d. Pl a tel ets e. Recombi na nt Fa ctor VII 219. On pos topera ve da y 3 a er a n uncompl i ca ted repea t ces a rea n del i very, the pa ent devel ops a fever of 38.2°C (100.8°F). She ha s no compl a i nts except for s ome ful l nes s i n her brea s ts . On exa mi na on s he a ppea rs i n no di s tres s ; l ung a nd ca rdi a c exa mi na ons a re norma l . Her brea s t exa mi na on revea l s ful l , firm brea s ts bi l a tera l l y s l i ghtl y tender wi th no erythema or ma s s es . She i s not brea s t-feedi ng. The a bdomen i s s o wi th firm, non-tender fundus a t the umbi l i cus . The l ochi a a ppea rs norma l a nd i s non-odorous . Uri na l ys i s a nd whi te bl ood cel l count a re norma l . Whi ch of the fol l owi ng i s a cha ra cteri s ti c of the ca us e of her puerpera l fever? a . Appea rs i n l es s tha n 5% of pos tpa rtum women b. Appea rs 3 to 4 da ys a fter the devel opment of l a ctea l s ecreti on c. Is a l mos t a l wa ys pa i nl es s d. Fever ra rel y exceeds 37.8°C (99.8°F) e. Is l es s s evere a nd l es s common i f l a cta ti on i s s uppres s ed 220. A 38-yea r-ol d G3P3 begi ns to brea s t-feed her 5-da y-ol d i nfa nt. The ba by l a tches on a ppropri a tel y a nd begi ns to s uckl e. In the mother, whi ch of the fol l owi ng i s a res pons e to s uckl i ng? a . Decrea s e of oxytoci n b. Increa s e of prol a cti n-i nhi bi ti ng fa ctor c. Increa s e of hypotha l a mi c dopa mi ne d. Increa s e of hypotha l a mi c prol a cti n e. Increa s e of l utei ni zi ng hormone—rel ea s i ng fa ctor 221. On pos tpa rtum da y 2 a er a va gi na l del i very, a 32-yea r-ol d G2P2 devel ops a cute s hortnes s of brea th a nd ches t pa i n. Her vi ta l s i gns a re bl ood pres s ure 120/80 mm Hg, pul s e 130 bea ts per mi nute, res pi ra tory ra te 32 brea ths per mi nute, a nd tempera ture 37.6°C (99.8°F). She ha s new ons et of cough. She a ppea rs to be i n mi l d di s tres s . Lung exa mi na on revea l s cl ea r ba s es wi th no ra l es or rhonchi . The ches t pa i n i s reproduci bl e wi th deep i ns pi ra on. Ca rdi a c exa mi na on revea l s ta chyca rdi a wi th 2/6 s ys tol i c ejec on murmur. Pul s e oxi metry revea l s a n oxygen s a tura on of 88% on room a i r a nd oxygen s uppl ementa ti on i s i ni ti a ted. Whi ch of the fol l owi ng i s the bes t di a gnos ti c tool to confi rm the di a gnos i s ? a . Arteri a l bl ood ga s b. Ches t x-ra y c. CT a ngi ogra phy d. Lower extremi ty Doppl ers e. Venti l a ti on-perfus i on s ca n 222. A 26-yea r-ol d G1P1 i s now pos topera ve da y (POD) 6 a er a l ow tra ns vers e ces a rea n del i very for a rres t of a c ve pha s e. On POD 2, the pa ent devel oped a fever of 39°C (102.2°F) a nd wa s noted to ha ve uteri ne tendernes s a nd foul -s mel l i ng l ochi a . She wa s s ta rted on broa d-s pectrum a n bi o c covera ge for endometri s . The pa ent s ta tes s he feel s fine now a nd wa nts to go home, but con nues to s pi ke fevers ea ch eveni ng. Her l ung, brea s t, a nd ca rdi a c exa mi na ons a re norma l . Her a bdomen i s nontender wi th firm, nontender uterus bel ow the umbi l i cus . On pel vi c exa mi na on her uterus i s a ppropri a tel y enl a rged, but nontender. The a dnexa a re nontender wi thout ma s s es . Her l ochi a i s norma l . Her whi te

bl ood cel l count i s 12 wi th a norma l di fferen a l . Bl ood, s putum, a nd uri ne cul tures a re a l l nega ve for growth a er 3 da ys . Her ches t x-ra y i s nega ti ve. Whi ch of the fol l owi ng s ta tements i s true rega rdi ng thi s pa ti ent’s condi ti on? a . It us ua l l y i nvol ves both the i l i ofemora l a nd ova ri a n vei ns . b. Anti mi crobi a l thera py i s us ua l l y i neffecti ve. c. Fever s pi kes a re ra re. d. Hepa ri n thera py i s a l wa ys needed for res ol uti on of fever. e. Vena ca va l thrombos i s ma y a ccompa ny ei ther ova ri a n or i l i ofemora l thrombophl ebi ti s . 223. A 24-yea r-ol d G1P1 pres ents for her rou ne pos tpa rtum vi s i t 6 weeks a er a n uncompl i ca ted va gi na l del i very. She s ta tes tha t s he i s ha vi ng s l eepi ng probl ems a nd i s feel i ng depres s ed over the pa s t 2 to 3 weeks . She revea l s tha t s he cri es on mos t da ys a nd feel s a nxi ous a bout ta ki ng ca re of her newborn s on. She deni es a ny wei ght l os s or ga i n, but s ta tes s he does n’t feel l i ke ea ng or doi ng a ny of her norma l a c vi es . She deni es s ui ci da l or homi ci da l i dea ti on. Whi ch of the fol l owi ng i s true rega rdi ng thi s pa ti ent’s condi ti on? a . A hi s tory of depres s i on i s not a ri s k fa ctor for devel opi ng pos tpa rtum depres s i on. b. Prena ta l preventi ve i nterventi on for pa ti ents a t hi gh ri s k for pos tpa rtum depres s i on i s bes t ma na ged a l one by a menta l hea l th profes s i ona l . c. Young, mul ti pa rous pa ti ents a re a t hi ghes t ri s k. d. Pos tpa rtum depres s i on i s a s el f-l i mi ti ng proces s tha t l a s ts for a ma xi mum of 3 months . e. About 8% to 15% of women devel op pos tpa rtum depres s i on. 224. A 35-yea r-ol d G3P3 pres ents to your office 3 weeks a er a n uncompl i ca ted va gi na l del i very. She ha s been s ucces s ful l y brea s t-feedi ng. She compl a i ns of chi l l s a nd a fever to 38.3°C (101°F) a t home. She s ta tes tha t s he feel s l i ke s he ha s flu, but deni es a ny s i ck conta cts . She ha s no medi ca l probl ems or pri or s urgeri es . The pa ent deni es a ny medi ci ne a l l ergi es . On exa mi na on s he ha s a l ow-gra de tempera ture of 38°C (100.4°F) a nd genera l l y a ppea rs i n no di s tres s . Hea d, ea r, throa t, l ung, ca rdi a c, a bdomi na l , a nd pel vi c exa mi na ons a re wi thi n norma l l i mi ts . A tri a ngul a r a rea of erythema i s l oca ted i n the upper outer qua dra nt of the l e brea s t. The a rea i s tender to pa l pa on. No ma s s es a re fel t a nd no a xi l l a ry l ympha denopa thy i s noted. Whi ch of the fol l owi ng i s the bes t opti on for trea tment of thi s pa ti ent? a . Admi s s i on to the hos pi ta l for i ntra venous a nti bi oti cs b. Bromocri pti ne to s uppres s mi l k producti on c. Inci s i on a nd dra i na ge d. Ora l di cl oxa ci l l i n for 7 to 10 da ys e. Ora l erythromyci n for 7 to 10 da ys 225. A 22-yea r-ol d G1 a t 34 weeks i s tes ted for tubercul os i s beca us e her fa ther, wi th whom s he l i ves , wa s recentl y di a gnos ed wi th tubercul os i s . Her s ki n tes t i s pos i ve a nd her ches t x-ra y revea l s a gra nul oma i n the upper l e l obe. Whi ch of the fol l owi ng i s true concerni ng i nfa nts born to mothers wi th a cti ve tubercul os i s ? a . The ri s k of a cti ve di s ea s e duri ng the fi rs t yea r of l i fe ma y a pproa ch 90% wi thout prophyl a xi s . b. Ba ci l l e Ca l mette-Guéri n (BCG) va cci na ti on of the newborn i nfa nt wi thout evi dence of a cti ve di s ea s e i s not a ppropri a te. c. Future a bi l i ty for tubercul i n s ki n tes ti ng i s l os t a fter BCG a dmi ni s tra ti on to the newborn. d. Neona ta l i nfecti on i s mos t l i kel y a cqui red by a s pi ra ti on of i nfected a mni oti c fl ui d. e. Congeni ta l i nfecti on i s common des pi te thera py. 226. A 21-yea r-ol d G1 a t 40 weeks , who underwent i nduc on of l a bor for s evere preecl a mps i a , del i vered a 3900-g ma l e i nfa nt vi a va gi na l del i very a er pus hi ng for 2½ hours . A s econd-degree mi dl i ne l a cera on a nd s i de-wa l l l a cera on were repa i red i n the us ua l fa s hi on under l oca l a na l ges i a . The es ma ted bl ood l os s wa s 450 cc. Ma gnes i um s ul fa te i s con nued pos tpa rtum for the s ei zure prophyl a xi s . Si x hours a er the del i very, the pa ent ha s di fficul ty voi di ng. A di s tended bl a dder ca n be pa l pa ted s upra pubi ca l l y a nd bl a dder ca theri za on produces 1000 cc of uri ne. Whi ch i s the fol l owi ng s ta tement rega rdi ng pos tpa rtum uri na ry retenti on i s true? a . Bl a dder ca theri za ti on i n l a bor i ncrea s es i ts ri s k. b. It i s more common i n mul ti pa rous pa ti ents . c. La bor epi dura l reduces the ri s k of uri na ry retenti on. d. Occurs l es s commonl y wi th i ns trumented del i veri es . e. Mos t commonl y occurs a fter s hort l a bors . 227. A 30-yea r-ol d G5P3 ha s undergone a repea t ces a rea n del i very. She wa nts to brea s t-feed. Her pa s t medi ca l hi s tory i s s i gni fica nt for hepa s B i nfec on, hypothyroi di s m, depres s i on, a nd brea s t reduc on. She i s recei vi ng i ntra venous a n bi o cs for endometri s . Whi ch of the fol l owi ng woul d prevent her from brea s t-feedi ng? a . Ma terna l reducti on ma mmopl a s ty wi th tra ns pl a nta ti on of the ni ppl es b. Ma terna l trea tment wi th a mpi ci l l i n c. Ma terna l trea tment wi th fl uoxeti ne d. Ma terna l trea tment wi th l evothyroxi ne e. Pa s t hepa ti ti s B i nfecti on 228. A 23-yea r-ol d G2P1 devel ops chori oa mni oni s duri ng l a bor a nd i s s ta rted on a mpi ci l l i n a nd genta mi ci n. She requi res a ces a rea n del i very for a rres t of a c ve pha s e l a bor a nd the s a me a n bi o cs a re con nued a er s urgery. On pos topera ve da y 3, the pa ent rema i ns febri l e a nd s ymptoma c wi th uteri ne funda l tendernes s . No ma s s es a re a ppreci a ted by pel vi c exa mi na on. She i s s ucces s ful l y brea s t-feedi ng a nd her brea s t exa mi na ti on i s norma l . Whi ch a nti bi oti c s houl d be i ni ti a ted to provi de better covera ge? a . Cefa zol i n b. Cl i nda myci n c. Moxi fl oxa ci n d. Pi pera ci l l i n wi th ta zoba cta m e. Va ncomyci n 229. A 32-yea r-ol d G2P2 devel ops fever a nd uteri ne tendernes s 1 da y a er ces a rea n del i very for nonrea s s uri ng feta l hea rt tones . She s ta rted on broa d-s pectrum a n bi o cs . On pos topera ve da y 4, the pa ent rema i ns febri l e a nd s ymptoma c wi th a bdomi na l a nd pel vi c tendernes s . Her l ung a nd ca rdi ova s cul a r exa ms a re norma l a nd s he ha s no cos tovertebra l a ngl e tendernes s . She i s s ucces s ful l y brea s t-feedi ng a nd her brea s t exa mi na on i s norma l . Computed tomogra phy (CT) of the a bdomen s hows a s ma l l bl a dder fla p hema toma . Wha t i s the next bes t s tep i n the ma na gement of thi s pa ti ent? a . CT-di rected needl e dra i na ge of hema toma

b. Conti nued trea tment wi th a nti bi oti cs c. Expl ora tory l a pa rotomy a nd dra i na ge of hema toma d. Hys terectomy e. Intra venous hepa ri n 230. A 21-yea r-ol d G2P2 ca l l s her phys i ci a n 7 da ys pos tpa rtum beca us e s he i s concerned tha t s he i s s l l bl eedi ng from the va gi na . She des cri bes the bl eedi ng a s l i ght pi nk to bri ght red a nd l es s hea vy tha n the firs t few da ys pos tdel i very. She deni es fever or a ny cra mpi ng pa i n. On exa mi na on s he i s a febri l e a nd ha s a n a ppropri a tel y s i zed, nontender uterus . The va gi na conta i ns a bout 10 cc of ol d, da rk bl ood. The cervi x i s cl os ed. Whi ch of the fol l owi ng i s the mos t a ppropri a te trea tment? a . Anti bi oti cs for endometri ti s b. Hi gh-dos e ora l es trogen for pl a centa l s ubi nvol uti on c. Oxytoci n for uteri ne a tony d. Sucti on di l a ti on a nd curetta ge for reta i ned pl a centa e. Rea s s ura nce 231. A 28-yea r-ol d G2P2 pres ents to the hos pi ta l 2 weeks a er va gi na l del i very wi th the compl a i nt of hea vy va gi na l bl eedi ng tha t s oa ks a s a ni ta ry na pki n every hour. Her pul s e i s 89 bea ts per mi nute, bl ood pres s ure 120/76 mm Hg, a nd tempera ture 37.1°C (98.9°F). Her a bdomen i s nontender a nd her fundus i s l oca ted a bove the s ymphys i s pubi s . On pel vi c exa mi na on, her va gi na conta i ned s ma l l bl ood cl ots a nd no a c ve bl eedi ng i s noted from the cervi x. Her uterus i s a bout 12 to 14 weeks s i ze a nd nontender. Her cervi x i s cl os ed. An ul tra s ound revea l s a n 8-mm endometri a l s tri pe. Her hemogl obi n i s 10.9, uncha nged from the one a t her va gi na l del i very. β-hCG i s nega ve. Whi ch of the fol l owi ng poten a l trea tments woul d be contra i ndi ca ted? a . Methyl ergonovi ne ma l ea te (Methergi ne) b. Oxytoci n i njecti on (Pi toci n) c. Ergonovi ne ma l ea te (Ergotra te) d. Pros ta gl a ndi ns e. Di l a ti on a nd curetta ge 232. A 22-yea r-ol d G1P0 ha s jus t undergone a s ponta neous va gi na l del i very. As the pl a centa i s bei ng del i vered, a red fles hy ma s s i s noted to be protrudi ng out from behi nd the pl a centa . Whi ch of the fol l owi ng i s the bes t next s tep i n ma na gement of thi s pa ti ent? a . Begi n i ntra venous oxytoci n i nfus i on b. Ca l l for i mmedi a te a s s i s ta nce from other medi ca l pers onnel c. Conti nue to remove the pl a centa ma nua l l y d. Ha ve the a nes thes i ol ogi s t a dmi ni s ter ma gnes i um s ul fa te e. Shove the pl a centa ba ck i nto the uterus 233. Fol l owi ng a va gi na l del i very, a woma n devel ops fever, l ower a bdomi na l pa i n, a nd uteri ne tendernes s . She i s a l ert, a nd her bl ood pres s ure a nd uri ne output a re good. She s ta rted on broa d-s pectrum a n bi o cs , but con nues to s pi ke fevers 4 da ys pos tpa rtum. Whi ch of the fol l owi ng i s mos t cl os el y ti ed to a deci s i on to proceed wi th hys terectomy? a . Des i res s teri l i za ti on b. Ima gi ng s howi ng pel vi c a bs ces s c. Ima gi ng s howi ng ga s i n the myometri um d. Pers i s tent fever grea ter tha n 102°F e. Septi c s hock 234. Three da ys a go you del i vered a 40-yea r-ol d G1P1 by ces a rea n s ec on fol l owi ng a rres t of des cent a er 2 hours of pus hi ng. La bor wa s a l s o s i gni fica nt for prol onged rupture of membra nes . The pa ent ha d a n epi dura l , whi ch wa s removed the da y fol l owi ng del i very. The nurs e pa ges you to come to s ee the pa ent on the pos tpa rtum floor beca us e s he ha s a fever of 38.8°C (102°F) a nd i s experi enci ng s ha ki ng chi l l s . Her bl ood pres s ure i s 120/70 mm Hg a nd her pul s e i s 120 bea ts per mi nute. She ha s been ea ng a regul a r di et wi thout di fficul ty a nd ha d a norma l bowel movement thi s morni ng. She i s a emp ng to brea s t-feed, but s a ys her mi l k ha s not come i n yet. On phys i ca l exa mi na on, her brea s ts a re mi l dl y engorged a nd tender bi l a tera l l y. Her l ungs a re cl ea r. Her a bdomen i s tender over the fundus , but no rebound i s pres ent. Her i nci s i on ha s s ome s erous dra i na ge a t the ri ght a pex, but no erythema i s noted. Her pel vi c exa mi na on revea l s uteri ne tendernes s but no ma s s es . Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Pel vi c a bs ces s b. Septi c pel vi c thrombophl ebi ti s c. Wound i nfecti on d. Endometri ti s e. Atel ecta s i s 235. You a re ca l l ed to s ee a 37-yea r-ol d G4P4 for a fever to 38.7°C (101.8°F). She i s pos topera ve da y 3 a er ces a rea n del i very for a rres t of a c vepha s e l a bor. She underwent a l ong i nduc on for pos tda te pregna ncy a nd ha d rupture of membra nes for more tha n 18 hours . Her other vi ta l s i gns i ncl ude pul s e 118 bea ts per mi nute, res pi ra tory ra te 16 brea ths per mi nute, a nd bl ood pres s ure 120/80 mm Hg. She compl a i ns of s ome i nci s i ona l a nd a bdomi na l pa i n, but i s otherwi s e fine. HEENT, l ung, brea s t, a nd ca rdi a c exa mi na ons a re wi thi n norma l l i mi ts . On a bdomi na l exa mi na on s he ha s uteri ne funda l tendernes s . Her i nci s i on ha s mi l d erythema a round the s ta pl e edges a nd s erous dra i na ge a l ong the l e s i de. Pel vi c exa mi na on revea l s a tender uterus , but no a dnexa l ma s s es . Whi ch of the fol l owi ng i s the mos t a ppropri a te a n bi o c to trea t thi s pa ent wi th i ni ti a l l y? a . Ora l Ba ctri m b. Ora l di cl oxa ci l l i n c. Ora l ci profl oxa ci n d. Intra venous genta mi ci n e. Intra venous cefoteta n 236. A 34-yea r-ol d G1P1 who del i vered her firs t ba by 5 weeks a go ca l l s your office a nd a s ks to s pea k wi th you. She tel l s you tha t s he i s feel i ng very overwhel med a nd a nxi ous . She feel s tha t s he ca nnot do a nythi ng ri ght a nd feel s s a d throughout the da y. She tel l s you tha t s he finds hers el f cryi ng a l l the ti me a nd i s una bl e to s l eep a t ni ght. Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Pos tpa rtum depres s i on

b. Ma terni ty bl ues c. Pos tpa rtum ps ychos i s d. Bi pol a r di s ea s e e. Pos tpa rtum bl ues 237. You a re doi ng pos tpa rtum rounds on a 23-yea r-ol d G1P1 who i s pos tpa rtum da y 2 a er a n uncompl i ca ted va gi na l del i very. As you wa l k i n the room, you note tha t s he i s cryi ng. She s ta tes s he ca n’t s eem to hel p i t. She deni es feel i ng s a d or a nxi ous . She ha s not been s l eepi ng wel l beca us e of ge ng up every 2 to 3 hours to brea s t-feed her new ba by. Her pa s t medi ca l hi s tory i s unrema rka bl e. Whi ch of the fol l owi ng i s the mos t a ppropri a te trea tment recommenda ti on? a . Ti me a nd rea s s ura nce, beca us e thi s condi ti on i s s el f-l i mi ted b. Referra l to ps ychi a try for couns el i ng a nd a nti depres s a nt thera py c. Referra l to ps ychi a try for a dmi s s i on to a ps ychi a try wa rd a nd thera py wi th Ha l dol d. A s l eep a i d e. Referra l to a ps ychi a tri s t who ca n a dmi ni s ter el ectroconvul s i ve thera py 238. A 20-yea r-ol d G1P1 i s pos tpa rtum da y 2 a fter a n uncompl i ca ted va gi na l del i very of a 6-l b 10-oz ba by boy. She i s tryi ng to deci de whether to ha ve you perform a ci rcumci s i on on her newborn. The boy i s i n the wel l -ba by nurs ery a nd i s doi ng very wel l . In couns el i ng thi s pa ent, you tel l her whi ch of the fol l owi ng recommenda ti ons from the Ameri ca n Pedi a tri c As s oci a ti on? a . Ci rcumci s i ons s houl d be performed routi nel y beca us e they decrea s e the i nci dence of ma l e uri na ry tra ct i nfecti ons . b. Ci rcumci s i ons s houl d be performed routi nel y beca us e they decrea s e the i nci dence of peni l e ca ncer. c. Ci rcumci s i ons s houl d be performed routi nel y beca us e they decrea s e the i nci dence of s exua l l y tra ns mi tted di s ea s es . d. Ci rcumci s i ons s houl d not be performed routi nel y beca us e of i ns uffi ci ent da ta rega rdi ng ri s ks a nd benefi ts . e. Ci rcumci s i ons s houl d not be performed routi nel y beca us e i t i s a ri s ky procedure a nd compl i ca ti ons s uch a s bl eedi ng a nd i nfecti on a re common. 239. You a re couns el i ng a new mother a nd fa ther on the ri s ks a nd benefits of ci rcumci s i on for thei r 1-da y-ol d s on. The pa rents a s k i f you wi l l us e a na l ges i a duri ng the ci rcumci s i on. Wha t do you tel l them rega rdi ng the recommenda ti ons for a dmi ni s teri ng pa i n medi ci ne for ci rcumci s i ons ? a . Ana l ges i a i s not recommended beca us e there i s no evi dence tha t newborns undergoi ng ci rcumci s i on experi ence pa i n. b. Ana l ges i a i s not recommended beca us e i t i s uns a fe i n newborns . c. Ana l ges i a i n the form of ora l Tyl enol i s the pa i n medi ci ne of choi ce recommended for ci rcumci s i ons . d. Ana l ges i a i n the form of a peni l e bl ock i s recommended. e. The a dmi ni s tra ti on of s uga r ora l l y duri ng the procedure wi l l keep the neona te preoccupi ed a nd ha ppy. 240. A pa ent wa s i nduced for bei ng pos erm a t 42½ weeks . Immedi a tel y fol l owi ng the del i very, you exa mi ne the ba by wi th the pedi a tri ci a ns a nd note the fol l owi ng on phys i ca l exa mi na on: a s ma l l a mount of ca r l a ge i n the ea rl obe, occa s i ona l crea s es over the a nteri or two-thi rds of the s ol es of the feet, 4-mm brea s t nodul e di a meter, fi ne a nd fuzzy s ca l p ha i r, a nd a s crotum wi th s ome but not extens i ve ruga e. Ba s ed on thi s phys i ca l exa mi na ti on, wha t i s the a pproxi ma te ges ta ti ona l a ge of thi s ma l e i nfa nt? a . 28 weeks b. 33 weeks c. 36 weeks d. 38 weeks e. 42 weeks 241. A 40-yea r-ol d G4P5 a t 39 weeks ges ta on ha s progres s ed ra pi dl y i n l a bor wi th a rea s s uri ng feta l hea rt ra te pa ern. She ha s ha d a n uncompl i ca ted pregna ncy wi th norma l prena ta l l a bs , i ncl udi ng a n a mni ocentes i s for a dva nced ma terna l a ge. The pa ent begi ns the s econd s ta ge of l a bor a nd a er 15 mi nutes of pus hi ng s ta rts to demons tra te deep va ri a bl e hea rt ra te a ccel era ons . You s us pect tha t s he ma y ha ve a fetus wi th a nucha l cord. You expedi entl y del i ver the ba by by l ow-outl et forceps a nd ha nd the ba by over to the neona tol ogi s ts ca l l ed to a end the del i very. As s oon a s the ba by i s ha nded off to the pedi a tri c tea m, i t l ets out a s trong s ponta neous cry. The i nfa nt i s pi nk wi th s l i ghtl y bl ue extremi es tha t a re a cti vel y movi ng a nd ki cki ng. The hea rt ra te i s noted to be 110 on a us cul ta ti on. Wha t Apga r s core s houl d the pedi a tri ci a ns a s s i gn to thi s ba by a t 1 mi nute of l i fe? a . 10 b. 9 c. 8 d. 7 e. 6 242. A 32-yea r-ol d G2P1 a t 41 weeks i s undergoi ng a n i nduc on of ol i gohydra mni os . Duri ng the cours e of her l a bor, the feta l hea rt ra te tra ci ng demons tra tes s evere va ri a bl e decel era ons tha t do not res pond to oxygen, flui d, or a mni oi nfus i on. The pa ent’s cervi x i s di l a ted to 4 cm. A l owtra ns vers e ces a rea n del i very i s performed for nonrea s s uri ng feta l hea rt tones . A er del i very of the fetus you s end a cord ga s , whi ch comes ba ck wi th the fol l owi ng a rteri a l bl ood va l ues : pH 7.29, Pco 2 50, a nd Po 2 20. Wha t condi ti on does the cord bl ood ga s i ndi ca te? a . Norma l feta l s ta tus b. Feta l a ci demi a c. Feta l hypoxi a d. Feta l a s phyxi a e. Feta l meta bol i c a ci dos i s 243. You a re a s ked to a s s i s t i n the wel l -born nurs ery wi th neona ta l ca re. Whi ch of the fol l owi ng i s a pa rt of routi ne ca re i n a hea l thy i nfa nt? a . Admi ni s tra ti on of ceftri a xone crea m to the eyes for prophyl a xi s for gonorrhea a nd chl a mydi a b. Admi ni s tra ti on of vi ta mi n A to prevent bl eedi ng probl ems c. Admi ni s tra ti on of hepa ti ti s B va cci na ti on for routi ne i mmuni za ti on d. Cool -wa ter ba th to remove verni x e. Pl a cement of a computer chi p i n l eft buttock for i denti fi ca ti on purpos es 244. You a re ma ki ng rounds on a 29-yea r-ol d G1P1 who underwent a n uncompl i ca ted va gi na l del i very a t term on the previ ous da y. The pa ent i s s l l very confus ed a bout whether s he wa nts to brea s t-feed. She i s a very bus y l a wyer a nd i s pl a nni ng on goi ng ba ck to work i n 4 weeks , a nd s he does not thi nk tha t s he ha s the me a nd dedi ca on tha t brea s t-feedi ng requi res . She a s ks you wha t you thi nk i s bes t for her to do. Whi ch of the

fol l owi ng i s a n a ccura te s ta tement rega rdi ng brea s t-feedi ng? a . Brea s t-feedi ng decrea s es the ti me to return of norma l mens trua l cycl es . b. Brea s t-feedi ng i s a s s oci a ted wi th a decrea s ed i nci dence of s udden i nfa nt dea th s yndrome. c. Brea s t-feedi ng i s a poor s ource of nutri ents for requi red i nfa nt growth. d. Brea s t-feedi ng i s a s s oci a ted wi th a n i ncrea s ed i nci dence of chi l dhood obes i ty. e. Brea s t-feedi ng i s a s s oci a ted wi th a decrea s ed i nci dence of chi l dhood a ttenti on defi ci t di s order. 245. A 22-yea r-ol d G1P1 who i s pos tpa rtum da y 2 a nd i s bo l e-feedi ng compl a i ns tha t her brea s ts a re very engorged a nd tender. She wa nts you to gi ve her s omethi ng to ma ke the engorgement go a wa y. Whi ch of the fol l owi ng i s recommended to rel i eve her s ymptoms ? a . Brea s t bi nder b. Bromocri pti ne c. Es trogen-conta i ni ng contra cepti ve pi l l s d. Pump her brea s ts e. Us e ora l a nti bi oti cs 246. A 36-yea r-ol d G1P1 comes to s ee you for a rou ne pos tpa rtum exa mi na on 6 weeks a er a n uncompl i ca ted va gi na l del i very. She i s currentl y nurs i ng her ba by wi thout a ny ma jor probl ems a nd wa nts to con nue to do s o for a t l ea s t 9 months . She i s rea dy to res ume s exua l a c vi ty a nd wa nts to know wha t her op ons a re for bi rth control . She does not ha ve a ny medi ca l probl ems . She i s a nons moker a nd i s not ta ki ng a ny medi ca ti ons except for her prena ta l vi ta mi ns . Whi ch of the fol l owi ng methods ma y decrea s e her mi l k s uppl y? a . Intra uteri ne devi ce b. Proges ti n onl y pi l l c. Depo-Provera d. Combi na ti on ora l contra cepti ves e. Foa m a nd condoms 247. A 30-yea r-ol d G3P3, who i s 8 weeks pos tpa rtum a nd regul a rl y brea s t-feedi ng ca l l s you a nd i s very concerned beca us e s he i s ha vi ng pa i n wi th i ntercours e s econda ry to va gi na l drynes s . Whi ch of the fol l owi ng s houl d you recommend to hel p her wi th thi s probl em? a . Ins truct her to s top brea s t-feedi ng b. Appl y hydrocorti s one crea m to the peri neum c. Appl y tes tos terone crea m to the vul va a nd va gi na d. Appl y es trogen crea m to the va gi na a nd vul va e. Appl y petrol eum jel l y to the peri neum 248. A 25-yea r-ol d G1P1 comes to s ee you 6 weeks a er a n uncompl i ca ted va gi na l del i very for a rou ne pos tpa rtum exa mi na on. She deni es a ny probl ems a nd ha s been brea s t-feedi ng her newborn wi thout a ny di fficul es s i nce l ea vi ng the hos pi ta l . Duri ng the bi ma nua l exa mi na on, you note tha t her uterus i s i rregul a r, firm, nontender, a nd a bout a 15-week s i ze. Whi ch of the fol l owi ng i s the mos t l i kel y e ol ogy for thi s enl a rged uterus ? a . Subi nvol uti on of the uterus b. The uterus i s a ppropri a te s i ze for 6 weeks pos tpa rtum c. Fi broi d uterus d. Adenomyos i s e. Endometri ti s 249. A 39-yea r-ol d G3P3 comes to s ee you on da y 5 a er a s econd repea t ces a rea n del i very. She i s concerned beca us e her i nci s i on ha s become very red a nd tender a nd pus s ta rted dra i ni ng from a s ma l l openi ng i n the i nci s i on thi s morni ng. She ha s been experi enci ng genera l ma l a i s e a nd reports a fever of 38.8°C (102°F). Phys i ca l exa mi na on i ndi ca tes tha t the Pfa nnens el i nci s i on i s i ndeed erythema tous a nd i s open a bout 1 cm a t the l e corner, a nd i s dra i ni ng a s ma l l a mount of purul ent l i qui d. There i s tendernes s a l ong the wound edges . Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent? a . Appl y Steri -Stri ps to cl os e the wound. b. Admi ni s ter l oca l a nti bi oti c oi ntment. c. Probe the fa s ci a . d. Ta ke the pa ti ent to the OR for debri dement a nd cl os ure of the s ki n. e. Rea pproxi ma te the wound edge under l oca l a na l ges i a . 250. A 30-yea r-ol d G3P3 i s pos topera ti ve da y 4 a fter a repea t ces a rea n del i very. Duri ng the s urgery s he recei ved 2 uni ts of pa cked red bl ood cel l s for a hemorrha ge rel a ted to uteri ne a tony. She i s to be di s cha rged home toda y. She compl a i ns of s ome yel l owi s h dra i na ge from her i nci s i on a nd rednes s tha t jus t s ta rted ea rl i er i n the da y. She s ta tes tha t s he feel s feveri s h. She i s brea s t-feedi ng. Her pa s t medi ca l hi s tory i s s i gni fi ca nt for type 2 di a betes mel l i tus a nd chroni c hypertens i on. She wei ghs 110 kg. Her vi ta l s i gns a re tempera ture 37.8°C (100.1°F), pul s e 69 bea ts per mi nute, res pi ra tory ra te 18 brea ths per mi nute, a nd bl ood pres s ure i s 143/92 mm Hg. Brea s t, l ung, a nd ca rdi a c exa mi na ons a re norma l . Her mi dl i ne ver ca l s ki n i nci s i on i s erythema tous a nd ha s a foul -s mel l i ng purul ent di s cha rge from the l ower s egment of the wound. It i s tender to touch. The uteri ne fundus i s not tender. Whi ch of the fol l owi ng i s her grea tes t ri s k fa ctor for her compl i ca ti on? a . Anemi a b. Corti cos teroi d thera py c. Di a betes d. Hypertens i on e. Obes i ty

The Puerperium, Lactation, and Immediate Care of the Newborn Answers

216. The answer is d. (Speroff, pp 350-354. ) Ambi guous geni ta l i a a t bi rth i s a medi ca l emergency, not onl y for ps ychol ogi ca l rea s ons for the pa rents but a l s o beca us e hi rs ute fema l e i nfa nts wi th congeni ta l a drena l hyperpl a s i a (CAH) ma y di e i f undi a gnos ed. CAH i s a n a utos oma l l y i nheri ted di s ea s e of a drena l fa i l ure tha t ca us es hypona tremi a a nd hyperka l emi a beca us e of l a ck of mi nera l ocor coi ds . A thorough phys i ca l exa mi na on i s the bes t i ni a l eva l ua on. Whi l e i t wi l l not gi ve the defini ve di a gnos i s of the s ex, i t ca n provi de cl ues . Are the gona ds pa l pa bl e i n the i ngui na l ca na l ? Are the l a bi a fus ed? Is there a va gi na or pouch? Is there hyper- or hypotens i on, or s i gns of dehydra on. Ka ryotype, el ectrol yte a na l ys i s , bl ood or uri ne a s s a ys for proges terone, 17α-hydroxyproges terone, a nd s erum a ndrogens s uch a s dehydroepi a ndros terone s ul fa te a re es s en a l to the workup. Pel vi c ul tra s ound or MRI ca n detect ova ri es or undes cended tes tes , but tha t i s not the firs t s tep i n ma na gement. La pa rotomy or l a pa ros copy i s s ometi mes neces s a ry for ectopi c gona dectomy a fter puberty ha s occurred. 217. The answer is c. (Cunningham, pp 766-767.) A di s a dva nta ge of home del i very i s the l a ck of fa ci l i es to control pos tpa rtum hemorrha ge. The woma n des cri bed i n the ques on del i vered a l a rge ba by, s uffered mul pl e s o s s ue i njuri es , a nd went i nto s hock, needi ng 9 uni ts of bl ood by the me s he rea ched the hos pi ta l . Sheeha n s yndrome s eems a l i kel y pos s i bi l i ty i n thi s woma n. Thi s s yndrome of a nteri or pi tui ta ry necros i s rel a ted to obs tetri c hemorrha ge ca n be di a gnos ed by 1 week pos tpa rtum, a s l a cta on fa i l s to commence norma l l y. Al though ma ny modern women choos e hormona l thera py to prevent l a cta on, the woma n des cri bed i n the ques on wa s i ntent on brea s t-feedi ng a nd s o woul d not ha ve recei ved s uppre s s a nt. She therefore coul d ha ve been expected to begi n l a cta on a t the us ua l me. Other s ymptoms of Sheeha n s yndrome i ncl ude a menorrhea , a trophy of the brea s ts , a nd l os s of thyroi d a nd a drena l func on. The other pres ented choi ces for l a te s equel a e a re ra ther fa rfetched. Hemochroma tos i s woul d not be expected to occur i n thi s hea l thy young woma n, es peci a l l y s i nce s he di d not recei ve prol onged tra ns fus i ons . Cus hi ng, Si mmonds , a nd Stei n-Leventha l s yndromes a re not known to be rel a ted to pos tpa rtum hemorrha ge. It i s i mporta nt to note tha t home del i very i s not a predi s pos i ng fa ctor to pos tpa rtum hemorrha ge. 218. The answer is b. (Cunningham, pp 766, 792-794.) Thi s pa ent ha s a l a rge pl a centa l a brup on whi ch i s the mos t common ca us e of cons ump ve coa gul opa thy i n pregna ncy. The bl eedi ng des cri bed s i gni fies tha t the pa ent ha s a s i gni fica nt coa gul opa thy wi th hypofibri nogenemi a . Prompt a nd vi gorous tra ns fus i on i s needed. Pa cked red bl ood cel l s wi l l res tore bl ood vol ume a nd i ncrea s e oxygen ca rryi ng ca pa ci ty. Fres h frozen pl a s ma (FFP) conta i ns a bout 600-700 mg of fibri nogen a nd wi l l promote cl o ng. Cryopreci pi ta te conta i ns cl o ng fa ctors a nd fibri nogen but i n much l es s a mount (200 mg) tha n FFP a nd ha s no a dva nta ge over the us e of FFP i n thi s bl eedi ng pa ent. Recombi na nt fa ctor VII ca n be us ed for the trea tment of s evere obs tetri ca l hemorrha ge but wi l l not be effec ve i f fibri nogen i s l ow. Pl a tel et tra ns fus i on i s cons i dered i n bl eedi ng pa ents wi th pl a tel ets l es s tha n 50,000. 219. The answer is e. (Cunningham, pp 658-661.) Puerpera l fever from brea s t engorgement i s rel a vel y uncommon, a ffec ng 13% to 18% of pos tpa rtum women. It a ppea rs 24 to 48 hours fol l owi ng i ni a on of l a ctea l s ecre on a nd ra nges from 38°C to 39°C (100.4°F to 102.2°F). Pa i n i s a n ea rl y a nd common s ymptom. Trea tment cons i s ts of brea s t s upport, i ce pa cks , a nd pa i n rel i evers . 220. The answer is d. (Cunningham, p 650.) The norma l s equence of events tri ggered by s uckl i ng i s a s fol l ows : through a res pons e of the centra l nervous s ys tem, dopa mi ne i s decrea s ed i n the hypotha l a mus . Dopa mi ne s uppres s i on decrea s es produc on of prol a c n-i nhi bi ng fa ctor (PIF), whi ch norma l l y tra vel s through a porta l s ys tem to the pi tui ta ry gl a nd; beca us e PIF produc on i s decrea s ed, produc on of prol a c n by the pi tui ta ry i s i ncrea s ed. At thi s me, the pi tui ta ry a l s o rel ea s es oxytoci n, whi ch ca us es mi l k to be expres s ed from the a l veol i i nto the l a c ferous ducts . Suckl i ng s uppres s es the produc on of l utei ni zi ng hormone—rel ea s i ng fa ctor a nd, a s a res ul t, a cts a s a mi l d contra cep ve (beca us e the mi dcycl e s urge of l utei ni zi ng hormone does not occur). 221. The answer is c. (Cunningham, pp 1024-1027.) The pa ent mos t l i kel y ha s a pul mona ry embol i s m. The reported i nci dence of pos tpa rtum pul mona ry embol i s m (PE) i s 1 i n 2700 to 1 i n 7000. The cl a s s i c tri a d— hemoptys i s , pl euri c ches t pa i n, a nd dys pnea —a ppea rs i n onl y 20% of ca s es . The mos t common s i gn on phys i ca l exa mi na on i s ta chypnea (> 16 brea ths /mi n). Ven l a on-perfus i on s ca ns wi th l a rge perfus i on defects a nd ven l a on mi s ma tches s upport the puta ve di a gnos i s of PE, but thi s findi ng ca n a l s o be s een wi th a tel ecta s i s or other di s orders of l ung a era on. To confirm the di a gnos i s , a CT pul mona ry a ngi ogra phy i s the bes t tool . Convers el y, a norma l ven l a on-perfus i on s ca n s ugges ts tha t ma s s i ve PE i s not the e ol ogy of the cl i ni ca l s ymptoms . An a rteri a l bl ood ga s wi l l confirm hypoxi a , but not confirm PE a s the ca us e. A ches t x-ra y coul d be done to rul e out other ca us es s uch a s pul mona ry edema or pneumoni a , but wi l l not ma ke the di a gnos i s of PE. 222. The answer is e. (Cunningham, pp 667-668.) The pa ent des cri bed ha s s ep c pel vi c thrombophl ebi s (SPT). Sep c pel vi c thrombophl ebi s ma y i nvol ve ei ther the i l i ofemora l or the ova ri a n vei n but ra rel y i nvol ves both s i tes i n the s a me pa ent. Vena ca va l thrombos i s ma y fol l ow ei ther ova ri a n or i l i ofemora l phl ebi s . The cl i ni ca l pres enta on i s tha t of a pel vi c i nfec on wi th pa i n a nd fever. Fol l owi ng a n mi crobi a l thera py, cl i ni ca l s ymptoms us ua l l y res ol ve, but fever s pi kes ma y con nue. Commonl y, pa ents do not a ppea r cl i ni ca l l y i l l . The di a gnos i s i s ma de by computeri zed tomogra phy (CT) or by ma gne c res ona nce i ma gi ng (MRI). Before thes e di a gnos c moda l i es were a va i l a bl e, the hepa ri n cha l l enge tes t wa s a dvoca ted—l ys i s of fever a er i ntra venous a dmi ni s tra on of hepa ri n wa s a ccepted a s di a gnos c for pel vi c thrombophl ebi s . Hepa ri n a dmi ni s tra on i n a ddi on to a n bi o c covera ge for SPT does not ha s ten recovery or i mprove outcome. Long-term a n coa gul a on i s defini tel y not recommended. 223. The answer is e. (Cunningham, pp 655-656.) Pa ents a t hi gh ri s k for pos tpa rtum depres s i on o en ha ve hi s tori es of depres s i on or pos tpa rtum depres s i on. They a re more l i kel y to be pri mi pa rous or ol der; they ma y ha ve ha d a l ong i nterva l between pregna nci es or a n unpl a nned pregna ncy or be wi thout a s uppor ve pa rtner. Prena ta l i nterven on mus t i ncl ude the obs tetri c tea m, wi th fa mi l y or peer s upport when pos s i bl e. Pos tpa rtum depres s i on i s va ri a bl e i n dura ti on, but occa s i ona l l y wi l l not res ol ve wi thout hos pi ta l i za ti on, thera py, or medi ca ti on. 224. The answer is d. (Cunningham, pp 653-654.) Puerpera l ma s s ma y be s uba cute, but i s o en cha ra cteri zed by chi l l s , fever, a nd ta chyca rdi a . If undi a gnos ed, i t ma y progres s to s uppura ve ma s s wi th a bs ces s forma on tha t requi res dra i na ge. The mos t common offendi ng orga ni s m i s Staphylococcus aureus, whi ch i s proba bl y tra ns mi ed from the i nfa nt’s nos e a nd throa t. A cul ture of the brea s t mi l k s houl d be done pri or to i ni a on of a n bi o c thera py. Di cl oxa ci l l i n, a peni ci l l i na s e-res i s ta nt a n bi o c, i s the i ni a l trea tment of choi ce. In peni ci l l i n-a l l ergi c pa ents , erythromyci n i s recommended. Trea tment s houl d l a s t for 7 to 10 da ys . If a ma s s i s pa l pa bl e, a n a bs ces s s houl d be s us pected. Inci s i on a nd dra i na ge i s recommended for a brea s t a bs ces s . Mi l k produc on s houl d not be s uppres s ed a nd the pa ent s houl d con nue to brea s t-feed on the a ffected brea s t; i f i t i s too pa i nful s he ma y pump. After a nti bi oti c thera py i s i ni ti a ted, the pa ti ent s houl d be reeva l ua ted to ens ure i mprovement. 225. The answer is c. (Cunningham, pp 1006-1007.) The goa l of ma na gement i n the i nfa nt born to a mother wi th a c ve tubercul os i s i s preven on of ea rl y neona ta l i nfec on. Congeni ta l i nfec on, a cqui red ei ther by a hema togenous route or by a s pi ra on of i nfected a mni o c flui d, i s ra re. Mos t neona ta l i nfec ons a re a cqui red by pos tpa rtum ma terna l conta ct. The ri s k of a c ve di s ea s e duri ng the firs t yea r of l i fe ma y a pproa ch 50% i f prophyl a xi s i s not i ns tuted. BCG va cci na on a nd da i l y i s oni co ni c a ci d hydra zi de (i s oni a zi d, INH) thera py a re both a ccepta bl e mea ns of thera py. BCG va cci na ti on ma y be ea s i er beca us e i t requi res onl y one i njecti on; however, the a bi l i ty to perform future tubercul i n s ki n tes ti ng i s l os t. 226. The answer is a. (Cunningham, p 655.) Uri na ry reten on occurs i n up to 4% of women a er va gi na l del i very. Loca l a nd epi dura l a na l ges i a

di mi ni s h bl a dder s ens a on a nd i ncrea s e the ri s k of reten on. Other ri s k fa ctors i ncl ude pri mi pa ri ty, oxytoci n us e, l ong l a bors over 10 hours , peri nea l l a cera ti ons , i ns trumented del i veri es , a nd ca theri za ti on duri ng l a bor. 227. The answer is a. (Cunningham, p 652.) There a re very few contra i ndi ca ons to brea s t-feedi ng. Mos t medi ca ons ta ken by the mother enter i nto brea s t mi l k to s ome degree. Brea s t-feedi ng i s i na dvi s a bl e when the mother i s bei ng trea ted wi th a n mi to c drugs , tetra cycl i nes , di a gnos c or thera peu c ra di oa c ve s ubs ta nces , or l i thi um ca rbona te. Acute puerpera l ma s s ma y be ma na ged qui te s ucces s ful l y whi l e the mother con nues to brea s t-feed. Reduc on ma mmopl a s ty wi th a utotra ns pl a nta on of the ni ppl e s i mpl y ma kes brea s t-feedi ng i mpos s i bl e. Ampi ci l l i n or l evothyroxi ne ca n be s a fel y us ed by brea s t-feedi ng mothers . A pa s t hi s tory of hepa s B i s not a contra i ndi ca on to brea s t-feedi ng. Wi th s ome a cute vi ra l i nfecti ons s uch a s hepa ti ti s B, there i s the pos s i bi l i ty of tra ns mi tti ng the vi rus i n mi l k. 228. The answer is b. (Cunningham, pp 661-667.) Pos tpa rtum endometri ti s i s much more common a fter ces a rea n del i very a nd the i nfecti on i s commonl y pol ymi crobi a l . Fever i s the mos t common cri teri a for the di a gnos i s . Fol l owi ng va gi na l del i very the a n bi o c trea tment of choi ce i s a mpi ci l l i n a nd genta mi ci n, the s a me a s the trea tment for chori oa mni oni s . A er ces a rea n del i very, broa d-s pectrum covera ge wi th cl i nda myci n a nd genta mi ci n i s the s ta nda rd of ca re, a nd a mpi ci l l i n i s a dded to cover enterococcus i f fever pers i s ts a er 48 to 72 hours . Cl i nda myci n s houl d be us ed for the trea tment of i nfec ons a er ces a rea n del i very to provi de a na erobi c covera ge. Chl ora mpheni col a nd tetra cycl i ne a re a l terna ve choi ces for a n bi o c thera py i n nonpregna nt women; however, tetra cycl i ne-res i s ta nt s tra i ns of Bacteroides fragilis ma y be emergi ng. Li ncomyci n a nd erythromyci n ca n a l s o be effec ve i n the ma na gement of a ffected women. Tetra cycl i nes a nd fluoroqui nol ones s houl d be a voi ded i n brea s tfeedi ng women. 229. The answer is b. (Cunningham, pp 661-667.) In pa ents wi th endometri s who con nue to s pi ke fevers whi l e recei vi ng a dequa te broa d-s pectrum a n bi o c covera ge, pa ra metri a l phl egmon (pel vi c cel l ul i s ) s houl d be s us pected. In women wi th phl egmon, con nued trea tment wi th broa ds pectrum a n bi o cs us ua l l y res ul ts i n cl i ni ca l i mprovement. Mos t a re a febri l e i n 5 to 7 da ys . CT i ma gi ng ca n be done to rul e out pel vi c a bs ces s es whi ch i f pres ent s houl d be dra i ned. Bl a dder fla p hema toma s a re commonl y i den fied on i ma gi ng a er ces a rea n del i very a nd requi re no trea tment unl es s a bs ces s i s s us pected. Hys terectomy i s res erved for women i n whom uteri ne necros i s i s s us pected. IV hepa ri n ha s been us ed by s ome a s a trea tment a l ong wi th a nti bi oti cs for s epti c pel vi c thrombophl ebi ti s , however i t does not ha s ten or i mprove recovery.

Add a mpi ci l l i n i f s eps i s or s us pected enterococca l i nfecti on 230. The answer is e. (Cunningham, p 648.) Bl oody l ochi a ca n pers i s t for up to 2 weeks wi thout i ndi ca ng a n underl yi ng pa thol ogy; however, i f bl eedi ng con nues beyond 2 weeks , i t ma y i ndi ca te pl a centa l s i te s ubi nvol u on, reten on of s ma l l pl a centa l fra gments , or both. At thi s poi nt, a ppropri a te di a gnos c a nd thera peu c mea s ures s houl d be i ni a ted. The phys i ci a n s houl d firs t es ma te the bl ood l os s a nd then perform a pel vi c exa mi na on i n s ea rch of uteri ne s ubi nvol u on or tendernes s . Exces s i ve bl eedi ng or tendernes s s houl d l ea d the phys i ci a n to s us pect reta i ned pl a centa l fra gments or endometri ti s . A l a rger tha n expected but otherwi s e a s ymptoma ti c uterus s upports the di a gnos i s of s ubi nvol uti on. 231. The answer is e. (Cunningham, p 648.) Uteri ne hemorrha ge a er the firs t pos tpa rtum week i s mos t o en the res ul t of reta i ned pl a centa l fra gments or s ubi nvol u on of the pl a centa l s i te. Cure a ge ma y do more ha rm tha n benefit by s mul a ng i ncrea s ed bl eedi ng. Ini a l thera py s houl d be a i med a t decrea s i ng the bl eedi ng by s mul a ng uteri ne contra c ons wi th the us e of Pi toci n, Methergi ne, or Ergotra te. Pros ta gl a ndi ns coul d a l s o be us ed i n thi s s etti ng. 232. The answer is b. (Cunningham, pp 780-782.) Thi s pa ent ha s a uteri ne i nvers i on. Summon a s s i s ta nce i mmedi a tel y, i ncl udi ng a n a nes thes i ol ogi s t. Ens ure tha t the pa ent ha s a dequa te IV a cces s a nd tha t bl ood i s a va i l a bl e i f needed. If a a ched, the pl a centa i s not removed un l the i nfus i on s ys tems a re opera ona l , flui ds a re bei ng gi ven, a nd a nes thes i a (prefera bl y ha l otha ne) ha s been a dmi ni s tered. To remove the pl a centa before thi s me i ncrea s es hemorrha ge. As s oon a s the uterus i s res tored to i ts norma l configura on, the a nes the c a gent us ed to provi de rel a xa on i s s topped a nd s i mul ta neous l y oxytoci n i s s ta rted to contra ct the uterus . 233. The answer is c. (Cunningham, pp 666-667.) Wi th a ppropri a te a n bi o c covera ge, mos t pa ents wi th endometri s a re a febri l e i n 5 to 7 da ys . Hys terectomy i s us ua l l y res erved for women who ha ve necros i s of the uteri ne i nci s i on typi ca l l y depi cted by ga s wi thi n the myometri um on i ma gi ng s tudi es . Percuta neous dra i na ge s houl d be a empted for pel vi c a bs ces s es . Si gns of s eps i s woul d be concerni ng, but firs t l i ne of trea tment woul d be s upporti ve ca re a nd a nti bi oti cs . A women des i re for s teri l i za ti on a l one s houl d not be the deci di ng fa ctor for hys terectomy i n thi s pa ti ent. 234. The answer is d. (Cunningham, pp 661-668.) Metri s , or i nfec on of the uterus , i s the mos t common i nfec on tha t occurs a er a ces a rea n s ec on. A l ong l a bor a nd prol onged rupture of membra nes a re predi s pos i ng fa ctors for metri s . In the pres ence of a pel vi c a bs ces s , us ua l l y s i gns of peri tonea l i rri ta on s uch a s rebound tendernes s , i l eus , a nd decrea s ed bowel s ounds a re pres ent. Wound i nfec ons occur wi th a n i nci dence of a bout 6% fol l owi ng ces a rea n del i veri es . Fever us ua l l y begi ns on the fourth or fi h pos topera ve da y, a nd erythema a round the i nci s i on a l ong wi th pus dra i na ge i s o en pres ent. In the ca s e of a wound i nfec on, firs t-l i ne trea tment i nvol ves dra i ni ng the i nci s i on. Atel ecta s i s ca n be a ca us e of pos topera ve fever, but the fever occurs genera l l y i n the firs t 24 hours . In a ddi on, on phys i ca l exa mi na on, a tel ecta s i s i s genera l l y a ccompa ni ed by decrea s ed brea th s ounds a t the l ung ba s es on a us cul ta on. It more commonl y occurs i n women who ha ve ha d genera l a nes thes i a , not a n epi dura l l i ke the pa ent des cri bed here. Sep c pel vi c thrombophl ebi s occurs uncommonl y a s a s equel a of pel vi c i nfec on. Venous s ta s i s occurs i n di l a ted pel vi c vei ns ; i n the pres ence of ba cteri a , i t ca n l ea d to s ep c thrombos es . Di a gnos i s i s us ua l l y ma de when pers i s tent fever s pi kes occur a fter trea tment for metri ti s . The pa ti ent us ua l l y ha s no uteri ne tendernes s , a nd bowel functi on tends to be norma l . 235. The answer is e. (Cunningham, pp 661-665.) The e ol ogy of metri s , l i ke tha t of a l l pel vi c i nfec ons , i s pol ymi crobi a l . Therefore, the a n bi o c covera ge s el ected s houl d trea t a erobi c a nd a na erobi c orga ni s ms . Common a erobes a s s oci a ted wi th metri s a re s ta phyl ococci , s treptococci , enterococci , E coli, Proteus, a nd Klebsiella. The a na erobi c orga ni s ms a s s oci a ted wi th pel vi c i nfec ons a re mos t commonl y Bacteroides, Peptococcus, Peptostreptococcus, a nd Clostridium. Genera l l y, a broa d-s pectrum a n bi o c, s uch a s the cepha l os pori ns cefoteta n or cefoxi n, i s a dmi ni s tered i ntra venous l y. The a n bi o c thera py i s genera l l y con nued un l the pa ent ha s been a febri l e for a t l ea s t 24 hours . Ba ctri m i s a s ul fa drug tha t i s commonl y gi ven ora l l y to trea t uncompl i ca ted uri na ry tra ct i nfec ons . Di cl oxa ci l l i n i s commonl y us ed ora l l y to trea t women wi th ma s s beca us e i t ha s good covera ge a ga i ns t S aureus, whi ch i s the mos t common orga ni s m res pons i bl e for thi s i nfec on. Ci profloxa ci n, a qui nol one, i s us eful i n the trea tment of compl i ca ted uri na ry tra ct i nfec ons . Thi s medi ca on i s not recommended for pregna nt or l a cta ng women beca us e a ni ma l s tudi es s how a n a s s oci a ti on of fl uoroqui nol ones wi th i rrevers i bl e a rthropa thy. 236. The answer is a. (Cunningham, pp 655-658.) Thi s pa ent i s exhi bi ng cl a s s i c s ymptoms of pos tpa rtum depres s i on. Pos tpa rtum depres s i on

devel ops i n a bout 8% to 15% of women a nd genera l l y i s cha ra cteri zed by a n ons et a bout 2 weeks to 12 months pos tdel i very a nd a n a vera ge dura on of 3 to 14 months . Women wi th pos tpa rtum depres s i on ha ve the fol l owi ng s ymptoms : i rri ta bi l i ty, l a bi l e mood, di fficul ty s l eepi ng, phobi a s , a nd a nxi ety. About 50% of women experi ence pos tpa rtum bl ues , or ma terni ty bl ues , wi thi n 3 to 6 da ys a er del i veri ng. Thi s mood di s turba nce i s thought to be preci pi ta ted by proges terone wi thdra wa l fol l owi ng del i very a nd us ua l l y res ol ves i n 10 da ys . Ma terni ty bl ues i s cha ra cteri zed by mi l d i ns omni a , tea rful nes s , fa gue, i rri ta bi l i ty, poor concentra on, a nd depres s ed a ffect. Pos tpa rtum ps ychos i s us ua l l y ha s i ts ons et wi thi n a few da ys of del i very a nd i s cha ra cteri zed by confus i on, di s ori enta on, a nd l os s of touch wi th rea l i ty. Pos tpa rtum ps ychos i s i s very ra re a nd occurs i n onl y 1 to 4 i n 1000 bi rths . Bi pol a r di s order or ma ni c-depres s i ve i l l nes s i s a ps ychi a tri c di s order cha ra cteri zed by epi s odes of depres s i on fol l owed by ma ni a . 237. The answer is a. (Cunningham, p 655.) Women experi enci ng pos tpa rtum bl ues us ua l l y do fine wi th rea s s ura nce a l one, beca us e thi s condi on us ua l l y res ol ves s ponta neous l y i n a s hort peri od of me. Women wi th pos tpa rtum depres s i on need referra l to a ps ychi a tri s t who ca n a dmi ni s ter ps ychothera py a nd pres cri be a n depres s a nts . Ha l dol i s a n a n ps ycho c tha t mi ght be a dmi ni s tered i n the trea tment of pos tpa rtum ps ychos i s . Sl eep a i ds a re not recommended. El ectroconvul s i ve thera py woul d be us ed to trea t depres s i on onl y i f a pa ent were unres pons i ve to pha rma col ogi c thera py. 238. The answer is d. (Cunningham, pp 601-602.) The Ameri ca n Aca demy of Pedi a tri cs a nd the Ameri ca n Col l ege of Obs tetri cs a nd Gynecol ogy do not recommend tha t rou ne ci rcumci s i on procedures be performed on newborn ma l e i nfa nts . It i s genera l l y a greed tha t ci rcumci s i on res ul ts i n a decrea s ed i nci dence of peni l e ca ncer, but there a re no wel l -des i gned s tudi es tha t i ndi ca te tha t ci rcumci s i on res ul ts i n a decrea s ed i nci dence of uri na ry tra ct i nfec ons i n ba bi es or a decrea s ed i nci dence of s exua l l y tra ns mi ed di s ea s es . When performed by a n experi enced pers on on a hea l thy, s ta bl e i nfa nt, ci rcumci s i ons a re genera l l y s a fe procedures , a l though poten a l compl i ca ons i ncl ude i nfec on a nd bl eedi ng. Pa rents s houl d di s cus s the ri s ks a nd benefi ts of the procedure a nd obta i n i nformed cons ent. 239. The answer is d. (Cunningham, p 602.) Ana l ges i a s houl d a l wa ys be provi ded to a newborn undergoi ng a ci rcumci s i on procedure, beca us e much evi dence s ugges ts tha t i nfa nts who undergo thi s procedure wi thout pa i n medi ci ne experi ence pa i n a nd s tres s . The a dmi ni s tra on of ora l Tyl enol or s ucros e i s not a dequa te for opera ve pa i n rel i ef. Topi ca l l i doca i ne crea m, dors a l peni l e nerve bl ock, a nd s ubcuta neous ri ng bl ock a re a l l effecti ve a nd s a fe moda l i ti es to a chi eve a na l ges i a i n newborns undergoi ng a ci rcumci s i on procedure. 240. The answer is d. (Cunningham, pp 598-599.) An es ma te of the ges ta ona l a ge of a newborn ca n be ma de ra pi dl y by a phys i ca l exa mi na on i mmedi a tel y fol l owi ng del i very. Importa nt phys i ca l cha ra cteri s cs tha t a re eva l ua ted a re the s ol e crea s es , brea s t nodul es , s ca l p ha i r, ea rl obes , a nd s crotum. In newborns who a re 39 weeks ges ta ti ona l a ge or more, the s ol es of the feet wi l l be covered wi th crea s es , the di a meter of the brea s t nodul es wi l l be a t l ea s t 7 mm, the s ca l p ha i r wi l l be coa rs e a nd s i l ky, the ea rl obes wi l l be thi ckened wi th ca r l a ge, a nd the s crotum wi l l be ful l wi th extens i ve ruga e. In i nfa nts tha t a re 36 weeks or l es s , there wi l l be a n a nteri or tra ns vers e s ol e crea s e onl y, the brea s t nodul e di a meter wi l l be 2 mm, the s ca l p ha i r wi l l be fine a nd fuzzy, the ea rl obes wi l l be pl i a bl e a nd l a ck ca r l a ge, a nd the s crotum wi l l be s ma l l wi th few ruga e. In i nfa nts of ges ta ona l a ge between 37 a nd 38 weeks , the s ol es of the feet wi l l ha ve occa s i ona l crea s es on the a nteri or two-thi rds of the feet, the brea s t nodul e di a meter wi l l be 4 mm, the s ca l p ha i r wi l l be fine a nd fuzzy, the ea rl obes wi l l ha ve a s ma l l a mount of ca r l a ge, a nd the s crotum wi l l ha ve s ome but not extens i ve ruga e. 241. The answer is b. (Cunningham, pp 594-595.) The Apga r s cori ng s ys tem, a ppl i ed a t 1 mi nute a nd a ga i n a t 5 mi nutes , wa s devel oped a s a n a i d to eva l ua te i nfa nts who requi re res us ci ta on. Hea rt ra te, res pi ra tory effort, mus cl e tone, reflex, i rri ta bi l i ty, a nd col or a re the five components of the Apga r s core. A s core of 0, 1, or 2 i s gi ven for ea ch of the five components , a nd the tota l i s a dded up to gi ve one s core. The ta bl e bel ow demons tra tes the s cori ng s ys tem.

The ba by des cri bed here recei ves a n Apga r s core of 9. One poi nt i s deducted for the ba by not bei ng compl etel y pi nk a nd ha vi ng bl ue extremi ti es . 242. The answer is a. (Cunningham, pp 595-598.) The bl ood ga s res ul ts des cri bed i n thi s ca s e a re norma l . Norma l va l ues for umbi l i ca l a rteri a l s a mpl es a re pH 7.25 to 7.3, Pco 2 50 mm Hg, Po 2 20 mm Hg, a nd bi ca rbona te 25 mEq. Aci demi a i s genera l l y defined a s a pH l es s tha n 7.20. Bi rth a s phyxi a genera l l y refers to hypoxi c i njury s o s evere tha t the umbi l i ca l a rtery pH i s l es s tha n 7.0, a pers i s tent Apga r s core i s between 0 a nd 3 for more tha n 5 mi nutes , neona ta l s equel a e exi s t s uch a s s ei zures or coma , a nd there i s mul ti orga n dys functi on. 243. The answer is c. (Cunningham, p 598.) The Centers for Di s ea s e Control recommends tha t a l l newborns recei ve rou ne i mmuni za on a ga i ns t hepa s B pri or to bei ng di s cha rged from the hos pi ta l . Onl y i f the mother i s pos i ve for hepa s B s urfa ce a n gen s houl d the neona te a l s o be pa s s i vel y i mmuni zed wi th hepa s B i mmune gl obul i n. Accordi ng to the Centers for Di s ea s e Control , a l l newborns s houl d recei ve eye prophyl a xi s a ga i ns t chl a mydi a a nd gonorrhea wi th ei ther s i l ver ni tra te, erythromyci n ophtha l mi c oi ntment, or tetra cycl i ne ophtha l mi c oi ntment. Vi ta mi n K i s rou nel y a dmi ni s tered to prevent hemorrha gi c di s ea s e of the newborn; brea s t mi l k conta i ns onl y very s ma l l a mounts of vi ta mi n K. Si nce the tempera ture of newborns drops very ra pi dl y a er bi rth, newl y del i vered i nfa nts mus t be moni tored i n a wa rm cri b. Al l i nfa nts mus t be a ccura tel y i denti fi ed vi a i denti fi ca ti on ba nds . 244. The answer is b. (Cunningham, pp 649-652.) Accordi ng to the Ameri ca n Aca demy of Pedi a tri cs , s ome of the benefits of nurs i ng i ncl ude a decrea s e i n i nfa nt di a rrhea , uri na ry tra ct i nfec ons , ea r i nfec ons , a nd dea th from s udden i nfa nt dea th s yndrome. Huma n mi l k i s i dea l food for neona tes . It provi des s peci es - a nd a ge-s peci fic nutri ents for the ba by. It ha s i mmunol ogi ca l fa ctors a nd a n ba cteri a l proper es a nd conta i ns fa ctors tha t a ct a s bi ol ogi ca l s i gna l s to promote cel l ul a r growth. Brea s t-feedi ng ca n del a y the res umpti on of ovul a ti on a nd mens es .

245. The answer is a. (Cunningham, p 652.) About 40% of women el ect not to brea s t-feed. Thes e women experi ence mi l k l ea ka ge, engorgement, a nd brea s t pa i n tha t begi ns 3 to 5 da ys pos tpa rtum. Ice pa cks a ppl i ed to the brea s ts , a wel l -fi ng bra or bi nder, a nd a na l ges i cs a re a l l a ppropri a te methods to ma na ge engorged brea s ts . Bromocri p ne, a drug us ed to l ower prol a c n l evel s a nd s uppres s l a cta on, i s no l onger recommended i n pos tpa rtum women beca us e thi s medi ca on bei ng a s s oci a ted wi th a n i ncrea s ed ri s k of s troke, myoca rdi a l i nfa rc ons , s ei zures , a nd ps ychi a tri c di s turba nces . 246. The answer is d. (Cunningham, p 652.) Us e of a n IUD, ba rri er methods , a nd hormona l contra cep ve a gents conta i ni ng onl y proges ns a re a l l a ppropri a te methods of bi rth control for brea s t-feedi ng women. It i s bes t for nurs i ng mothers to a voi d es trogen-conta i ni ng contra cepti ves beca us e es trogen prepa ra ti ons ca n i nhi bi t l a cta ti on or decrea s e mi l k s uppl y. 247. The answer is d. (Cunningham, p 658.) Coi tus ca n be pa i nful i n brea s t-feedi ng women beca us e of a n i ncrea s e i n va gi na l drynes s tha t i s ca us ed by a n a s s oci a ted hypoes trogeni s m. Wa ter-s ol ubl e l ubri ca nts or es trogen crea m a ppl i ed topi ca l l y to the va gi na l mucos a ca n be hel pful . In a ddi on, the fema l e s uperi or pos i on ma y be recommended duri ng i ntercours e s o tha t the woma n ca n control the depth of peni l e penetra on. Tes tos terone crea m i s not us ed for the trea tment of va gi na l a trophy. 248. The answer is c. (Cunningham, pp 646-648.) The uterus a chi eves i ts previ ous nonpregna nt s i ze by a bout 4 weeks pos tpa rtum. Subi nvol u on (ces s a on of the norma l i nvol u on) of the uterus ca n occur i n ca s es of reta i ned pl a centa or uteri ne i nfec on. In s uch ca s es , the uterus i s l a rger a nd s o er tha n i t s houl d be on bi ma nua l exa mi na on. In a ddi on, the pa ent us ua l l y experi ences prol onged di s cha rge a nd exces s i ve uteri ne bl eedi ng. Wi th endometri s , the pa ent wi l l a l s o ha ve a tender uterus on exa mi na on, a nd wi l l compl a i n of fever a nd chi l l s . In a denomyos i s , por ons of the endometri a l l i ni ng grow i nto the myometri um, ca us i ng menorrha gi a a nd dys menorrhea . On phys i ca l exa mi na on, the uterus i s us ua l l y tender to pa l pa on, boggy, a nd s ymmetri ca l l y enl a rged. The pa ent des cri bed here ha s a phys i ca l exa mi na on mos t cons i s tent wi th fi broi ds . Uteri ne l ei omyoma s woul d ca us e the uterus to be fi rm, i rregul a r, a nd enl a rged. 249 and 250. The answers are 249-c, 250-e. (Cunningham, p 665.) The i nci dence of i nci s i ona l wound i nfec on fol l owi ng ces a rea n del i very i s a pproxi ma tel y 6%. Ri s k fa ctors tha t predi s pos e to wound i nfec ons i ncl ude obes i ty, di a betes , cor cos teroi d thera py, a nemi a , poor hemos ta s i s , a nd i mmunos uppres s i on. Obes i ty confers the hi ghes t ri s k. The us e of preopera ve prophyl a c c a n bi o cs decrea s es the i nci dence of wound i nfec on to a bout 2%. Us ua l l y, i nci s i ona l a bs ces s es wi l l ca us e a fever a bout pos topera ve da y 4, a nd erythema , i ndura on, a nd dra i na ge from the i nci s i on a re a l s o frequentl y noted. Openi ng of the i nci s i on a nd s urgi ca l dra i na ge a re key to curi ng the i nfec on. Broa d-s pectrum a n mi crobi a l a gents a re a l s o a dmi ni s tered. In a l l ca s es of wound i nfec on, the i nci s i on mus t be probed to rul e out a wound dehi s cence (s epa ra on of the wound i nvol vi ng the fa s ci a l l a yer). As l ong a s the fa s ci a l l a yer i s i nta ct, the open wound i s kept cl ea n a nd a l l owed to hea l by s econda ry i ntenti on.

Gynecology

Preventive Care and Health Maintenance Questions 251. A 71-yea r-ol d G2P2 pres ents to your gynecol ogy office for a rou ne exa mi na on. She s a ys s he i s very hea l thy a nd deni es ta ki ng a ny medi ca on. She ha s no hi s tory of a bnorma l Pa p s mea rs a nd ha s onl y ha d one s exua l pa rtner i n her l i fe me. She i s a nons moker a nd ha s a n occa s i ona l cockta i l wi th her di nner. She does not ha ve a ny compl a i nts . In a ddi on, s he deni es a ny fa mi l y hi s tory of ca ncer. The pa ent tel l s you tha t s he i s a wi dow a nd l i ves a l one i n a n a pa rtment i n town. Her grown chi l dren ha ve fa mi l i es of thei r own a nd l i ve fa r a wa y. She s ta tes tha t s he i s s el f-s uffici ent a nd s pends her me vi s i ng fri ends a nd vol unteeri ng a t a l oca l mus eum. Her bl ood pres s ure i s 140/70 mm Hg. Her hei ght i s 5 4 i n a nd s he wei ghs 130 l b. Whi ch of the fol l owi ng a re the mos t a ppropri a te s creeni ng tes ts to order for thi s pa ti ent? a . Pa p s mea r a nd ma mmogra m b. Pa p s mea r, ma mmogra m, a nd col onos copy c. Ma mmogra m, col onos copy, a nd bone dens i tometry d. Ma mmogra m, col onos copy, bone dens i tometry, a nd TB s ki n tes t e. Ma mmogra m, col onos copy, bone dens i tometry, TB s ki n tes t, a nd a udi tory tes ti ng 252. A 72-yea r-ol d G5P5 pres ents to your office for wel l -woma n exa mi na on. Her l a s t exa mi na on wa s 7 yea rs a go, when s he turned 65. She ha s rou ne checks a nd l a bora tory tes ts wi th her i nterni s t ea ch yea r. Her l a s t ma mmogra m wa s 6 months a go a nd wa s norma l . She ta kes a di ure c for hypertens i on. She i s a re red s chool tea cher. Her phys i ca l exa mi na on i s norma l . Whi ch of the fol l owi ng i s the bes t va cci na on to recommend for thi s pa ti ent? a . Di phtheri a -pertus s i s b. Hepa ti ti s B va cci ne c. Infl uenza va cci ne d. Mea s l es -mumps -rubel l a e. Pneumocys ti s 253. A 65-yea r-ol d G3P3 pres ents to your office for a nnua l checkup. She ha d her l a s t wel l -woma n exa mi na on 20 yea rs a go when s he ha d a hys terectomy for fibroi ds . She deni es a ny medi ca l probl ems , except s ome occa s i ona l s ffnes s i n her joi nts ea rl y i n the morni ng. She ta kes a mul vi ta mi n da i l y. Her fa mi l y hi s tory i s s i gni fica nt for ca rdi a c di s ea s e i n both her pa rents a nd brea s t ca ncer i n a ma terna l a unt a t the a ge of 42 yea rs . Her phys i ca l exa mi na ti on i s norma l . Whi ch of the fol l owi ng i s the mos t a ppropri a te s et of l a bora tory tes ts to order for thi s pa ti ent? a . Li pi d profi l e a nd fa s ti ng bl ood s uga r b. Li pi d profi l e, fa s ti ng bl ood s uga r, a nd TSH c. Li pi d profi l e, fa s ti ng bl ood s uga r, TSH, a nd CA-125 d. Li pi d profi l e, fa s ti ng bl ood s uga r, TSH, a nd uri na l ys i s e. Li pi d profi l e, fa s ti ng bl ood s uga r, TSH, uri na l ys i s , a nd CA-125 254. You a re fol l owi ng up on the res ul ts of rou ne tes ng of a 68-yea r-ol d G4P3 for her wel l -woma n exa mi na on. Her phys i ca l exa mi na on wa s norma l for a pos tmenopa us a l woma n. Her Pa p s mea r revea l ed pa ra ba s a l cel l s , her ma mmogra m wa s norma l , l i pi d profil e wa s norma l , a nd the uri na l ys i s s hows hema turi a . Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent? a . Col pos copy. b. Endometri a l bi ops y. c. Rena l s onogra m. d. Uri ne cul ture. e. No further trea tment/eva l ua ti on i s neces s a ry i f the pa ti ent i s a s ymptoma ti c. 255. A 74-yea r-ol d woma n pres ents to your office for wel l -woma n exa mi na on. Her l a s t Pa p s mea r a nd ma mmogra m were 3 yea rs a go. She ha s hypertens i on, hi gh chol es terol , a nd os teoa rthri s . She s topped s moki ng 15 yea rs a go, a nd deni es a l cohol us e. Ba s ed on thi s pa ent’s hi s tory whi ch of the fol l owi ng medi ca l condi ti ons s houl d be thi s pa ti ent’s bi gges t concern? a . Al zhei mer di s ea s e b. Brea s t ca ncer c. Cerebrova s cul a r di s ea s e d. Hea rt di s ea s e e. Lung ca ncer f. Tra uma 256. A 21-yea r-ol d G0 fema l e pres ents to your office for a rou ne a nnua l gynecol ogi c exa mi na on. She reports tha t s he ha s previ ous l y been s exua l l y a c ve, but currentl y i s not da ng a nyone. She ha s ha d three s exua l pa rtners i n the pa s t a nd s a ys s he di l i gentl y us ed condoms . She i s a s eni or i n col l ege a nd i s doi ng wel l a ca demi ca l l y a nd ha s ma ny fri ends . She l i ves a t home wi th her pa rents a nd a younger s i bl i ng. She deni es a ny fa mi l y hi s tory of medi ca l probl ems , but s a ys her 80-yea r-ol d gra ndmother wa s recentl y di a gnos ed wi th brea s t ca ncer. She deni es a ny other fa mi l y hi s tory of ca ncer. She s a ys s he i s hea l thy a nd ha s no hi s tory of medi ca l probl ems or s urgeri es . She reports ha vi ng ha d chi cken pox. She s mokes toba cco a nd dri nks beer occa s i ona l l y, but deni es a ny i l l i ci t drug us e. Her mens es s ta rted a t a ge 13 a nd a re regul a r a nd l i ght. She deni es a ny dys menorrhea . Her bl ood pres s ure i s 90/60 mm Hg. Her hei ght i s 5 6 i n a nd s he wei ghs 130 l b. Ba s ed on thi s pa ent’s hi s tory, wha t woul d be the mos t l i kel y ca us e of dea th i f s he were to di e a t a ge 21? a . Sui ci de b. Homi ci de c. Motor vehi cl e a cci dents d. Ca ncer e. Hea rt di s ea s e 257. A 17-yea r-ol d G1P1 pres ents to your office for her yea rl y wel l -woma n exa mi na on. She ha d a n uncompl i ca ted va gi na l del i very l a s t yea r. She

ha s been s exua l l y a c ve for the pa s t 4 yea rs a nd ha s ha d four di fferent s exua l pa rtners , but ha s been mona gomous i n the l a s t yea r wi th the s a me pa rtner. Her mens es occurs every 28 da ys a nd l a s ts for 4 da ys . She deni es a ny i ntermens trua l s po ng, pos tcoi ta l bl eedi ng, or va gi na l di s cha rge. She deni es toba cco, a l cohol , or i l l i ci t drug us e. Whi ch of the fol l owi ng a re a ppropri a te s creeni ng tes ts for thi s pa ti ent? a . Gonorrhea a nd chl a mydi a s creeni ng b. Gonorrhea , chl a mydi a , a nd cervi ca l ca ncer s creeni ng c. Gonorrhea , chl a mydi a , a nd s yphi l i s s creeni ng d. Gonorrhea , chl a mydi a , hepa ti ti s B, hepa ti ti s C, a nd s yphi l i s s creeni ng e. Gonorrhea , chl a mydi a , hepa ti ti s B, hepa ti ti s C, herpes s i mpl ex a nd s yphi l i s 258. A 15-yea r-ol d woma n pres ents to your office for her rou ne phys i ca l exa mi na on whi l e s he i s on s ummer brea k from s chool . She deni es a ny medi ca l probl ems or pri or s urgeri es . She ha d chi cken pox a t a ge 4. Her mens es s ta rted a t the a ge of 12 a nd a re regul a r. She ha s recentl y become s exua l l y a c ve wi th her 16-yea r-ol d boyfri end. She s ta tes tha t they us e condoms for contra cep on. Her phys i ca l exa mi na on i s norma l . Whi ch of the fol l owi ng va cci nes i s a ppropri a te to a dmi ni s ter to thi s pa ti ent? a . Hepa ti ti s A va cci ne b. Huma n pa pi l l oma vi rus va cci ne c. Meni ngococca l va cci ne d. Pneumococca l va cci ne e. Va ri cel l a va cci ne 259. A 26-yea r-ol d woma n pres ents to your office for her wel l -woma n exa mi na on. She deni es a ny medi ca l probl ems or pri or s urgeri es . She s ta tes tha t her cycl es a re monthl y. She i s s exua l l y a c ve a nd us es ora l contra cep ve pi l l s for bi rth control . Her phys i ca l exa mi na on i s norma l . She reports tha t her 43-yea r-ol d pa terna l a unt wa s recentl y di a gnos ed wi th brea s t ca ncer a nd i s undergoi ng trea tment. She reports tha t her pa terna l gra ndmother di ed from ova ri a n ca ncer a t the a ge of 75. She wa nts gene c tes ng (BRCA) for brea s t a nd ova ri a n ca ncer. Whi ch of the fol l owi ng s ta tements rega rdi ng geneti c tes ti ng for brea s t a nd ova ri a n ca ncer i s true? a . Al l fema l e rel a ti ves of a n i ndi vi dua l wi th brea s t ca ncer s houl d undergo geneti c tes ti ng. b. Geneti c tes ti ng detects a l l germl i ne muta ti ons a s s oci a ted wi th the BRCA1 a nd BRCA2. c. Geneti c tes ti ng i s onl y recommended for i ndi vi dua l s wi th a ffected i ndi vi dua l s on the ma terna l s i de of the fa mi l y. d. Mos t ca s es of brea s t ca ncer a re due to germl i ne muta ti ons i n BRCA1 a nd BRCA2. e. When pos s i bl e, the geneti c tes ti ng s houl d begi n wi th the pers on who ha s ova ri a n ca ncer or ea rl y on-s et brea s t ca ncer. 260. A 21-yea r-ol d woma n pres ents to your office for wel l women exa mi na on a nd s creeni ng for s exua l l y tra ns mi ed i nfec ons . Her mens es s ta rted a t the a ge of 13 a nd a re regul a r. She i s currentl y s exua l l y a c ve wi th her 20-yea r-ol d boyfri end a nd ha s ha d 3 s exua l pa rtners i n her l i feti me. She us es Depo-Provera a nd condoms for contra cepti on. She ha s a hi s tory of a s thma , for whi ch s he us es a n i nha l er a s needed. She deni es a ny pri or s urgeri es . Her fa mi l y hi s tory i s s i gni fica nt for hypertens i on, hi gh chol es terol a nd hea rt di s ea s e i n her fa ther, a ge 48. She wei ghs 125 l b a nd i s normotens i ve. Bes i des s creeni ng for cervi ca l ca ncer a nd s exua l l y tra ns mi ed i nfec ons , wha t other rou ne s creeni ng s houl d be done for her a t thi s vi s i t? a . Bone mi nera l dens i ty b. Hemogl obi n A1c c. Li pi d profi l e d. Thyroi d s ti mul a ti ng hormone e. Uri na l ys i s 261. A ma rri ed 41-yea r-ol d G5P3114 pres ents to your office for a rou ne exa mi na on. She reports bei ng hea l thy except for a hi s tory of mi gra i ne hea da ches . Al l her Pa p s mea rs ha ve been norma l . She devel oped ges ta ona l di a betes i n her l a s t pregna ncy. She dri nks a l cohol s oci a l l y, a nd a dmi ts to s moki ng occa s i ona l l y. Her gra ndmother wa s di a gnos ed wi th ova ri a n ca ncer when s he wa s i n her fi i es . Her bl ood pres s ure i s 140/90 mm Hg; hei ght i s 5 ft 5 i n; wei ght i s 150 l b. Whi ch of the fol l owi ng i s the mos t common ca us e of dea th i n women of thi s pa ti ent’s a ge? a . HIV b. Ca rdi a c di s ea s e c. Acci dents d. Sui ci de e. Ca ncer 262. A 44-yea r-ol d G6P3215 pres ents for her wel l -woma n exa mi na on. She tel l s you tha t a l l of her del i veri es were va gi na l a nd tha t her l a rges t chi l d wei ghed 2900 g a t bi rth. How ma ny ful l -term pregna nci es di d thi s pa ti ent ha ve? a. 1 b. 2 c. 3 d. 5 e. 6 263. A 40-yea r-ol d G3P2012 pres ents for her wel l -woma n exa mi na on, her l a s t Pa p s mea r a nd vi s i t to a doctor wa s 5 yea rs a go. She ha s ha d two va gi na l del i veri es a nd her l a rges t ba by wei ghed 4000 g. She deni es a ny current medi ca l probl ems but ha d a hi s tory of ges ta ona l di a betes i n her l a s t pregna ncy. She ha d a pos tpa rtum bi l a tera l tuba l l i ga on. Her mens trua l cycl es a re regul a r every 28 da ys a nd l a s t 5 da ys . She i s s exua l l y a c ve i n a monoga mous rel a ons hi p wi th her hus ba nd of 16 yea rs . She s ta tes tha t wi th cough s he ma y occa s i ona l l y l os e s ome uri ne; otherwi s e s he ha s no compl a i nts . On exa mi na on s he wei ghs 90 kg a nd her bl ood pres s ure i s 132/81 mm Hg. Her brea s t a nd pel vi c exa mi na ons a re norma l . Wha t a re the mos t a ppropri a te s creeni ng tes ts for thi s pa ti ent? a . Pa p s mea r, gonorrhea , chl a mydi a tes ti ng b. Pa p s mea r, fa s ti ng gl ucos e, l i pi d profi l e c. Pa p s mea r, fa s ti ng gl ucos e, l i pi d profi l e, uri na l ys i s d. Pa p s mea r, fa s ti ng gl ucos e, l i pi d profi l e, TSH, uri na l ys i s e. Pa p s mea r, fa s ti ng gl ucos e, l i pi d profi l e, ma mmogra m, uri na l ys i s 264. A 36-yea r-ol d G2P2 pres ents for her wel l -woma n exa mi na on. She ha s ha d two s ponta neous va gi na l del i veri es wi thout compl i ca ons . Her l a rges t chi l d wei ghed 3500 g a t bi rth. She us es ora l contra cep ve pi l l s a nd deni es a ny hi s tory of a n a bnorma l Pa p s mea r. She does not s moke, but dri nks a bout four mes per week. Her wei ght i s 70 kg. Her vi ta l s i gns a re norma l . A er pl a cement of the s pecul um, you note a cl ea r cys t

a pproxi ma tel y 2.5 cm i n s i ze on the l a tera l wa l l of the va gi na on the ri ght s i de. The cys t i s nontender a nd does not ca us e the pa ent a ny dys pa reuni a or di s comfort. Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s of thi s ma s s ? a . Ba rthol i n duct cys t b. Ga rtner duct cys t c. Li poma d. Hema toma e. Incl us i on cys t 265. A 50-yea r-ol d G4P4 pres ents for her wel l -woma n exa mi na on. She ha d one ces a rea n del i very fol l owed by three va gi na l del i veri es . Her mens es s topped 1 yea r a go a nd s he occa s i ona l l y s l l ha s a hot fla s h. She tel l s you tha t a bout 10 yea rs a go s he wa s trea ted wi th a l a s er coni za on for ca rci noma i n s i tu of her cervi x. Si nce tha t me, a l l of her Pa p tes ts ha ve been norma l . Wha t recommenda on s houl d you ma ke rega rdi ng how frequentl y s he s houl d undergo Pa p s mea r tes ti ng? a . Every 3 months b. Every 6 months c. Every yea r d. Every 2 yea rs e. Every 3 yea rs 266. A 45-yea r-ol d G3P3 pres ents for her yea rl y exa mi na on. She l a s t s a w a doctor 7 yea rs a go a er s he ha d her l a s t chi l d. She ha d three va gi na l del i veri es , the l a s t of whi ch wa s compl i ca ted by ges ta ona l di a betes a nd preecl a mps i a . She ha s not been s exua l l y a c ve i n the pa s t yea r. She once ha d a n a bnorma l Pa p s mea r for whi ch s he underwent cryothera py. Her cycl es a re every 35 da ys a nd l a s t for 7 da ys . She des cri bes the flow a s hea vy for the firs t two da ys a nd occa s i ona l l y pa s s es bl ood cl ots the s i ze of qua rters . She deni es a ny medi ca l probl ems . Her fa mi l y hi s tory i s s i gni fica nt for corona ry a rtery di s ea s e i n her da d a ge 65 a nd a ma terna l a unt who devel oped ova ri a n ca ncer a t the a ge of 67. She i s normotens i ve a nd her brea s t a nd pel vi c exa mi na ons a re norma l . Al ong wi th a Pa p s mea r, ma mmogra m, fa s ng gl ucos e, a nd l i pi d profil e, wha t other s creeni ng tes t i s recommended for thi s pa ti ent? a . CA-125 b. Hemogl obi n l evel c. Hepa ti ti s C d. Thyroi d s ti mul a ti ng hormone e. Uri na l ys i s 267. A 30-yea r-woma n pres ents to your office wi th the fea r of devel opi ng ova ri a n ca ncer. Her 70-yea r-ol d gra ndmother recentl y di ed from ova ri a n ca ncer. You di s cus s wi th her the ri s ks fa ctors a nd preven on for ova ri a n ca ncer. Whi ch of the fol l owi ng ca n decrea s e a woma n’s ri s k of ova ri a n ca ncer? a . Us e of combi na ti on ora l contra cepti ve thera py b. Menopa us e a fter a ge 55 c. Nons teroi da l a nti -i nfl a mma tory drugs d. Nul l i pa ri ty e. Ovul a ti on i nducti on medi ca ti ons 268. A 42-yea r-ol d G4P3104 pres ents for her wel l -woma n exa mi na on. She ha s ha d three va gi na l del i veri es a nd one ces a rea n del i very for breech. She s ta tes her cycl es a re regul a r a nd deni es a ny s exua l l y tra ns mi ed di s ea s es . Currentl y s he a nd her hus ba nd us e condoms , but they ha te the ha s s l e of a coi ta l -dependent method. She i s i nteres ted i n a more effec ve contra cep on beca us e they do not wa nt a ny more chi l dren. She reports occa s i ona l mi gra i ne hea da ches a nd ha d a s eri ous a l l ergi c rea c on to a nes thes i a a s a chi l d when s he underwent a tons i l l ectomy. She dri nks a nd s mokes s oci a l l y. She wei ghs 78 kg, a nd her bl ood pres s ure i s 142/89 mm Hg. Duri ng her office vi s i t, you couns el the pa ent a t l ength rega rdi ng bi rth control methods . Whi ch of the fol l owi ng i s the mos t a ppropri a te contra cepti ve method for thi s pa ti ent? a . Intra uteri ne devi ce b. La pa ros copi c bi l a tera l tuba l l i ga ti on c. Combi na ti on ora l contra cepti ves d. Di a phra gm e. Tra ns derma l pa tch 269. A 48-yea r-ol d G2P2 pres ents for her wel l -woma n exa mi na on. She ha d two uneven ul va gi na l del i veri es . She ha d a va gi na l hys terectomy for fibroi ds a nd menorrha gi a . She deni es a ny medi ca l probl ems , but ha s not s een a doctor i n 6 yea rs . Her fa mi l y hi s tory i s s i gni fica nt for s troke, di a betes , a nd hi gh bl ood pres s ure. On exa mi na on s he i s a pl ea s a nt fema l e, s ta nds 5 3 i n ta l l , a nd wei ghs 85 kg. Her bl ood pres s ure i s 150/92 mm Hg, pul s e 70 bea ts per mi nute, res pi ra tory ra te 14 brea ths per mi nute, a nd tempera ture 37°C (98.4°F). Her brea s t, l ung, ca rdi a c, a bdomen, a nd pel vi c exa mi na ti ons a re norma l . The next a ppropri a te s tep i n the ma na gement of thi s pa ti ent’s bl ood pres s ure i s whi ch of the fol l owi ng? a . Beta -bl ocker b. Ca l ci um cha nnel bl ocker c. Di ureti c d. Di et, exerci s e, wei ght l os s , a nd repea t bl ood pres s ure i n 2 months 270. A 32-yea r-ol d woma n pres ents for her yea rl y exa mi na on. She ha s been s moki ng one pa ck of ci ga re es a da y for the pa s t 12 yea rs . She wa nts to s top, a nd you ma ke s ome recommenda ti ons to her. Whi ch of the fol l owi ng i s true rega rdi ng s moki ng ces s a ti on i n women? a . Ni nety percent of thos e who s top s moki ng rel a ps e wi thi n 3 months . b. Ni coti ne repl a cement i n the form of chewi ng gum or tra ns derma l pa tches ha s not been s hown to be effecti ve i n s moki ng ces s a ti on progra ms . c. Smokers do not benefi t from repea ted wa rni ngs from thei r doctor to s top s moki ng. d. Stoppi ng col d turkey i s the onl y wa y to s ucces s ful l y a chi eve s moki ng ces s a ti on. e. No ma tter how l ong one ha s been s moki ng, s moki ng ces s a ti on a ppea rs to i mprove the hea l th of the l ungs .

Preventive Care and Health Maintenance

Answers 251. The answer is c. (Schorge, pp 5-10, 626-27. ACOG Commi ee Opinion Number 483, April 2011.) In pos tmenopa us a l women, rou ne s creeni ng for col on ca ncer i s recommended wi th a col onos copy to be performed every 10 yea rs . Al terna vel y, flexi bl e s i gmoi dos copy ca n be performed every 5 yea rs a l ong wi th a yea rl y feca l occul t bl ood tes t. Ma mmogra phy s houl d be performed every 1 to 2 yea rs i n a l l women 50 to 74 yea rs of a ge. Pos tmenopa us a l women, who a re not on hormone repl a cement thera py, a nd a l l women 65 yea rs or ol der s houl d be s creened for os teoporos i s wi th a DEXA s ca n to determi ne bone mi nera l dens i ty. Screeni ng for cervi ca l ca ncer wi th Pa p s mea rs ma y be di s con nued a er a ge 70 i n l ow ri s k women (no pri or a bnorma l Pa ps or trea tment for cervi ca l ca ncer, no hi s tory of HPV or HIV i nfec on, a nd not i mmunocompromi s ed). Tubercul os i s s ki n tes ng need to be performed onl y i n i ndi vi dua l s wi th HIV i nfec on, thos e who ha ve cl os e conta ct wi th i ndi vi dua l s s us pected of ha vi ng TB, thos e who a re IV drug us ers , thos e who a re res i dents of nurs i ng homes or l ong-term-ca re fa ci l i es , or thos e who work i n a profes s i on tha t i s hea l th ca re rel a ted. Thi s pa ti ent does not ha ve a ny ri s k fa ctors tha t woul d neces s i ta te TB tes ti ng. Audi tory tes ti ng i s not a routi ne s creeni ng tes t. 252. The answer is c. (Schorge, pp 6-8. ACOG Commi ee Opinion Number 483, April 2011.) Women more tha n 65 yea rs ol d s houl d ha ve a l l of the fol l owi ng i mmuni za ons : teta nus -di phtheri a boos ter every 10 yea rs , i nfluenza vi rus va cci ne a nnua l l y, a nd a one- me pneumococca l va cci ne. Hepa s B va cci ne woul d be i ndi ca ted onl y i n i ndi vi dua l s a t hi gh ri s k (i e, i nterna ona l tra vel ers , i ntra venous drug us ers , a nd thei r s exua l conta cts , thos e who ha ve occupa ona l expos ure to bl ood or bl ood products , pers ons wi th chroni c l i ver or rena l di s ea s e, or res i dents of i ns tu ons for the devel opmenta l l y di s a bl ed, a nd i nma tes of correc ona l i ns tu ons ). Herpes zos ter i s i ndi ca ted for women over the a ge of 65 i f not previ ous l y i mmuni zed. 253. The answer is d. (Schorge, pp 8-20. ACOG Commi ee Opinion Number 483, April 2011.) Women more tha n 65 yea rs ol d s houl d undergo chol es terol tes ng every 5 yea rs , fa s ng gl ucos e tes ng every 3 yea rs , s creeni ng for thyroi d di s ea s e wi th a TSH every 5 yea rs , a nd peri odi c uri na l ys i s i s recommended i n women over the a ge of 65 yea rs . CA-125 tes ng i s not recommended for s creeni ng for ova ri a n ca ncer. There a re ma ny beni gn condi ons whi ch ca n ca us e a n el eva ted CA-125, s uch a s pregna ncy, endometri os i s , fibroi ds , mens es , pel vi c i nfla mma tory di s ea s e, peri tonea l di s ea s e, a nd l i ver di s ea s e. 254. The answer is d. (Katz, pp 148-152. ACOG Commi ee Opinion Number 483, April 2011.) A uri na l ys i s tha t i s pos i ve for bl ood s houl d be fol l owed up wi th a uri ne cul ture to detect a n a s ymptoma c uri na ry tra ct i nfec on before further workup i s done or referra l to a urol ogi s t i s ma de. Pa ra ba s a l cel l s on a Pa p s mea r i ndi ca te l a ck of es trogen a nd a re a norma l fi ndi ng i n pos tmenopa us a l women a nd requi re no further eva l ua ti on. 255. The answer is d. (Katz, pp 148-152. ACOG Commi ee Opinion Number 483, April 2011.) In order of decrea s i ng i nci dence, the l ea di ng ca us es of dea th i n women more tha n 65 yea rs ol d a re the fol l owi ng: di s ea s es of the hea rt, ca ncer, cerebrova s cul a r di s ea s es , chroni c obs truc ve pul mona ry di s ea s es , pneumoni a a nd i nfl uenza , di a betes mel l i tus , rena l di s ea s es , a cci dents , a nd s epti cemi a . 256. The answer is c. (ACOG Committee Opinion Number 483, April 2011.) The l ea di ng ca us es of dea th i n a dul ts between the a ges of 19 a nd 39 yea rs ol d, i n order of decrea s i ng frequency, a re a s fol l ows : ma l i gna nt neopl a s ms , a cci dents , di s ea s es of the hea rt, s ui ci de, HIV i nfec on, homi ci de, cerebrova s cul a r a cci dents , di a betes , l i ver di s ea s es , a nd chroni c res pi ra tory di s ea s es . 257. The answer is a. (Schorge, pp 5, 8, 626-627. ACOG Prac ce Bulle n Number 109, December 2009.) Rou ne s creeni ng for s exua l l y tra ns mi ed di s ea s e i s not wa rra nted for a l l women; however, a l l s exua l l y a c ve women 200 ng/dL) a nd ra pi dl y devel op vi ri l i zi ng cha ra cteri s cs s uch a s tempora l ba l di ng, cl i tora l hypertrophy, voi ce deepeni ng, brea s t a trophy, a nd termi na l ha i r between the brea s ts a nd on the ba ck. Women wi th i di opa thi c hi rs u s m ha ve grea ter a c vi ty of 5α-reducta s e tha n do una ffected women. They ha ve hi rs u s m wi th a di a gnos c eva l ua on tha t gi ves no expl a na on for the exces s ha i r. Women wi th l a te-ons et congeni ta l a drena l hyperpl a s i a a re hi rs ute owi ng to a n i ncrea s e i n a drena l a ndrogen produc on ca us ed by a defici ency i n 21hydroxyl a s e. 372. The answer is d. (Schorge, p 393.) Thyroi d dys func on a nd hyperprol a c nemi a ca n both be a s s oci a ted wi th hi rs u s m, a nd therefore i t i s i mporta nt to check l evel s of TSH a nd prol a c n. In order to rul e out congeni ta l a drena l hyperpl a s i a ca us ed by a defici ency i n 21-hydroxyl a s e, a 17αhydroxyproges terone l evel s houl d be dra wn. Very hi gh l evel s of tota l tes tos terone woul d i ndi ca te the pres ence of a n a ndrogen-s ecre ng ova ri a n tumor. El eva ted l evel s of dehydroepi a ndros tenedi one woul d be cons i s tent wi th PCOS. There i s no rol e for orderi ng a n i s ol a ted es trone l evel i n the

workup a nd eva l ua ti on of hi rs uti s m. 373. The answer is d. (Schorge, pp 395-396.) Ora l contra cep ves ha ve l ong been us ed i n the ma na gement of PCOS beca us e they s uppres s pi tui ta ry l utei ni zi ng hormone s ecre on, s uppres s ova ri a n a ndrogen s ecre on, a nd i ncrea s e ci rcul a ng s ex hormone-bi ndi ng gl obul i n (SHBG). Medi ca ons s uch a s me ormi n tha t i mprove i ns ul i n s ens i vi ty ha ve been us ed to trea t PCOS. Spi ronol a ctone, whi ch i s a di ure c a nd a l dos terone a goni s t, ha s been us ed to trea t PCOS beca us e i t bi nds to the a ndrogen receptor a s a n a nta goni s t. Wei ght l os s i s recommended a s pa rt of the trea tment for women wi th PCOS beca us e i t reduces hyperi ns ul i nemi a . Me ormi n us e i s a s i mpl e s tep i n the a empt to i nduce ovul a on i n pa ents wi th PCOS. Ins ul i n i s thought to a ct on the ova ry to s mul a te a ndrogen s ecre on. In a ddi on, hyperi ns ul i nemi a decrea s es SHBG. There i s no rol e for the us e of dexa metha s one to trea t PCOS. Gl ucocorti coi d thera py i s i ndi ca ted i n ca s es of congeni ta l a drena l hyperpl a s i a . 374. The answer is e. (Schorge, pp 174-182.) The ca s e pres ented i s a typi ca l repres enta on of a pa ent wi th dys func ona l uteri ne bl eedi ng a ri buted to a novul a on. The ons et of mena rche i n young women i s typi ca l l y fol l owed by a pproxi ma tel y 5 yea rs of i rregul a r cycl es tha t res ul t from a novul a ti on s econda ry to i mma turi ty of the hypotha l a mi c-pi tui ta ry a xi s . Uteri ne ca ncer, cervi ca l pol yps , or cervi ca l pa thol ogy woul d be ra re i n a gi rl of thi s a ge. Thes e other ca us es of a bnorma l bl eedi ng woul d be more common i n ol der women. Of cours e, pregna ncy s houl d a l wa ys be cons i dered a s a pos s i bl e ca us e i n a l l women of reproduc ve a ge. Appropri a te l a b tes ts to order i n the emergency room woul d be a BHCG (to rul e out pregna ncy), a bl eedi ng me (20% of a dol es cents wi th dys func ona l uteri ne bl eedi ng ha ve a coa gul a on defect), a nd bl ood type a nd s creen (s i nce s he i s orthos ta c s he ma y requi re a bl ood tra ns fus i on). A CBC wi l l s how the degree of bl ood l os s thi s pa ent ha s s uffered. Mea s uri ng a n es tra di ol l evel woul d s erve no purpos e i n the workup of thi s pa ti ent. 375. The answer is d. (Schorge, pp 174-178.) Thi s pa ent pres ents a n exa mpl e of chroni c a novul a on i n a n ol der woma n. She gi ves a cl a s s i c hi s tory of cha ngi ng from regul a r, monthl y peri ods to i rregul a r, i nfrequent epi s odes of va gi na l bl eedi ng. Pa ents wi th chroni c a novul a on o en ha ve underl yi ng medi ca l probl ems s uch a s di a betes , thyroi d probl ems , or pol ycys c ova ri a n s yndrome. A pa ent wi th uteri ne fibroi ds ma y ha ve hea vy peri ods , but the regul a ri ty of the peri ods i s not a ffected unl es s the pa ent ha s underl yi ng ovul a tory dys func on. A cervi ca l pol yp woul d cl ea rl y be s een on phys i ca l exa mi na on a nd, l i ke uteri ne fibroi ds , woul d not a ffect the mi ng of mens trua on. Pa ents wi th cervi ca l pol yps o en compl a i n of bl eedi ng between peri ods , us ua l l y provoked by s exua l i ntercours e. Si nce the pa ent’s pregna ncy tes t i s nega ve, s he ca nnot ha ve a n i ncompl ete a borti on. Pa ti ents wi th coa gul a ti on defects ha ve probl ems wi th hea vy peri ods from the ti me of mena rche. 376. The answer is d. (Beckmann, pp 362-364; Speroff, pp 553-560.) The tra ns va gi na l ul tra s ound hel ps to di rect the next s tep i n the ca re of thi s pa ent. Her endometri a l s tri pe i s thi n s ugges ng tha t s he ha s s hed her endometri um to i ts ba s a l i s l a yer. In women who ha ve s uffered hea vy a nd a cute bl eedi ng a nd ha ve a n a trophi c endometri um, 25 mg of conjuga ted es trogen s houl d be a dmi ni s tered every 4 hours un l the bl eedi ng s ubs i des . Es trogen wi l l hel p s top the bl eedi ng by rebui l di ng the endometri um a nd s mul a ng cl o ng a t the ca pi l l a ry l evel . Si nce thi s pa ent’s bl eedi ng i s due to a n a trophi c endometri um, es trogen thera py i s the preferred trea tement. Ha d the tra ns va gi na l ul tra s ound s hown a thi ckened endometri a l s tri pe, hys teros copy a nd D&C i s i ndi ca ted a s i t wi l l s top the bl eedi ng more ra pi dl y tha n medi ca l trea tment. In ol der women, a D&C mi ght be hel pful i n obta i ni ng s s ue for pa thol ogy to rul e out endometri a l ca ncer. In thi s young pa ent who i s res us ci ta ted a nd s ta bi l i zed wi th i ntra venous flui ds , there i s no i ndi ca on for a bl ood tra ns fus i on a s l ong a s the bl eedi ng a ba tes . Iron thera py a l one woul d not be a dequa te for thi s pa ent; the bl eedi ng mus t be s topped firs t. An pros ta gl a ndi ns ha ve no rol e i n curta i l i ng hemorrha ge i n a woma n s ufferi ng from a novul a on. They ha ve been us ed wi th s ome s ucces s i n ovul a tory women who ha ve hea vy cycl es or i n women wi th menorrha gi a ca us ed by us e of the i ntra uteri ne devi ce. It i s thought tha t pros ta gl a ndi n s yntheta s e i nhi bi tors reduce the a mount of bl eedi ng by promoti ng va s ocons tri cti on a nd pl a tel et a ggrega ti on. 377. The answer is c. (Schorge, pp 300-303.) The onl y medi ca ons tha t ha ve been s hown i n ra ndomi zed, doubl e-bl i nd, pl a cebo-control l ed tri a l s to be cons i s tentl y effec ve i n trea ng the emo ona l s ymptoms of PMS a re the s el ec ve s erotoni n reupta ke i nhi bi tors . Such a n depres s a nts i ncl ude fl uoxeti ne, s ertra l i ne, a nd pa roxeti ne. Some women ca n be effecti vel y trea ted by l i mi ti ng us e of the medi ca ti on to the l utea l pha s e. 378. The answer is c. (Schorge, pp 492-499.) It i s wel l es ta bl i s hed tha t the us e of ERT/HRT i ncrea s es the us er’s ri s k of a thromboembol i c event two-to threefol d. The us e of combi ned HRT does not i ncrea s e the ri s k of uteri ne ca ncer, col on ca ncer, or Al zhei mer di s ea s e. There i s much l i tera ture to s upport the i dea tha t HRT us e decrea s es the ri s k of col on ca ncer a nd pos s i bl y Al zhei mer di s ea s e. There i s no s ci en fic evi dence tha t HRT us e a ffects the i nci dence of ma l i gna nt mel a noma . 379. The answer is b. (Schorge, pp 110, 482.) Es trogen us e decrea s es tota l chol es terol a nd LDL a nd i ncrea s es HDL a nd tri gl yceri des . 380. The answer is d. (Schorge, p 473.) The hot flus h i s the firs t phys i ca l s ymptom of decl i ni ng ova ri a n func on. More tha n 95% of peri menopa us a l /menopa us a l women experi ence thes e va s omotor s ymptoms . Hot flus hes ma y begi n s evera l yea rs before the ces s a on of mens trua on. When a woma n experi ences a hot flus h, s he typi ca l l y feel s a s udden s ens a on of hea t over the ches t a nd fa ce tha t l a s ts between 1 a nd 2 mi nutes . Thi s feel i ng of hea t i s fol l owed by a s ens a ti on of cool i ng or a col d s wea t. The enti re hot fl us h l a s ts a bout 3 mi nutes tota l . Es trogen thera py wi l l us ua l l y ca us e res ol u on of the hot flus h wi thi n 3 to 6 weeks . Wi thout es trogen thera py, hot flus hes on a vera ge res ol ve s ponta neous l y wi thi n 2 to 3 yea rs a er ces s a on of mens trua on. Al though hot flus hes a re norma l , they ma y i nterfere wi th a woma n’s s l eep, ca us i ng s i gni fi ca nt i nterference wi th her s ens e of wel l -bei ng. 381 to 385. The answers are 381-d, 382-b, 383-a, 384-a, 385-c. (Schorge, pp 323-325, 745-746.) True s exua l precoci ty i n gi rl s i s cha ra cteri zed by norma l gona dotropi n l evel s (a s oppos ed to expected l ow prepuberta l gona dotropi n l evel s ) a nd a norma l ovul a tory pa ern. It repres ents prema ture a c va on of a norma l l y opera ng hypotha l a mi c-pi tui ta ry a xi s . Al though i t i s us ua l l y i di opa thi c, true s exua l precoci ty ca n a ri s e from cerebra l ca us es s uch a s tumors or a hi s tory of encepha l i s or meni ngi s , a s wel l a s from hypothyroi di s m, pol yos to c fibrous dys pl a s i a , neurofibroma tos i s , a nd other di s orders . In gi rl s who ha ve precoci ous ps eudopuberty, the endocri ne gl a nds , us ua l l y under neopl a s c i nfluences , produce el eva ted a mounts of es trogens (i s os exua l precoci ous ps eudopuberty) or a ndrogens (heteros exua l precoci ous ps eudopuberty). Ova ri a n tumors a ppea r to be the mos t common ca us e of i s os exua l precoci ous ps eudopuberty; s ome ova ri a n tumors , i ncl udi ng dys germi noma s a nd chori oca rci noma s , ca n produce s o much gona dotropi n tha t pregna ncy tes ts a re pos i ve. Incompl ete s exua l precoci ty, whi ch i s us ua l l y i di opa thi c, i s cha ra cteri zed by onl y pa r a l s exua l ma turi ty, s uch a s prema ture thel a rche or prema ture a drena rche (puba rche). Incompl ete s exua l precoci ty ca n be a ccompa ni ed by a bnorma l func on of the centra l nervous s ys tem (eg, menta l defici ency). Gona dotropi n l evel s a re frequentl y norma l i n thes e pa ents . In gona dotropi n-produci ng tumors , hi gh l evel s of gona dotropi ns s uch a s FSH a re produced wi th s ubs equent produc on of es trogen. Exa mpl es of thes e ra re tumors a re hepa toma , chori oepi thel i oma , a nd pres a cra l tumors . 386 to 390. The answers are 386-a, 387-b, 388-c, 389-e, 390-f. (Schorge, pp 435-438.) Hys teros a l pi ngogra phy i s a n i mporta nt tool i n the eva l ua on of i nfer l i ty. It provi des i nforma on rega rdi ng the s ha pe of the uteri ne ca vi ty a nd the pa tency of the tubes . Tuba l fa ctors , ma ny of whi ch fol l ow from s exua l l y tra ns mi ed di s ea s es , a re a n i mporta nt ca us e of i nfer l i ty. The figure i n ques on 386 di s pl a ys bi l a tera l hydros a l pi nx a nd cl ubbi ng of the tubes wi th no evi dence of a ny s pi l l a ge i nto the peri tonea l ca vi ty. The uteri ne ca vi ty i n thi s hys teros a l pi ngogra m i s norma l . In the figure i n ques on 387, there i s uni l a tera l hydros a l pi nx a nd evi dence of a dhes i ons wi thi n the uteri ne ca vi ty cons i s tent wi th As herma n s yndrome. There i s

no fil l i ng of the other tube. In the figure i n ques on 388, one tube fil l s a nd ha s uni l a tera l hydros a l pi nx; the other s hows l ocul a on a nd mi ni ma l flui d a ccumul a on. The uteri ne ca vi ty here i s norma l , i n contra s t to the ca vi ty s hown i n ques on 387. The figure i n ques on 389 s hows s a l pi ngi s i s thmi ca nodos a , i n whi ch there i s a cha ra cteri s c “s a l t-a nd-pepper” pa ern of tuba l fil l i ng a nd evi dence of a di ver cul um of the tube on one s i de. The figure i n ques on 390 s hows norma l fil l i ng a nd s pi l l a ge of contra s t medi a . Thi s i s a norma l hys teros a l pi ngogra m. None of the figures s how bi l a tera l proxi ma l occl us i on.

Pelvic Relaxation and Urology Questions 391. A 50-yea r-ol d woma n compl a i ns of l ea ka ge of uri ne. A er s tres s uri na ry i ncon nence, whi ch of the fol l owi ng i s the mos t common ca us e of uri na ry i nconti nence? a . Functi ona l i nconti nence b. Urge i nconti nence c. Uns ta bl e urethra d. Urethra l di verti cul um e. Overfl ow i nconti nence 392. A 78-yea r-ol d woma n compl a i ns of l ea ka ge of uri ne. Whi ch of the fol l owi ng i s the mos t common ca us e of thi s condi ti on i n pa ti ents i n thi s a ge ra nge? a . Ana tomi c s tres s uri na ry i nconti nence b. Urethra l di verti cul um c. Overfl ow i nconti nence d. Urge i nconti nence e. Fi s tul a 393. A hea l thy 59-yea r-ol d woma n wi th no hi s tory of uri na ry i ncon nence undergoes va gi na l hys terectomy a nd a nteropos teri or repa i r for uteri ne prol a ps e, a l a rge cys tocel e, a nd a rectocel e. Two weeks pos topera vel y, s he pres ents to your office wi th a new compl a i nt of i ntermi ent l ea ka ge of uri ne. Wha t i s the mos t l i kel y ca us e of thi s compl a i nt fol l owi ng her s urgery? a . Urethra l di verti cul um b. Overfl ow i nconti nence c. Rectova gi na l fi s tul a d. Stres s uri na ry i nconti nence e. Ves i cova gi na l fi s tul a 394. A 53-yea r-ol d pos tmenopa us a l woma n, G3P3, pres ents for eva l ua on of troubl es ome uri na ry l ea ka ge for the pa s t 6 weeks . Whi ch of the fol l owi ng i s the mos t a ppropri a te fi rs t s tep i n thi s pa ti ent’s eva l ua ti on? a . Uri na l ys i s a nd cul ture b. Urethra l pres s ure profi l es c. Intra venous pyel ogra m d. Cys tourethrogra m e. Urethrocys tos copy 395. A 38-yea r-ol d woma n G4P4 i s undergoi ng eva l ua on for feca l i ncon nence. She ha s no di a gnos ed medi ca l probl ems . Whi ch of the fol l owi ng i s the mos t l i kel y ca us e of thi s pa ti ent’s condi ti on? a . Recta l prol a ps e b. Di a betes c. Obs tetri c tra uma d. Pres eni l e dementi a e. Exces s i ve ca ffei ne i nta ke 396. You a re di s cus s i ng s urgi ca l op ons wi th the fa mi l y of a n el derl y pa ent wi th s ymptoma c pel vi c orga n prol a ps e. Pa r a l col pocl ei s i s (Le Fort procedure) ma y be more a ppropri a te tha n va gi na l hys terectomy a nd a nteri or a nd pos teri or (A&P) repa i r for pa ents i n whi ch of the fol l owi ng ci rcums ta nces ? a . The pa ti ent who does i s debi l i ta ted a nd i n a nurs i ng home b. The pa ti ent who ha s ha d pos tmenopa us a l bl eedi ng c. The pa ti ent who ha s ha d endometri a l hyperpl a s i a d. The pa ti ent who ha s ha d cervi ca l dys pl a s i a tha t requi res col pos copi c eva l ua ti on e. The pa ti ent who ha s ha d a hi s tory of uri na ry i nconti nence 397. A 65-yea r-ol d woma n pres ents to your office for eva l ua on of geni ta l prol a ps e. She ha s a hi s tory of chroni c hypertens i on, wel l control l ed wi th a ca l ci um cha nnel bl ocker. She ha s ha d three ful l -term s ponta neous va gi na l del i veri es . The l a s t ba by wei ghed 9 l b a nd requi red forceps to del i ver the hea d. She s a ys s he ha d a l a rge tea r i n the va gi na i nvol vi ng the rectum duri ng the l a s t del i very. She ha s a hi s tory of chroni c cons pa on a nd o en us es a l a xa ve to hel p her ha ve a bowel movement. She ha s s moked for more tha n 30 yea rs a nd ha s a s moker’s cough. She entered menopa us e a t a ge 52 but ha s never ta ken hormone repl a cement thera py. Whi ch of the fol l owi ng fa ctors i s l ea s t i mporta nt i n the s ubs equent devel opment of geni ta l prol a ps e i n thi s pa ti ent? a . Chroni c cough b. Chroni c cons ti pa ti on c. Chroni c hypertens i on d. Chi l dbi rth tra uma e. Menopa us e 398. A 63-yea r-ol d woma n i s undergoi ng a tota l a bdomi na l hys terectomy (TAH) for a typi ca l endometri a l hyperpl a s i a . She men oned to her doctor 2 weeks pri or to the s urgery tha t s he ha s ha d probl ems wi th l ea ka ge of uri ne wi th s tra i ni ng a nd occa s i ona l epi s odes of uri na ry urgency. A uri ne cul ture a t tha t vi s i t i s nega ti ve. She ha s ha d preopera ti ve cys tometri cs done i n the doctor’s offi ce s howi ng l os s of uri ne duri ng Va l s a l va ma neuvers a l ong wi th evi dence of detrus or i ns ta bi l i ty. The doctor ha s el ected to do a retropubi c bl a dder neck s us pens i on fol l owi ng the TAH. A Ma rs ha l l -

Ma rche -Kra ntz procedure (MMK) i s done to a a ch the bl a dder neck to the pubi c s ymphys i s . The pa ent does wel l a er her s urgery a nd i s rel ea s ed from the hos pi ta l on pos topera ti ve da y 3. Whi ch of the fol l owi ng s houl d her doctor a dvi s e her pri or to her di s cha rge? a . Uri na ry retenti on i s very common a fter a n MMK procedure a nd often requi res l ong-term s el f-ca theteri za ti on. b. She ha s a 5% ri s k of enterocel e forma ti on. c. The MMK procedure i s hi ghl y effecti ve, wi th grea ter tha n 90% l ong-term cure ra te. d. Os tei ti s pubi s occurs i n a pproxi ma tel y 10% of pa ti ents a fter a n MMK, but i s ea s i l y trea ted wi th ora l a nti bi oti cs . e. She wi l l not need a ny a ddi ti ona l trea tment for her bl a dder dys functi on. 399. A 30-yea r-ol d G3P3 i s bei ng eva l ua ted for uri na ry urgency, uri na ry frequency, a nd dys uri a . She a l s o compl a i ns of pa i n wi th i ns er on when a emp ng i ntercours e. She frequentl y dri bbl es a few drops of uri ne a er s he fini s hes voi di ng. She ha s ha d three ful l -term s ponta neous va gi na l del i veri es . Her l a s t ba by wei ghed more tha n 9 l b. She reca l l s ha vi ng ha d mul pl e s utures pl a ced i n the va gi na l a rea a er del i very of tha t chi l d. She a l s o ha s a hi s tory of mul pl e uri na ry tra ct i nfec ons s i nce s he wa s a teena ger. On pel vi c exa mi na on, s he ha s a 1-cm tender s uburethra l ma s s . Wi th pa l pa on of the ma s s , a s ma l l a mount of bl ood- nged pus i s expres s ed from the urethra . Whi ch of the fol l owi ng i s the mos t l i kel y ca us e of thi s pa ti ent’s probl em? a . Urethra l pol yp b. Urethra l fi s tul a c. Urethra l s tri cture d. Urethra l evers i on e. Urethra l di verti cul um 400. A pa ent i s s een on the s econd pos topera ve da y a er a di fficul t a bdomi na l hys terectomy compl i ca ted by hemorrha ge from the l e uteri ne a rtery pedi cl e. Mul pl e s utures were pl a ced i nto thi s a rea to control bl eedi ng. Her es ma ted bl ood l os s wa s 500 mL. The pa ent now ha s fever, l e ba ck pa i n, l e cos tovertebra l a ngl e tendernes s , a nd hema turi a . Her vi ta l s i gns a re tempera ture 38.2°C (100.8°F), bl ood pres s ure 110/80 mm Hg, res pi ra tory ra te 18 brea ths per mi nute, a nd pul s e 102 bea ts per mi nute. Her pos topera ve hemogl obi n dropped from 11.2 to 9.8, her whi te bl ood cel l count i s 9.5, a nd her crea ti ni ne ros e from 0.6 to 1.8 mg/dL. Wha t i s next bes t s tep i n the ma na gement of thi s pa ti ent? a . Order ches t x-ra y. b. Order i ntra venous pyel ogra m. c. Order rena l ul tra s ound. d. Sta rt i ntra venous a nti bi oti cs . e. Tra ns fus e two uni ts of pa cked red bl ood cel l s . 401. A 44-yea r-ol d woma n compl a i ns of uri na ry i ncon nence. She l os es uri ne when s he l a ughs , coughs , a nd pl a ys tenni s . Urodyna mi c s tudi es a re performed i n the office wi th a mul pl e-cha nnel ma chi ne. If thi s pa ent ha s genui ne s tres s uri na ry i ncon nence, whi ch of the fol l owi ng do you expect to s ee on the cys tometri c s tudy? a . An a bnorma l l y s hort urethra b. Mul ti pl e uni nhi bi ted detrus or contra cti ons c. Tota l bl a dder ca pa ci ty of 1000 cc d. Norma l urethra l pres s ure profi l e e. Fi rs t urge to voi d a t 50 cc 402. A 59-yea r-ol d G4P4 pres ents to your office compl a i ni ng of l os i ng uri ne when s he coughs , s neezes , or enga ges i n certa i n types of s trenuous phys i ca l a c vi ty. The probl em ha s go en i ncrea s i ngl y wors e over the pa s t few yea rs , to the poi nt where the pa ent finds her a c vi es of da i l y l i vi ng compromi s ed s econda ry to fea r of emba rra s s ment. She deni es a ny other uri na ry s ymptoms s uch a s urgency, frequency, or hema turi a . In a ddi on, s he deni es a ny probl ems wi th her bowel movements . Her pri or s urgeri es i ncl ude tons i l l ectomy a nd a ppendectomy. She ha s a dul t-ons et di a betes a nd her bl ood s uga rs a re wel l control l ed wi th ora l Me ormi n. The pa ent ha s no hi s tory of a ny gynecol ogi c probl ems i n the pa s t. She ha s four chi l dren who were a l l del i vered va gi na l l y. Thei r wei ghts ra nged from 8 to 9 l b. Her l a s t del i very wa s forceps a s s i s ted. She ha d a thi rddegree l a cera on wi th tha t bi rth. She i s currentl y s exua l l y a c ve wi th her pa rtner of 25 yea rs . She ha s been menopa us a l for 4 yea rs a nd ha s never ta ken a ny hormone repl a cement thera py. Her hei ght i s 5 6 i n, a nd s he wei ghs 190 l b. Her bl ood pres s ure i s 130/80 mm Hg. Ba s ed on the pa ent’s hi s tory, whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Overfl ow i nconti nence b. Stres s uri na ry i nconti nence c. Uri na ry tra ct i nfecti on d. Detrus or i ns ta bi l i ty e. Ves i cova gi na l fi s tul a 403. A 49-yea r-ol d G4P4 pres ents to your office compl a i ni ng of a 2-month hi s tory of l ea ka ge of uri ne every me s he exerci s es . She ha s ha d to l i mi t her phys i ca l a c vi es beca us e of the l os s of uri ne. She ha s ha d burni ng wi th uri na on a nd s ome bl ood i n her uri ne for the pa s t few da ys . Whi ch of the fol l owi ng i s the bes t next s tep i n the eva l ua ti on a nd ma na gement of thi s pa ti ent? a . Phys i ca l exa mi na ti on b. Pl a cement of a pes s a ry c. Uri na l ys i s wi th uri ne cul ture d. Cys tos copy e. Offi ce cys tometri cs 404. A 46-yea r-ol d woma n pres ents to your office compl a i ni ng of s omethi ng bul gi ng from her va gi na for the pa s t yea r. It ha s been ge ng progres s i vel y more promi nent. She ha s s ta rted to no ce tha t s he l ea ks uri ne wi th l a ughi ng a nd s neezi ng. She s l l ha s peri ods regul a rl y every 26 da ys . She i s ma rri ed. Her hus ba nd ha d a va s ectomy for contra cep on. A er a ppropri a te eva l ua on, you di a gnos e a s econd-degree cys tocel e. She ha s no uteri ne prol a ps e or rectocel e. Whi ch of the fol l owi ng i s the bes t trea tment pl a n to offer thi s pa ti ent? a . Anti chol i nergi c medi ca ti ons b. Anti bi oti c thera py wi th Ba ctri m c. Le Fort col pocl ei s i s d. Surgi ca l correcti on wi th a bl a dder neck s us pens i on procedure e. Us e of va gi na l es trogen crea m 405. An obes e 46-yea r-ol d G6P1051 wi th type 1 di a betes s i nce a ge 12 pres ents to your office compl a i ni ng of uri na ry i ncon nence. She ha s been

menopa us a l s i nce a ge 44. Her di a betes ha s been poorl y control l ed for yea rs beca us e of her noncompl i a nce wi th i ns ul i n thera py. She o en ca nnot tel l when her bl a dder i s ful l , a nd s he wi l l uri na te on hers el f wi thout wa rni ng. Whi ch of the fol l owi ng fa ctors i n thi s pa ent’s hi s tory ha s l i kel y contri buted the mos t to the devel opment of her uri na ry i nconti nence? a . Menopa us e b. Obes i ty c. Obs tetri c hi s tory d. Age e. Subopti ma l di a beti c control 406. A 76-yea r-ol d woma n pres ents for eva l ua on of uri na ry i ncon nence. She ha d a hys terectomy for fibroi d tumors of the uterus a t a ge 48. A er compl ete eva l ua on, you determi ne tha t the pa ent ha s genui ne s tres s uri na ry i ncon nence. On phys i ca l exa mi na on, s he ha s a hypermobi l e urethra , but there i s no cys tocel e or rectocel e. There i s no va gi na l va ul t prol a ps e. Office cys tometri cs confirms genui ne s tres s uri na ry i ncon nence. Whi ch of the fol l owi ng s urgi ca l procedures s houl d you recommend to thi s pa ti ent? a . Kel l y pl i ca ti on b. Anteri or a nd pos teri or col porrha phy c. A mi durethra l s l i ng procedure d. Abdomi na l s a cra l col popexy e. Burch procedure 407. A pa ent pres ents to your office a pproxi ma tel y 2 weeks a er ha vi ng a tota l va gi na l hys terectomy wi th a nteri or col porrha phy a nd Burch procedure for uteri ne prol a ps e a nd s tres s uri na ry i ncon nence. She compl a i ns of a cons ta nt l os s of uri ne throughout the da y. She deni es a ny urgency or dys uri a . Whi ch of the fol l owi ng i s the mos t l i kel y expl a na ti on for thi s compl a i nt? a . Fa i l ure of the procedure b. Uri na ry tra ct i nfecti on c. Ves i cova gi na l fi s tul a d. Detrus or i ns ta bi l i ty e. Di a beti c neuropa thy 408. A 90-yea r-ol d G5P5 wi th mul pl e medi ca l probl ems i s brought i nto your gynecol ogy cl i ni c a ccompa ni ed by her gra ndda ughter. The pa ent ha s hypertens i on, chroni c a nemi a , corona ry a rtery di s ea s e, a nd os teoporos i s . She i s menta l l y a l ert a nd ori ented a nd l i ves i n a n a s s i s ted l i vi ng fa ci l i ty. She ta kes numerous medi ca ons , but i s very func ona l a t the current me. She i s a wi dow a nd not s exua l l y a c ve. Her chi ef compl a i nt i s a s ens a on of hea vi nes s a nd pres s ure i n the va gi na . She deni es a ny s i gni fica nt uri na ry or bowel probl ems . On performa nce of a phys i ca l exa mi na on, you note tha t the cervi x i s jus t i ns i de the l evel of the i ntroi tus . Ba s ed on the phys i ca l exa mi na on, whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Norma l exa mi na ti on b. Fi rs t-degree uteri ne prol a ps e c. Second-degree uteri ne prol a ps e d. Thi rd-degree uteri ne prol a ps e e. Compl ete proci denti a 409. An 86-yea r-ol d woma n pres ents to your office for her wel l -woma n exa mi na on. She ha s no compl a i nts . On pel vi c exa mi na on performed i n the s upi ne a nd upri ght pos i ons , the pa ent ha s s econd-degree prol a ps e of the uterus . Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent? a . Rea s s ura nce b. Pl a cement of a pes s a ry c. Va gi na l hys terectomy d. Le Fort procedure e. Anteri or col porrha phy 410. An 81-yea r-ol d woma n pres ents to your office compl a i ni ng tha t her uterus fel l out 2 months a go. She ha s mul pl e medi ca l probl ems , i ncl udi ng chroni c hypertens i on, conges ve hea rt fa i l ure, a nd os teoporos i s . She i s l i mi ted to s i ng i n a wheel cha i r beca us e of her hea l th probl ems . Her fa l l en uterus ca us es s i gni fica nt pa i n. On phys i ca l exa mi na on, the pa ent i s fra i l a nd requi res a s s i s ta nce wi th ge ng on the exa mi na on ta bl e. She ha s compl ete proci den a of the uterus . Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent? a . Rea s s ura nce b. Pl a cement of a pes s a ry c. Va gi na l hys terectomy d. Le Fort procedure e. Anteri or col porrha phy 411. A 78-yea r-ol d woma n wi th chroni c obs truc ve pul mona ry di s ea s e, chroni c hypertens i on, a nd hi s tory of myoca rdi a l i nfa rc on requi ri ng a ngi opl a s ty pres ents to your office for eva l ua on of s omethi ng ha ngi ng out of her va gi na . She ha d a hys terectomy for beni gn i ndi ca ons a t a ge 48. For the pa s t few months , s he ha s been experi enci ng the s ens a on of pel vi c pres s ure. La s t month s he fel t a bul ge a t the va gi na l openi ng. Two weeks a go s omethi ng fel l out of the va gi na . On pel vi c exa mi na on, the pa ent ha s tota l evers i on of the va gi na . There i s a n a rc of s uperfici a l ul cera ti on a t the va gi na l a pex mea s uri ng 2 to 3 cm i n di a meter. Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent? a . Bi ops y of the va gi na l ul cera ti on b. Schedul e a bdomi na l s a cra l col popexy c. Pl a ce a pes s a ry d. Pres cri be ora l es trogen e. Pres cri be topi ca l va gi na l es trogen crea m 412. A 40-yea r-ol d G3P3 comes to your office for a rou ne a nnua l GYN exa mi na on. She tel l s you tha t s he gets up s evera l mes duri ng the ni ght to voi d. On further ques oni ng, s he a dmi ts to you tha t duri ng the da y s he s ome mes gets the urge to voi d, but s ome mes ca nnot qui te ma ke i t to the ba throom. She a ri butes thi s to ge ng ol der a nd i s not extremel y concerned, a l though s he o en wea rs a pa d when s he goes out i n ca s e s he l os es s ome uri ne. Thi s pa ent i s very hea l thy otherwi s e a nd does not ta ke a ny medi ca on on a regul a r ba s i s . She s l l ha s regul a r, monthl y

mens trua l peri ods . She ha s ha d three norma l s ponta neous va gi na l del i veri es of i nfa nts wei ghi ng between 7 a nd 8 l b. An office di ps ck of her uri ne does not i ndi ca te a ny bl ood, ba cteri a , WBCs , or protei n. Her uri ne cul ture i s nega ve. Ba s ed on her office pres enta on a nd hi s tory, whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Uri na ry s tres s i nconti nence b. Uri na ry tra ct i nfecti on c. Urge i nconti nence d. Ves i cova gi na l fi s tul a 413. A 38-yea r-ol d woma n pres ents to your office compl a i ni ng of uri na ry i ncon nence. Her s ymptoms a re s ugges ve of urge i ncon nence. She a dmi ts to dri nki ng s evera l l a rge gl a s s es of i ced tea a nd wa ter on a da i l y ba s i s beca us e her mother a l wa ys tol d her to dri nk l ots of l i qui ds to l ower her ri s k of bl a dder i nfec ons . Uri na l ys i s a nd uri ne cul ture a re nega ve. A er confirmi ng the di a gnos i s wi th phys i ca l exa mi na on a nd office cys tometri cs , whi ch of the fol l owi ng trea tments s houl d you recommend to the pa ti ent a s the next s tep i n the ma na gement of her probl em? a . Ins truct her to s ta rt performi ng Kegel exerci s es . b. Tel l her to hol d her uri ne for 6 hours a t a ti me to enl a rge her bl a dder ca pa ci ty. c. Ins truct her to el i mi na te exces s wa ter a nd ca ffei ne from her da i l y fl ui d i nta ke. d. Pres cri be a n a nti chol i nergi c. e. Schedul e cys tos copy. 414. A 45-yea r-ol d woma n wi th previ ous l y documented urge i ncon nence con nues to be s ymptoma c a er fol l owi ng your a dvi ce for cons erva ve s el f-trea tment. Whi ch of the fol l owi ng i s the bes t next s tep i n ma na gement? a . Pres cri be Di tropa n (oxybutyni n chl ori de). b. Pres cri be es trogen thera py. c. Schedul e a retropubi c s us pens i on of the bl a dder neck. d. Refer her to a urol ogi s t for urethra l di l a ti on. e. Schedul e a voi di ng cys tourethrogra m. 415. An 18-yea r-ol d G0 comes to s ee you compl a i ni ng of a 3-da y hi s tory of uri na ry frequency, urgency, a nd dys uri a . She pa ni cked thi s morni ng when s he no ced the pres ence of bri ght red bl ood i n her uri ne. She a l s o reports s ome mi dl i ne l ower a bdomi na l di s comfort. She ha d i ntercours e for the firs t me 5 da ys a go a nd reports tha t s he us ed condoms . On phys i ca l exa mi na on, there a re no l a cera ons of the externa l geni ta l i a , there i s no di s cha rge from the cervi x or i n the va gi na , a nd the cervi x a ppea rs norma l . Bi ma nua l exa mi na on i s norma l except for mi l d s upra pubi c tendernes s . There i s no fl a nk tendernes s , a nd the pa ti ent’s tempera ture i s norma l . Whi ch of the fol l owi ng i s the mos t l i kel y di a gnos i s ? a . Chl a mydi a cervi ci ti s b. Pyel onephri ti s c. Acute cys ti ti s d. Acute a ppendi ci ti s e. Moni l i a l va gi ni ti s 416. A 28-yea r-ol d woma n pres ents to your office wi th s ymptoms of a uri na ry tra ct i nfec on. Thi s i s her s econd i nfec on i n 2 months . You trea ted the l a s t i nfec on wi th Ba ctri m DS for 3 da ys . Her s ymptoms never rea l l y i mproved. Now s he ha s wors eni ng l ower a bdomi na l di s comfort, dys uri a , a nd frequency. She ha s ha d no fever or fla nk pa i n. Phys i ca l exa mi na on s hows onl y mi l d s upra pubi c tendernes s . Whi ch of the fol l owi ng i s the bes t next s tep i n the eva l ua ti on of thi s pa ti ent? a . Uri ne cul ture b. Intra venous pyel ogra m c. Cys tos copy d. Wet s mea r e. CT s ca n of the a bdomen wi th contra s t 417. You ha ve di a gnos ed a hea l thy, s exua l l y a c ve 24-yea r-ol d fema l e pa ent wi th a n uncompl i ca ted a cute uri na ry tra ct i nfec on. Whi ch of the fol l owi ng i s the l i kel y orga ni s m res pons i bl e for thi s pa ti ent’s i nfecti on? a . Chl a mydi a b. Ps eudomona s c. Kl ebs i el l a d. Escherichia coli e. Candida albicans 418. A 32-yea r-ol d woma n pres ents to your office wi th dys uri a , uri na ry frequency, a nd uri na ry urgency for 24 hours . She i s hea l thy but i s a l l ergi c to s ul fa drugs . Uri na l ys i s s hows l a rge bl ood, l eukocytes , a nd ni tri tes i n her uri ne. Whi ch of the fol l owi ng medi ca ons i s the bes t to trea t thi s pa ti ent’s condi ti on? a . Di cl oxa ci l l i n b. Ba ctri m c. Ni trofura ntoi n d. Azi thromyci n e. Fl a gyl 419. You a re s eei ng a pa ent i n the emergency room who compl a i ns of fever, chi l l s , fla nk pa i n, a nd bl ood i n her uri ne. She ha s ha d s evere na us ea a nd s ta rted vomi ng a er the fever devel oped. She wa s di a gnos ed wi th a uri na ry tra ct i nfec on 3 da ys a go by her pri ma ry ca re phys i ci a n. The pa ent never took the a n bi o cs tha t s he wa s pres cri bed beca us e her s ymptoms i mproved a er s he s ta rted dri nki ng cra nberry jui ce. The pa ent ha s a tempera ture of 38.8°C (102°F). She ha s s evere ri ght-s i ded CVA tendernes s . She ha s s evere s upra pubi c tendernes s . Her cl ea n-ca tch uri na l ys i s s hows a l a rge a mount of ketones , RBCs , WBCs , ba cteri a , a nd s qua mous cel l s . Whi ch of the fol l owi ng i s the mos t a ppropri a te next s tep i n the ma na gement of thi s pa ti ent? a . Tel l her to ta ke the ora l a nti bi oti cs tha t s he wa s pres cri bed a nd gi ve her a pres cri pti on of Phenerga n recta l s uppos i tori es . b. Admi t the pa ti ent for IV fl ui ds a nd IV a nti bi oti cs . c. Admi t the pa ti ent for di a gnos ti c l a pa ros copy. d. Admi t the pa ti ent for a n i ntra venous pyel ogra m a nd cons ul ta ti on wi th a urol ogi s t. e. Arra nge for a home hea l th a gency to go to the pa ti ent’s home to a dmi ni s ter IV fl ui ds a nd ora l a nti bi oti cs .

420. A 22-yea r-ol d woma n ha s been s eei ng you for trea tment of recurrent uri na ry tra ct i nfec ons over the pa s t 6 months . She ma rri ed 6 months a go a nd beca me s exua l l y a c ve a t tha t me. She s eems to become s ymptoma c s hortl y a er ha vi ng s exua l i ntercours e. Whi ch of the fol l owi ng i s the mos t a ppropri a te recommenda ti on for thi s pa ti ent to hel p her wi th her probl em? a . Refer her to a urol ogi s t. b. Schedul e a n IVP. c. Pres cri be prophyl a cti c uri na ry a nti s pa s modi c. d. Pres cri be a nti bi oti c s uppres s i on. e. Recommend us e of condoms to prevent recurrence of the UTIs .

Pelvic Relaxation and Urology Answers 391. The answer is b. (Schorge, pp 512-514.) Stres s i ncon nence i s the i nvol unta ry l os s of uri ne when i ntra ves i ca l pres s ure exceeds the ma xi mum urethra l pres s ure i n the a bs ence of detrus or a c vi ty. The mos t common ca us e of uri na ry i ncon nence i s i ncompetence of the urethra l s phi ncter, termed s tres s uri na ry i ncon nence. The other ma jor ca us e of i ncon nence i s urge i ncon nence. Wi th urge i ncon nence, the bl a dder l ea ks uri ne due to i nvol unta ry, uni nhi bi ted detrus or contra c ons of grea ter tha n 15 cm H 2 O wi th s i mul ta neous urethra l rel a xa on. Other ca us es of uri na ry i ncon nence a re l es s common a nd i ncl ude overflow s econda ry to uri na ry reten on, congeni ta l a bnorma l i es , i nfec ons , fis tul a s , a nd urethra l di ver cul a . Urethra l di ver cul a cl a s s i ca l l y pres ent wi th dri bbl i ng i ncon nence a er voi di ng. Func ona l i ncon nence occurs when a pa ent ca nnot rea ch the toi l et i n ti me due to phys i ca l , cogni ti ve, or ps ychol ogi ca l l i mi ta ti ons . 392. The answer is d. (Schorge, pp 512-514.) As a pa ent a ges , the i nci dence of urge i ncon nence i ncrea s es dra ma ca l l y. Al though es trogen ha s been reported to decrea s e urgency, frequency, a nd nocturi a i n menopa us a l women, i ts effect on correc on of s tres s uri na ry i ncon nence or urge i ncon nence i s uncl ea r. In the el derl y popul a on there a re a l s o ma ny tra ns i ent ca us es of i ncon nence tha t the phys i ci a n s houl d cons i der. Thes e i ncl ude demen a , medi ca ons (es peci a l l y α-a drenergi c bl ockers ), decrea s ed pa ent mobi l i ty, endocri ne a bnorma l i es (hyperca l cemi a , hypothyroi di s m), s tool i mpa cti on, a nd uri na ry tra ct i nfecti ons . 393. The answer is d. (Schorge, p 553.) Ma ny pa ents who ha ve uteri ne prol a ps e or a l a rge protubera nt cys tocel e wi l l be con nent beca us e of urethra l obs truc on ca us ed by the cys tocel e or prol a ps e. In fa ct, a t mes thes e pa ents ma y need to reduce the prol a ps e i n order to voi d. Fol l owi ng s urgi ca l repa i r, i f the urethroves i ca l junc on i s not properl y el eva ted, s tres s uri na ry i ncon nence ma y res ul t. Thi s i ncon nence ma y pres ent wi thi n the firs t few da ys to weeks fol l owi ng s urgery. Rectova gi na l fis tul a woul d pres ent wi th pa s s a ge of s tool from va gi na . Ves i cova gi na l fi s tul a woul d pres ent wi th conti nuous l ea ka ge of uri ne from the va gi na . Detrus or i ns ta bi l i ty woul d ha ve been pres ent pri or to her s urgery. 394. The answer is a. (Schorge, p 522.) When pa ents pres ent wi th uri na ry i ncon nence, a uri na l ys i s a nd cul ture s houl d be performed to eva l ua te for a cute or i nters a l cys s . In pa ents di a gnos ed wi th a uri na ry tra ct i nfec on, trea tment s houl d be i ni a ted a nd then the pa ent s houl d be reeva l ua ted. It i s not uncommon for s ymptoms of uri na ry l ea ka ge to res ol ve a er a ppropri a te thera py. A er obta i ni ng the hi s tory a nd phys i ca l exa mi na on a nd eva l ua ng a uri na l ys i s a nd uri ne cul ture, i ni a l eva l ua on of the i ncon nent pa ent i ncl udes a cys tometrogra m, check for res i dua l uri ne vol ume, s tres s tes t, a nd uri na ry di a ry. A cys tometrogra m i s a tes t tha t determi nes urethra l a nd bl a dder pres s ures a s a func on of bl a dder vol ume; a l s o noted a re the vol umes a nd pres s ures when the pa ent firs t ha s the s ens a on of need to voi d, when ma xi ma l bl a dder ca pa ci ty i s rea ched, a nd s o on. Res i dua l uri ne vol ume i s determi ned by bl a dder ca theteri za on a er the pa ent ha s voi ded; when uri ne rema i ns a fter voi di ng, i nfecti on a nd i nconti nence ma y res ul t. 395. The answer is c. (Schorge, pp 554-559.) The mos t common ca us e of feca l i ncon nence i s obs tetri c tra uma wi th i na dequa te repa i r. The recta l s phi ncter ca n be compl etel y l a cera ted, but a s l ong a s the pa ent reta i ns a func ona l puborecta l i s s l i ng, a hi gh degree of con nence wi l l be ma i nta i ned. Genera l l y, the pa ent i s con nent of formed s tool but not of fla tus . Other ca us es of feca l i ncon nence i ncl ude s eni l i ty, centra l nervous s ys tem (CNS) di s ea s e, recta l prol a ps e, di a betes , chroni c di a rrhea , a nd i nfla mma tory bowel di s ea s e. Whi l e recta l prol a ps e, CNS di s ea s e, a nd s eni l i ty a re thus poten a l ca us es of thi s condi on, they ca n be excl uded by the hi s tory of the pa ent i n the ques on. Approxi ma tel y 20% of a l l di a be cs compl a i n of feca l i ncon nence. Thera py for feca l i ncon nence i ncl udes bul k-formi ng a nd a n s pa s modi c a gents , es peci a l l y i n thos e pa ti ents pres enti ng wi th di a rrhea . Al l ca ffei na ted bevera ges s houl d be s topped. Bi ofeedba ck a nd el ectri ca l s ti mul a ti on of the recta l s phi ncter a re other pos s i bl e cons erva ve trea tments . Surgi ca l repa i r of a defect i s i ndi ca ted when cons erva ve mea s ures fa i l , when the defect i s l a rge, or when s ymptoms wa rra nt a more a ggres s i ve trea tment a pproa ch. 396. The answer is a. (Schorge, p 549.) Pa r a l col pocl ei s i s by the Le Fort procedure i s rea s ona bl e for el derl y pa ents who a re not good ca ndi da tes for va gi na l hys terectomy a nd a nteri or a nd pos teri or (A&P) repa i r a s trea tment for va gi na l a nd uteri ne prol a ps e. The techni que i nvol ves pa r a l denuda on of oppos i ng s urfa ces of the va gi na l mucos a fol l owed by s urgi ca l a ppos i on, thereby res ul ng i n pa r a l obl i tera on of the va gi na . Pa ents who a re ca ndi da tes for thi s procedure mus t ha ve no evi dence of cervi ca l dys pl a s i a or endometri a l hyperpl a s i a , ha ve a n a trophi c endometri um, a nd no l onger des i re s exua l func on s i nce the va gi na i s es s en a l l y obl i tera ted a nd there i s no l onger a cces s to the cervi x or uterus vi a the va gi na . Uri na ry i ncon nence ca n be a s i de effect of thi s procedure, s o ca re mus t be exerci s ed i n the denuda on of va gi na l mucos a nea r the bl a dder. In a pa ent who a l rea dy ha s uri na ry i ncon nence, the Le Fort opera on woul d be rel a vel y contra i ndi ca ted. An A&P repa i r es s en a l l y i nvol ves exci s i on of redunda nt mucos a a l ong the a nteri or a nd pos teri or wa l l s of the va gi na , a t the s a me me s trengtheni ng the va gi na l wa l l s by s uturi ng the l a tera l pa ra va gi na l fa s ci a together i n the mi dl i ne. 397. The answer is c. (Schorge, pp 512-514.) Al l the fa ctors men oned i n the ques on a re commonl y s een i n pa ents wi th geni ta l rel a xa on (wi th forma on of a n enterocel e, rectocel e, cys tocel e, or urethrocel e, a l one or i n combi na on) a nd uteri ne prol a ps e. Undoubtedl y, the mos t i mporta nt fa ctor i s the a ctua l qua l i ty of the s s ue i ts el f. There i s a much l ower i nci dence of uteri ne prol a ps e a nd enterocel e forma on i n bl a ck a nd As i a n pa ents i n compa ri s on wi th whi tes . Any fa ctors tha t i ncrea s e a bdomi na l pres s ure ca n a ggra va te or further deteri ora te the prol a ps e. Al though the a ctua l number of del i veri es i s proba bl y not i mporta nt, tra uma c del i veri es , es peci a l l y thos e i n whi ch the recta l s phi ncter i s l a cera ted or i mproperl y repa i red, ha ve been a s s oci a ted wi th pel vi c rel a xa ti on. Chroni c hypertens i on i s not a ri s k fa ctor for geni ta l prol a ps e. 398. The answer is b. (Schorge, pp 518, 528.) There a re ma ny procedures tha t wi l l provi de s ucces s ful correc on of s tres s uri na ry i ncon nence. One of

the a bdomi na l procedures tha t s ucces s ful l y cures s tres s i ncon nence i s the Ma rs ha l l -Ma rche -Kra ntz (MMK) procedure, whi ch i nvol ves the a a chment of the peri urethra l s s ue to the s ymphys i s pubi s . The l ong-term cure ra te for a n MMK procedure i s a round 80%. In a pproxi ma tel y 1% to 2% of pa ents undergoi ng the procedure, the pa i nful l y debi l i ta ng condi on of os tei s pubi s wi l l devel op. Trea tment of thi s a s ep c i nfla mma on of the s ymphys i s i s s ubop ma l , a nd the cours e i s us ua l l y chroni c. Uri na ry reten on a er a n MMK procedure occa s i ona l l y occurs , but the probl em us ua l l y res ol ves wi thi n 1 week. Short-term i ntermi ent or i ndwel l i ng ca theteri za on i s the trea tment for uri na ry reten on. Enterocel es ma y occur i n a pproxi ma tel y 5% of women who ha ve undergone the MMK procedure. In a ddi on to the s urgery, the pa ent i n ques on wi l l requi re medi ca l trea tment for her i nconti nence a s her preopera ti ve cys tometri cs s howed evi dence of detrus or i ns ta bi l i ty. 399. The answer is e. (Schorge, pp 576-582.) Urethra l di ver cul a occur i n 3% to 4% of a l l women. The typi ca l s ymptoms i ncl ude uri na ry frequency, urgency, dys uri a , hema turi a , a nd dys pa reuni a . Frequentl y, pa ents wi l l ha ve a hi s tory of frequent UTIs , dri bbl i ng, or i ncon nence. A urethra l di ver cul um i s o en pa l pa bl e a s a ma s s on the a nteri or va gi na l wa l l under the urethra . Al though urethra l pol yps , evers i on, fis tul a , a nd s tri cture ma y pres ent wi th s i mi l a r s ymptoms , there i s no s uburethra l ma s s pres ent. 400. The answer is c. (Schorge, p 860.) The pa ent mos t l i kel y ha s a uretera l i njury a t the l oca on of the l e uteri ne a rtery. A noni nva s i ve rena l ul tra s ound i s fa s t, i nexpens i ve, a nd a ccura te wa y to ma ke the di a gnos i s . Intra venous pyel ogra ms a l though us ed i n the pa s t a re outda ted tes ts a nd ha ve been repl a ced by us e of computed tomogra phy (CT). A CT s ca n wi th contra s t gi ves excel l ent i nforma on on the i ntegri ty a nd func on of the rena l col l ec ng s ys tem; however, when the s erum crea ni ne i s el eva ted, i ntra venous contra s t ca n ca us e s i gni fica nt rena l da ma ge a nd i s contra i ndi ca ted i n thos e ci rcums ta nces . A ches t x-ra y woul d not be hel pful i n ma ki ng the di a gnos i s . Intra venous a n bi o cs a re not i ndi ca ted a t thi s me s i nce there i s not cl ea r evi dence of a n i nfec on (norma l whi te bl ood cel l count). A uretera l i njury i ts el f wi l l ca us e a tempera ture el eva ti on. The pa ti ent ha s a norma l drop i n hemogl obi n for the s urgi ca l bl ood l os s a nd does not ha ve s i gns of hemodyna mi c i ns ta bi l i ty to wa rra nt a bl ood tra ns fus i on a t thi s ti me. 401. The answer is d. (Schorge, pp 522-525.) As a ca theter i s i ntroduced for performi ng a cys tometrogra m, mea s urement of res i dua l uri ne i s obta i ned. Duri ng the cys tometrogra m, a norma l firs t s ens a on i s of ful l nes s fel t a t 100 mL. Urge i s fel t a t a pproxi ma tel y 350 mL, wi th ma xi mum ca pa ci ty a t 450 mL. The pri ma ry rea s on to perform a cys tometrogra m i s to rul e out uni nhi bi ted detrus or contra c ons whi ch a re not pres ent i n women wi th genui ne s tres s uri na ry i nconti nence. The urethra l pres s ure profi l e i s norma l i n women wi th genui ne s tres s uri na ry i nconti nence. 402. The answer is b. (Schorge, pp 512-525.) Thi s pa ent’s hi s tory i s mos t cons i s tent wi th a di a gnos i s of uri na ry s tres s i ncon nence. Genui ne s tres s i ncon nence i s a condi on of i mmedi a te i nvol unta ry l os s of uri ne when i ntra ves i ca l pres s ure exceeds the ma xi mum urethra l pres s ure i n the a bs ence of detrus or a c vi ty. Pa ents wi th thi s condi on compl a i n of burs ts of uri ne l os s wi th phys i ca l a c vi ty or a cough, l a ugh, or s neeze. The ca us e of s tres s i ncon nence i s s tructura l , a ri buted to a cys tocel e or urethrocel e. In ca s es of overflow i ncon nence, pa ents experi ence a con nuous l os s of a s ma l l a mount of uri ne a nd a s s oci a ted s ymptoms of ful l nes s a nd pres s ure. Overflow i ncon nence i s us ua l l y ca us ed by obs truc on or l os s of neurol ogi c control . Women wi th detrus or i ns ta bi l i ty/dys s ynergi a ha ve a l os s of bl a dder i nhi bi on a nd compl a i n of urgency, frequency, a nd nocturi a . Ves i cova gi na l fis tul a s a re uncommon a nd us ua l l y occur a s a compl i ca on of beni gn gynecol ogi c procedures . Women wi th thi s compl i ca on us ua l l y pres ent wi th a pa i nl es s a nd con nuous l os s of uri ne from the va gi na . Some mes the uncontrol l ed l os s of uri ne i s not con nuous but rel a ted to a cha nge i n pos i on or pos ture. In the ca s e of uri na ry tra ct i nfec ons , women us ua l l y pres ent wi th s ymptoms of frequency, urgency, nocturi a , dys uri a , a nd hema turi a . 403. The answer is a. (Schorge, pp 520-522.) In thi s pa ti ent wi th pres umed uri na ry s tres s i nconti nence by hi s tory, the next s tep i n the eva l ua ti on woul d be the performa nce of a phys i ca l exa mi na on to document a cys tocel e, urethrocel e, or other evi dence of pel vi c rel a xa on. A uri ne cul ture, cys tos copy, a nd cys tometri cs ma y a l s o be pa rt of the workup for thi s pa ent’s chi ef compl a i nt, but the phys i ca l exa mi na on s houl d be the very next s tep. Pl a cement of a pes s a ry i s one of the trea tments for a cys tocel e, once the di a gnos i s ha s been ma de. 404. The answer is d. (Schorge, pp 527-528.) Surgi ca l thera py for s tres s uri na ry i ncon nence a ri buted to cys tocel e a nd l os s of urethra l s upport i nvol ves s us pens i on of the bl a dder neck vi a Kel l y pl i ca on, retropubi c s us pens i on (Ma rs ha l l -Ma rche -Kra ntz a nd Burch procedures ), or s l i ng procedures (Pereyra a nd Sta mey procedures or tra ns obtura tor or tra ns va gi na l ta pes ). Pl a cement of a pes s a ry i s a n opti on to rel i eve a cys tocel e, but i s not i dea l i n thi s pa ent, who i s s exua l l y a c ve. An bi o cs s uch a s Ba ctri m woul d be us ed to trea t a uri na ry tra ct i nfec on, but woul d not a ffect s tre s s i ncon nence. A Le Fort procedure i s performed i n pa ents wi th va gi na l va ul t prol a ps e a nd pel vi c rel a xa on who a re poor s urgi ca l ca ndi da tes a nd not s exua l l y a c ve. The procedure i nvol ves obl i tera ng the va gi na l ca na l to provi de s upport to the pel vi c s tructures . An chol i nergi c drugs s uch a s Di tropa n (oxybutyni n chl ori de) a re us ed to rel a x the bl a dder i n the trea tment of detrus or i ns ta bi l i ty. The us e of va gi na l es trogen crea m ma y rel i eve va gi na l a trophy a nd i mprove pa ent comfort i n pos tmenopa us a l pa ents , but i t wi l l not correct the cys tocel e or trea t i nconti nence. 405. The answer is e. (Schorge, pp 519-520.) Poorl y control l ed di a betes ca n res ul t i n neuropa thi es to va ri ous orga ns i ncl udi ng the bl a dder. Thi s ca n res ul t i n l os s of bl a dder s ens a on a nd s ubs equent overflow uri na ry i ncon nence. Di a betes i s not a ca us e of pel vi c rel a xa on. In pel vi c rel a xa on, there i s a l os s of connec ve s s ue s upport a dja cent to the reproduc ve tra ct orga ns a nd i n the peri neum. Na tura l a gi ng of the s s ue, i ntri ns i c wea knes s es ca us ed by gene cs , bi rth tra uma , hypoes trogeni s m, a nd chroni c el eva on of i ntra a bdomi na l pres s ure beca us e of obes i ty, cough, or hea vy l i fti ng a re a l l fa ctors tha t contri bute to pel vi c rel a xa ti on. 406. The answer is c. (Schorge, p 528.) A mi durethra l s l i ng procedure s uch a s the tra ns obtura tor ta pe or tra ns va gi na l ta pe pl a cement woul d be the mos t a ppropri a te s urgi ca l trea tment for s tres s uri na ry i ncon nence i n thi s pa ent. Kel l y pl i ca on i s a n ol der procedure us ed to s us pend the urethra a nd ha s a l ower cure ra te for s tres s i ncon nence tha n the Burch procedure. The Burch procedure s us pends the bl a dder neck to Cooper l i ga ment of the pubi c bone us i ng a n a bdomi na l a pproa ch. Anteri or a nd pos teri or col porrha phy a re procedures us ed to correct cys tocel es a nd rectocel es a nd a re not i ndi ca ted i n thi s pa ent. Sa cra l col popexy i s a procedure to repa i r prol a ps e of the va gi na by s us pendi ng the va gi na l va ul t from the s a crum. The mi durethra l s l i ng procedures a re mi ni ma l l y i nva s i ve requi ri ng onl y s ma l l va gi na l a nd s ki n i nci s i ons . Addi ona l l y they ma y be performed a s a n outpa ti ent procedure. 407. The answer is c. (Schorge, p 573.) Both ves i cova gi na l a nd ureterova gi na l fis tul a s a re compl i ca ons tha t occur ra rel y a er beni gn gynecol ogi c procedures . Seventy-five percent of fis tul a s occur a er a bdomi na l hys terectomi es a nd 25% occur a s a res ul t of va gi na l opera ons . Cl a s s i ca l l y, uri na ry tra ct fis tul a s pres ent wi th pa i nl es s a nd con nuous l os s of uri ne 8 to 12 da ys a er s urgery. Uri na ry tra ct i nfec ons a nd bl a dder dys s ynergi a pres ent wi th dys uri a , urgency, a nd frequency. Si nce thi s pa ent ha s no s ymptoms of s tres s i ncon nence, fa i l ure of the procedure woul d not be the correct a ns wer. 408. The answer is c. (Schorge, pp 535-536.) The degree or s everi ty of pel vi c rel a xa on i s ra ted on a s ca l e of 1 to 3, ba s ed on the des cent of the orga n or s tructure i nvol ved. Fi rs t-degree prol a ps e i nvol ves des cent l i mi ted to the upper two-thi rds of the va gi na . Second-degree prol a ps e i s pres ent when the s tructure i s a t the va gi na l i ntroi tus . In ca s es of thi rd-degree prol a ps e, the s tructure i s outs i de the va gi na . Tota l proci den a of the uterus

i s the s a me a s a thi rd-degree prol a ps e, whi ch mea ns tha t the uterus woul d be l oca ted outs i de the body. 409 to 410. The answers are 409-a, 410-b. (Schorge, pp 544-547.) Uteri ne prol a ps e tha t does not bother the pa ent or ca us e her a ny grea t di s comfort does not requi re trea tment. Thi s es peci a l l y a ppl i es to our pa ent, who i s el derl y a nd a poor s urgi ca l ca ndi da te. Pl a cement of a pes s a ry provi des mecha ni ca l s upport to pel vi c s s ue, whi l e hys terectomy a nd the Le Fort procedure a re s urgi ca l trea tments for prol a ps e. An a nteri or col porrha phy i s a s urgi ca l method to reduce a cys tocel e. Pes s a ri es provi de mecha ni ca l s upport for the pel vi c orga ns . Thes e devi ces come i n a va ri ety of s i zes a nd s ha pes a nd a re pl a ced i n the va gi na to provi de s upport. Pes s a ri es a re i dea l for pa ents who a re not good s urgi ca l ca ndi da tes . Thei r compl i ca ti ons i ncl ude va gi na l tra uma , necros i s , di s cha rge from i nfl a mma ti on, a nd uri na ry s tres s i nconti nence. 411. The answer is c. (Schorge, p 547.) Va gi na l va ul t prol a ps e occurs i n up to 18% of pa ents who ha ve undergone hys terectomy. Symptoms i ncl ude pel vi c pres s ure, ba cka che, a nd a ma s s protrudi ng from the va gi na . Dependi ng upon the dura on of the prol a ps e, the pa ent ma y a l s o ha ve va gi na l ul cera ons from the rubbi ng of the prol a ps ed va gi na a ga i ns t the underga rments . Thi s pa ent i s a poor s urgi ca l ca ndi da te gi ven her mul pl e medi ca l probl ems ; therefore a bdomi na l s a cra l col popexy i s contra i ndi ca ted. For the s a me rea s ons s he s houl d not be gi ven ora l es trogen trea tment. The preferred trea tment i s to pl a ce a pes s a ry to prevent the va gi na from rubbi ng a ga i ns t cl othi ng. The pa ent s houl d a l s o a ppl y a topi ca l es trogen crea m to the l es i on a nd the prol a ps ed va gi na to hel p wi th hea l i ng of the ul cer. If the ul cer does not res ol ve, bi ops y i s i ndi ca ted. 412 to 414. The answers are 412-d, 413-c, 414-a. (Schorge, pp 518-526.) The pres enta on of the pa ent i n ques on 412 i s mos t cons i s tent wi th urge i ncon nence. Urge i ncon nence i s the i nvol unta ry l os s of uri ne a s s oci a ted wi th a s trong des i re to voi d. Mos t urge i ncon nence i s ca us ed by detrus or or bl a dder dys s ynergi a i n whi ch there i s a n i nvol unta ry contra c on of the bl a dder duri ng di s tens i on wi th uri ne. The i ni a l ma na gement of pa ents s uch a s the one i n ques on 413 urge i ncl udes bl a dder tra i ni ng, el i mi na on of exces s ca ffei ne a nd flui d i nta ke, bi ofeedba ck, or medi ca l thera py. If cons erva ve mea s ures fa i l , a s i n the pa ent i n ques on 414, trea tment wi th a n chol i nergi c drugs (oxybutyni n chl ori de), βs ympa thomi me c a goni s ts (meta proterenol s ul fa te), Va l i um, a n depres s a nts (i mi pra mi ne hydro-chl ori de), a nd dopa mi ne a goni s ts (Pa rl odel ) ha ve been s ucces s ful . Thes e pha rma col ogi c a gents wi l l rel a x the detrus or mus cl e. In pos tmenopa us a l women who a re not on es trogen repl a cement thera py, es trogen thera py ma y i mprove uri na ry control . Kegel exerci s es ma y s trengthen the pel vi c mus cul a ture a nd i mprove bl a dder control i n women wi th s tres s uri na ry i nconti nence. 415 to 420. The answers are 415-c, 416-a, 417-d, 418-c, 419-b, 420-d. (Schorge, pp 70-72.) Approxi ma tel y 15% to 20% of women devel op uri na ry tra ct i nfec ons (cys s ) a t s ome poi nt duri ng thei r l i ves . Cys s i s di a gnos ed when a cl ea n-ca tch uri ne s a mpl e ha s a concentra on of a t l ea s t 100,000 ba cteri a per mL of uri ne a nd when the pa ent s uffers the s ymptoms of dys uri a , frequency, urgency, a nd pa i n. The mos t common e ol ogy of uri na ry tra ct i nfec ons (UTIs ) i s E coli. Trea tment of a UTI i nvol ves obta i ni ng a cul ture a nd s ta r ng a pa ent on a n a n bi o c regi men of s ul fa or ni trofura ntoi n, whi ch ha ve good covera ge a ga i ns t E coli a nd a re rel a vel y i nexpens i ve. Pa ents trea ted for a UTI s houl d ha ve a fol l ow-up cul ture done 10 to 14 da ys a er the i ni a l di a gnos i s to document a cure. Pa ents trea ted for a UTI, who ha ve pers i s tent s ymptoms a er trea tment s houl d ha ve a uri ne cul ture performed to eva l ua te for the pres ence of res i s ta nt orga ni s ms . Pa ents wi th a cute pyel onephri s ma y be trea ted on a n outpa ent ba s i s unl es s they ca nnot tol era te ora l a n bi o c thera py or s how evi dence of s eps i s . Women who experi ence recurrent UTIs wi th i ntercours e benefit from voi di ng i mmedi a tel y a er i ntercours e. If thi s trea tment method fa i l s , then prophyl a c c trea tment wi th a n a n bi o c effecti ve a ga i ns t E coli ma y hel p prevent recurrent UTIs . Uri na ry a nti s pa s modi cs do not prevent i nfecti on.

Human Sexuality and Contraception Questions 421. A 20-yea r-ol d G0 a nd her pa rtner, a 20-yea r-ol d ma n, pres ent for couns el i ng for s exua l dys func on. Pri or to thei r rel a ons hi p, nei ther ha d been s exua l l y a c ve. Both deny a ny medi ca l probl ems . In medi ca l experi ence, whi ch type of ma l e or fema l e s exua l dys func on ha s the l owes t cure ra te? a . Prema ture eja cul a ti on b. Va gi ni s mus c. Pri ma ry i mpotence d. Seconda ry i mpotence e. Fema l e orga s mi c dys functi on 422. A 28-yea r-ol d G3P3 pres ents to your office for contra cep ve couns el i ng. She deni es a ny medi ca l probl ems or s exua l l y tra ns mi ed di s ea s es . You couns el her on the ri s ks a nd benefits of a l l contra cep ve methods . Whi ch of the fol l owi ng i s the mos t common form of contra cep on us ed by reproducti ve-a ge women i n the Uni ted Sta tes ? a . Pi l l s b. Condom c. Di a phra gm d. Intra uteri ne devi ce (IUD) e. Steri l i za ti on 423. A 21-yea r-ol d woma n pres ents to your office for her wel l -woma n exa mi na on. She ha s recentl y become s exua l l y a c ve a nd des i res a n effecti ve contra cepti ve method. She ha s no medi ca l probl ems , but fa mi l y hi s tory i s s i gni fi ca nt for brea s t ca ncer i n a ma terna l a unt a t the a ge of 42. She i s worri ed a bout ge ng ca ncer from ta ki ng bi rth control pi l l s . You di s cus s wi th her the ri s ks a nd benefits of contra cep ve pi l l s . You tel l her tha t whi ch of the fol l owi ng neopl a s ms ha s been a s s oci a ted wi th the us e of ora l contra cepti ves ? a . Brea s t ca ncer b. Ova ri a n ca ncer c. Endometri a l ca ncer d. Hepa ti c ca ncer e. Hepa ti c a denoma 424. A 39-yea r-ol d G3P3 pres ents for her pos tpa rtum exa mi na on a nd des i res a l ong-term contra cep ve method, but i s uns ure i f s he wa nts s teri l i za on. She ha s been ha ppi l y ma rri ed for 15 yea rs a nd deni es a ny s exua l l y tra ns mi ed di s ea s es . Her pa s t medi ca l hi s tory i s s i gni fica nt for mi l d hypertens i on, for whi ch s he ta kes a l ow-dos e di ure c. She i s cons i deri ng the copper i ntra uteri ne devi ce a nd wa nts to know how i t works . Whi ch of the fol l owi ng i s the bes t expl a na ti on for the mecha ni s m of the a cti on of the copper i ntra uteri ne devi ce (IUD)? a . Decrea s ed tuba l moti l i ty i nhi bi ts ovum tra ns port. b. Chroni c ba cteri a l endometri ti s i nterferes wi th i mpl a nta ti on. c. Prema ture endometri a l s l oughi ng a s s oci a ted wi th menorrha gi a ca us es ea rl y a borti on. d. An i nfl a mma tory res pons e wi thi n the endometri um ki l l s s perm. e. Thi ckened cervi ca l mucus bl ocks s perm tra ns port. 425. A 21-yea r-ol d G0 pres ents to your office beca us e her mens es i s 2 weeks l a te. She s ta tes tha t s he i s ta ki ng her bi rth control pi l l s correctl y; s he ma y ha ve mi s s ed a da y a t the begi nni ng of the pa ck, but took i t a s s oon a t s he remembered. She deni es a ny medi ca l probl ems , but 3 or 4 weeks a go s he ha d a “vi ra l s toma ch flu” a nd mi s s ed 2 da ys of work for na us ea , vomi ng, a nd di a rrhea . Her cycl es a re us ua l l y regul a r even wi thout contra cep ve pi l l s . She ha s been on the pi l l for 5 yea rs a nd recentl y devel oped s ome mi dcycl e bl eedi ng, whi ch us ua l l y l a s ts a bout 2 da ys . She ha s been s exua l l y a c ve wi th the s a me pa rtner for the pa s t 3 months a nd ha s a hi s tory of chl a mydi a 3 yea rs a go. She ha s ha d a tota l of 10 s exua l pa rtners . A uri ne pregna ncy tes t i s pos i ve. Whi ch of the fol l owi ng i s the ma jor ca us e of unpl a nned pregna nci es i n women us i ng ora l contra cepti ves ? a . Brea kthrough ovul a ti on a t mi dcycl e b. Hi gh frequency of i ntercours e c. Incorrect us e of ora l contra cepti ves d. Ga s troi ntes ti na l ma l a bs orpti on e. Devel opment of a nti bodi es 426. An i ntra uteri ne pregna ncy of a pproxi ma tel y 10 weeks ges ta on i s confirmed i n a 30-yea r-ol d G5P4 woma n wi th a n IUD i n pl a ce. The pa ent expres s es a s trong des i re for the pregna ncy to be con nued. On exa mi na on, the s tri ng of the IUD i s noted to be protrudi ng from the cervi ca l os . Whi ch of the fol l owi ng i s the mos t a ppropri a te cours e of a cti on? a . Lea ve the IUD i n pl a ce wi thout a ny other trea tment. b. Lea ve the IUD i n pl a ce a nd conti nue prophyl a cti c a nti bi oti cs throughout pregna ncy. c. Remove the IUD i mmedi a tel y. d. Termi na te the pregna ncy beca us e of the hi gh ri s k of i nfecti on. e. Perform a l a pa ros copy to rul e out a heterotopi c ectopi c pregna ncy. 427. A 34-yea r-ol d G1P1 wi th a hi s tory of pul mona ry embol i s m pres ents to your office to di s cus s contra cep on. Her cycl es a re regul a r. She ha s a hi s tory of pel vi c i nfla mma tory di s ea s e l a s t yea r, for whi ch s he wa s hos pi ta l i zed. She ha s currentl y been s exua l l y a c ve wi th the s a me pa rtner for the pa s t yea r. She wa nts to us e condoms a nd a s permi ci de. You couns el her on the ri s ks a nd benefits . Whi ch of the fol l owi ng s ta tements i s true rega rdi ng s permi ci des found i n va gi na l foa ms , crea ms , a nd s uppos i tori es ? a . The a cti ve a gent i n s permi ci des i s nonoxynol -9. b. Spermi ci des a re protecti ve a ga i ns t s exua l l y tra ns mi tted i nfecti ons .

c. Effecti venes s i s hi gher i n younger us ers . d. Effecti venes s i s hi gher tha n tha t of the di a phra gm. e. Thes e a gents a re a s s oci a ted wi th a n i ncrea s ed i nci dence of congeni ta l ma l forma ti ons . 428. A 32-yea r-ol d woma n pres ents to your office for her wel l -woma n exa mi na on. She i s a l s o worri ed beca us e s he ha s not been a bl e to a chi eve orga s m wi th her new pa rtner, wi th whom s he ha s ha d a rel a ons hi p for the pa s t 3 months . She ha d three pri or s exua l pa rtners a nd a chi eved orga s m wi th them. Her medi ca ons i ncl ude a combi ned ora l contra cep ve pi l l for bi rth control , cl oni di ne for chroni c hypertens i on, a nd fluoxe ne for depres s i on. She s mokes one pa ck per da y a nd dri nks one dri nk per week. She ha d a cervi ca l cone bi ops y for s evere cervi ca l dys pl a s i a 6 months a go. Whi ch of the fol l owi ng i s the mos t l i kel y ca us e of her s exua l dys functi on? a . Al cohol b. Bi rth control pi l l s c. Cl oni di ne d. Di s rupti on of cervi ca l nerve pa thwa ys e. Fl uoxeti ne f. Ni coti ne 429. A 22-yea r-ol d woma n pres ents to your office for a wel l -woma n exa mi na on. She ha s been s exua l l y a c ve wi th one ma l e pa rtner for the pa s t yea r. She ha s not a chi eved orga s m wi th her pa rtner. On further ques oni ng, s he ha s never a chi eved orga s m wi th other pa rtners or wi th ma s turba ti on or the us e of a vi bra tor. Whi ch of the fol l owi ng s ta tements i s true rega rdi ng her condi ti on? a . It i s unrel a ted to pa rtner beha vi or. b. The i nfl uence of rel i gi ous bel i efs i s a ma jor eti ol ogy. c. It i s unrel a ted to pa rtner’s s exua l performa nce. d. It i s not a s s oci a ted wi th a hi s tory of ra pe. e. It a l wa ys ha s a n underl yi ng phys i ca l eti ol ogy. 430. A 23-yea r-ol d woma n pres ents to your office wi th the compl a i nt of a red s pl otchy ra s h on her ches t tha t occurs duri ng i ntercours e. It i s nonpuri c a nd pa i nl es s . She s ta tes tha t i t us ua l l y res ol ves wi thi n a few mi nutes to a few hours a er i ntercours e. Whi ch of the fol l owi ng i s the mos t l i kel y ca us e of the ra s h? a . Al l ergi c rea cti on to her pa rtner’s pheromones b. Decrea s ed s ys tol i c bl ood pres s ure duri ng the pl a tea u pha s e c. Increa s ed es trogen duri ng the exci tement pha s e d. Va s oconges ti on duri ng the exci tement pha s e e. Va s ocons tri cti on duri ng the orga s mi c pha s e 431. A 19-yea r-ol d woma n pres ents for vol unta ry termi na on of pregna ncy 8 weeks a er her expected (mi s s ed) mens es . She previ ous l y ha d regul a r mens es every 28 da ys . Pregna ncy i s confirmed by β -huma n chori oni c gona dotropi n (β-hCG), a nd ul tra s ound confirms expected ges ta ona l a ge. Whi ch of the fol l owi ng techni ques for termi na ti on of pregna ncy woul d be s a fe a nd effecti ve i n thi s pa ti ent a t thi s ti me? a . Di l a ti on a nd eva cua ti on (D&E) b. Hypertoni c s a l i ne i nfus i on c. Sucti on di l a ti on a nd curetta ge (D&C) d. Mi s opros tol e. Hys terotomy 432. A 48-yea r-ol d woma n pres ents to your office wi th the compl a i nt of va gi na l drynes s duri ng i ntercours e. She deni es a ny medi ca l probl ems or pri or s urgeri es a nd does not ta ke a ny medi ca ons . She s l l ha s regul a r mens trua l cycl es every 28 da ys . She deni es a ny s exua l l y tra ns mi ed di s ea s es . She des cri bes her s exua l rel a ons hi p wi th her hus ba nd a s s a s fyi ng. Her phys i ca l exa mi na on i s norma l . Components of the na tura l l ubri ca ti on produced by the fema l e duri ng s exua l a rous a l a nd i ntercours e i ncl ude whi ch of the fol l owi ng? a . Fl ui d from Skene gl a nds b. Mucus produced by endocervi ca l gl a nds c. Vi s cous fl ui d from Ba rthol i n gl a nds d. Tra ns uda te-l i ke ma teri a l from the va gi na l wa l l s e. Uterotuba l fl ui d 433. A 62-yea r-ol d woma n pres ents for a nnua l exa mi na on. Her l a s t s ponta neous mens trua l peri od wa s 9 yea rs a go, a nd s he ha s been rel ucta nt to us e pos tmenopa us a l hormone repl a cement beca us e of a s trong fa mi l y hi s tory of brea s t ca ncer. She now compl a i ns of di mi ni s hed i nteres t i n s exua l a cti vi ty. Whi ch of the fol l owi ng i s the mos t l i kel y ca us e of her compl a i nt? a . Decrea s ed va gi na l l ength b. Decrea s ed ova ri a n functi on c. Al i ena ti on from her pa rtner d. Untrea ta bl e s exua l dys functi on e. Phys i ol ogi c a norga s mi a 434. A 22-yea r-ol d nul l i pa rous woma n ha s recentl y become s exua l l y a cti ve. She cons ul ts you beca us e of pa i nful coi tus , wi th the pa i n l oca ted a t the va gi na l i ntroi tus . It i s a ccompa ni ed by pa i nful i nvol unta ry contra c on of the pel vi c mus cl es . Other tha n confirma on of thes e findi ngs , the pel vi c exa mi na ti on i s norma l . Whi ch of the fol l owi ng i s the mos t common ca us e of thi s condi ti on? a . Endometri os i s b. Ps ychogeni c ca us es c. Ba rthol i n gl a nd a bs ces s d. Vul va r a trophy e. Ova ri a n cys t 435. A 23-yea r-ol d woma n pres ents for her pos tpa rtum vi s i t a nd contra cep on ma na gement. She del i vered by s ponta neous va gi na l del i very 6 weeks a go a nd i s brea s eedi ng. A er revi ewi ng her hi s tory a nd performi ng phys i ca l exa mi na on, you di s cus s the va ri ous methods of contra cep on wi th the pa ent. She opts for depot medroxyproges terone a ceta te (DepoProvera ). Whi ch of the fol l owi ng i s a di s a dva nta ge of DepoProvera ?

a . Impa i rment of l a cta ti on b. Increa s ed ri s k of hepa ti c ca ncer c. Iron-defi ci ency a nemi a d. Irrevers i bl e bone l os s e. Prol onged a novul a ti on 436. A 36-yea r-ol d woma n pres ents to your office for contra cep on. She ha s ha d three va gi na l del i veri es wi thout compl i ca ons . Her medi ca l hi s tory i s s i gni fica nt for hypertens i on, wel l -control l ed wi th a di ure c, a nd a s ei zure di s order. Her l a s t s ei zure wa s 12 yea rs a go. Currentl y s he does not ta ke a ny a n epi l ep c medi ca ons . She a l s o compl a i ns of s tres s -rel a ted hea da ches tha t a re rel i eved wi th a n over-the-counter pa i n medi ca on. She deni es a ny hi s tory of s urgeri es . She i s di vorced, s mokes one pa ck of ci ga re es per da y, a nd ha s three to four a l cohol i c dri nks per week. On exa mi na on, her vi ta l s i gns i ncl ude wei ght 90 kg, bl ood pres s ure 126/80 mm Hg, pul s e 68 bea ts per mi nute, res pi ra tory ra te 16 brea ths per mi nute, a nd tempera ture 36.4°C (97.6°F). Her exa mi na ti on i s norma l except for s ome l ower extremi ty nontender va ri cos i ti es . She ha s ta ken bi rth control pi l l s i n the pa s t a nd wa nts to res ta rt them beca us e they hel p wi th her cra mps . Whi ch of the fol l owi ng woul d contra di ct the us e of combi na ti on ora l contra cepti ve pi l l s i n thi s pa ti ent? a . Va ri cos e vei ns b. Tens i on hea da che c. Sei zure di s orders d. Smoki ng i n a woma n over 35 yea rs of a ge e. Mi l d es s enti a l hypertens i on 437. A 30-yea r-ol d woma n pres ents for a phys i ca l exa mi na on for work. She deni es a ny medi ca l probl ems or s urgeri es i n the pa s t. She ha s ha d no pregna nci es . She i s s exua l l y a c ve a nd ha s been us i ng ora l contra cep ve pi l l s for the pa s t 6 yea rs . She deni es a ny a l l ergi es to medi ca ons . On exa mi na on, her wei ght i s 62 kg, bl ood pres s ure 120/78 mm Hg, pul s e 76 bea ts per mi nute, res pi ra tory ra te 15 brea ths per mi nute, tempera ture 36.8°C (98.4°F). Her phys i ca l exa mi na on i s norma l . Whi ch of the fol l owi ng i s a known benefit of combi na on es trogen pl us proges n ora l contra cepti ves ? a . Decrea s ed a cti vi ty of rheuma toi d a rthri ti s b. Decrea s ed ri s k of brea s t ca ncer c. Decrea s ed ri s k of cervi ca l dys pl a s i a d. Decrea s ed tri gl yceri de l evel s e. Decrea s ed ri s k of ga l l bl a dder di s ea s e 438. A 32-yea r-ol d woma n pres ents to your offi ce to di s cus s contra cepti on. She ha s recentl y s topped brea s t-feedi ng her 8-month-ol d s on a nd wa nts to s top her proges n-onl y pi l l beca us e her cycl es a re i rregul a r on i t. You recommend a combi na on pi l l to hel p regul a te her cycl e. You a l s o men on tha t wi th es trogen a dded, the contra cep ve effica cy i s a l s o hi gher. In combi na on bi rth control pi l l s , whi ch of the fol l owi ng i s the pri ma ry contra cepti ve effect of the es trogeni c component? a . Convers i on of ethi nyl es tra di ol to mes tra nol b. Atrophy of the endometri um c. Suppres s i on of cervi ca l mucus s ecreti on d. Suppres s i on of l utei ni zi ng hormone (LH) s ecreti on e. Suppres s i on of fol l i cl e-s ti mul a ti ng hormone (FSH) s ecreti on 439. A 22-yea r-ol d woma n pres ents to your office for her wel l -woma n exa mi na on a nd contra cep on. She ha s no medi ca l probl ems or pri or s urgeri es . She does not s moke or dri nk. Her vi ta l s i gns a nd phys i ca l exa mi na on a re norma l . You expl a i n the ri s ks a nd benefits of combi na on ora l contra cep ve pi l l s to the pa ent. She wa nts to know how they wi l l keep her from ge ng pregna nt. Whi ch of the fol l owi ng mecha ni s ms bes t expl a i ns the contra cepti ve effect of bi rth control pi l l s tha t conta i n both s yntheti c es trogen a nd proges ti n? a . Di rect i nhi bi ti on of oocyte ma tura ti on b. Inhi bi ti on of ovul a ti on c. Producti on of uteri ne s ecreti ons tha t a re toxi c to devel opi ng embryos d. Impa i rment of i mpl a nta ti on hyperpl a s ti c cha nges of the endometri um e. Impa i rment of s perm tra ns port ca us ed by uterotuba l obs tructi on 440. Fi ve pa ents pres ent for contra cep ve couns el i ng, ea ch reques ng tha t a n IUD be i ns erted. Whi ch of the fol l owi ng i s a contra i ndi ca on to the us e of a n IUD? a . Abnorma l i ti es of the uterus res ul ti ng i n di s torti on of the ca vi ty b. Chori oa mni oni ti s duri ng pregna ncy 6 months a go c. Hi s tory of Chl a mydi a i nfecti on trea ted 4 months a go d. Hi s tory of l oop el ectroca utery exci s i on procedure of the cervi x e. Hi s tory of recurrent ca ndi da vul vi ti s 441. A 30-yea r-ol d woma n pres ents to your office for her wel l -woma n exa mi na on a nd contra cep on. She ha s two pri or va gi na l del i veri es wi thout a ny compl i ca ons . Her medi ca l hi s tory i s s i gni fica nt for deep venous thrombos i s i n her ri ght l eg a er her l a s t del i very. Her fa mi l y hi s tory i s s i gni fica nt for corona ry hea rt di s ea s e i n her fa ther a nd brea s t ca ncer i n her mother di a gnos ed a t the a ge of 62 yea rs . A er a di s cus s i on of her choi ces for contra cepti on s he opts for a proges ti n-onl y pi l l (mi ni -pi l l ). Whi ch of the fol l owi ng i s true rega rdi ng the us e of proges ti n-onl y pi l l s ? a . Contra i ndi ca ted i n women wi th mi gra i ne hea da ches b. Decrea s e ri s k of ova ri a n cys ts c. Inhi bi ti on of ovul a ti on i s the ma i n mecha ni s m of a cti on d. Ma y wors en a cne e. More effecti ve tha n i njecta bl e proges ti ns 442. A 19-yea r-ol d pa ent ca l l s i n your office reques ng emergency contra cep on beca us e a condom s he a nd her boyfri end were us i ng broke duri ng i ntercours e l a s t ni ght. You couns el the pa ent a ppropri a tel y a nd provi de a s ui ta bl e method of contra cep on. Whi ch of the fol l owi ng s ta tements i s true rega rdi ng emergency contra cepti on? a . If a n es ta bl i s hed pregna ncy i s pres ent us e of Pl a n B wi l l ca us e a n a borti on. b. Mi fepri s tone i s l es s effecti ve tha n the Yuptze method. c. Out of 100 women us i ng emergency contra cepti on 10 wi l l become pregna nt.

d. The emergency contra cepti ve, Pl a n B, requi res a pres cri pti on. e. The ma jor mecha ni s m of a cti on of emergency hormone contra cepti ves i s i nhi bi ti on or del a y of ovul a ti on. 443. A coupl e pres ents to your office to di s cus s s teri l i za on. They a re very ha ppy wi th thei r four chi l dren a nd do not wa nt a ny more. You di s cus s wi th them the pros a nd cons of both fema l e a nd ma l e s teri l i za on. The 34-yea r-ol d ma n undergoes a va s ectomy. Whi ch of the fol l owi ng i s the mos t frequent i mmedi a te compl i ca ti on of thi s procedure? a . Infecti on b. Impotence c. Hema toma d. Sponta neous rea na s tomos i s e. Sperm gra nul oma s

Questions 444 to 448 For ea ch fema l e pa ent s eeki ng contra cep on, s el ect the method tha t i s medi ca l l y contra i ndi ca ted for tha t pa ent. Ea ch l e ered op on ma y be us ed once, more tha n once, or not a t a l l . a . Proges ti n-onl y contra cepti ve pi l l s b. Copper conta i ni ng i ntra uteri ne devi ce c. Condoms d. La pa ros copi c tuba l l i ga ti on e. Di a phra gm 444. A woma n wi th Wi l s on di s ea s e 445. A woma n wi th a hi s tory of brea s t ca ncer 446. A woma n wi th modera te cys tocel e 447. A woma n wi th s everel y reduced functi ona l ca pa ci ty a s a res ul t of chroni c obs tructi ve pul mona ry di s ea s e 448. A woma n wi th a known l a tex a l l ergy

Questions 449 to 455 For the fol l owi ng cl i ni ca l s cena ri os , s el ect the mos t a ppropri a te s exua l dys func on di s order. Ea ch l e ered op on ma y be us ed once, more tha n once, or not a t a l l . a . Dys pa reuni a b. Fema l e orga s mi c di s order c. Fema l e s exua l a rous a l di s order d. Hypoa cti ve s exua l des i re di s order e. Sexua l a vers i on di s order f. Va gi ni s mus 449. A 35-yea r-ol d G2P2 s ta tes s he jus t does n’t wa nt to ha ve s ex wi th her current pa rtner. It i s ca us i ng di fficul es i n the rel a ons hi p. Upon further ques oni ng s he reports a n a bs ence of s exua l fa nta s i es or drea ms . She deni es a ny medi ca l probl ems or medi ca ons a nd ha s a norma l phys i ca l exa mi na ti on. 450. A 22-yea r-ol d G0 woma n pres ents for s exua l couns el i ng. She ha s been da ng the s a me 23-yea r-ol d ma n for 3 months . She rea l l y l i kes hi m a nd enjoys bei ng wi th hi m; however, when s exua l opportuni ty a ri s es , s he ha s i ntens e a nxi ety a nd ca nnot conti nue the s exua l encounter. 451. A 40-yea r-ol d G3P3 reports s he i s ha vi ng di fficul ty wi th a dequa te l ubri ca on a nd s mul a on duri ng s exua l a c vi ty wi th her current pa rtner of 10 yea rs . She wa nts to ha ve s ex a nd reports ha vi ng s exua l drea ms . She ha s no medi ca l probl ems or deni es ta ki ng a ny medi ca ons a nd her phys i ca l exa mi na ti on i s norma l . 452. A 52-yea r-ol d G3P3 compl a i ns of i na bi l i ty to cl i ma x duri ng i ntercours e wi th her hus ba nd over the l a s t 6 months . She deni es a ny cha nges i n thei r rel a ons hi p or ps ychos oci a l s tres s ors . She s ta tes tha t s he ha s s ome va gi na l drynes s but s a s fa ctori l y us es a l ubri ca nt. She s ta tes s he gets a rous ed, ha s a s trong des i re for s ex a nd feel s tha t s ti mul a ti on i s a dequa te. She i s otherwi s e hea l thy a nd onl y ta kes a mul ti vi ta mi n. 453. A 25-yea r-ol d G1P1 woma n pres ents wi th pa i n a nd di fficul ty ha vi ng i ntercours e for the l a s t 3 months . She ga ve bi rth vi a a n uncompl i ca ted va gi na l del i very 5 months a go a nd recentl y s topped brea s t feedi ng. She s ta tes the pa i n occurs wi th penetra on a nd a t mes s he ca nnot compl ete the s exua l a ct beca us e the pa i n i s s o i ntens e. Her rel a ti ons hi p wi th her hus ba nd i s bei ng a ffected. 454. A 33-yea r-ol d woma n pres ents wi th compl a i nts of pa i nful i ntercours e. She ha s a new s exua l pa rtner for the l a s t month. She s ta tes tha t the pa i n us ua l l y occurs wi th deep penetra on a nd i n certa i n pos i ons . She reports norma l feel i ngs of a rous a l , cl i ma x, a nd norma l l ubri ca on. She deni es a ny va gi na l di s cha rge a nd reports us i ng condoms for contra cep on. She ha s no medi ca l probl ems or pri or s urgeri es a nd does n’t ta ke a ny medi ca ti ons . 455. A 42-yea r-ol d G1P1 ha s recentl y s ta rted da ng a ga i n a er her di vorce 3 yea rs a go. She ha s been s eei ng the s a me ma n for the l a s t 3 months . They ha ve ha d s evera l s exua l encounters , but s he reports a l a ck of i nteres t i n ha vi ng s ex. She reports a norma l s exua l des i re when s he wa s younger a nd wonders i f hormona l cha nges a re ca us i ng her l a ck of i nteres t. She ha s a hi s tory of hypertens i on whi ch i s wel l control l ed wi th metroprol ol a nd s he deni es a hi s tory of depres s i on but ha s been ta ki ng fluoxe ne s i nce her di vorce to hel p her cope wi th the s tres s es of her l i fe cha nge.

Questions 456 to 460 For ea ch s i tua on i nvol vi ng ora l contra cep ves , s el ect the mos t a ppropri a te res pons e. Ea ch l e ered op on ma y be us ed once, more tha n once, or

not a t a l l . a . Stop pi l l s a nd res ume a fter 7 da ys . b. Conti nue pi l l s a s us ua l . c. Conti nue pi l l s a nd us e a n a ddi ti ona l form of contra cepti on. d. Ta ke a n a ddi ti ona l pi l l . e. Stop pi l l s a nd s eek a medi ca l exa mi na ti on. 456. Na us ea duri ng fi rs t cycl e of pi l l s 457. No mens es duri ng 7 da ys fol l owi ng 21-da y cycl e of correct us e 458. Pi l l forgotten for 1 da y 459. Pi l l forgotten for 3 conti nuous da ys 460. Li ght bl eedi ng a t mi dcycl e duri ng fi rs t month on pi l l

Human Sexuality and Contraception Answers 421. The answer is c. (Schorge, pp 309-311.) In a 5-yea r fol l ow-up s tudy of coupl es trea ted by Ma s ters a nd Johns on, the cure ra tes for va gi ni s mus a nd prema ture eja cul a on a pproa ched 100%. Orga s mi c dys func on wa s corrected i n 80% of women, a nd s econda ry i mpotence (i mpotence des pi te a hi s tory of previ ous coi ta l s ucces s ) res ol ved i n 70% of men. Pri ma ry i mpotence (chroni c a nd compl ete i na bi l i ty to ma i nta i n a n erec on s uffici ent for coi tus ) ha d the wors t prognos i s , wi th cure reported i n onl y a pproxi ma tel y 50% of ca s es . Other thera pi s ts report very s i mi l a r s ta ti s ti cs . 422. The answer is a. (Schorge, p 106.) In s tudi es of contra cep ve methods us ed by reproduc ve-a ge women i n the Uni ted Sta tes , 19% us ed pi l l s . Fema l e s teri l i za ti on wa s the s econd choi ce a mong women wi th 17%. Condoms were the thi rd choi ce wi th 11% of the women s urveyed us i ng them. 423. The answer is e. (Schorge, pp 111-113.) Begi nni ng wi th hi gh-dos e combi na on contra cep ve pi l l s us ed more tha n 30 yea rs a go, pi l l s ha ve been s tudi ed extens i vel y for a pos s i bl e a s s oci a on wi th neopl a s i a . There i s onl y s ca nt evi dence from thi s experi ence tha t us e of ora l contra cep ves i ncrea s es the ri s k of a ny type of ca ncer. A s l i ghtl y hi gher ri s k of cervi ca l ca rci noma wa s obs erved i n s ome s tudi es of us ers of ora l contra cep ves . Thes e s tudi es were not control l ed, however, for confoundi ng va ri a bl es s uch a s mul pl e pa rtners or a ge a t ons et of s exua l i ntercours e, a nd i t i s genera l l y bel i eved now tha t a ny i ncrea s ed ri s k i n contra cep ve pi l l us ers woul d be a ri buta bl e to thes e other fa ctors a nd not to the s teroi ds thems el ves . Al though, the ri s k of devel opi ng beni gn l i ver a denoma s (whi ch i f rupture ca n ca us e l i fe-threa teni ng hemorrha ge) i s i ncrea s ed s omewha t i n us ers of ora l contra cepti ves , the ri s k of hepa ti c ca rci noma i s not i ncrea s ed. 424. The answer is d. (Schorge, p 119.) A l oca l i zed i nfla mma tory res pons e i n the endometri um i ni a tes l ys oma l a c va on whi ch i s s permi ci da l the re by preven ng fer l i za on of the ovum. The endometri um i s a l s o uns ui ta bl e for i mpl a nta on due to the i nfla mma tory res pons e. Wi th proges n IUDs thi ckened cervi ca l mucus ma y i nterfere wi th s perm penetra on, but thi s i s not cons i s tent a nd ca nnot be rel i ed on for contra cep ve effect. 425. The answer is c. (Schorge pp 106-110.) The pregna ncy ra te wi th bi rth control pi l l s , ba s ed on theore ca l effec venes s , i s 0.1%. However, the pregna ncy ra te i n a ctua l us e i s 0.7%. Thi s i ncrea s e i s owi ng to i ncorrect us e of the pi l l s . Brea kthrough ovul a on on combi na on bi rth control pi l l s , when the pi l l s a re ta ken correctl y, i s thought to be a very ra re occurrence. Uni ntended pregna ncy i n women correctl y us i ng ora l contra cep ve pi l l s i s not rel a ted to s exua l frequency, ga s troi ntes ti na l di s turba nces , or the devel opment of a nti bodi es . 426. The answer is c. (Schorge, p 120.) Al though there i s a n i ncrea s ed ri s k of s ponta neous a bor on, a nd a s ma l l ri s k of i nfec on, a n i ntra uteri ne pregna ncy ca n occur a nd con nue s ucces s ful l y to term wi th a n IUD i n pl a ce. However, i f the pa ent wi s hes to keep the pregna ncy a nd i f the s tri ng i s vi s i bl e, the IUD s houl d be removed i n a n a empt to reduce the ri s k of i nfec on, a bor on, or both. Al though the i nci dence of ectopi c pregna nci es wi th a n IUD wa s a t one me thought to be i ncrea s ed, i t i s now recogni zed tha t i n fa ct the overa l l i nci dence i s uncha nged. The a ppa rent i ncrea s e i s the res ul t of the dra ma c decrea s e i n i ntra uteri ne i mpl a nta on wi thout a ffec ng ectopi c i mpl a nta on. Thus , whi l e the overa l l proba bi l i ty of pregna ncy i s dra ma ca l l y decrea s ed, when a pregna ncy does occur wi th a n IUD i n pl a ce, there i s a hi gher proba bi l i ty tha t i t wi l l be a n ectopi c one. Wi th thi s i n mi nd, i n the a bs ence of s i gns a nd s ymptoms s ugges ve of a n ectopi c pregna ncy, es peci a l l y a er ul tra s ound documenta on of a n i ntra uteri ne pregna ncy, l a pa ros copy i s not i ndi ca ted. The i nci dence of heterotopi c pregna ncy, i n whi ch i ntra uteri ne a nd extra uteri ne i mpl a nta ti on occur, i s no hi gher tha n a pproxi ma tel y 1 i n 2500 pregna nci es . 427. The answer is a. (Schorge, p 124.) Spermi ci des a va i l a bl e i n the Uni ted Sta tes conta i n nonoxynol -9, tha t i mmobi l i zes or ki l l s s perm on conta ct. They do not provi de protec on a ga i ns t s exua l l y tra ns mi ed i nfec ons . Spermi ci des provi de a mecha ni ca l ba rri er a nd need to be pl a ced hi gh i n the va gi na i n conta ct wi th the cervi x before ea ch coi ta l a ct. Hi gh pregna ncy ra tes typi ca l l y a s s oci a ted wi th s permi ci des a re mos tl y due to i ncons i s tent us e ra ther tha n method fa i l ure. Thei r effec venes s i ncrea s es wi th i ncrea s i ng a ge of the women who us e them, proba bl y beca us e of i ncrea s ed mo va on. The effec venes s of s permi ci des i s s i mi l a r to tha t of the di a phra gm, a nd i ncrea s es wi th the concomi ta nt us e of condoms . Al though i t ha s been reported tha t contra cep ve fa i l ures wi th s permi ci des ma y be a s s oci a ted wi th a n i ncrea s ed i nci dence of congeni ta l ma l forma ti ons , thi s fi ndi ng ha s not been confi rmed i n s evera l l a rge s tudi es a nd i s not bel i eved to be va l i d. 428. The answer is c. (Katz, pp 184-190.) Cl oni di ne, a n a n hypertens i ve a gent, ca n ca us e i nhi bi on of orga s m i n women. Studi es ha ve s hown tha t i t decrea s es va gi na l bl ood vol ume a nd i nhi bi ts s exua l a rous a l . Sel ec ve s erotoni n reupta ke i nhi bi tors us ua l l y decrea s e l i bi do. In women s ens i ve to hormona l cha nges , combi na on contra cep ve pi l l s ca n decrea s e free tes tos terone a nd decrea s e l i bi do. Ma s ters a nd Johns on i den fied the cl i tori s a s the center of s exua l s a s fa c on i n women. Orga s m a nd s exua l gra fica on ha s been a s s oci a ted wi th nerve endi ngs i n the cl i tori s , mons pubi s , l a bi a , a nd pres s ure receptors i n the pel vi s . Even though the cervi x ha s a ri ch nerve s uppl y, there i s no s ci en fic evi dence tha t i t pl a ys a rol e i n the s exua l res pons e.

429. The answer is b. (Katz, p 190.) Ma ny fa ctors ca n contri bute to the devel opment of pri ma ry orga s mi c dys func on i n women. By defini on, thes e women wi l l not ha ve been a bl e to a chi eve orga s m through a ny mea ns a t a ny me i n thei r l i ves ; rea s ons for thei r dys func on ca n i ncl ude the i nfluence of orthodox rel i gi ous or ri gi d fa mi l i a l bel i efs , di s s a s fa c on wi th thei r pa rtner’s beha vi ora l or s oci a l tra i ts , or pa s t tra uma s uch a s ra pe. Sexua l dys functi on, pa rti cul a rl y prema ture eja cul a ti on i n a ma l e pa rtner, ca n rei nforce a woma n’s orga s mi c dys functi on. 430. The answer is d. (Katz, pp 184-185.) The res pons e of women to s exua l s mul a on i s genera l i zed a nd a ffects ma ny di fferent orga n s ys tems . Duri ng the exci tement or s educ on pha s e, va s oconges on l ea ds to brea s t engorgement a nd the devel opment of a ra s h on the brea s ts , ches t, a nd epi ga s tri c a rea , whi ch i s ca l l ed the “s ex flus h.” Hea rt ra te a nd bl ood pres s ure a l s o i ncrea s e duri ng thi s pha s e. Va s oconges on a l s o occurs i n the cl i tori s , l a bi a , a nd va gi na , a nd a tra ns uda ve l ubri ca nt devel ops i n the va gi na . The pl a tea u pha s e i s ma rked by grea ter va s oconges on throughout the body a nd retra c on of the cl i tori s . Duri ng the orga s mi c pha s e, the s exua l tens i on i s rel ea s ed vi a mus cul a r contra c ons throughout the body, but nota bl y i n the va gi na , a nus , a nd uterus . Cha nges i n hormones s uch a s es trogen a re not pa rt of the s exua l res pons e. 431. The answer is c. (Schorge, pp 150-153.) Surgi ca l a bor on i s a mong the s a fes t procedures i n medi ci ne, wi th a s eri ous compl i ca on ra te i n the firs t tri mes ter of l es s tha n 1%. In the firs t tri mes ter a er 49 da ys of ges ta on, s uc on di l a on a nd cure a ge i s the method of choi ce. Outpa ent medi ca l a bor on i s a s a fe a nd a ccepta bl e a l terna ve to s urgi ca l a bor on i n s el ect women wi th pregna nci es l es s tha n 49 da ys of ges ta on. Three medi ca ons ha ve been us ed: mi fepri s tone (a n proges n), methotrexa te (a n meta bol i te) a nd mi s opros tol (pros ta gl a ndi n). Va ri ous s chemes ha ve been found to be effec ve. Us ua l l y mi fepri s tone or methotrexa te i s i ni a l l y a dmi ni s tered fol l owed by mi s opros tol . Intra a mni o c i njec on of hyper-toni c s a l i ne i s no l onger cons i dered a ppropri a te beca us e i t ha s a much hi gher i nci dence of s eri ous compl i ca ons , i ncl udi ng dea th, hyperos mol a r cri s i s , ca rdi a c fa i l ure, peri toni s , hemorrha ge, a nd coa gul a on a bnorma l i es . There a re fa r be er medi ci nes a va i l a bl e, a nd s a l i ne s houl d no l onger be us ed. Di l a on a nd eva cua on (D&E) i s a s urgi ca l procedure s i mi l a r i n concept to a di l a on a nd cure a ge (D&C). However, i ns tea d of cure a ge (s cra pi ng) to remove the products of concep on, va ri ous forceps a re pl a ced i nto the uteri ne ca vi ty to remove the products of concep on. D&E i s performed for termi na on of l a ter pregna nci es , genera l l y thos e i n the s econd tri mes ter. Hys terotomy i s a s urgi ca l procedure i n whi ch the uterus i s opened tra ns a bdomi na l l y a nd the contents eva cua ted. It i s a procedure done for termi na on of more a dva nced pregna nci es when a l l other methods of termi na on a re uns ucces s ful or contra i ndi ca ted, or, for exa mpl e, when reta i ned products of concep on ca nnot be expel l ed wi th medi ca ti on or other mecha ni ca l mea ns s uch a s D&E. 432. The answer is d. (Katz, pp 184-185.) Ma s ters a nd Johns on obs erved a tra ns uda te-l i ke flui d ema na ng from the va gi na l wa l l s duri ng s exua l res pons e. Thi s mucoi d ma teri a l , whi ch i s s uffici ent for compl ete va gi na l l ubri ca on, i s produced by tra ns uda on from the venous pl exus s urroundi ng the va gi na a nd a ppea rs s econds a er the i ni a on of s exua l exci tement. No a c vi ty by Skene gl a nds wa s noted, a nd produc on of cervi ca l mucus duri ng s exua l s mul a on wa s obs erved i n onl y a few s ubjects . Fl ui d from Ba rthol i n gl a nds a ppea rs l ong a er va gi na l l ubri ca on i s wel l es ta bl i s hed; i n a ddi on, i t a ppea rs to ma ke onl y a mi nor contri bu on to l ubri ca on i n the l a te pl a tea u pha s e. Uteri ne a nd tuba l s ecreti ons do not contri bute to thi s l ubri ca ti on. 433. The answer is b. (Schorge, p 310.) Sexua l i ty con nues des pi te a gi ng. However, there a re phys i ol ogi c cha nges tha t mus t be recogni zed. La ck of es trogen from di mi ni s hed ova ri a n func on l ea ds to decrea s ed geni ta l bl ood flow, decrea s ed va gi na l l ubri ca on a nd a trophy of va gi na l s s ues . Thes e ca n l ea d to di s comfort wi th i ntercours e. Va gi na l l ubri ca nts a nd es trogen repl a cement thera py (ERT) ma y hel p. Es trogen ha s been s hown to i mprove l ubri ca on, bl ood flow, a nd va gi na l compl i a nce. Sexua l dys func on ca n be phys i ol ogi c (eg, from l owered l i bi do). Beca us e a gi ng does not a l ter the ca pa ci ty for orga s m or produce va gi ni s mus , a further eva l ua on s houl d be i ni a ted i f thes e s ymptoms pers i s t a er a pos tmenopa us a l woma n a fter trea tment i s i ni ti a ted. 434. The answer is b. (Katz, pp 188-190.) Thi s pa ent pres ents wi th va gi ni s mus , defined a s i nvol unta ry pa i nful s pa s m of the pel vi c mus cl es a nd va gi na l outl et. It i s us ua l l y ps ychogeni c. It s houl d be di fferen a ted from fri gi di ty, whi ch i mpl i es l a ck of s exua l des i re, a nd dys pa reuni a , whi ch i s defined a s pel vi c a nd/or ba ck pa i n or other di s comfort a s s oci a ted wi th s exua l a c vi ty. Dys pa reuni a i s frequentl y a s s oci a ted wi th pel vi c pa thol ogy s uch a s endometri os i s , pel vi c a dhes i ons , or ova ri a n neopl a s ms . The pa i n of va gi ni s mus ma y be ps ychogeni c i n ori gi n, or ma y be ca us ed by pel vi c pa thol ogy s uch a s a dhes i ons , endometri os i s , or l ei omyoma s . Trea tment of va gi ni s mus i s pri ma ri l y ps ychothera peu c, a s orga ni c vul va r or pel vi c ca us es (s uch a s a trophy, Ba rthol i n gl a nd cys t, or a bs ces s ) a re very ra re. 435. The answer is e. (Schorge, pp 116-117.) Depot medroxyproges terone a ceta te (Depo-Provera ) i s a hi ghl y effec ve contra cep on. Its effec venes s i s compa ra bl e to or even be er tha n pi l l s . Its mecha ni s ms of a c on i ncl ude: ovul a on s uppres s i on, cervi ca l mucus thi ckeni ng, a nd deci dua l i za on of endometri um ma ki ng i t unfa vora bl e for i mpl a nta on. It ha s no i mpa i rment of l a cta on, a nd i ron defici ency a nemi a i s l es s l i kel y due to a menorrhea whi ch devel ops i n 80% of us ers . Its pri nci pa l di s a dva nta ges a re i rregul a r bl eedi ng a nd prol onged a novul a on whi ch res ul ts i n del a yed return of fer l i ty a er di s con nua on of the medi ca on. Wei ght ga i n i s o en a ri buted to depot medroxyproges terone, but concl us i ve evi dence i s l a cki ng. Cervi ca l a nd hepa c ca ncers do not a ppea r to be i ncrea s ed a nd ova ri a n a nd endometri a l ca ncers a re decrea s ed. Los s of bone mi nera l dens i ty i s one concern, but thi s l os s i s revers i bl e a fter di s conti nua ti on of the medi ca ti on. 436. The answer is d. (Schorge, pp 110-115.) Women wi th a bs ol ute contra i ndi ca ons s houl d not ta ke combi na on ora l contra cep ve pi l l s . Rel a ve contra i ndi ca ti ons to the us e of the bi rth control pi l l requi re cl i ni ca l judgment a nd i nformed cons ent.

437. The answer is a. (Schorge, pp 110-113.) Combi na on es trogen pl us proges n ora l contra cep ves ha ve ma ny benefits i ncl udi ng: i ncrea s ed bone dens i ty, reduced mens trua l bl ood l os s a nd a nemi a , decrea s ed ri s k of ectopi c pregna ncy, i mproved dys menorrhea l from endometri os i s , fewer premens trua l compl a i nts , decrea s ed ri s k of endometri a l a nd ova ri a n ca ncer, reduc on i s va ri ous beni gn brea s t di s ea s es , i nhi bi on of hi rs u s m progres s i on, i mprovement of a cne, preven on of a therogenes i s , decrea s ed i nci dence a nd s everi ty of a cute s a l pi ngi s a nd decrea s ed a c vi ty of rheuma toi d a rthri s . There i s a correl a on between the ri s k of cervi ca l dys pl a s i a a nd ora l contra cep ve us e. Thi s ma y be due to l a ck of us e of ba rri er methods wi th the pi l l a nd tra ns mi s s i on of huma n pa pi l l oma vi rus or more frequent s creeni ng i n pi l l us ers . Pi l l s do not reduce the ri s k of brea s t ca ncer a nd thei r rol e i n the devel opment of brea s t ca ncer i n pi l l us ers i s uncl ea r. One l a rge s tudy s howed no i ncrea s e ri s k a nd one s tudy s howed s ma l l i ncrea s ed ri s k (1.16 rel a ve ri s k) i n current us ers . Pi l l s i ncrea s e s erum tri gl yceri des ; a nd they ma y a ccel era te the devel opment of ga l l bl a dder di s ea s e i n s us cepti bl e women. 438. The answer is e. (Katz, pp 282-284.) The two es trogeni c compounds us ed i n ora l contra cep ves a re ethi nyl es tra di ol a nd i ts 3-methyl ether, mes tra nol . To become bi ol ogi ca l l y effec ve, mes tra nol mus t be demethyl a ted to ethi nyl es tra di ol , beca us e mes tra nol does not bi nd to the es trogeni c cytos ol receptor. The es trogeni c component of bi rth control pi l l s wa s ori gi na l l y a dded to control i rregul a r endometri a l des qua ma on res ul ng i n undes i ra bl e va gi na l bl eedi ng. However, thes e es trogens i mpos ed pos s i bl e ri s ks tha t woul d not be i nherent i n the proges ta ona l component a l one. For exa mpl e, thrombos i s , the mos t s eri ous s i de effect of the pi l l , i s di rectl y rel a ted to the dos e of es trogen. The hi gher the es trogen dos e, the more l i kel y there wi l l be thrombo c compl i ca ons . The combi na on pi l l prevents ovul a on by i nhi bi ng gona dotropi n s ecre on a nd exer ng i ts pri nci pa l effect on pi tui ta ry a nd hypotha l a mi c centers . Proges terone pri ma ri l y s uppres s es LH s ecre on, whi l e es trogen pri ma ri l y s uppres s es FSH s ecre on. Proges ns a re res pons i bl e for endometri a l cha nges tha t res ul t i n a n envi ronment not conduci ve to i mpl a nta ti on, a nd producti on of cervi ca l mucus tha t reta rds s perm mi gra ti on. 439. The answer is b. (Speroff, p 873.) The ma rked effec venes s of the combi ned ora l contra cep ve pi l l , whi ch conta i ns a s ynthe c es trogen a nd a proges n, i s rel a ted to i ts mul pl e a n fer l i ty a c ons . The pri ma ry effect i s to s uppres s gona dotropi ns a t the me of the mi dcycl e LH s urge, thus i nhi bi ng ovul a on. The prol onged proges ta ona l effect a l s o ca us es thi ckeni ng of the cervi ca l mucus a nd a trophi c (not hyperpl a s c) cha nges of the endometri um, thus i mpa i ri ng s perm penetra bi l i ty a nd ovum i mpl a nta on, res pec vel y. Proges ta ona l a gents i n ora l contra cep ves work by a nega ti ve feedba ck mecha ni s m to i nhi bi t the s ecreti on of LH a nd, a s a res ul t, prevent ovul a ti on. They a l s o ca us e deci dua l i za ti on a nd a trophy of the endometri um, thereby ma ki ng i mpl a nta on i mpos s i bl e. Some evi dence i ndi ca tes tha t proges ta ona l a gents ma y cha nge ovum a nd s perm mi gra on pa erns wi thi n the reproduc ve s ys tem. Proges ns do not prevent i rregul a r bl eedi ng. Es trogen i n bi rth control pi l l s enha nces the nega ve feedba ck of the proges ns a nd s ta bi l i zes the endometri um to prevent i rregul a r mens es . Ora l contra cep ves ha ve no di rect effect on oocyte ma tura ti on a nd do not ca us e uterotuba l obs tructi on. 440. The answer is a. (Schorge, pp 120-121.) A previ ous pregna ncy wi th a n IUD i s not a contra i ndi ca on to the us e of a n IUD. The ri s k of a nother pregna ncy wi th the IUD i n pl a ce i s not i ncrea s ed. Previ ous cervi ca l s urgery i n the fa ce of a norma l Pa p s mea r a nd no cervi ca l s tenos i s i s not a contra i ndi ca on to IUD us e. The ma nufa cturers l i s t the fol l owi ng contra i ndi ca ons to the us e of a n IUD: (1) pregna ncy or s us pi ci on of pregna ncy; (2) a bnorma l i es of the uterus res ul ng i n di s tor on of the uteri ne ca vi ty; (3) a cute pel vi c i nfla mma tory di s ea s e (PID) or hi s tory of PID unl es s there ha s been a s ubs equent uteri ne pregna ncy; (4) untrea ted a cute cervi ci s or va gni s , i ncl udi ng ba cteri a l va gi nos i s , un l the i nfec on i s control l ed; (5) pos tpa rtum endometri s or s ep c a bor on wi thi n the pa s t 3 months ; (6) geni ta l bl eedi ng of unknown e ol ogy; (7) known or s us pected uteri ne or cervi ca l neopl a s i a , or unres ol ved a bnorma l cytol ogi ca l s mea r; (8) mul pl e s exua l pa rtners for the woma n or her pa rtner; a nd (9) condi ti ons tha t l ea d to i ncrea s ed s us cepti bi l i ty to i nfecti ons s uch a s (but not l i mi ted to) l eukemi a , AIDS, or i ntra venous drug us e; (10) hi s tory of ectopi c pregna ncy or condi on tha t woul d l ea d to ectopi c pregna ncy; (11) geni ta l a c nomycos i s ; (12) a previ ous l y i ns erted IUD tha t ha s not been removed; (13) copper a l l ergy or Wi l s on di s ea s e (for IUDs tha t conta i n copper); (14) known or s us pected brea s t ca ncer or a cute l i ver di s ea s e or tumor (for l evonorges trel conta i ni ng IUDs ). 441. The answer is d. (Schorge, p 116.) Proges n-onl y pi l l s a re i dea l for women wi th contra i ndi ca ons to es trogen a nd i ncrea s ed ri s k of ca rdi ova s cul a r compl i ca ons , s uch a s women wi th a hi s tory of thrombos i s , hypertens i on, mi gra i ne hea da ches , or s mokers over the a ge of 35 yea rs . They a re a l s o a good choi ce for l a cta ng women. Mi ni -pi l l s do not rel i a bl y i nhi bi t ovul a on a nd thei r effec venes s rel i es more hea vi l y on cervi ca l mucus a l tera ons a nd endometri a l effects . Irregul a r bl eedi ng i s a common s i de effect a s i s the ri s k of contra cep ve fa i l ure. They ha ve a

hi gher pregna ncy ra te tha n combi na on pi l l s or other methods s uch a s i njecta bl e proges ns or i ntra uteri ne devi ces . Wi th fa i l ures there i s a n i ncrea s ed ri s k of ectopi c pregna ncy. Another di s a dva nta ge i s tha t i t needs to be ta ken a t the s a me me every da y. If a mi ni -pi l l i s ta ken even 4 hours l a te, a n a ddi ona l contra cep ve mus t be us ed for the next 2 da ys . The mi ni -pi l l does not i mprove a cne a nd ma y a ctua l l y wors en i t. Functi ona l ova ri a n cys ts devel op wi th a grea ter frequency i n women us i ng proges ti n-onl y pi l l s , but i nterventi on i s ra rel y needed. 442. The answer is e. (Schorge, pp 117-118.) Emergency contra cep on i s wa rra nted for preven on of unwa nted pregna ncy i n mes of unprotected s exua l i ntercours e. Two hormona l methods a re a va i l a bl e: the Yuptze method (es trogen a nd proges n pi l l s ) a nd Pl a n B (proges n onl y). A number of combi ned (es trogen-proges n) contra cep ves a re FDA-a pproved for us e a s emergency contra cep on. The ta bl ets a re ta ken wi thi n 72 hours of i ntercours e, i n two dos es 12 hours a pa rt. Thi s method i s hi ghl y effec ve a nd decrea s es pregna ncy by 94%. Typi ca l l y i f 100 women ha d unprotected i ntercours e duri ng the s econd or thi rd week of thei r mens trua l cycl e 8 woul d become pregna nt. If they us ed thi s emergency contra cep on regi men, onl y 2 woul d concei ve. Na us ea a nd vomi ng a re common due to the hi gh dos es of es trogen, due to thi s i t i s common to pres cri be a n a n -eme c to ta ke before ea ch dos e. Pl a n B i s a proges n onl y emergency contra cep ve method whi ch conta i ns 0.75 mg of l evonorges trel , a nd s i mi l a rl y the firs t dos e i s ta ken wi thi n 72 hours a nd a s econd dos e i s repea ted i n 12 hours . Si nce i t does not conta i n es trogen, na us ea a nd emes i s a re not common a nd i t i s be er tol era ted tha n the Yuptze method. It a l s o ha s a s l i ghtl y hi gher effica cy (1.1 pregna nci es ). Pl a n B i s FDA-a pproved to be s ol d over the counter to women 18 yea rs of a ge a nd ol der wi thout a pres cri p on. The ma jor mecha ni s m of a c on of both of thes e methods i s i nhi bi on or del a y of ovul a on. Other mecha ni s ms s ugges ted a re endometri a l effects tha t prevent i mpl a nta on, s perm penetra on or tuba l mo l i ty. Es ta bl i s hed pregna nci es a re not ha rmed by ei ther method. Another method of emergency contra cep on i s to i ns ert a copper-conta i ni ng i ntra uteri ne devi ce up to 5 da ys a er unprotected i ntercours e. The fa i l ure ra te i s a bout 1%. Mi fepri s tone (RU-486) i s a potent a n -proges terone tha t ca n be us ed a s emergency contra cep on. It i nterferes wi th i mpl a nta on a nd a s i ngl e dos e i s more effec ve a nd ha s l es s s i de effects tha n the Yuptze regi men. 443. The answer is c. (Katz, pp 315-316.) Va s ectomy i s performed by i s ol a ng the va s deferens , cu ng i t, a nd cl os i ng the ends by ei ther ful gura on or l i ga on. Compl i ca ons tha t ma y a ri s e i ncl ude hema toma i n up to 5% of s ubjects , s perm gra nul oma s (i nfla mma tory res pons es to s perm l ea ka ge), s ponta neous rea na s tomos i s , a nd, ra rel y, i nfec ons . Sexua l func on fol l owi ng hea l i ng i s ra rel y a ffected. Va s ectomy i n the ma l e, however, s houl d not be cons i dered effec ve un l a n exa mi na on of the eja cul a te i s s perm-free on two s ucces s i ve occa s i ons . Fa i l ure ra te i s 1%. It ha s a l ower compl i ca ti on ra te a nd cos t tha n outpa ti ent l a pa ros copi c s teri l i za ti ons i n fema l es . 444 to 448. The answers are 444-b, 445-a, 446-e, 447-d, 448-c. (Schorge, pp 105-132.) Proges n onl y pi l l s a re contra i ndi ca ted i n women wi th unexpl a i ned uteri ne bl eedi ng or brea s t ca ncer. Both condoms a nd the di a phra gm, us ed i n conjunc on wi th s permi ci des , a re effec ve contra cep ves . The di a phra gm s houl d ca reful l y fit i n the va gi na a nd i s therefore not a ppl i ca bl e to women wi th a na tomi c di s tor on of the va gi na . La tex condoms s houl d not be us ed i n women wi th a known l a tex a l l ergy. Ma nufa cturer’s contra i ndi ca ons to IUD us e i ncl ude: hi s tory of a cute, chroni c or recurrent pel vi c i nfla mma tory di s ea s e (PID), mul pl e s exua l pa rtners , or ectopi c pregna ncy or condi on predi s pos i ng to ectopi c pregna ncy. Wi l s on’s di s ea s e or copper a l l ergy a re contra i ndi ca ons to the us e of a copper-conta i ni ng IUD. Al though tuba l l i ga on ma y be cons i dered i n the pa ent wi th chroni c obs truc ve l ung di s ea s e, the ri s k of genera l a nes thes i a a nd s urgi ca l i nterven on i n thi s pa ent i s proba bl y hi gh enough to i ndi ca te a more cons erva ti ve a pproa ch, s uch a s the us e of a n IUD. 449 to 455. The answers are 449-d, 450-e, 451-c, 452-b, 453-f, 454-a, 455-d. (Schorge, pp 310-311; Katz, pp 184-189.) Fema l e s exua l dys functi on di s orders a re cha ra cteri zed by pa i nful i ntercours e or di s turba nces i n des i re, a rous a l , orga s m or res ol u on tha t ca us es ma rked di s tres s or i nterpers ona l di fficul ty. Sexua l dys func on i s not be er a ccounted for by a nother ps ychi a tri c di s order a nd i s not due excl us i vel y to a s ubs ta nce or medi ca l condi on. Hypoa c ve s exua l des i re di s order i s the pers i s tent or recurrent a bs ence of s exua l fa nta s i es or des i re for s exua l a c vi ty. Al cohol a nd drugs ma y i nterfere wi th s exua l des i re. Medi ca ons s uch a s a n hypertens i ves , a n chol i nergi cs , a n depres s a nts , na rco cs , s eda ves , a nd others ma y decrea s e a rous a l a nd i nhi bi t s exua l i nteres t. Sexua l a vers i on di s order i s a pers i s tent or recurrent extreme a vers i on to or a voi da nce of s exua l geni ta l conta ct. Sexua l prompts or a dva nces by a pa rtner a re di s mi s s ed. It ma y be a cqui red fol l owi ng s exua l or phys i ca l a bus e or tra uma a nd ma y be l i fe-l ong. When pres ented wi th a s exua l opportuni ty, the i ndi vi dua l ma y experi ence pa ni c a a cks or extreme a nxi ety. Sexua l a rous a l di s order i s the pers i s tent i na bi l i ty to a a i n or ma i nta i n un l compl e on of s exua l a c vi ty a n a dequa te l ubri ca on-s wel l i ng res pons e of s exua l exci tement. The i na bi l i ty to become a rous ed a l s o ma y be rel a ted to a nxi ety or i na dequa te s mul a on. Va gi ni s mus i s the recurrent i nvol unta ry s pa s m of the mus cul a ture of the l ower thi rd of the va gi na tha t i nterferes wi th s exua l i ntercours e a nd penetra on. Us ua l l y a t the root of va gi ni s mus i s a combi na on of phys i ca l or nonphys i ca l tri ggers tha t ca us e the body to a n ci pa te pa i n. Rea c ng to the a n ci pa on of pa i n, the body a utoma ca l l y ghtens the va gi na l mus cl es , a nd s ex becomes pa i nful . Peni l e entry ma y be more di fficul t or i mpos s i bl e dependi ng upon the s everi ty mus cl e contra c on. Dys pa reuni a i s recurrent or pers i s tent geni ta l /pel vi c pa i n a s s oci a ted wi th s exua l i ntercours e (not ca us ed by va gi ni s mus or l a ck of l ubri ca ti on). 456 to 460. The answers are 456-b, 457-b, 458-d, 459-c, 460-b. (Katz, pp 296-297.) Common s i de effects of bi rth control pi l l s i ncl ude na us ea , brea kthrough bl eedi ng, bl oa ng, a nd l eg cra mps . If thes e s i de effects a re experi enced i n the firs t two or three cycl es of pi l l s —when they a re mos t common—the pi l l s ma y be s a fel y con nued, a s thes e effects us ua l l y remi t s ponta neous l y. On occa s i on, fol l owi ng correct us e of a ful l cycl e of pi l l s , wi thdra wa l bl eedi ng ma y fa i l to occur (s i l ent mens es ). Pregna ncy i s a very unl i kel y expl a na on for thi s event; therefore, pi l l s s houl d be res umed a s us ua l (a er 7 da ys ) jus t a s i f bl eedi ng ha d occurred. However, i f a s econd cons ecu ve peri od ha s been mi s s ed, pregna ncy s houl d be more s eri ous l y cons i dered a nd rul ed out by a pregna ncy tes t, medi ca l exa mi na on, or both. Women occa s i ona l l y forget to ta ke pi l l s ; however, when onl y a s i ngl e pi l l ha s been omi ed, i t ca n be ta ken i mmedi a tel y i n a ddi on to the us ua l pi l l a t the us ua l me. Thi s s i ngl e-pi l l omi s s i on i s a s s oci a ted wi th l i l e i f a ny l os s i n effec venes s . If three or more pi l l s a re omi ed, the pi l l s houl d be res umed a s us ua l , but a n a ddi ona l contra cep ve method (eg, condoms ) s houl d be us ed through one ful l cycl e. Al though mos t s i de effects ca us ed by bi rth control pi l l s ca n be cons i dered mi nor, s eri ous s i de effects do s ometi mes occur. A pa i nful , s wol l en ca l f ma y s i gna l thrombophl ebi ti s .

Sexual Abuse and Domestic Violence Questions 461. A 20-yea r-ol d woma n pres ents to your office wi th the compl a i nt of a bdomi na l pa i n. Through further ques oni ng, the woma n revea l s tha t s he wa s s exua l l y a s s a ul ted a t a pa rty 3 weeks a go by a ma l e fri end whom s he recentl y s ta rted da ng. She s ta tes tha t s he ha s not revea l ed thi s to a nyone el s e a nd ha s not i nformed the pol i ce beca us e s he wa s dri nki ng. Her a bdomi na l a nd pel vi c exa mi na ons a re norma l . Whi ch of the fol l owi ng i s the bes t ma na gement to offer thi s pa ti ent? a . Couns el pa ti ent to s ue ma l e fri end. b. Provi de a n a nti depres s a nt. c. Provi de emergency contra cepti on. d. Tes t for a nd trea t s exua l l y tra ns mi tted i nfecti ons . e. Order CT of the a bdomen a nd pel vi s . 462. You a re a chi ef res i dent a t a uni vers i ty hos pi ta l a nd a re ca l l ed down to the emergency room a t 5:00 AM on a Sa turda y to eva l ua te a n 18-yea rol d undergra dua te, who pres ented to the emergency room compl a i ni ng of bei ng a vi c m of s exua l a s s a ul t whi l e a endi ng a fra terni ty pa rty the eveni ng before. When you fi rs t encounter thi s pa ti ent to ta ke a deta i l ed hi s tory, s he rema i ns very ca l m but ha s troubl e rememberi ng the deta i l s of the experi ence. She deni es a ny i nges on of a ny a l cohol or i l l i ci t drugs . Whi ch of the fol l owi ng i s mos t l i kel y a component of the a cute pha s e of the ra pe tra uma s yndrome? a . No phys i ca l compl a i nts . b. Dura ti on for up to 6 months a fter the event. c. Al wa ys i n control of emoti ons . d. The rea cti on of the vi cti m ma y be i nfl uenced by vi cti m’s rel a ti ons hi p to the a tta cker. e. The vi cti m’s copi ng mecha ni s ms us ua l l y rema i n i nta ct. 463. A 36-yea r-ol d woma n drops by your office unexpectedl y a nd wa nts to be s een for chroni c pel vi c pa i n. She ha s s een you i n the pa s t for wel l woma n exa mi na ti ons a nd ha s been trea ted for chl a mydi a . She s mokes a nd dri nks s oci a l l y. She ha s no medi ca l probl ems or pri or s urgeri es . Duri ng ques oni ng her a bout her chi ef compl a i nt, s he revea l s tha t s he wa s s exua l l y a s s a ul ted l a s t ni ght a t a cl ub a er ha vi ng dri nks wi th s ome gi rl fri ends . You a empt to ta ke deta i l ed hi s tory of the a s s a ul t; however, the woma n’s memory s eems cl oudy a nd i ncons i s tent. Her phys i ca l exa mi na ti on i s unrema rka bl e. The vi cti m’s i na bi l i ty to thi nk cl ea rl y a nd remember thi ngs i s bes t expl a i ned by whi ch of the fol l owi ng? a . Al cohol us e b. Hea d i njury c. Il l i ci t drug us e d. Ra pe tra uma s yndrome e. Seconda ry ga i n 464. You a re ca l l ed to the emergency depa rtment to eva l ua te a n 18-yea r-ol d woma n for a vul va r l a cera on. She i s a ccompa ni ed by her mother a nd fa ther. The fa ther expl a i ns tha t the i njury wa s ca us ed by a fa l l onto the s upport ba r on her bi cycl e. You i ntervi ew the woma n a l one a nd find out tha t her fa ther ha s been s exua l l y a s s a ul ti ng her. Whi ch of the fol l owi ng s ta tements bes t des cri bes i njuri es rel a ted to s exua l a s s a ul t? a . Mos t i njuri es a re cons i dered ma jor a nd requi re s urgi ca l correcti on. b. Mos t i njuri es requi re hos pi ta l i za ti on. c. More tha n 50% of vi cti ms wi l l ha ve a n i njury. d. Mos t i njuri es occur a fter the a s s a ul t ha s ta ken pl a ce. e. Va gi na l a nd vul va r l a cera ti ons a re common i n vi rgi na l vi cti ms . 465. You a re eva l ua ti ng a ra pe vi cti m i n the emergency depa rtment. As a phys i ci a n, your l ega l requi rement i ncl udes whi ch of the fol l owi ng? a . Identi fi ca ti on of the a tta cker b. Deta i l ed nota ti on of i njuri es c. Del i very of evi dence to a l a w enforcement fa ci l i ty d. Trea ti ng pa ti ent even i f s he refus es e. Wri ti ng the di a gnos i s of ra pe i n the pa ti ent’s cha rt 466. You a re a n i ntern worki ng the ni ght s hi i n the emergency depa rtment. Duri ng the eva l ua on of a s exua l a s s a ul t vi c m, your a endi ng phys i ci a n a s ks you to order the a ppropri a te l a bora tory tes ts . Whi ch of the fol l owi ng tes ts s houl d be ordered? a . HIV, HBs Ag, Pa p s mea r, RPR, a nd uri ne cul ture b. HIV, HBs Ag, Pa p s mea r, RPR, a nd uri ne pregna ncy tes t c. Chl a mydi a a nd gonorrhea cul tures , compl ete bl ood count, HIV, HBs Ag, Pa p s mea r, a nd RPR d. Chl a mydi a a nd gonorrhea cul tures , HIV, HBs Ag, Pa p s mea r, RPR, a nd uri ne pregna ncy tes t e. Chl a mydi a a nd gonorrhea cul tures , HIV, HBs Ag, RPR, uri ne cul ture, a nd uri ne pregna ncy tes t 467. You a re eva l ua ng a 19-yea r-ol d woma n for a s exua l a s s a ul t. She deni es a ny medi ca l probl ems or a l l ergi es to medi ca ons . Her pregna ncy tes t i s nega ti ve. Whi ch of the fol l owi ng a nti bi oti c prophyl a xes do you recommend for s exua l l y tra ns mi tted i nfecti ons ? a . Azi thromyci n 1 g ora l l y pl us Ceftri a xone 125 mg IM. b. Ceftri a xone 125 mg IM. c. Ci profl oxa ci n 500 mg PO twi ce da i l y x 7 da ys . d. Metroni da zol e 2 g ora l l y i n a s i ngl e dos e. e. No a nti bi oti c prophyl a xi s i s i ndi ca ted. 468. Duri ng your eva l ua on of a s exua l a s s a ul t vi c m i n the emergency depa rtment, s he expres s es her fea r of becomi ng pregna nt due to the a tta ck. Whi ch of the fol l owi ng i s the bes t method to recommend for emergency contra cepti on?

a . None, beca us e i t wi l l ca us e a n a borti on a nd i s mora l l y wrong. b. None, beca us e i t wi l l be i neffecti ve i f ta ken more tha n 12 hours a fter coi tus . c. An i ntra uteri ne devi ce, beca us e i t i s 99% effecti ve. d. Combi na ti on es trogen a nd proges ti n contra cepti ve pi l l s . e. Pl a n B, a proges ti n onl y contra cepti on. 469. A er your eva l ua on a nd trea tment of a ra pe vi c m ha s been compl eted, you di s cha rge the pa ent to home. When i s the bes t me to s chedul e a fol l ow-up a ppoi ntment for the pa ti ent? a . 24 to 48 hours . b. 1 week. c. 6 weeks . d. 12 weeks . e. There i s no need for the pa ti ent to ha ve a ny a ddi ti ona l fol l ow-up a s l ong a s s he feel s wel l . 470. A ra pe vi c m returns to your office 2 months a er the a a ck for a fol l ow-up vi s i t. She i nforms you tha t her s l eep ha s i mproved a nd s he ca n now be by hers el f wi thout feel i ng a nxi ous or pa ni cked. She ha s a l s o devel oped new fri ends hi ps through her church. She s ta tes tha t s he i s cha ngi ng jobs a nd movi ng to a new town. She feel s tha t wi th thi s cha nge s he wi l l be i n control of her l i fe. The bes t recommenda on you ca n ma ke for the recovery of thi s pa ti ent i s whi ch of the fol l owi ng? a . Conti nue couns el i ng. b. Fa ce her a tta cker to bri ng cl os ure to thi s event. c. Get her to a ccept res pons i bi l i ty for the a tta ck. d. Stop couns el i ng s i nce her recovery i s now compl ete. e. Ta ke a nxi ol yti c medi ca ti on. 471. A fa mi l y medi ci ne phys i ci a n refers a 19-yea r-ol d woma n to you for a bnorma l findi ngs duri ng her wel l -woma n exa mi na on. She emi gra ted to the Uni ted Sta tes wi th her fa mi l y 6 yea rs a go from Wes t Afri ca . She i s not s exua l l y a c ve a t thi s me but ha s ha d one pa rtner 2 yea rs a go. She deni es a ny s exua l l y tra ns mi ed di s ea s es . She i s on ni trofura ntoi n for recurrent uri na ry tra ct i nfec ons ; otherwi s e s he i s hea l thy. She deni es a ny s urgeri es , but s he remembers undergoi ng a s peci a l ceremony a s young chi l d i n Afri ca . Lung, ca rdi a c, brea s t, a nd a bdomi na l exa mi na on i s wi thi n norma l l i mi ts . On pel vi c exa mi na on you note extens i ve s ca rri ng on the vul va , a nd the l a bi a mi nora ha ve been removed. The prepuce of the cl i tori s i s mi s s i ng a nd the cl i tori s i s s ca rred over. Whi ch of the fol l owi ng i s mos t l i kel y a res ul t of the procedure the pa ti ent ha d i n Afri ca ? a . Amenorrhea b. Decrea s ed va gi na l i nfecti ons c. Ea s i er va gi na l del i veri es d. Enha nced s exua l functi on e. Ps ychos oma ti c s ymptoms 472. You a re the gynecol ogi s t coveri ng the emergency depa rtment. The emergency room phys i ci a n ca l l s you down to eva l ua te a 5-yea r-ol d gi rl who wa s brought i n by her mother. The mother i s concerned tha t her da ughter ma y ha ve been s exua l l y mol es ted. She feel s thi s wa y beca us e her da ughter ha s been a cti ng fl i rta ti ous a round boys a nd a l s o beca us e s he noted s ome bl oody di s cha rge on her da ughter’s underwea r. The chi l d l i ves a t home wi th her mother, 1-yea r-ol d brother, ma terna l a unt, a nd 18-yea r-ol d cous i n. The chi l d’s fa ther i s dea d a nd mother i s not s eei ng a nyone currentl y. Whi ch of the fol l owi ng i s the mos t l i kel y a bus er? a . Ma l e s tra nger b. Fema l e s tra nger c. Ma l e rel a ti ve d. Fema l e rel a ti ve 473. A mother bri ngs i n her 16-yea r-ol d da ughter for a n eva l ua on of chroni c a bdomi na l pa i n. You ha ve s een the gi rl ma ny mes before for va ri ous va gue compl a i nts over the pa s t yea r. She ha s regul a r cycl es tha t l a s t 4 da ys wi th medi um to l i ght flow. She deni es dys menorrhea , ga s troi ntes na l s ymptoms , or feel i ng depres s ed. She deni es a ny s exua l a c vi ty. The mother s ta tes tha t l a tel y s he ha s been doi ng poorl y i n s chool . She deni es drug or a l cohol us e. Her mother thi nks i t ma y be rel a ted to recent cha nges a t home s i nce the mother’s boyfri end moved i n. Your exa mi na on a nd l a bora tory tes ts a re norma l . A previ ous workup by a ga s troenterol ogi s t wa s a l s o nega ve. Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent’s s ymptoms ? a . Ini ti a te bi ofeedba ck thera py for chroni c pa i n. b. Order i mmedi a te ps ychi a tri c eva l ua ti on. c. Pres cri be a nti bi oti c for chroni c ga s troenteri ti s . d. Pres cri be a nti depres s a nt. e. Ques ti on the pa ti ent a bout pos s i bl e s exua l a bus e. 474. You a re ca l l ed to the pedi a tri c emergency depa rtment to eva l ua te a 7-yea r-ol d gi rl for s exua l a s s a ul t. As a hea l th ca re provi der ta ki ng ca re of thi s gi rl , whi ch of the fol l owi ng a re you requi red to do? a . Admi ni s ter a nti bi oti cs onl y i f tes ti ng for i nfecti on i s pos i ti ve. b. Dema nd tha t the chi l d be pl a ced i n fos ter ca re pendi ng further i nves ti ga ti on. c. Hos pi ta l i ze the chi l d unti l the offender ha s been a pprehended. d. Inform the pa rents tha t they mus t noti fy the pol i ce. e. Noti fy chi l d wel fa re a uthori ti es . 475. A 25-yea r-ol d G1P0 pres ents to your office for a rou ne return OB vi s i t a t 30 weeks . On l i s teni ng to the feta l hea rt tones , you no ce tha t the pa ent ha s a number of brui s es on the a bdomen. You a s k the pa ent wha t ha ppened, a nd s he tel l s you the brui s es res ul ted from a fa l l s he s uffered s evera l da ys ea rl i er, when s he s l i pped on the s ta i rs . The pa ent returns to your office 3 weeks l a ter for a nother rou ne vi s i t, a nd you note tha t s he ha s a broken a rm i n a ca s t. She s ta tes tha t s he fel l a ga i n. You ques on her a bout phys i ca l a bus e a nd the pa ent begi ns cryi ng a nd revea l s a l ong-s ta ndi ng hi s tory of a bus e by her hus ba nd. Whi ch of the fol l owi ng i s the mos t l i kel y rea s on for upper extremi ty i njury i n thi s pa ti ent? a . Injury from bei ng res tra i ned b. Defens i ve i njury c. Fa l l from bei ng pus hed

d. Injury rel a ted to s tri ki ng ba ck a t her hus ba nd e. Sel f-i nfl i cted wounds 476. An el derl y woma n i s brought to your cl i ni c for a gynecol ogi ca l exa mi na on by a nei ghbor for va gi na l bl eedi ng. She a ppea rs unkempt a nd fra i l . Her fri end i s concerned a bout a bus e by the pa ent’s fa mi l y. You i ntervi ew a nd exa mi ne the pa ent a nd ma ke the a ppropri a te referra l s for s oci a l s ervi ces . Wha t i s the common type of a bus e of the el derl y? a . Emoti ona l b. Fi na nci a l c. Negl ect d. Phys ci a l e. Sexua l 477. You a re i n the emergency depa rtment eva l ua ng a 42-yea r-ol d woma n who wa s s hot by her hus ba nd duri ng a n a rgument. You recogni ze her beca us e you ha ve trea ted her numerous mes for va ri ous compl a i nts . Whi ch of the fol l owi ng i s a common cha ra cteri s c of i n ma te pa rtner vi ol ence? a . Vi cti ms repea tedl y vi s i t cl i ni cs a nd emergency depa rtments for di fferent compl a i nts . b. Vi cti ms a re rel ucta nt to revea l a bus e when thei r phys i ci a ns a s k them a bout i t. c. The events a re i s ol a ted a nd not a s s oci a ted wi th other a bus es . d. The hea d a nd neck a re ra re a rea s of i njury. e. Si gns a nd s ymptoms a re us ua l l y evi dent, a nd the correct di a gnos i s i s ma de mos t of the ti me. 478. You a re eva l ua ng a 36-yea r-ol d woma n i n the emergency depa rtment for a broken a rm. She s ta tes tha t s he s l i pped i n the tub. Thi s i s the thi rd me you ha ve s een her for a tra uma -rel a ted i njury i n the pa s t 6 months . You s us pect domes c vi ol ence. A er trea ng her broken a rm a nd eva l ua ti ng her emoti ona l s ta tus , whi ch of the fol l owi ng i s the next a ppropri a te s tep i n the ma na gement of thi s pa ti ent? a . Confront the pa ti ent’s pa rtner. b. Di s cha rge her to home. c. Offer couns el i ng a nd res ources . d. Order her to l ea ve her pa rtner. e. Provi de a n a nti depres s a nt. 479. You a re ca l l ed to the emergency depa rtment to eva l ua te a 23-yea r-ol d G1 who i s 6-weeks pregna nt a nd ha s va gi na l bl eedi ng. You ha ve s een her i n your office before for her wel l -woma n exa mi na on. You ha d a s s i s ted her i n recei vi ng couns el i ng a nd a s s i s ta nce for rel a ons hi p probl ems wi th her verba l l y a bus i ve boyfri end. She s ta tes tha t they a re now ma rri ed a nd thei r rel a ons hi p ha s i mproved. You ma ke the di a gnos i s of a threa tened a bor on i n the emergency depa rtment a nd s chedul e the pa ent for a n OB vi s i t a t your office i n 2 weeks . Whi ch of the fol l owi ng i s the norma l cours e of a n a bus i ve rel a ti ons hi p duri ng pregna ncy? a . Abus e i s uncommon duri ng pregna ncy. b. An i ncrea s e i n a bus e occurs i n a bout 20% of rel a ti ons hi ps . c. Abus e i s us ua l l y di rected a wa y from the brea s t a nd a bdomen. d. Pregna nt women who a re a bus ed us ua l l y ha ve fewer compl a i nts . e. Abus ed women us ua l l y recei ve a dequa te prena ta l ca re. 480. You a re s eei ng a 37-yea r-ol d woma n i n your office for fol l ow-up of a n i njury rel a ted to domes c vi ol ence. She s ta tes tha t her hus ba nd i s over wi th hi s a bus i ve beha vi or a nd i s trea ng her l i ke roya l ty. He ha s bought her a new neckl a ce to s how how s orry he i s a bout the i nci dent. She ha s cha nged her pl a ns to s eek couns el i ng a nd to move out. Whi ch of the fol l owi ng i s the mos t l i kel y outcome i n thi s s i tua ti on? a . Abus er a ccepts res pons i bi l i ty for hi s beha vi or. b. Ces s a ti on of a l l a bus e. c. Decrea s ed epi s odes of vi ol ence. d. Increa s i ng s everi ty of ba tteri ng. e. Rol e revers a l wi th vi cti m ta ki ng control of rel a ti ons hi p.

Sexual Abuse and Domestic Violence Answers 461. The answer is d. (Schorge, pp 305-307.) The phys i ci a n’s res pons i bi l i ty i n the ca re of a ra pe vi c m i ncl udes medi ca l , medi ca l -l ega l , a nd emo ona l s upport. The phys i ci a n’s medi ca l res pons i bi l i es i ncl ude trea tment of i njuri es , tes ng, a nd preven on a nd trea tment of both i nfec ons a nd pregna ncy. Thi s pa ent ha s a norma l exa mi na on, a nd a CT i s not i ndi ca ted. The pa ent s houl d be tes ted for s exua l l y tra ns mi ed di s ea s es a nd gi ven prophyl a c c a n bi o cs to trea t s uch di s ea s es . Al s o, the pa ent s houl d be tes ted for pregna ncy a nd, i f s he i s not pregna nt a t the me, offered emergency contra cep on. Thi s pa ent i s not a ca ndi da te for a n emergency contra cep ve, beca us e the s exua l a s s a ul t occurred 3 weeks a go. (Emergency contra cep on s houl d be gi ven wi thi n 72 hours of the event.) Even though there ca n be l ong-s ta ndi ng ps ychol ogi ca l cons equences of ra pe, a nti depres s a nts a re not i ndi ca ted a t thi s ti me i n thi s pa ti ent. 462. The answer is d. (Schorge, p 307.) The i mmedi a te or a cute pha s e of the ra pe tra uma s yndrome ca n l a s t for hours to da ys . It i s a s s oci a ted wi th a pa ra l ys i s of the vi c m’s us ua l copi ng mecha ni s ms . The vi c m’s res pons e ma y be compl ete emo ona l brea kdown or wel l -control l ed beha vi or. The a ctua l rea c on of the vi c ms wi l l depend on ma ny fa ctors , i ncl udi ng us e of force, l ength of a a ck or how l ong they were hel d a ga i ns t thei r wi l l , a nd thei r rel a ons hi p to the a a cker (s tra nger vers us s omeone cl os e to them). The vi c m i s us ua l l y di s orga ni zed i mmedi a tel y a er the a s s a ul t a nd ha s both phys i ca l a nd emoti ona l compl a i nts . 463. The answer is d. (Schorge, p 307.) As pa rt of the ra pe tra uma s yndrome, vi c ms of s exua l a s s a ul t ma y a ppea r ca l m, tea rful , or a gi ta ted, or they ma y demons tra te a combi na on of thes e emo ons . In a ddi on, vi c ms of s exua l a s s a ul t ma y s uffer a n i nvol unta ry l os s of cogni on wherei n they

ca nnot thi nk cl ea rl y or remember thi ngs . 464. The answer is e. (Schorge, p 306.) Injuri es occur i n 12% to 40% of s exua l a s s a ul t vi c ms . Mos t occur when the vi c m i s res tra i ned or phys i ca l l y coerced i nto the s exua l a ct. Mos t a re mi nor a nd requi re s i mpl e repa i r. Onl y 1% requi re ma jor s urgi ca l repa i r a nd hos pi ta l i za on. The phys i ci a n s houl d eva l ua te for i njuri es s uch a s a bra s i ons , brui s es , s cra tches , a nd l a cera ons on the neck, a bdomen, ba ck, bu ocks , a nd extremi es , a s wel l a s the pel vi c a rea . La cera ons of the va gi na a nd vul va a re common i n chi l dren, vi rgi na l vi c ms , a nd el derl y women. If ora l penetra on wa s forced, the oropha rynx s houl d a l s o be exa mi ned. 465. The answer is b. (Schorge, p 306.) Your l ega l requi rement a s a phys i ci a n eva l ua ng a s exua l a s s a ul t vi c m i ncl udes documenta on of hi s tory, exa mi na on a nd nota on of i njuri es , a nd col l ec on of cl othi ng a nd va gi na l , recta l , oropha rynx, pubi c ha i r s a mpl es , a nd fingerna i l s cra pi ngs , a s a ppropri a te, for tes ng. You mus t s ubmi t a ny s peci mens to forens i c a uthori es a nd recei ve a recei pt for the pa ent’s cha rt. It i s i mporta nt to obta i n cons ent pri or to exa mi ni ng a nd col l ec ng s peci mens . Si nce rape a nd assault a re l ega l l y defined terms , they s houl d not be s ta ted a s a di a gnos i s . 466. The answer is e. (Schorge, pp 306-307.) The fol l owi ng a re the i ni a l l a bora tory tes ts tha t s houl d be performed a t the me of exa mi ni ng a ra pe vi c m: gonorrhea a nd chl a mydi a cul tures from the va gi na , a nus , a nd throa t; RPR; hepa s a n gens ; HIV; U/A; uri ne C a nd S; a nd pregna ncy tes t. A pa p s mea r i s a s creeni ng tes t for cervi ca l ca ncer a nd i s not pa rt of the eva l ua ti on i n ca s es of ra pe a nd s exua l a s s a ul t. 467. The answer is a. (Schorge, p 307.) An bi o c prophyl a xi s for gonorrhea a nd chl a mydi a s houl d be gi ven. Recommended trea tment i s ce ri a xone 125 mg i ntra mus cul a rl y i n a s i ngl e dos e pl us a zi thromyci n 1 g ora l l y i n a s i ngl e dos e. Op ona l trea tments i ncl ude hepa s B va cci na on, metroni da zol e 2 g ora l l y a nd prophyl l a xi s for HIV wi th zi dovudi ne a nd l a mi vudi ne. 468. The answer is e. (Schorge, pp 306-307.) “Emergency contra cep on” (medi ca on prophyl a xi s ) to prevent pregna ncy s houl d be offered to women fol l owi ng s exua l a s s a ul t. Fi rs t there s houl d be a pregna ncy tes t to excl ude pregna ncy. Na us ea i s a very common s i de effect wi th combi na on es trogen/proges n pi l l s us ed for emergency contra cep on. Pl a n B, a proges n onl y form of emergency contra cep on, ha s a much l ower ra te of na us ea a nd i s be er tol era ted, ma ki ng i t the preferred choi ce. Prophyl a xi s ca n be gi ven up to 72 hours a er the a s s a ul t but ha s been s hown to be effec ve up to 5 da ys a er the ra pe. Emergency contra cep on ha s effica cy ra tes of 74% to 89%. Pa ents s houl d be i nformed tha t thei r next mens es ma y be del a yed a nd couns el ed to get a pregna ncy tes t i f i t i s del a yed more tha n 2 weeks . A copper IUD ca n be i ns erted for emergency contra cepti on but s houl d be a voi ded unti l a cti ve i nfecti on ca n be rul ed out. 469. The answer is a. (Schorge, p 307.) The pa ent s houl d recei ve fol l ow-up couns el i ng wi thi n 24 to 48 hours , a nd s ubs equent fol l ow-up a ppoi ntments ca n be a rra nged a t 1 a nd 4 weeks . The pa ti ent s houl d not l ea ve wi thout pl a ns for fol l ow-up. 470. The answer is a. (Schorge, p 307.) The reorga ni za on pha s e of the ra pe tra uma s yndrome i nvol ves l ong-term a djus tments a nd ma y l a s t for months to yea rs . Fl a s hba cks a nd ni ghtma res ma y con nue a nd phobi a s ma y devel op. Vi c ms ma y a l s o ma ke ma ny new l i fes tyl e cha nges (eg, movi ng, ma ki ng new fri ends , ge ng a new job). Thi s i s a n a empt by vi c ms to rega i n control over thei r l i ves . Medi ca l a nd couns el i ng ca re s houl d rema i n nonjudgmenta l , s ens i ti ve, a nd a ttuned to the pa ti ent’s overa l l wel l -bei ng. It i s i mporta nt for the pa ti ent to conti nue couns el i ng duri ng thi s ti me for ful l recovery to be a chi eved. 471. The answer is e. (Katz, p 207.) Fema l e geni ta l mu l a on i s a form of s exua l a bus e recentl y obs erved i n a rea s of the worl d s uch a s Afri ca , the Mi ddl e Ea s t, a nd Southea s t As i a . It i s o en performed by untra i ned pra c oners wi thout a nes thes i a , us ua l l y i n ea rl y chi l dhood through 14 yea rs of a ge. Ma ny compl i ca ons ca n occur, s uch a s i nfec on, teta nus , s hock, hemorrha ge, a nd dea th. Long-term compl i ca ons i ncl ude chroni c i nfec on, s ca r a nd a bs ces s forma on, s teri l i ty, obs tetri ca l compl i ca ons , a nd i ncon nence. Ps ychol ogi ca l probl ems rel a ted to s exua l a bus e ma y a l s o be evi dent, s uch a s a nxi ety, depres s i on, a nd s exua l dys functi on. 472. The answer is c. (Schorge, p 308.) Approxi ma tel y 80% of ca s es of s exua l a bus e of a chi l d i nvol ve a fa mi l y member. Fa ther-da ughter i nces t a ccounts for 75% of a l l ca s es i n whi ch a fa mi l y member i s i nvol ved, wi th the rema i nder a nother cl os e rel a ve s uch a s brother, mother, uncl e, or cous i n. 473. The answer is e. (Schorge, p 308.) Chi l dren who ha ve been a bus ed us ua l l y exhi bi t gui l t, a nger, beha vi ora l probl ems , unexpl a i ned phys i ca l s ymptoms , poor s chool performa nce, a nd s l eep di s turba nces . Phys i ci a ns who eva l ua te pa ents wi th va gue chroni c pa i n s yndromes tha t s how no evi dence of phys i ca l e ol ogy s houl d i nves ga te s exua l a bus e a s a pos s i bl e contri butor. Couns el i ng s houl d be offered a s pa rt of the trea tment i f a bus e i s encountered. 474. The answer is e. (Schorge, p 308.) In eva l ua ng a chi l d of s us pected s exua l a s s a ul t, you s houl d ca reful l y obta i n a hi s tory a nd a l l ow the chi l d to s a y wha t ha ppened. Techni ques of exa mi ni ng a ra pe vi c m s houl d be empl oyed (col l ec on of cul tures , cl othi ng, ha i r s a mpl es , etc). The pol i ce a nd chi l d protec ve s ervi ces s houl d be no fied. Any i njuri es s houl d be trea ted, a nd the chi l d s houl d be hos pi ta l i zed onl y i f needed ba s ed on i njuri es . Appropri a te a nti bi oti c prophyl a xi s s houl d be gi ven a nd couns el i ng s houl d be s chedul ed. The chi l d s houl d be returned to the home onl y i f i t i s deemed s a fe. 475. The answer is b. (Schorge, p 308.) The mos t common s i tes of i njury a re the hea d, neck, ches t, a bdomen, brea s t, a nd upper extremi es . An upper extremi ty ma y be fra ctured a s the woma n a empts to defend hers el f. In ma te pa rtner vi ol ence occurs to 7 to 20% of pregna nt women a nd doctors s houl d s creen for domes ti c vi ol ence duri ng the prena ta l peri od. 476. The answer is c. (Schorge, p 308.) Wi th the i ncrea s i ng a ge of the popul a on i n the U.S. el der a bus e i s becomi ng a bi g probl em. Over 2 mi l l i on el derl y a re mi s trea ted a nnua l l y a nd mos t ca s es go unreported. There a re s even types of el der a bus e: phys i ca l , emo ona l , s exua l , fina nci a l expl oi ta on, negl ect, s el f-negl ect, a nd mi s cel l a neous . By fa r, negl ect i s the mos t common form of a bus e. It mos t o en occurs a t the ha nds of fa mi l y members a nd i n the home of the el der. Ri s k fa ctors i ncl ude: ca regi ver s tres s , cogni ve i mpa i rment of the pa ent, need for a s s i s ta nce wi th a cti vi ti es of da i l y l i vi ng, confl i cts wi thi n the fa mi l y, a nd poor s oci a l s upport. 477. The answer is a. (Schorge, p 308.) About 25% of women trea ted for i njuri es i n emergency depa rtments a re vi c ms of domes c vi ol ence. Such women us ua l l y ma ke repea ted vi s i ts to cl i ni cs a nd emergency rooms wi th a va ri ety of s oma c compl a i nts . Phys i ci a ns trea ng thes e pa ents correctl y ma ke the di a gnos i s i n onl y 3% of the ca s es . Mos t women report tha t they woul d be wi l l i ng to di vul ge thei r domes c a bus e to a phys i ci a n i f the phys i ci a n were to a s k. Pa rtner a bus e i s us ua l l y s een i n conjunc on wi th other a bus es s uch a s el derl y a bus e a nd chi l d a bus e. Phys i ca l i njury i n ca s es of domes ti c vi ol ence us ua l l y i nvol ves the fol l owi ng a rea s : hea d a nd neck, trunk, s ki n, a nd extremi ti es .

478. The answer is c. (Schorge, p 308.) As a phys i ci a n, you s houl d trea t the i njuri es a nd a s s es s the emo ona l needs of the pa ent from a ps ychi a tri c s ta ndpoi nt, s uch a s pos s i bl e depres s i on or a nxi ety. If s uch a condi on exi s ts , you s houl d refer the pa ent to a menta l hea l th worker. You s houl d i nves ga te the pa ent’s own a wa renes s of her s i tua on a nd her wi l l i ngnes s to ta ke a ppropri a te a c on. The phys i ci a n’s job i s to recogni ze domes c vi ol ence a nd to ens ure couns el i ng for the pa ent s o tha t s he unders ta nds her ri ghts a nd op ons a nd ca n protect hers el f a nd her chi l dren. A vi cti m of a bus e ma y not l ea ve her s i tua ti on for economi c rea s ons or fea r of retri buti on. 479. The answer is b. (Schorge, p 308.) Phys i ca l a bus e i s common i n pregna ncy, occurri ng i n up to 10% of pregna nci es . In women who ha ve been previ ous l y a bus ed, a bout 20% wi l l experi ence a n i ncrea s e i n a bus e duri ng pregna ncy. Abus ed women us ua l l y recei ve i na dequa te prena ta l ca re a nd ha ve more s oma ti c compl a i nts tha n thos e who ha ve not been a bus ed. Ba tteri ng i s frequentl y di rected towa rd the brea s ts a nd a bdomen. 480. The answer is d. (Schorge, p 308.) Domes c vi ol ence a a cks us ua l l y run i n cycl es of three pha s es . The firs t pha s e cons i s ts of a bui l dup of tens i on wi th a n es ca l a on of fri c on between fa mi l y members . It i ncl udes na me-ca l l i ng, i n mi da on, a nd mi l d phys i ca l a bus e. The s econd pha s e i s the a cute ba eri ng, whi ch i s a n uncontrol l ed di s cha rge of bui l t-up tens i on. Verba l or phys i ca l a bus e ma y occur. Al cohol i s us ua l l y i nvol ved i n two-thi rds of ca s es . The thi rd pha s e occurs a er the a bus e ha s ta ken pl a ce. At thi s me the ba erer a pol ogi zes , begs forgi venes s , a nd s hows remors e. Abus ers wi l l offer gi s a nd ma ke promi s es to the vi c m. They a re o en very cha rmi ng i n thi s pha s e. The cycl es repea t thems el ves , wi th the firs t pha s e becomi ng l onger a nd i ncrea s i ng i n i ntens i ty; the ba eri ng i s us ua l l y more s evere, a nd the thi rd pha s e us ua l l y decrea s es i n both l ength a nd i ntens i ty. Ba tterers a re frequentl y men who refus e to ta ke res pons i bi l i ty for thei r a cti ons a nd often bl a me the vi cti m. As the cycl es conti nue, ba tterers us ua l l y ga i n more control over thei r vi cti ms .

Ethical and Legal Issues in Obstetrics and Gynecology Questions 481. Whi ch of the fol l owi ng i s not a requi rement for hos pi ta l s a ccordi ng to the Federa l Pa ti ent Sel f-Determi na ti on Act? a . To provi de a l l a dul ts wi th i nforma ti on a bout thei r ri ght to a ccept or refus e trea tment i n the event of l i fe-threa teni ng condi ti ons b. To s ta te the i ns ti tuti on’s pol i cy on a dva nce di recti ves c. To prohi bi t di s cri mi na ti on i n ca re provi ded to a pa ti ent on the ba s i s of the pa ti ent’s a dva nced di recti ve d. To requi re dona ti on of orga ns a fter dea th e. To a l l ow pa ti ents to deci de who ha s the ri ght to ma ke deci s i ons for them 482. A 31-yea r-ol d G3P3 Jehova h’s Wi tnes s begi ns to bl eed hea vi l y 2 da ys a er a ces a rea n s ec on. She refus es tra ns fus i on a nd s a ys tha t s he woul d ra ther di e tha n recei ve a ny bl ood or bl ood products . You pers ona l l y feel tha t you ca nnot do nothi ng a nd wa tch her di e. Appropri a te a c ons tha t you ca n ta ke under thes e ci rcums ta nces i ncl ude whi ch of the fol l owi ng? a . Tel l i ng the pa ti ent to fi nd a nother phys i ci a n who wi l l ca re for her b. Tra ns fus i ng her forci bl y c. Onl y provi de s upporti ve ca re d. Getti ng a court order a nd tra ns fus i ng e. Ha vi ng the pa ti ent’s hus ba nd s i gn a rel ea s e to forci bl y tra ns fus e her 483. A phys i ci a n i s bei ng s ued for ma l pra c ce by the pa rents of a ba by born wi th cerebra l pa l s y. Whi ch of the fol l owi ng i s not a prerequi s i te for fi ndi ng the phys i ci a n gui l ty of ma l pra cti ce? a . A doctor-pa ti ent rel a ti ons hi p wa s es ta bl i s hed. b. The phys i ci a n owed a duty to the pa ti ent. c. The phys i ci a n brea ched a duty to the pa ti ent. d. The brea ch of duty ca us ed da ma ge to the pl a i nti ff. e. The phys i ci a n fa i l ed to gi ve expert ca re to the pa ti ent. 484. A 27-yea r-ol d woma n who ha s previ ous l y recei ved no prena ta l ca re pres ents a t term. On ul tra s ound, s he i s s hown to ha ve a pl a centa previ a , but refus es to ha ve a ces a rea n s ecti on for a ny rea s on. Importa nt poi nts to cons i der i n her ma na gement i ncl ude whi ch of the fol l owi ng? a . The obs tetri ci a n’s obl i ga ti on to the s uppos edl y norma l fetus s upers edes the obl i ga ti on to the hea l thy mother. b. The i ncl us i on of s evera l peopl e i n thi s compl ex s i tua ti on ra i s es the l ega l ri s k to the phys i ci a n. c. Chi l d a bus e s ta tutes requi re the phys i ci a n to get a court order to force a ces a rea n s ecti on. d. Court-ordered ces a rea n s ecti ons ha ve a l mos t a l wa ys been determi ned to a chi eve the bes t ma na gement. e. A hos pi ta l ethi cs commi ttee s houl d be convened to eva l ua te the s i tua ti on. 485. Your 36-yea r-ol d pa ent i s a dmi ed to the hos pi ta l for i nduc on of l a bor a t 42 weeks ges ta on. She provi des the hos pi ta l wi th her l i vi ng wi l l a t the me of her a dmi s s i on. She s i gned the wi l l 5 yea rs a go, but s he s a ys to her nurs e tha t s he s l l wa nts to a bi de by the wi l l . She ha s a l s o s i gned a n orga n donor ca rd a l l owi ng the ha rves ti ng of her orga ns i n the event of her dea th. Why i s her l i vi ng wi l l not va l i d for thi s hos pi ta l i za ti on? a . In the event tha t s he becomes del i ri ous duri ng l a bor, s he wi l l be una bl e to cha nge her mi nd. b. She i s pregna nt. c. It ha s been too ma ny yea rs s i nce the s i gni ng of the wi l l . d. Si gni ng a n orga n donor ca rd a utoma ti ca l l y i nva l i da tes a l i vi ng wi l l . e. Her hus ba nd ma y deci de l a ter on tha t he di s a grees wi th her l i vi ng wi l l .

Questions 486 to 490 Your pa ent i s a 44-yea r-ol d G4P4 wi th s ymptoma c uteri ne fibroi ds tha t a re unres pons i ve to medi ca l thera py. The pa ent ha s s evere menorrha gi a to the poi nt tha t when s he mens trua tes , s he ca nnot l ea ve the hous e. You recommend to her tha t s he undergo a tota l a bdomi na l hys terectomy. You couns el her tha t s he ma y need a bl ood tra ns fus i on i f s he ha s a l a rge bl ood l os s duri ng the s urgi ca l procedure. Her current hema tocri t i s 25.0. The pa ti ent i s a Jehova h’s Wi tnes s who a da ma ntl y refus es to ha ve a bl ood tra ns fus i on, even i f i t res ul ts i n her dea th. 486. Whi ch of the fol l owi ng i s not a n ethi ca l concern tha t needs to be cons i dered when worki ng through thi s ca s e? a . Lega l i s s ues b. Pa ti ent preferences c. Qua l i ty-of-l i fe i s s ues d. Medi ca l i ndi ca ti ons 487. The pa ti ent’s i ns ura nce compa ny refus es to pa y for the s urgi ca l procedure. Whi ch of the fol l owi ng ethi ca l a rea s i s i nvol ved? a . Autonomy b. Jus ti ce c. Contextua l i s s ue d. Pa ti ent preference e. Qua l i ty of l i fe 488. Res pect for the pa ti ent’s a utonomy or own wi s hes requi res tha t whi ch of the fol l owi ng be a s s es s ed? a . The needs of s oci ety b. The duty not to i nfl i ct ha rm c. The i mpa ct tha t the trea tment wi l l ha ve on the pa ti ent’s qua l i ty of l i fe d. Cons i dera ti on of wha t i s the bes t trea tment

e. The pa ti ent’s pers ona l va l ues 489. Pri or to performi ng the a bdomi na l hys terectomy, you mus t obta i n the pa ent’s i nformed cons ent. Whi ch of the fol l owi ng i s not a key el ement of i nformed cons ent? a . The pa ti ent mus t ha ve the a bi l i ty to comprehend medi ca l i nforma ti on. b. Al terna ti ves to the procedure mus t be pres ented. c. If the pa ti ent i s i nca pa bl e of provi di ng cons ent, the procedure ca nnot be performed. d. The ri s ks of the procedure mus t be pres ented. e. The benefi ts of the procedure mus t be pres ented. 490. The pa ent reques ts tha t you do not ta l k a t a l l to her hus ba nd a bout her medi ca l ca re. Thi s reques t fa l l s under whi ch of the fol l owi ng ethi ca l concepts ? a . Informed cons ent b. Confi denti a l i ty c. Nonma l efi cence d. Adva nced di recti ve

Questions 491 to 500 Ma tch the ethi ca l concern or pri nci pl e wi th the a ppropri a te defi ni ti on. Ea ch l ettered opti on ma y be us ed once, more tha n once, or not a t a l l . a . Pa ti ent preferences b. Benefi cence c. Qua l i ty of l i fe d. Nonma l efi cence e. Autonomy f. Medi ca l i ndi ca ti on g. Contextua l i s s ues h. Jus ti ce 491. The duty not to i nfl i ct ha rm or i njury 492. The duty to promote the good of the pa ti ent 493. Gi vi ng the pa ti ent hi s or her due 494. Res pect of the pa ti ent’s ri ght to s el f-determi na ti on 495. Wha t does the pa ti ent wa nt? 496. Wha t i s the bes t trea tment? 497. Wha t i mpa ct wi l l the propos ed trea tment ha ve on the pa ti ent’s l i fe? 498. Wha t a re the needs of s oci ety? 499. Wha t a re the trea tment a l terna ti ves ? 500. Wha t i mpa ct wi l l l a ck of the propos ed trea tment ha ve on the pa ti ent’s l i fe? 501. Ms Jones i s a 28-yea r-ol d woma n who ha s a greed to be a ges ta ona l s urroga te for a coupl e who ca nnot bea r chi l dren. She pres ents to your offi ce for prena ta l ca re. Whi ch of the fol l owi ng i s your res pons i bi l i ty a s a n obs tetri ci a n ca ri ng for a ges ta ti ona l s urroga te? a . Cons ul t wi th i ntended pa rents rega rdi ng a l l cl i ni ca l i nterventi ons a nd ma na gement of the pregna ncy. b. Di s cus s the hea l th of the s urroga te a nd progres s of the pregna ncy wi th the i ntended pa rents wi thout cons ent of the s urroga te mother. c. Ma ke recommenda ti ons for prena ta l ca re i n a ccorda nce wi th the a greement between the ges ta ti ona l s urroga te a nd the i ntended pa rents . d. Onl y provi de prena ta l ca re to her, i f the a dopti ve mother i s a l s o your pa ti ent. e. Provi de a ppropri a te ca re rega rdl es s of the pa ti ent’s pl a ns to keep or rel i nqui s h the future chi l d. 502. A 24-yea r-ol d pa ent who you ha ve been s eei ng for rou ne gynecol ogi ca l ca re reports tha t s he i s cons i deri ng becomi ng a s urroga te mother for a coupl e s he knows a t work. As her phys i ci a n, wha t i s your res pons i bi l i ty to her i n prepa ri ng her to become a s urroga te? a . Conta ct the i ntended pa rents s o tha t you ca n provi de ca re for them a l s o. b. Expl a i n to her tha t you wi l l requi re a n a ddi ti ona l fee to ca re for her pregna ncy s i nce s he wi l l be a s urroga te. c. Recommend tha t s he uti l i ze the s a me l ega l couns el a s the i ntended pa rents . d. Refer her to menta l hea l th couns el i ng. e. Revi ew the s urroga te contra ct to ens ure tha t s he i s bei ng ful l y compens a ted.

Ethical and Legal Issues in Obstetrics and Gynecology Answers 481. The answer is d. (Sco , pp 939-954.) Hos pi ta l s mus t now i nform pa ents a bout thei r ri ghts to a ccept or refus e termi na l ca re. Such i nforma on ha s to be documented i n the pa ent’s cha rt. The pa ent ha s the op on to ma ke a cl ea r a s s i gnment of who ca n ma ke deci s i ons i f the pa ent

ca nnot. Pa ti ents a re not requi red to a l l ow orga n dona ti on. 482. The answer is c. (ACOG, Committee Opinion 321.) Determi na on of ethi ca l conduct i n doctor-pa ent rel a ons hi ps ca n s ome mes be very di fficul t for the phys i ci a n who i s confronted wi th a pa ent’s a utonomy i n ma ki ng a deci s i on tha t the phys i ci a n finds i ncomprehens i bl e. However, the a utonomy of the pa ent who i s ori ented a nd a l ert mus t be res pected even i f i t mea ns i n effect tha t the pa ent i s commi ng s ui ci de. The obta i ni ng of a court order to tra ns fus e a n a dul t a ga i ns t hi s or her wi l l i s a l mos t never a n a ccepta bl e op on a nd l ea ds to a tremendous l y s l i ppery s l ope of the doctor’s control of the pa ent’s beha vi or. A pa ent’s s pous e a l s o does not ha ve l ega l a uthori ty to ma ke deci s i ons for the pa ent i f the pa ent i s competent, a wa ke, a nd a l ert. The s i tua on i s di fferent when a chi l d i s i nvol ved, a nd then s oci eta l i nteres ts ca n occa s i ona l l y overri de pa renta l a utonomy. It woul d be i na ppropri a te for a phys i ci a n to a ba ndon a pa ent wi thout obta i ni ng s ui ta bl e covera ge from a nother qua l i fied phys i ci a n. Tra ns fus i ng forci bl y i s a s s a ul t a nd ba ery; thus , i n thi s ca s e, the phys i ci a n mus t a dhere to the pa ent’s wi s hes a nd, i f need be, l et her di e. 483. The answer is e. (Ransom, pp 786-792.) Negl i gence l a w governs conduct a nd embra ces a cts of both commi s s i on a nd omi s s i on (i e, wha t a pers on di d or fa i l ed to do). In genera l , the l a w expects a l l pers ons to conduct thems el ves i n a fa s hi on tha t does not expos e others to a n unrea s ona bl e ri s k of ha rm. In a fiduci a ry rel a ons hi p s uch a s the phys i ci a n—pa ent rel a ons hi p, the phys i ci a n i s hel d to a hi gher s ta nda rd of beha vi or beca us e of the i mba l a nce of knowl edge. In genera l , the rea l gi s t of negl i gence i s not ca rel es s nes s or i nep tude, but ra ther, how unrea s ona bl e wa s the ri s k of ha rm to the pa ent ca us ed by the phys i ci a n’s a c on? Thus phys i ci a ns a re hel d a ccounta bl e to a s ta nda rd of ca re tha t a s ks the ques on, “Wha t woul d the rea s ona bl e phys i ci a n do under thi s s peci fic s et of ci rcums ta nces ?” The phys i ci a n i s not hel d a ccounta bl e to the l evel of the l ea di ng experts i n a ny gi ven fi el d, but ra ther to the preva i l i ng s ta nda rds a mong a vera ge pra cti ti oners . When a doctor-pa ti ent rel a ti ons hi p i s es ta bl i s hed, the defenda nt owes a duty to the pa ent. If the defenda nt brea ches tha t duty—tha t i s , a cts i n a wa y tha t i s i ncons i s tent wi th the s ta nda rd of ca re a nd tha t ca n be s hown to ha ve ca us ed da ma ge di rectl y to the pa ent ( proximate damage)—then the phys i ci a n ma y be hel d l i a bl e for compens a ti on. 484. The answer is e. (Gleicher, pp 206-210.) When confronted by a compl ex s i tua on i n whi ch there a re confli c ng va l ues a nd ri ghts , ge ng the mos t peopl e i nvol ved i s the bes t a pproa ch to reduce ri s k a nd to come up wi th the bes t, mos t defens i bl e a ns wer under the current ci rcums ta nces . The obs tetri ci a n s houl d empl oy wha tever depa rtmenta l or hos pi ta l res ources a re a va i l a bl e. A s ta ndi ng ethi cs commi ee or a n a d hoc commi ee to dea l wi th s uch compl ex s i tua ons i s o en a va i l a bl e a nd wi l l mi ni mi ze the ul ma te medi col ega l probl ems tha t ca n ens ue when ba d outcomes s eem l i kel y. The obs tetri ci a n mus t further recogni ze tha t he or s he ha s two pa ents , but tha t i t i s not cl ea r, nor i s i t l egi s l a ted, whos e i nteres ts ta ke pri ori ty. However, genera l ethi ca l opi ni on i s tha t the mother genera l l y s houl d come firs t. Mos t court-ordered ces a rea n s ec ons ha ve been performed on pa ents who were es tra nged from the medi ca l s ys tem, a nd thi s s ets a very ba d precedent for further s ta te i nterven on i n doctorpa ent rel a ons hi ps a nd ma terna l ri ghts . Chi l d a bus e s ta tutes do not a t thi s poi nt requi re a court order to force a ces a rea n s ec on even for a hea l thy fetus , a nd a court order woul d a l mos t never be a ppropri a te. 485. The answer is b. (Scott, pp 939-954.) Li vi ng wi l l s repres ent the cha nce for pa ents to decl a re thei r wi s hes i n a dva nce of s i tua ons i n whi ch they become no l onger competent to do s o. They a re revoca bl e by the pa ent a t a ny me a nd a re a utoma ca l l y i nva l i d i f the pa ent i s pregna nt, a s a nother bei ng i s i nvol ved. Li vi ng wi l l s ca n be s et a s i de i f a l ong peri od ha s el a ps ed s i nce thei r dra i ng a nd the wi s hes a re not known to be current. Al s o, there i s the poten a l for confli ct i f the pa ent ha s s i gned a donor ca rd a nd prol onga on of l i fe woul d be needed to ca rry out thos e wi s hes . Genera l l y, s uch a cti on woul d not be honored unl es s rel a ti vel y expedi ti ous a rra ngements were pos s i bl e. 486 to 490. The answers are 486-a, 487-b, 488-e, 489-c, 490-b. (Beckmann, pp 26-29; ACOG, Commi ee Opinion 395.) Pa ent preferences , qua l i ty-of-l i fe i s s ues , a nd medi ca l i ndi ca ons a re a l l exa mpl es of ethi ca l concerns tha t mus t be ta ken i nto a ccount when worki ng through ethi ca l di l emma s . Cons i dera on of l ega l i s s ues i s not a fa ctor i n ethi ca l deci s i on ma ki ng. If the pa ent’s i ns ura nce compa ny refus es to pa y for the i ndi ca ted procedure (i n thi s ca s e, hys terectomy), the ethi ca l pri nci pl e of jus ce (the pa ent s houl d be gi ven her due) i s bei ng cha l l enged. Autonomy i s the ethi ca l pri nci pl e whereby the pa ent ha s the ri ght to s el f-determi na on. Therefore, the needs of s oci ety (a contextua l i s s ue) a re not cons i dered a s a fa ctor of a utonomy. Informed cons ent requi res tha t the pa ent be a bl e to unders ta nd the ri s ks , benefits , a nd a l terna ves of a pa r cul a r medi ca l procedure. If the pa ent i s una bl e to unders ta nd the medi ca l i nforma on, a l ega l gua rdi a n ca n be a s s i gned to ma ke thos e deci s i ons for hi m or her. A pa ti ent’s des i re not to ha ve hi s or her medi ca l hi s tory di s cus s ed wi th a nyone el s e i nvol ves the ethi ca l concept of confi denti a l i ty. 491 to 500. The answers are 491-d, 492-b, 493-h, 494-e, 495-a, 496-f, 497-c, 498-g, 499-f, 500-c. (ACOG Ethics in Obstetrics and Gynecology, pp 3-5, 21-22.) 501. The answer is e. (ACOG Ethics in Obstetrics and Gynecology, pp 50-55.) When a pregna nt s urroga te s eeks medi ca l ca re for a n es ta bl i s hed pregna ncy, the obs tetri ci a n s houl d expl ore wi th the s urroga te her unders ta ndi ng of her l ega l a greement wi th the i ntended pa rents . She s houl d be ca red for a s a ny other obs tetri ca l pa ent. The obs tetri ci a n’s profes s i ona l obl i ga on i s to s upport the wel l -bei ng of the pregna nt woma n a nd her fetus , a nd to provi de a ppropri a te ca re rega rdl es s of her pl a ns to keep or gi ve up the ba by. The pregna nt s urroga te s houl d be the one to gi ve cons ent rega rdi ng trea tment of the pregna ncy i n the cl i ni c or on l a bor a nd del i very. The obs tetri ci a n s houl d ma ke trea tment deci s i ons tha t a re i n the bes t i nteres t of the s urroga te a nd her fetus , rega rdl es s of the a greement between her a nd the i ntended pa rents . Pa ent confiden a l i ty s houl d be ma i nta i ned. The pa ent’s medi ca l i nforma on s houl d onl y be gi ven to the i ntended pa rents wi th the s urroga te’s expl i ci t cons ent. The obs tetri ci a n s houl d a voi d confli cts of i nteres t a nd s houl d not fa ci l i ta te a woma n’s becomi ng a ges ta ona l s urroga te for a coupl e for whom the phys i ci a n i s trea ti ng. 502. The answer is d. (ACOG Ethics in Obstetrics and Gynecology, pp 50-55.) When a pproa ched by a pa ent cons i deri ng becomi ng a s urroga te mother, the phys i ci a n s houl d a ddres s medi ca l ri s ks a nd benefits a l ong wi th ethi ca l a nd l ega l concerns . Recommenda ons for i ndependent l ega l couns el a nd expl i ci t wri en precondi ons a nd con ngency a greements s houl d be ma de. The phys i ci a n s houl d not trea t the coupl e for whom the pa ent wi l l become a s urroga te. Referra l for menta l hea l th couns el i ng s houl d be provi ded pri or to i ni a on of pregna ncy to expl ore poten a l ps ychol ogi ca l ri s ks a nd effects on the s urroga te mother. Compens a on to the s urroga te s houl d not be determi ned by the phys i ci a n or be con ngent on the s ucces s ful del i very of a hea l thy i nfa nt. The phys i ci a n s houl d recei ve onl y us ua l fees for medi ca l s ervi ces , other pa yments for fina nci a l ga i n a re i na ppropri a te.

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Index A Abdomi na l pregna ncy, 96 Abdomi na l ul tra s ound, 69 Abnorma l bl eedi ng, 250, 272–273, 281 Aborti ons ha bi tua l , 23 s ponta neous , 1–2 techni ques for, 309, 321 types of, 82, 99–100 Abrupti on, 140, 151–152, 176 Abs ol ute contra i ndi ca ti ons , 323 Accuta ne (i s otreti noi n), 24 Achondropl a s i a , 5, 26 Aci demi a , 184 Acti ve l a bor, 149, 154 Acute a ppendi ci ti s , 127 Acute a s thma exa cerba ti on, 133–134 Acute chol ecys ti ti s , 127 Acute fa tty l i ver, 132–133 Acute pa ncrea ti ti s , 113, 126–127 Acute s a l pi ngi ti s , 240 Acycl ovi r, 125 Adenoca rci noma s , 214, 233–234 Adenomyos i s , 248, 270–271 Adnexa l cys ts , 205, 209, 227 Adrena l hyperpl a s i a , congeni ta l , 35, 175, 270, 274, 280–281 AGUS (a typi ca l gl a ndul a r cel l s of undetermi ned s i gni fi ca nce), 220, 238 Al cohol , us e of duri ng pregna ncy, 11, 24, 29, 30–31 Al l ergi c rea cti ons , 128 Ambi guous geni ta l i a , 161, 175 Amenorrhea , 249, 253–255, 271–272, 275, 277–278 Amni ocentes i s , 8, 14, 28, 34, 106 Amni oti c fl ui d embol i s m, 150 Ampi ci l l i n, 102 Androi d pel vi s , 66 Anencepha l y, 9, 26, 35 Anes thes i a , 142, 153–154 Aneupl oi dy, 24 Angi oma s , 47 Anorexi a nervos a , 274 Anovul a ti on, 259, 281 Antepa rtum ca re, 51–78 Anteri or a nd pos teri or (A&P) repa i r, 299 Anteri or col porrha phy, 303 Anthropoi d pel vi s , 66 Anti bi oti c thera py, 21, 331, 338 Anti body tes ti ng, 218 Anti convul s a nts , 31 Anti hypertens i ve thera py, 98 Anti vi ra l thera py, 131, 238 A&P (a nteri or a nd pos teri or) repa i r, 299 Apga r s cori ng s ys tem, 171, 183 Appendi ci ti s , 112, 126–127 Arres t di s orders , 153 Arres t of l a bor, 155 ASB (a s ymptoma ti c ba cteri uri a ), 114, 127–128 As herma n s yndrome, 251, 273–274, 284 As thma , 133–134 As ymptoma ti c ba cteri uri a (ASB), 114, 127–128 Atel ecta s i s , 181 Atrophi c va gi ni ti s , 239 Atypi ca l gl a ndul a r cel l s of undetermi ned s i gni fi ca nce (AGUS), 220, 238 Axi l l a ry node meta s ta s es , 217, 234 B Ba ck pa i n, 77, 267 Ba cteremi a , 128 Ba cteri a l va gi nos i s , 222, 239 Ba ctri m (tri methopri m-s ul fa methoxa zol e), 29, 181 Ba rthol i n duct cys ts , 202

Ba rthol i n gl a nd, 228 Beni gn cys ti c tera toma s , 227 Beta metha s one, 88 Bi cornua te uterus , 248, 270 Bi l a tera l tuba l l i ga ti on, 203 Bi ophys i ca l profi l e (BPP) tes t, 53, 60, 68–69, 74, 75–77 Bi pa ri eta l di a meter, 66 Bi pol a r di s order, 182 Bi rth a s phyxi a , 184 Bi rth defects , 2–3, 24, 117, 131 Bi s hop s core, 73–74 Bl a dder dys s ynergi a , 304 Bl a dder fl a p hema toma s , 166, 179 Bl eedi ng a bnorma l , 250, 272–273, 281 pos tmenopa us a l , 225–226, 243 pos tpa rtum, 166–167, 180 va gi na l , 83–86, 88, 90–91, 99, 104–105 Bl eomyci n, 233 Bl ood pres s ure, 195, 204 Bl ues , pos tpa rtum, 169, 182 BPP (bi ophys i ca l profi l e) tes t, 53, 60, 68–69, 74, 75–77 Bra xton-Hi cks contra cti ons , 154 BRCA1 muta ti on, 199–200 BRCA2 muta ti on, 199–200 Brea s t ca ncer, 199–202, 306 Brea s t ca rci noma , 217, 234 Brea s t engorgement, 172 Brea s t-feedi ng benefi ts of, 172, 184 bi rth control a nd, 172, 185 contra i ndi ca ti ons to, 178–179 fa ctors preventi ng, 165 va gi na l drynes s a nd, 173, 185 Brea s ts di s orders of, 205–243 s el f-exa mi na ti ons of, 201–202 Breech pres enta ti on, 57, 72, 148, 158–159 Brenner tumors , 231 Bromocri pti ne, 184 Burch procedure, 291, 302 C CA-125 tes ti ng, 198, 203 CAH (congeni ta l a drena l hyperpl a s i a ), 35, 175, 270, 274, 280–281 Ca na va n di s ea s e, 32 Ca ndi di a s i s , 239–240 Cepha l i c pres enta ti ons , 66–67 Cepha l opel vi c di s proporti on (CPD), 151, 153 Cercl a ge, 99, 103 Cervi ca l bi ops i es , 24 Cervi ca l ca ncer, 199, 202, 205, 227–228, 230 Cervi ca l cytol ogy, 202–203 Cervi ca l dys pl a s i a , 219, 243 Cervi ca l i ns uffi ci ency, 99 Cervi ca l neopl a s i a , 237 Cervi ca l s ti tch, 99, 103 Cervi ci ti s , 104 Ces a rea n s ecti on i nfecti ons , 173–174, 185–186 l ow tra ns vers e, 67 refus a l of, 344, 350 s teri l i za ti on a nd, 61, 76–77 Cha ncroi d, 236 Chemothera peuti c a gents , 212 Chemothera py, 100–101 Chi l d a bus e, 333–334, 339–340 Chl a mydi a , 198, 240 Chlamydia trachomatis, 237, 240 Chl ora mpheni col , 29, 37, 125–126 Chol ecys ti ti s , 127 Chol era i mmuni za ti on, 37 Chol es terol tes t, 198 Chol es tyra mi ne, 130

Chori oa mni oni ti s , 34, 102, 166, 179 Chori oca rci noma s , 215, 233, 234 Chori oni c vi l l us s a mpl i ng (CVS), 8, 28, 35, 106–107 Chromos oma l a berra ti ons , 1, 23–24 Chromos ome a na l ys i s , 92 Chroni c vul va r pruri tus , 239 Ci ga rette s moki ng, 11, 33, 196, 204 Ci profl oxa ci n, 181 Ci rcumci s i on, 169–170, 182–183 Ci s pl a ti n, 233 Cl i ma cteri c, 246, 267 Cl i nda myci n, 179 Cl obeta s ol , 232 Cl oni di ne, 320 Cl ue cel l s , 222, 239 Coa gul opa thy, 176 Coca i ne, 33 Coffee cons umpti on, 33 Col onos copy, 197 Col pos copy, 237 Compl ete breech pres enta ti on, 158 Compl ete hyda ti di form mol e, 84 Compl i ca ti ons medi ca l , 111–136 obs tetri ca l , 79–109 s urgi ca l , 111–136 Compres s i on ul tra s onogra phy, 126, 134 Condoms , 327 Condyl oma , 211 Condyl oma a cumi na ta , 235 Congeni ta l a drena l hyperpl a s i a (CAH), 35, 175, 270, 274, 280–281 Congeni ta l rubel l a s yndrome, 111, 125, 134 Congeni ta l va ri cel l a , 125 Conges ti ve hea rt fa i l ure, 99 Cons ti pa ti on, 41, 47–48 Contra cepti on, 305–328 brea s t-feedi ng a nd, 172, 185 effects of other medi ca ti ons on, 3 emergency, 331, 338–339 i ntra uteri ne devi ce, 203, 306, 307, 312, 318–319, 325, 327 methods of, 195, 203–204 ora l , 305, 307, 311–312, 318, 319, 322–324, 328 Contra cti on s tres s tes t, 75 Cord bl ood ga s , 171, 184 Cordocentes i s , 34, 107 Cornea l a bra s i ons , 157 Corpus l uteum cys ts , 235 CPD (cepha l opel vi c di s proporti on), 151, 153 Cra ni opha ryngi oma s , 249, 271 Cul docentes i s , 101 CVS (chori oni c vi l l us s a mpl i ng), 8, 28, 35, 106–107 Cycl ophos pha mi de, 233 Cys ti c fi bros i s , 32, 35 Cys ti c hygroma s , 26, 35–36 Cys tometrogra m, 298, 300 Cys tos a rcoma phyl l odes , 242 Cytomega l ovi rus , 134–135 D Da na zol , 250, 273 Da rk-fi el d mi cros copy, 236 D&C (s ucti on di l a ti on a nd curetta ge), 321 D&E (s ucti on di l a ti on a nd eva cua ti on), 321 Dea th, l ea di ng ca us es of, 198, 200–201 Deep vei n thrombos i s , 121 Del i very, 137–159 Demerol (meperi di ne), 153 Depo-Provera , 310, 322 Dermoi d tumors (opened ma ture cys ti c tera toma s ), 213, 233 Detrus or i ns ta bi l i ty, 301 DEXA s ca n, 197 Di a betes bi rth defects a s s oci a ted wi th, 117 effects of, 114, 128–129

ges ta ti ona l , 118, 128, 132 ma l forma ti ons , 131 neuropa thy, 290, 302 Di a gona l conjuga te, 66 Di a phra gms , 203–204, 327 Di cl oxa ci l l i n, 178, 181 Di fl ora s one, 232 Di l a nti n (phenytoi n), 24 Di l a ti on, 151 Di tropa n (oxybutyni n chl ori de), 302 Di zygoti c twi ns , 39, 45 Domes ti c vi ol ence, 329–341 Doppl er fl ow s tudi es , 68 Doppl er s tethos cope, 69 Doppl er vel oci metry, 107 Doubl e footl i ng breech pres enta ti on, 158 Down s yndrome, 2, 7, 25, 28, 30 Doxorubi ci n, 233 Duodena l a tres i a , 36 Dys menorrhea , 247, 254, 268, 276 Dys pa reuni a , 322, 328 Dys pnea (s hortnes s of brea th), 43, 48–49, 121, 133–134 Dys s ynergi a , 301 E Ea rl y-prol i fera ti ve endometri um, 216, 234 Ecl a mps i a , 97–98, 108 Ectopi c pregna ncy, 86, 101–102 ECV (externa l cepha l i c vers i on), 72–73 Edema , 55, 70–71 El der a bus e, 340 El ecti ve cercl a ge pl a cement, 81 Emergency contra cepti on, 313, 325–326, 331, 338–339 Encepha l ocel e, 26 Endocri nol ogy, 245–284 Endometri a l bi ops i es , 24 Endometri os i s , 250, 254, 272, 276–277 Endometri ti s , 179, 185 Endotoxi n rel ea s e, 128 Enl a rged uterus , 173 Epi dura l a na l ges i a , 156 Epi dura l a nes thes i a , 154 Epi dura l bl ock, 154 Epi l eps y, 11, 31 Epi s i otomy, 140, 147, 156, 157–158 Epi thel i a l tumors , 231 Erb (Erb-Duchenne) pa l s y, 156–157 ERT (es trogen repl a cement thera py), 322 Erythromyci n, 125 Es tra di ol l evel , 259, 281 Es trogen, 255, 261, 278, 282–283 Es trogen crea m, 185 Es trogen repl a cement thera py (ERT), 322 Es trone l evel , 259 Ethi ca l i s s ues , 343–352 Ethi nyl es tra di ol , 324 Exerci s e, pregna ncy a nd, 4, 25 Expa nded AFP tes t, 34 Externa l cepha l i c vers i on (ECV), 72–73, 158–159 F Fa ce pres enta ti on, 151 Fa l s e l a bor, 154 Fa t necros i s , 242 Feca l i nconti nence, 286, 298 Federa l Pa ti ent Sel f-Determi na ti on Act, 343, 349 Fema l e geni ta l muti l a ti on, 332, 339 Fema l e s exua l dys functi on di s orders , 327 Fenes tra ted pl a centa , 49 Feta l a l cohol s yndrome, 30–31 Feta l crown-rump l ength, 69 Feta l demi s e, 80, 97 Feta l hea rt a cti on, 56, 72 Feta l hea rt ra te (FHR) tra ci ng, 52, 63–64, 75, 77–78

Feta l hydrocepha l y, 71–72 Feta l hydrops , 94, 108, 136 Feta l l ung ma turi ty, 52 Feta l movement, 40 Feta l pul mona ry ma tura ti on, 68 Feta l s urvei l l a nce, 51–78 FFP (fres h frozen pl a s ma ), 176 FHR (feta l hea rt ra te) tra ci ng, 52, 63–64, 75, 77–78 Fi broa denoma s , 224, 242 Fi brocys ti c cha nges , 242 Fi broi d tumors , 225–226, 242 Fi rs t-degree epi s i otomy, 157 Fl uores cent treponema l a nti body (FTA) tes t, 218 Fl uoros copi c procedures , 32 Fl uoxeti ne, 282 Fol ey ca theter, 105, 109 Fol l i cul a r cys ts , 235 Fol l ow-up a ppoi ntments , for s exua l a s s a ul t vi cti ms , 331, 339 Forceps , 138, 146–147, 157 Fourth-degree epi s i otomy, 158 Fra nk breech pres enta ti on, 73, 158 Frei s ki n tes t, 236 Fres h frozen pl a s ma (FFP), 176 FTA (fl uores cent treponema l a nti body) tes t, 218 Ful mi na nt l i ver fa i l ure, 123, 135 Functi ona l i nconti nence, 297 Functi ona l ova ri a n cys ts , 235 Funda l hei ght, 56, 71–72, 92, 105–106 Funda l pl a centa , 162 Furos emi de, 70 G Ga rtner duct cys ts , 202 Ga s tri c refl ux, 47–48 Ga ucher di s ea s e, 32 GBS (Group B s treptococci ), 138, 150 Genera l a nes thes i a , 155 Geneti c di s orders , 13, 32–33 Geneti c ri s k a s s es s ment, 199–200 Geneti cs , 1–38 Geni ta l herpes , 117, 130–131 Geni ta l prol a ps e, 287, 299 Geni ta l i a , a mbi guous , 161, 175 Ges ta ti ona l a ge, es ti ma ti ng, 170, 183 Ges ta ti ona l di a betes , 118, 128, 132 Ges ta ti ona l s urroga tes , 348, 351–352 Ges ta ti ona l thrombocytopeni a , 133 Gl ucos e-6-phos pha te dehydrogena s e (G6PD) defi ci ency, 35 Gl ucos uri a , 43, 48 Gona da l dys genes i s , 269 Gona dobl a s toma s , 233 Gona dotropi n l evel s , 257, 280 Gonorrhea , 9, 125–126, 198 G6PD (gl ucos e-6-phos pha te dehydrogena s e) defi ci ency, 35 Gra nul os a tumors , 232–233 Gra ves di s ea s e, 118, 131 Gra y ba by s yndrome, 29 Groi n pa i n, 55 Group B s treptococci (GBS), 138, 150 Growth res tri cti on, 53, 92, 106–107, 122 Gynecoi d pel vi s , 66 Gynecol ogy brea s t, di s orders of, 205–243 contra cepti on, 305–328 domes ti c vi ol ence, 329–341 endocri nol ogy, 245–284 ethi ca l i s s ues , 343–352 hea l th ma i ntena nce, 187–204 huma n s exua l i ty, 305–328 i nferti l i ty, 245–284 l ega l i s s ues , 343–352 mens trua l dys functi on, 245–284 pel vi s di s orders of, 205–243

rel a xa ti on of, 285–304 preventi ve ca re, 187–204 s exua l a bus e, 329–341 urol ogy, 285–304 H Ha l obeta s ol , 232 Hea l th ma i ntena nce, 187–204 HELLP s yndrome, 133 Hema toma s , 166, 179, 202 Hemogl obi n l evel a s s es s ment, 203 Hemorrha ge, 138 Hepa ti ti s A, 37 Hepa ti ti s B, 115, 129, 135 Hepa ti ti s B va cci ne, 197 Hepa ti ti s C s creeni ng, 198 Herba l thera pi es , 13, 33 Herpes ges ta ti oni s , 130 Herpes zos ter, 125, 197 HGSIL (hi gh-gra de s qua mous i ntra epi thel i a l l es i on), 210, 219–220, 237 Hi rs uti s m, 253, 276 HIV i nfecti on, 236 HLAs (huma n l eukocyte a nti gens ), 35 Hormone repl a cement thera py (HRT), 245, 261, 266, 282 Hot fl us h, 283 1-hour gl ucos e cha l l enge tes t, 70 HPV (huma n pa pi l l oma vi rus ), 210, 232, 235, 237 HRT (hormone repl a cement thera py), 245, 261, 266, 282 Huma n l eukocyte a nti gens (HLAs ), 35 Huma n pa pi l l oma va cci ne, 199 Huma n pa pi l l oma vi rus (HPV), 210, 232, 235, 237 Huma n s exua l i ty, 305–328 Hunti ngton di s ea s e, 35 Hyda ti di form mol es , 100 Hydra l a zi ne, 109 Hydra mni os , 81, 99 Hydrocepha l us , 26 Hydronephros i s , 36, 48, 208, 229–330 Hydrops , 136 Hydroureter, 48 Hyperemes i s gra vi da rum, 47, 86, 102, 132 Hyperpl a s i a , 252, 274 Hyperprol a cti nemi a , 241, 251, 274 Hypertens i on, 77, 108, 204 Hyperthyroi di s m, 118, 131 Hypoa cti ve s exua l des i re di s order, 327 Hypotoni c uteri ne dys functi on, 153 Hys terectomy, 96–97, 179–180, 208, 230, 243, 285, 288, 297–298 Hys teros a l pi ngogra ms , 251, 256, 263–265, 273, 279–280, 283–284 Hys terotomy, 321 I Immedi a te ca re of newborn, 161–186 Immune thrombocytopeni c purpura (ITP), 133 Immuni za ti ons hi s tory of mul ti pl e s exua l pa rtners , 199 pregna ncy a nd, 8, 31–32 recommenda ti ons , 12, 21–22, 31, 37–38 women 65 a nd over, 188, 197 Impeda nce pl ethys mogra phy, 126 Impeti go herpeti formi s , 130 In vi tro ferti l i za ti on (IVF), 4 Inci s i ona l wound i nfecti on, 185–186 Incl us i on cys ts , 202 Incompl ete a borti on, 99 Incompl ete breech pres enta ti on, 158 Indoci n, 104 Indometha ci n, 89, 104 Inducti on of l a bor, 74 Inevi ta bl e a borti on, 99 Inferi or vena ca va s yndrome, 46 Inferti l i ty, 245–284 Infl uenza va cci ne, 37, 197 INH (i s oni coti ni c a ci d hydra zi de), 129

Inheri ta nce pa tterns , 15 Injuri es rel a ted to s exua l a s s a ul t, 330, 338, 340 Interna l poda l i c vers i on, 159 Inters pi nous di a meter, 66 Intes ti na l obs tructi ons , 47 Intra ducta l pa pi l l oma , 241 Intra fa s ci a l hys terectomy, 228 Intra hepa ti c chol es ta s i s , 130, 132 Intra mus cul a r na rcoti cs , 154–155 Intra uteri ne devi ce (IUD), 203, 306, 307, 312, 318–319, 325, 327 Intra uteri ne feta l demi s e, 80, 97 Intra uteri ne growth res tri cti on (IUGR), 53, 106–107 Intra uteri ne pres s ure ca theter (IUPC), 155 Intra venous hydra ti on, 128 Intra venous pyel ogra m (IVP), 42 Inva s i ve cervi ca l ca rci noma , 206 Inva s i ve vul va r ca rci noma , 228–229 Iron s uppl ements , 42, 48 Is oni coti ni c a ci d hydra zi de (INH), 129 Is otreti noi n (Accuta ne), 24 ITP (i mmune thrombocytopeni c purpura ), 133 IUD (i ntra uteri ne devi ce), 203, 306, 307, 312, 318–319, 325, 327 IUGR (i ntra uteri ne growth res tri cti on), 53, 106–107 IUPC (i ntra uteri ne pres s ure ca theter), 155 IVF (i n vi tro ferti l i za ti on), 4 IVP (i ntra venous pyel ogra m), 42 K Ka l l ma nn s yndrome, 268–270 Ka ryotypi ng, 5, 25, 34 Kegel exerci s es , 304 Kel l y pl i ca ti on, 302 Kl umpke pa ra l ys i s , 157 Krukenberg tumors , 233 L La beta l ol , 109 La bor, 137–159 a cti ve, 149, 154 a rres t of, 155 i nducti on of, 74 preterm, 88–89, 103 s econda ry a rres t i n, 152 s ta ges of, 142, 154 La cta ti on, 161–186 La pa ros copy, 101 La pa rotomy, 101 La te s ecretory endometri um, 216, 234 La te s yphi l i s , 236 La tent pha s e, 152–153, 158 Le Fort procedure, 286, 299, 302 Leci thi n-to-s phi ngomyel i n (L/S) ra ti o, 68 Lega l i s s ues , 330, 338, 343–352 Lei omyos a rcoma s , 242–243 Lemon s i gn, 36 Leuprol i de (Lupron), 269 LGV (l ymphogra nul oma venereum), 218, 236 Li chen s cl eros us , 210, 232, 239 Li e of fetus , 66 Li pi d profi l e, 200 Li poma s , 202 Li vi ng wi l l s , 344, 350–351 Loca l bl ock, 154 Low ba ck pa i n, 62, 77 L/S (l eci thi n-to-s phi ngomyel i n) ra ti o, 68 LSD (l ys ergi c a ci d di ethyl a mi de), 33 Lubri ca ti on, 309, 321 Lupron (l euprol i de), 269 Lutea l pha s e, 253, 256, 275, 279 Lymphogra nul oma venereum (LGV), 218, 236 Lys ergi c a ci d di ethyl a mi de (LSD), 33 M Ma gnes i um s ul fa te, 97, 104, 109 Ma gneti c res ona nce i ma gi ng (MRI), 32

Ma l pra cti ce, 343, 349–350 Ma mmogra phy, 197, 201–202, 203 Ma ni c-depres s i ve i l l nes s , 182 Ma ri jua na , 34 Ma rs ha l l -Ma rchetti -Kra ntz (MMK) procedure, 287, 299–300 Ma terna l rubel l a i nfecti on, 125 Ma terna l s erum α-fetoprotei n (MSAFP) s creeni ng, 7, 14, 26–27, 30 Ma terna l s erum a na l yte a na l ys i s , 28 Ma terna l -feta l phys i ol ogy, 39–49 Medi ca ti ons , effects of, 3 Medi ol a tera l epi s i otomy, 140 Membra nous pl a centa , 49 Meni ngococca l va cci ne, 199 Menopa us e, 262, 283 Mens trua l dys functi on, 245–284 Mentum tra ns vers e pos i ti on, 67 Meperi di ne (Demerol ), 153 Meta s ta ti c s erous cys ta denoca rci noma s , 206, 227–228 Metri ti s , 167–168, 180–181 Mi croa l bumi nuri a , 117 Mi croi nva s i ve ca rci noma s , 228 Mi dl i ne epi s i otomy, 140, 151 Mi dprol i fera ti ve endometri um, 216 Mi durethra l s l i ng procedure, 302 MIF (Mül l eri a n-i nhi bi ti ng fa ctor), 252, 275 Mi fepri s tone (RU-486), 326 Mi gra i ne hea da ches , 192, 203 Mi s opros tol , 74 Mi s s ed a borti on, 100 Mi xed Mül l eri a n tumors , 215, 234 MMK (Ma rs ha l l -Ma rchetti -Kra ntz) procedure, 287, 299–300 Modi fi ed BPP tes t, 60 Mol a r pregna ncy, 101 MOM (mul ti pl es of the medi a n), 7, 14, 27 Monozygoti c twi ns , 45 Morphi ne, 158 MRI (ma gneti c res ona nce i ma gi ng), 32 MSAFP (ma terna l s erum α-fetoprotei n) s creeni ng, 7, 14, 26–27, 30 Mül l eri a n a genes i s , 254, 269 Mül l eri a n-i nhi bi ti ng fa ctor (MIF), 252, 275 Mul ti pl e ma rker s creeni ng tes t, 34 Mul ti pl es of the medi a n (MOM), 7, 14, 27 Mumps i mmuni za ti on, 38 Myoma s , uteri ne, 242 N Na rcoti cs , 153 Neisseria gonorrhoeae, 112 Neona ta l a l l oi mmune thrombocytopeni a , 133 Neona ta l herpes i nfecti on, 136 Neura l tube defects , 29–30 Neurofi broma tos i s , 35 Newborns ges ta ti ona l a ge of, 170, 183 i mmedi a te ca re of, 161–186 routi ne ca re of, 171, 184 Ni coti ne repl a cement thera py, 204 Ni fedi pi ne, 104, 109 Ni ppl e di s cha rge, 224, 241 Ni trofura ntoi n, 37 Nucha l tra ns l ucency, 25–26, 27–28 Nucl ea r medi ci ne s tudi es , 32 O Obes i ty, pregna ncy a nd, 10, 30 Obs tetri c a nes thes i a , 142, 143, 153–154 Obs tetri c conjuga te, 66 Obs tetri c hi s tory, 201 Obs tetri c tra uma , 298 Obs tetri cs a ntepa rtum ca re, 51–78 compl i ca ti ons medi ca l , 111–136 obs tetri ca l , 79–109

del i very, 137–159 ethi ca l i s s ues , 343–352 feta l s urvei l l a nce, 51–78 geneti cs , 1–38 i mmedi a te ca re of newborn, 161–186 l a bor, 137–159 l a cta ti on, 161–186 l ega l i s s ues , 343–352 ma terna l -feta l phys i ol ogy, 39–49 pl a centa ti on, 39–49 preconcepti on couns el i ng, 1–38 prena ta l di a gnos i s , 1–38 puerperi um, 161–186 Ocul a r tra uma , 157 Ol i gohydra mni os , 36, 74–75, 81 Ol i gomenorrhea , 273 Ompha l ocel es , 26 Opened ma ture cys ti c tera toma s (dermoi d tumors ), 213, 233 Ora l a nti hi s ta mi nes , 130 Ora l contra cepti ves , 305, 307, 311–312, 317, 318, 319, 322–324, 328 Os teogenes i s i mperfecta , 35 Os teoporos i s , 246, 267 Ova ri es ca ncer of, 194, 199–200, 203 cys ts of, 240 neopl a s ms of, 209, 227–228, 230–231 tumors of, 211–212, 283 Overfl ow i nconti nence, 301 Oxybutyni n chl ori de (Di tropa n), 302 Oxytoci n, 151–152 P Pa cl i ta xel , 232 Pa ncrea ti ti s , a cute, 113, 126–127 Pa p s mea r tes t, 193, 198, 201, 202–203, 237, 338 Pa pi l l a ry s erous cys ta denoca rci noma s , 231 Pa pul a r derma ti ti s , 130 Pa ra ba s a l cel l s , 198 Pa rti a l col pocl ei s i s (Le Fort procedure), 286, 299, 302 Pa rvovi rus , 135–136 Pa ti ent a utonomy, 343, 345–346, 349, 351 PEFR (pea k expi ra tory fl ow ra te), 121 Pel vi c cel l ul i ti s , 179 Pel vi c thrombophl ebi ti s , 181 Pel vi s cl a s s i fi ca ti on of, 51, 66 di s orders of, 205–243 i nfl a mma tory di s ea s e of, 223–224, 240 pa i n of, 223 rel a xa ti on of, 285–304 Percuta neous umbi l i ca l bl ood s a mpl i ng (PUBS), 28, 34, 106–107 Peri nea l bl ock, 155 Perma nent s teri l i za ti on, 313 Pes s a ry, 303 Phenytoi n (Di l a nti n), 24 Phl egmon, 179 Phys i ca l a bus e, 334–336, 340–341 Pi toci n, 74–75, 149, 155 Pi tti ng edema , 70 Pi tui ta ry a bl a ti on, 249, 271 Pl a centa a ccreta , 49, 96, 105 Pl a centa di ffus a , 49 Pl a centa i ncreta , 96 Pl a centa percreta , 96 Pl a centa previ a , 49, 96–97, 104–105 Pl a centa , types of, 43–44, 49 Pl a centa l a brupti on, 104 Pl a centa ti on, 39–49 Pl a i n fi l ms , 32 Pl a n B, 326, 338 Pl a typel l oi d pel vi s , 66 PMS (premens trua l s yndrome), 255, 260, 278, 282 Pneumoni a , 121 Pol i omyel i ti s i mmuni za ti on, 37

Pol ycys ti c ova ri a n s yndrome, 257–258, 260, 275–276, 280–282 Pol yhydra mni os , 71–72, 80, 97 Pos tcoi ta l tes ti ng, 24, 256, 279 Pos tmenopa us a l bl eedi ng, 225–226, 243 Pos tpa rtum bl ues , 169, 182 Pos tpa rtum depres s i on, 164, 169, 177–178, 181–182 Pos tpa rtum hemorrha ges , 161–162, 175–176 Pos tpa rtum ps ychos i s , 182 PPD (puri fi ed protei n deri va ti ve), 115 Precoci ous ps eudopuberty, 283 Precoci ous puberty, 248, 255, 266–267, 269, 278–279 Preconcepti on couns el i ng, 1–38 Preecl a mps i a , 77, 94–95, 97–98, 108 Pregna ncy a bdomi na l , 96 cervi ca l ca ncer a nd, 230 da ti ng, 54, 69–70 exerci s e a nd, 4, 25 mol a r, 101 obes i ty a nd, 10, 30 ruptured tuba l , 101 uri na ry tra ct i nfecti ons a nd, 9 va cci nes a nd, 8, 28–29 Prema ture rupture of membra nes (PROM), 102–103 Premens trua l s yndrome (PMS), 255, 260, 278, 282 Prena ta l di a gnos i s , 1–38 Preterm l a bor, 71, 88–89, 103 Pri ma ry i mpotence, 318 Pri ma ry s yphi l i s , 236 Proges terone, 24, 257, 279 Proges ti n onl y pi l l s , 313, 325, 326–327 Prol i fera ti ve endometri um, 216, 234 Prol i fera ti ve reti nopa thy, 131 PROM (prema ture rupture of membra nes ), 102–103 Prophyl a xi s , 138 Pros ta gl a ndi n E2 , 74 Pruri go ges ta ti oni s , 130 Pruri ti c l es i ons , 209, 231 Pruri ti c urti ca ri a l pa pul es a nd pl a ques of pregna ncy (PUPPP), 116, 129–130 Puberty, ons et of, 245–247, 266–267 PUBS (percuta neous umbi l i ca l bl ood s a mpl i ng), 28, 34, 106–107 Pudenda l bl ock, 153, 155 Puerpera l fever, 162, 176 Puerpera l ma s ti ti s , 164, 178 Puerperi um, 161–186 Pul mona ry embol i s ms , 163, 177 PUPPP (pruri ti c urti ca ri a l pa pul es a nd pl a ques of pregna ncy), 116, 129–130 Puri fi ed protei n deri va ti ve (PPD), 115 Pyel onephri ti s , 114, 128 Pyri doxi ne, 129 Q Qua d s creen, 34 R Ra bi es va cci ne, 38 Ra di a ti on effects on fetus , 12, 24–25, 32 ra di os ens i ti ve ti s s ue, 208, 229 Ra di ca l hys terectomy, 208, 230 Ra pe, 329–334, 337–340 Ra pe tra uma s yndrome, 329–330, 332, 337, 339 Ra s hes , 116, 309, 320 RDS (res pi ra tory di s tres s s yndrome), 68, 87, 103 Rel a ti ve contra i ndi ca ti ons , 323 Retrogra de mens trua ti on, 276–277 Rh group s creeni ng, 93, 107 Rh i mmune gl obul i n, 108 Rh i s oi mmuni za ti on, 94 RhoGAM, 93, 108 Ri fa mpi n, 129 Ri pe cervi x, 73–74 Ri todri ne, 103 Round l i ga ment pa i n, 71, 77

Rubel l a i mmuni za ti on, 38 Rubel l a i nfecti on, 134 Ruptured tuba l pregna ncy, 101 S Sa cra l col popexy, 302 Sa ddl e bl ock, 153–154 Sa l pi ngi ti s i s thmi ca nodos a , 284 Sa l ta tory pa ttern, 67 Sa rcoma botryoi des , 231 Seconda ry a rres t i n l a bor, 152 Seconda ry s yphi l i s , 236 Second-degree epi s i otomi es , 158 Sel ecti ve s erotoni n reupta ke i nhi bi tors , 282 Semen a na l ys i s , 256, 279 Sens i ti ve s erum qua nti ta ti ve pregna ncy tes t, 69 Septi c a borti ons , 97 Septi c pel vi c thrombophl ebi ti s (SPT), 177 Seroconvers i on, 218 Serous ca rci noma s , 210, 231 Sertol i -Leydi g cel l tumors , 232, 280 Serum ma gnes i um, 109 Sex fl us h, 320 Sexua l a bus e, 329–341 Sexua l a rous a l di s order, 327 Sexua l a vers i on di s order, 327 Sexua l dys functi on, 305, 308, 310, 315–316, 318, 320, 322, 327 Sexua l precoci ty, 262, 283 Sexua l i ty, 305–328 Sheeha n s yndrome, 175–176 Shortnes s of brea th (dys pnea ), 43, 48–49, 121, 133–134 Shoul der dys toci a s , 145, 156 Si gmoi dos copy, 197 Si ngl e-a gent chemothera py, 100–101 Si nus oi da l pa ttern, 67 Sma l l pox i mmuni za ti on, 37 Smoki ng, 11, 33, 196, 204 Soft di a s tol i c murmur, 115, 129 Specti nomyci n, 125 Spermi ci des , 308, 319–320, 327 Spi der vei ns , 41, 47 Spi na bi fi da , 37 Spi na l bl ock, 153 Sponta neous a borti ons , 1–2, 23 SPT (s epti c pel vi c thrombophl ebi ti s ), 177 Squa mous cel l ca ncer, 207 “s ta rga zer” hea d pos i ti on, 57, 73 Steri l i za ti on, 61, 76–77, 102, 305, 313, 318 Streptococcus di s ea s e, 136 Streptomyci n, 37, 129 Stres s i nconti nence, 285, 289–291, 297–298, 300–303 Stroma l tumors , 231 Subi nvol uti on of uterus , 185 Subs ta nce a bus e, 14 Succenturi a te pl a centa , 49 Suckl i ng, 162, 176–177 Sucti on di l a ti on, 84 Sucti on di l a ti on a nd curetta ge (D&C), 321 Sucti on di l a ti on a nd eva cua ti on (D&E), 321 Sul fona mi des , 37 Supi ne hypotens i ve s yndrome, 46 Symmetri c growth res tri cti on, 92 Symphys i otomy, 156 Syphi l i s , 135, 198–199, 235–236 Sys tol i c ejecti on murmurs , 115, 129 T Ta y-Sa chs di s ea s e, 32 Terbuta l i ne, 103 Terti a ry s yphi l i s , 236 Tes ti cul a r femi ni za ti on, 277 Tes tos terone crea m, 185 Teta nus -di phtheri a i mmuni za ti on, 37 Tetra cycl i nes , 24, 29, 37

Theca cel l tumors , 232–233 Theca l utei n cys ts , 235 Thi rd-degree epi s i otomi es , 158 Threa tened a borti on, 99 Thrombocytopeni a , 120, 133 Thromboembol i c di s ea s e, 113, 126 Thyroi d tes ti ng, 200 TOAs (tubo-ova ri a n a bs ces s es ), 224, 240–241 Toba cco us e, 11, 31, 33–34, 196, 204 Tocol yti c thera py, 103 Toni c-cl oni c s ei zure, 80 Topi ca l corti cos teroi ds , 130 Tota l proci denti a , 303 Toxoplasma gondii, 135 Toxopl a s mos i s , 112, 126 Tra ce protei n, 71 Tra ns derma l ni coti ne pa tches , 204 Tra ns fus i ons , 176, 343, 345–346, 349, 351 Treponema pallidum, 235–236 Trichomonas va gi ni ti s , 240 Tri methopri m-s ul fa methoxa zol e (Ba ctri m), 29 Tri s omi es , 26 True conjuga te, 66 Tuba l l i ga ti ons , 61, 101–102 Tubercul os i s , 165, 178 Tubercul os i s s ki n tes ti ng, 197 Tubo-ova ri a n a bs ces s es (TOAs ), 224, 240–242 Twi ns di zygoti c, 39, 45 hydra mni os a nd, 81 monozygoti c, 45 ol i gohydra mni os a nd, 81 Twi n-to-twi n tra ns fus i on s yndrome, 99, 103–104 Typhoi d i mmuni za ti on, 37 U Ul tra s ound bi rth defects a nd, 6 di a gnos ti c, 16–20, 27, 32, 35–37, 68–69 mea s urements , 7 Umbi l i ca l a rteri es , 45–46 Umbi l i ca l l i ga ments , 46 Unfa vora bl e cervi x, 73–74 Uni l a tera l i nva s i ve vul va r ca rci noma , 207 Upper extremi ty i njury, 334, 340 Ureterova gi na l fi s tul a s , 302–303 Urethra l di verti cul a , 288, 297, 300 Urge i nconti nence, 293–294, 304 Uri na l ys i s , 198, 200 Uri na ry l ea ka ge, 285–286, 289–291, 293, 297–298, 300–303, 304 Uri na ry retenti on, 165, 178 Uri na ry tra ct i nfecti ons (UTIs ), 9, 103, 294–296, 301, 304 Urol ogy, 285–304 Uteri ne a tony, 91 Uteri ne fi broi ds , 71–72, 242 Uteri ne i nvers i on, 167, 180 Uteri ne l ei omyoma s , 185 Uteri ne l ei omyos a rcoma s , 242–243 Uteri ne myoma s , 242 Uteri ne prol a ps e, 291–292, 303 Uteri ne s eptum, 249, 271 Uterotoni c a gents , 105 Uterus bi cornua te, 248, 270 enl a rged, 173 s ubi nvol uti on of, 185 UTIs (uri na ry tra ct i nfecti ons ), 9, 103, 294–296, 301, 304 V Va cuum del i veri es , 146, 157 Va gi na l bl eedi ng, 166–167, 180 Va gi na l di s cha rge, 222, 239 Va gi na l drynes s , 173, 185 Va gi na l es trogen crea m, 302

Va gi na l growths , 217 Va gi na l hema toma s , 157 Va gi na l va ul t prol a ps e, 292, 303 Va gi ni s mus , 322, 327 Va l trex (va l a cycl ovi r), 238 Va ri cel l a -zos ter, 125, 134 Va ri cocel es , 252, 274 Va ri va x, 125 Va s a previ a , 46, 49 Va s cul a r s pi ders , 41, 47 Va s ectomy, 313, 326 VDRL (Venerea l Di s ea s e Res ea rch La bora tory) tes t, 218 Venous s ta s i s , 181 Venous thromboembol i , 134 Ves i cova gi na l fi s tul a s , 301, 302–303 VIN (vul va r i ntra epi thel i a l neopl a s i a ), 239 Vi ncri s ti ne, 233 Vi ra l s heddi ng, 130–131 Vi ta mi n s uppl ements , 13, 33 Vul va r di s comfort, 221 Vul va r i ntra epi thel i a l neopl a s i a (VIN), 239 Vul va r ves ti bul i ti s , 221, 238 Vul vodyni a , 238–239 W Wei ght ga i n, 54, 70 X X-ra ys , 3, 24 Y Yel l ow fever i mmuni za ti on, 38 Yuptze method, 326 Z Za va nel l i ma neuver, 156 Zos ta va x, 125