يسعد فريق العمل بالموقع ان يقدم لكم محاضرة الاستاذ الدكتور : عبد المجيد مشالى

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المحاضرة صوتيا

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الاطلس يحتوى على معظم جارات المتحف مع ذكر اسم الجار ونوع العملية وصور الالات ووسائل منع الحمل

الاطلس من عمل فريق مانس ميد

فجزاهم الله كل خير

What is a Pap smear

A Pap smear (also known as the Pap test) is a medical procedure in which a sample of cells from a woman’s cervix (the end of the uterus that extends into the vagina) is collected and spread (smeared) on a microscope slide. The cells are examined under a microscope in order to look for pre-malignant (before-cancer) or malignant (cancer) changes.

A Pap smear is a simple, quick, and relatively painless screening test. Its specificity – which means its ability to avoid classifying a normal smear as abnormal (a “false positive” result) – while very good, is not perfect. The sensitivity of a Pap smear – which means its ability to detect every single abnormality — while good, is also not perfect, and some “false negative” results (in which abnormalities are present but not detected by the test) will occur. Thus, a few women develop cervical cancer despite having regular Pap screening.

In the vast majority of cases, a Pap test does identify minor cellular abnormalities before they have had a chance to become malignant and at a point when the condition is most easily treatable. The Pap smear is not intended to detect other forms of cancer such as those of the ovary, vagina, or uterus. Cancer of these organs may be discovered during the course of the gynecologic (pelvic) exam, which usually is done at the same time as the Pap smear.

Who should have a Pap smear

Pregnancy does not prevent a woman from having a Pap smear. Pap smears can be safely done during pregnancy.

Pap smear testing is not indicated for women who have had a hysterectomy (with removal of the cervix) for benign conditions. Women who have had a hysterectomy in which the cervix is not removed, called subtotal hysterectomy, should continue screening following the same guidelines as women who have not had a hysterectomy.

Which women are at increased risk for having an abnormal Pap smear

A number of risk factors have been identified for the development of cervical cancer and precancerous changes in the cervix.

1-HPV: The principal risk factor is infection with the genital wart virus, also called the human papillomavirus (HPV), although most women with HPV infection do not get cervical cancer. (See below for details). About 95%-100% of cervical cancers are related to HPV infection. Some women are more likely to have abnormal Pap smears than other women.

2-Smoking: One common risk factor for premalignant and malignant changes in the cervix is smoking. Although smoking is associated with many different cancers, many women do not realize that smoking is strongly linked to cervical cancer. Smoking increased the risk of cervical cancer about two to four fold.

3-Weakened immune system: Women whose immune systems are weakened or have become weakened by medications (for example, those taken after an organ transplant) also have a higher risk of precancerous changes in the cervix.

4-Medications: Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at increased risk.

5-Other risk factors: Other risk factors for precancerous changes in the cervix and an abnormal Pap testing include having multiple sexual partners and becoming sexually active at a young age.

How is a Pap smear done

A woman should have a Pap smear when she is not menstruating. The best time for screening is between 10 and 20 days after the first day of her menstrual period. For about two days before testing, a woman should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician). These agents may wash away or hide any abnormal cervical cells.

A Pap smear can be done in a doctor’s office, a clinic, or a hospital by either a physician or other specially trained health care professional, such as a physician assistant, a nurse practitioner, or a nurse midwife.

With the woman positioned on her back, the clinician will often first examine the outside of the patient’s genital and rectal areas, including the urethra (the opening where urine leaves the body), to assure that they look normal.

A speculum is then inserted into the vaginal area (the birth canal). (A speculum is an instrument that allows the vagina and the cervix to be viewed and examined.)

A cotton swab is sometimes used to clear away mucus that might interfere with an optimal sample.

A small brush called a cervical brush is then inserted into the opening of the cervix (the cervical os) and twirled around to collect a sample of cells. Because this sample comes from inside the cervix, is called the endocervical sample (”endo” meaning inside).

A second sample is also collected as part of the Pap smear and is called the ectocervical sample (”ecto” meaning outside).

These cells are collected from a scraping of the area surrounding, but not entering, the cervical os.

Both the endocervical and the ectocervical samples are gently smeared on a glass slide and a fixative (a preservative) is used to prepare the cells on the slide for laboratory evaluation.

What are the risks of having a Pap smear

There are absolutely no known medical risks associated with Pap smear screening. (However, there are medical risks from not having a Pap smear.)

What treatments are available if a Pap smear is abnormal

If a Pap smear is interpreted as abnormal, there are a number of different management and treatment options including colposcopy, conization, cryocauterization, laser therapy, and large-loop excision of the transformation zone.

All of these procedures have essentially the same overall cure rate of over 90%. However, the procedures do vary considerably in a number of other respects and so will be discussed separately.

1-Colposcopy: Colposcopy is a procedure that allows the physician to take a closer look at the cervix. The colposcope is essentially a magnifying glass for the cervix. For colposcopy to be adequate, the whole cervical lesion, as well as the whole transformation zone (the transition between the vagina-like lining and the uterus-like lining), must be seen.

During colposcopy, the cervix is cleaned and soaked with 3% acetic acid. This acid not only cleans the surface of the cervix but it also allows cellular abnormalities to show up as white areas (called acetowhite epithelium or acetowhite lesions).

If suspicious areas of cervical tissue are seen during colposcopy, a biopsy (tissue sampling) is often done. The sample is sent to the laboratory for analysis by a pathologist and the biopsy results determine the next step in the treatment.

The procedure is essentially painless and quite simple, usually taking only several minutes to perform. Generally, the woman is instructed not to have intercourse, douche, or use tampons for about a week afterwards if a biopsy is done. Pregnancy is not a contraindication to colposcopy. Colposcopy can adequately evaluate 90% of women who have abnormal Pap smear results.

In unusual circumstances, colposcopy does not allow an adequate view of the cervix and another procedure called conization is necessary in order to obtain a tissue biopsy.

2-Conization: This is still the standard method to which all other methods are compared. Conization allows the entire area of abnormal tissue to be removed and provides the maximum amount of cervical tissue for laboratory evaluation to rule out the presence of invasive cancer. After the cervical area is visualized, generally by colposcopy, a cone-shaped specimen of tissue (perhaps 1/2-1 inch long and 3/4 inch wide) is taken from around the endocervical canal.

Conization is usually done on an out-patient basis under anesthesia in a hospital or surgical facility. For three weeks after the procedure, the woman needs to avoid douching and using tampons and refrain from sexual intercourse.

Cure rates close to 100% are achieved with conization as long as the cells along the margins of treatment are normal.

With conization, there are associated risks from anesthesia and postoperative hemorrhage (bleeding-in about 10% of cases) as well as possible future adverse effects on fertility. Conization is generally performed only on women who have had unsatisfactory colposcopy results, have adenocarcinoma in situ (a diagnosis of cancer) already, or whose Pap smears suggest they may have some invasion of cancer into the nearby tissue.

Hysterectomy (surgical removal of the uterus and the cervix) for non-cancerous abnormal Pap smears is now rarely done. A hysterectomy is appropriate only for those women who are finished with childbearing and have severe pre-cancerous abnormalities that have persisted despite other treatments. It may also be appropriate for women with certain specific findings after conization.

3-Cryocauterization: Cryocauterization is a simple and safe procedure. A probe, called a cryoprobe, is first cooled by carbon dioxide and then touched to the abnormal cervical area. This freezes and kills the cells, resulting in the sloughing of the abnormal tissue.

A woman undergoing cryocauterization can expect a watery vaginal discharge for several weeks after the procedure.

4-Laser therapy: Laser therapy makes use of the principle that laser light can be produced by electricity running through gas. In the treatment of cervical lesions, the gas is usually carbon dioxide. This type of laser can instantly boil water and therefore can also be used to kill and vaporize cells.

When a laser beam (using a tiny wand called a micromanipulator) is directed into the cervix at an area of abnormal cervical tissue, the light energy is converted to heat, which in turn causes cell death, as occurs with cryocauterization. However, the laser apparatus is expensive, and its use requires more skill than other treatment options, such as cryocauterization. The procedure is also painful and generally requires general anesthesia.

The benefit of laser therapy is that it may cause less cervical scarring as compared to cryocauterization. This in turn may mean that, should the woman need colposcopy in the future, the chances of adequately viewing her cervix may be better after laser therapy.

5-Large-loop excision (LEEP) of the transformation zone: Large-loop excision of the transformation zone (LEEP) removes the cervical transformation zone (the area where the vaginal-type lining changes to the uterine-type lining) using a thin-wire loop to administer electrocautery. It allows samples to be collected for additional tissue analysis and can be performed in the office under local anesthesia.

Specialized (more frequent) follow-up is necessary after LEEP. This follow-up includes Pap smears, colposcopy, and sometimes other techniques. When there is no more evidence of abnormal cervical tissue, it may be possible to resume annual screening Pap smears.

A hysterectomy is a surgical procedure whereby the uterus (womb) is removed. Hysterectomy is the most common non-obstetrical surgical procedure of women in the United States.

?How common is hysterectomy

Approximately 300 out of every 100,000 women will undergo a hysterectomy.

?Why is a hysterectomy performed

The most common reason hysterectomy is performed is for uterine fibroids The next most common reasons are:

abnormal uterine bleeding (vaginal bleeding),

cervical dysplasia (pre-cancerous conditions of the cervix),

endometriosis, and uterine prolapse (including pelvic relaxation).

How is a hysterectomy performed?

In the past the most common hysterectomy was done by an incision (cut) through the abdomen (abdominal hysterectomy). Now most surgeries can utilize laparoscopic assisted or vaginal hysterectomies (performed through the vagina rather than through the abdomen) for quicker and easier recovery. The hospital stay generally tends to be longer with an abdominal hysterectomy than with a vaginal hysterectomy, and hospital charges tend to be higher. The procedures seem to take comparable lengths of time (about two hours), unless the uterus is of a very large size, in which case a vaginal hysterectomy may take longer.

?What are complications of a hysterectomy

Complications of a hysterectomy include infection, pain, and bleeding in the surgical area. An abdominal hysterectomy has a higher rate of post-operative infection and pain than does a vaginal hysterectomy.

?What are the types of hysterectomies

1-Total abdominal hysterectomy

This is the most common type of hysterectomy. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated. Cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids are treated with total abdominal hysterectomy. Total abdominal hysterectomy may also be done in some unusual cases of very severe pelvic pain, after a very thorough evaluation to identify the cause of the pain, and only after several attempts at non-surgical treatments. Clearly a woman cannot bear children herself after this procedure, so it is not performed on women of childbearing age unless there is a serious condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause.

2-Vaginal hysterectomy

During this procedure, the uterus is removed through the vagina. A vaginal hysterectomy is appropriate only for conditions such as uterine prolapse, endometrial hyperplasia, or cervical dysplasia. These are conditions in which the uterus is not too large, and in which the whole abdomen does not require examination using a more extensive surgical procedure. The woman will need to have her legs raised up in a stirrup device throughout the procedure. Women who have not had children may not have a large enough vaginal canal for this type of procedure. If a woman has too large a uterus, cannot have her legs raised in the stirrup device for prolonged periods, or has other reasons why the whole upper abdomen must be further examined, the doctor will usually recommend an abdominal hysterectomy (see above). In general, laparoscopic vaginal hysterectomy is more expensive and has higher complication rates than abdominal hysterectomy.

3-Laparoscopy-assisted vaginal hysterectomy (LAVH)

Laparoscopy-assisted vaginal hysterectomy (LAVH) is similar to the vaginal hysterectomy procedure described above, but it adds the use of a laparoscope. A laparoscope is a very thin viewing tube with a magnifying glass-like device at the end of it. Certain women would be best served by having laparoscopy used during vaginal hysterectomy because it allows the upper abdomen to be carefully inspected during surgery. Examples of uses of the laparoscope would be for early endometrial cancer (to verify lack of spread of cancer), or if oophorectomy (removal of the ovaries) is planned. Compared to simple vaginal hysterectomy or abdominal hysterectomy, it is a more expensive procedure, is more prone to complications, requires longer to perform, and is associated with longer hospital stays. Just as with simple vaginal hysterectomy without a laparoscope, the uterus must not be excessively large. The physician will also review the medical situation to be sure there are no special risks prohibiting use of the procedure, such as prior surgery that could have increased the risk for abnormal scarring (adhesions). If a woman has such a history of prior surgery, or if she has a large pelvic mass, a regular abdominal hysterectomy is probably best.

4-Supracervical hysterectomy

A supracervical hysterectomy is used to remove the uterus while sparing the cervix, leaving it as a “stump.” The cervix is the area that forms the very bottom of the uterus, and sits at the very end (top) of the vaginal canal (see illustration above). The procedure probably does not totally rule out the possibility of developing cancer in this remnant “stump.” Women who have had abnormal Pap smears or cervical cancer clearly are not appropriate candidates for this procedure. Other women may be able to have the procedure if there is no reason to have the cervix removed. In some cases the cervix is actually better left in place, such as some cases of severe endometriosis. It is a simpler procedure and requires less time to perform. It may give some added support of the vagina, decreasing the risk for the development of protrusion of the vaginal contents through the vaginal opening (vaginal prolapse).

5-Laparoscopic supra cervical hysterectomy

The laparoscopic supra cervical hysterectomy procedure is performed like the LAVH procedure, although usually cautery is used to cut the cervix off at the cervical stump, and the tissue is all removed through a laparoscopic tool. Recovery is very quick. Cervical preservation is less likely to result in menses (menstruation) as the endocervix is usually cauterized.

6-Radical hysterectomy

The radical hysterectomy procedure involves more extensive surgery than a total abdominal hysterectomy because it also includes removing tissues surrounding the uterus and removal of the upper vagina. Radical hysterectomy is most commonly performed for early cervical cancer. There are more complications with radical hysterectomy compared to abdominal hysterectomy. These include injury to the bowels and urinary system.

7-Oophorectomy and salpingo-oophorectomy (removal of the ovaries and/or Fallopian tubes)

Oophorectomy is the surgical removal of the ovary(s), while salpingo-oophorectomy is the removal of the ovary and its adjacent Fallopian tube. These two procedures are performed for ovarian cancer, removal of suspicious ovarian tumors, or Fallopian tube cancer (which is very rare). They may also be performed due to complications of infection, or in combination with hysterectomy for cancer. Occasionally, women with inherited types of cancer of the ovary or breast will have an oophorectomy as preventive (prophylactic) surgery in order to reduce the risk of future cancer of the ovary or breast.

?What are the alternatives to a hysterectomy

As mentioned above, a hysterectomy for conditions other than cancer is generally not considered until after other tests or medications are unsuccessful. There are also newer procedures, such as uterine artery embolization (UAE) or surgical removal of a portion of the uterus (myomectomy), that are being used to treat excessive uterine bleeding. Endometrial ablation technique and newer medications are also alternatives

1.A 20-year-old female comes to the physician because she has never had a period. She has no medical problems, has never had surgery, and takes no medications. Examination shows that she is a tall female with long extremities. She has normal size breasts, although the areolas are pale. She has little axillary hair. Pelvic examination is significant for scant pubic hair and a short, blind-ended vaginal pouch. Which of the following is the most appropriate next step in the management of this patient?

a) No intervention is necessary

b)Bilateral gonadectomy

c)Unilateral gonadectomy

d)Bilateral mastectomy

e)Unilateral mastectomy

________________________________________

2.A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nulliparity, and early age at menarche. She takes no other medications. Examination is within normal limits. Which of the following is this patient most likely to develop while taking tamoxifen?

a) Breast cancer

b)Elevated LDL cholesterol

c)Endometrial changes

d)Myocardial infarction

e)Osteoporosis

________________________________________

3. A 22-year-old woman comes to the physician for an annual examination. She has been sexually active since the age of 15 and has not had regular Pap smears or examinations. She is currently sexually active with multiple partners and intermittently uses condoms. She has no medical problems and takes no medications. Her examination is unremarkable. Her Pap smear is described as satisfactory but limited by the absence of endocervical cells. It is otherwise within normal limits. Which of the following is the most appropriate next step in management?

a)Repeat the Pap smear in 1 year

b)Repeat the endocervical portion of the Pap test as soon as possible

c) Perform colposcopy with colposcopically directed biopsies

d)Perform laparoscopy with laparoscopically directed biopsies

e)Perform exploratory laparotomy

________________________________________

4.A 24-year-old woman comes to the physician because of right lower quadrant abdominal pain. She has had the pain off and on for the past month, but it is now increasing. She has no other symptoms and no medical problems. Examination reveals a mildly tender, right adnexal mass. Pelvic ultrasound shows a 7 cm right adnexal complex cyst. Urine hCG is negative. The patient is taken to the operating room for laparotomy and right ovarian cystectomy. Microscopically the cyst has cartilage, adipose tissue, intestinal glands, hair, and a calcification that appears to be a tooth. There is also a large amount of thyroid tissue. Which of the following is the most likely diagnosis?

a)Corpus luteum

b)Ectopic pregnancy

c)Gastric carcinoma

d)Struma ovarii

e) Thyroid carcinoma

________________________________________

5.A 60-year-old woman comes to the physician for an annual examination. She has no complaints. She had her last menstrual period at age 55 and has had no vaginal bleeding since. She has no medical problems and has never had surgery. She takes no medications and has no allergies to medications. The physical examination is unremarkable. She is concerned about cancer and wants to know which type is the major cause of cancer death in women. Which of the following is the correct response?

a)Breast cancer

b)Cervical cancer

c)Endometrial cancer

d)Lung cancer

e) Ovarian cancer

________________________________________

6.A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma (dermoid). Which of the following is the most appropriate next step in management?

a)Repeat pelvic examination in 1 year

b)Repeat pelvic ultrasound in 6 weeks

c)Prescribe the oral contraceptive pill

d)Perform hysteroscopy

e)Perform laparotomy

________________________________________

7.A 32-year-old woman, gravida 3, para 2, at 37 weeks’ gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response?

a)There is no evidence that breast-feeding increases HCV transmission

b)There is strong evidence that breast-feeding increases HCV transmission

c)Complete isolation is not needed but breast-feeding is prohibited

d)The patient should be completely isolated from the baby

e)Casual contact with the baby is prohibited

________________________________________

8.A 25-year-old woman, gravida 2, para 1, at 22 weeks’ gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. coli at 12 weeks’ gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management?

a) No further treatment or diagnostic study is necessary

b)Prophylactic antibiotics for the remainder of the pregnancy

c)Intravenous antibiotics for the remainder of the pregnancy

d)Intravenous pyelogram

e)Abdominal CT Scan

________________________________________

9.A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy?

a)Ampicillin

b)Ampicillin-gentamicin

c)Clindamycin-gentamicin

d)Clindamycin-metronidazole

e)Metronidazole

________________________________________

10. A 64-year-old woman undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine prolapse. On postoperative day 1,

a complete blood count shows the following:

Leukocytes…….5500/mm3 Hematocrit…….36%

Platelets………..245,000/mm3

By postoperative day 2, the patient is alert and able to ambulate without difficulty. She has no complaints. She has not taken in nutrition orally but is receiving IV fluids. She is voiding without difficulty and has passed flatus.

Her temperature is 37 C (98.6 F),

blood pressure is 124/72 mm Hg,

pulse is 86/min,

and respirations are 12/min.

Examination shows her abdomen to be soft, nontender, and non-distended. The incision is clean, dry, and intact. The rest of the examination is unremarkable. Which of the following is a reason for keeping this patient hospitalized for a longer period of time?

a)Absent oral intake

b)Evidence of infection

c)Hematocrit

d)Urinary tract function

e)Vital signs

________________________________________

11.A 39-year-old woman, gravida 3, para 2, at 40 weeks’ gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient?

a)Administer antibiotics to the mother after vaginal delivery

b)Administer antibiotics to the mother now and allow vaginal delivery

c)Perform cesarean delivery

d) Perform cesarean delivery and then administer antibiotics to the mother

e)Perform intra-amniotic injection of antibiotics

________________________________________

12. A 43-year-old primigravid woman at 10 weeks’ gestation comes to the physician for a prenatal visit. She is feeling well except for some occasional nausea. She has had no bleeding from the vagina, abdominal pain, dysuria, frequency, or urgency. She has asthma for which she occasionally uses an inhaler. Examination is normal for a woman at 10 weeks gestation. Urine dipstick is positive for nitrites and leukocyte esterase and a urine culture shows 50,000 colony forming units per milliliter of Escherichia coli. Which of the following is the most appropriate next step in management?

a)Wait to see if symptoms develop

b)Resend another urine culture

c)Obtain a renal ultrasound

d) Treat with oral antibiotics

e)Admit for intravenous antibiotics

________________________________________

13. A 29-year-old primigravid woman at 34 weeks’ gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response?

a) Gestational diabetes is associated with fetal anomalies

b)Gestational diabetes is associated with intrauterine growth restriction

c)Gestational diabetes is associated with macrosomia

d)Gestational diabetes is not associated with future diabetes

e)Gestational diabetes with normal fasting glucose is associated with stillbirth

________________________________________

14.A 36-year-old primigravid woman at 36 weeks’ gestation comes to the physician for a prenatal visit. She is experiencing good fetal movement and has had no loss of fluid, bleeding from the vagina, or contractions. She has no complaints. Her past medical history is significant for mitral stenosis, which she developed after an episode of rheumatic fever as a child. She also has asthma for which she uses an albuterol inhaler daily. She has herpes outbreaks approximately once a year. At her last visit she was found to be positive for Group B Streptococcus colonization. For which of the following disease processes would this patient benefit by having a forceps-assisted vaginal delivery at the time of delivery?

a)Asthma

b)Group B Streptococcus (GBS) colonization

c)Herpes

d)Mitral stenosis

e)This patient would not benefit from a forceps-assisted vaginal delivery

________________________________________

15. A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management?

a)Offer elective cesarean section after amniocentesis to determine lung maturity

b)Offer elective cesarean section at 38 weeks

c)Offer elective cesarean section at 34 weeks

d)Recommend forceps-assisted vaginal delivery

e) Recommend vaginal delivery

________________________________________

16. A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis?

a) Constitutional delay

b) Dysfunctional uterine bleeding

c)Dysmenorrhea

d)Primary amenorrhea

e)Secondary amenorrhea

________________________________________

17.A 32-year-old woman comes to the physician because of amenorrhea. She had menarche at age 13 and has had normal periods since then. However, her last menstrual period was 8 months ago. She also complains of an occasional milky nipple discharge. She has no medical problems and takes no medications. She is particularly concerned because she would like to become pregnant as soon as possible. Examination shows a whitish nipple discharge bilaterally, but the rest of the examination is unremarkable. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is normal. Prolactin is elevated. Head MRI scan is unremarkable. Which of the following is the most appropriate pharmacotherapy?

a)Bromocriptine

b)Dicloxacillin

c)Magnesium sulfate

d)Oral contraceptive pill (OCP)

e) Thyroxine

________________________________________

18.A 32-year-old woman, gravida 3, para 2, at 14 weeks’ gestation comes to the physician for a prenatal visit. She has some mild nausea, but otherwise no complaints. She has no significant medical problems and has never had surgery. She takes no medications and has no known drug allergies. She is concerned for two reasons. First, the “flu season” is coming, and she seems to get sick every year. Second, a child at her son’s daycare center recently broke out with welts and was sent home. Which of the following vaccinations should this patient most likely be given?

a) Influenza

b)Measles

c)Mumps

d)Rubella

e)Varicella

________________________________________

19.A 35-year-old woman, gravida 3, para 2, at 39 weeks’ gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5 centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5 centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management?

a)Expectant management

b)Intravenous oxytocin

c)Cesarean delivery

d)Forceps-assisted vaginal delivery

e)Vacuum-assisted vaginal delivery

________________________________________

20. A 27-year-old woman, gravida 2, para 1, at 20 weeks’ gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient’s likelihood of having a successful vaginal delivery?

a) 0%

b) 25%

c)50%

d)70%

e) 100%

________________________________________

21. A 62-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman in no apparent distress. Pelvic examination is unremarkable. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. Which of the following is the most appropriate next step in management?

a) Chemotherapy

b)Cone biopsy

c)Dilation and curettage

d)Hysteroscopy

e)Hysterectomy

________________________________________

22.A 35-year-old woman, gravida 4, para 3, at 38 weeks’ gestation comes to the labor and delivery ward after a gush of clear fluid from the vagina. After the gush, she has had increasing contractions. Sterile speculum examination shows a pool of clear fluid in the vagina that is nitrazine positive. Cervical examination shows that the patient is 5 cm dilated, with the fetal face presenting in a mentum anterior position. External uterine monitoring shows that the patient is contracting every 2 minutes, and external fetal monitoring shows that the fetal heart rate is in the 140s and reactive. Which of the following is the most appropriate next step in management?

a)Expectant management

b)Oxytocin augmentation

c)Forceps delivery

d)Vacuum delivery

e)Cesarean section

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23.A 36-year-old woman, gravida 3, para 2, at 33 weeks’ gestation comes to the physician for a prenatal visit. She has some fatigue but no other complaints. Her current pregnancy has been complicated by a Group B Streptococcus urine infection at 16 weeks. Her past obstetric history is significant for a primary, classic cesarean delivery 5 years ago for a non-reassuring fetal tracing. Two years ago, she had a repeat cesarean delivery. Past surgical history is significant for an appendectomy 10 years ago. Which of the following is the major contraindication to a vaginal birth after cesarean (VBAC) in this patient?

a) Classic uterine scar

b)Group B Streptococcus urine infection

c)Previous appendectomy

d)Prior cesarean delivery for non-reassuring fetal tracing

e)Two prior cesarean deliveries

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24.A patient who has been taking tamoxifen to prevent breast cancer for the past 6 months presents complaining of irregular vaginal bleeding. An endometrial biopsy is performed that demonstrates atypical hyperplasia. Which of the following is the most appropriate next step in management?

a)Discontinue the tamoxifen

b)Increase the tamoxifen dose

c)Repeat the endometrial biopsy

d)Schedule a pelvic ultrasound

e)Switch the patient to estrogen

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25.A 18-year-old woman comes to the physician for an annual examination. She has no complaints. She has been sexually active for the past 2 years. She uses the oral contraceptive pill for contraception. She has depression for which she takes fluoxetine. She takes no other medications and has no allergies to medications. Her family history is negative for cancer and cardiac disease. Examination is unremarkable. Which of the following screening tests should this patient most likely have?

a) Colonoscopy

b)Mammogram

c)Pap smear

d)Pelvic ultrasound

e)Sigmoidoscopy

1) Explanation:

The correct answer is

B. This patient has the findings that are most consistent with androgen insensitivity syndrome (formerly called testicular feminization syndrome). This syndrome results from genetic defects leading to abnormal androgen receptor function. Patients with androgen insensitivity syndrome are genotypically males (46, XY) but phenotypically females-with breasts and no external male genitalia. The reason that breasts develop is that estrogens, which are expressed at puberty and which also result from peripheral conversion of androgens, act upon the breast tissues unopposed by androgens because of the androgen receptor defect. This unopposed estrogen leads to breast growth and the resultant breasts are normal sized, although they have undeveloped nipples and pale areolae. There are no internal female organs, because mullerian-inhibiting substance is present during development. There are no external male organs because of the androgen receptor defect. Testicles do exist, but they are intra-abdominal. The gonads have a high rate of malignant degeneration in patients with androgen insensitivity syndrome and therefore, after puberty, they should be removed via bilateral gonadectomy. It is important to wait until after puberty so that full development can take place. To state that no intervention is necessary (choice A) is incorrect. If the gonads are not removed from a patient with androgen insensitivity syndrome there is a significant risk that the patient will develop a gonadal malignancy. To perform a unilateral gonadectomy (choice C) is incorrect. To leave one of the gonads in would still run the risk of malignant degeneration in that gonad. Once puberty has taken place, therefore, both gonads should be removed. To perform a bilateral mastectomy (choice D) or a unilateral mastectomy (choice E) would be incorrect. In patients with androgen insensitivity syndrome (testicular feminization syndrome) the primary concern is for gonadal malignancy and not breast malignancy.

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2) Explanation:

The correct answer is

C. Tamoxifen is a nonsteroidal agent with both pro- and antiestrogenic properties. It was first approved in 1977 by the U.S. Food and Drug Administration for use in postmenopausal women with advanced breast cancer. Since that time, it has been approved for many other uses related to breast cancer: as adjuvant therapy in postmenopausal women with resected node-positive disease, in postmenopausal women with metastatic breast cancer, and as adjuvant therapy in women (pre- and postmenopausal) with resected node-negative disease. Recently, much attention has been focused on its use for breast cancer prevention. There is evidence that women at high risk for the development of breast cancer may reduce their risk by taking tamoxifen. However, although tamoxifen appears to be antiestrogenic at the level of the breast, it appears to act in a proestrogenic fashion at the level of the endometrium. Many women on tamoxifen will develop endometrial changes, including polyp formation, hyperplasia, and frank invasive carcinoma. Thus, women on tamoxifen need to be followed carefully, and prompt evaluation of abnormal vaginal bleeding should be conducted. Tamoxifen is used to prevent breast cancer (choice A). Tamoxifen, like estrogen, has been shown to lower blood levels of LDL cholesterol (choice B). Women on tamoxifen appear to be at no greater risk, and may be at a lower risk, for the development of myocardial infarction (choice D). Tamoxifen, like estrogen, has been shown to increase bone density and to reduce the likelihood of development of osteoporosis (choice E).

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3) Explanation:

The correct answer is

B. A Papanicolaou smear should ideally be a sampling of the transformation zone. An adequate sample should show endocervical cells. When endocervical cells are not present, there is some question as to whether the transformation zone was fully sampled. If a woman has no risk factors for cervical dysplasia, has had three normal annual Pap smears in a row, and has a current Pap that shows no abnormality other than the absence of endocervical cells, then the Pap smear can be repeated in 1 year. This patient, however, has significant risk factors for cervical dysplasia, including early initiation of sexual activity, multiple partners, and unprotected intercourse. Therefore, this patient needs the endocervical portion of the Pap test to be repeated as soon as possible. To repeat the Pap smear in 1 year (choice A) would be incorrect management. As noted above, repeating the Pap smear in 1 year is correct only in patients who have no risk factors for cervical dysplasia, three normal annual Pap smears, and a present Pap that is normal except for the lack of endocervical cells. To perform a colposcopy with colposcopically directed biopsies (choice C) would not be correct. This patient has a normal Pap smear overall. The lack of endocervical cells makes the smear incomplete but not abnormal. To perform laparoscopy with laparoscopically directed biopsies (choice D) would not be correct. Laparoscopy does not allow evaluation of the cervix and is not indicated for abnormal or incomplete Pap smears. To perform an exploratory laparotomy (choice E) is not indicated. Again, this patient has a normal but incomplete Pap smear, and major surgery would not be correct management.

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4) Explanation:

The correct answer is

D. Cystic teratomas, also known as dermoid cysts, are the most common benign ovarian neoplasm. They account for approximately 1/3 of all ovarian neoplasms. They may be composed of a variety of cell types and have a mixture of tissues, as this patient has. When thyroid tissue makes up more than 50% of the teratoma, the dermoid is then referred to as struma ovarii. Approximately 3% of ovarian teratomas fall into this category and there is an association of struma ovarii with carcinoid tumor. Struma ovarii is unilateral in approximately 90% of patients and most (80%) are benign. Rarely struma ovarii is a cause of hyperthyroidism and patients with this manifestation may have symptoms of hyperthyroidism, as well as elevated levels of thyroid hormones and decreased levels of thyroid stimulating hormone (TSH). Treatment of struma ovarii is by surgical removal of the tumor. A corpus luteum (choice A) is a common cause of complex cysts in young women. However, a corpus luteum does not contain thyroid tissue, hair, teeth, and other such tissues. Ectopic pregnancy (choice B) can cause an adnexal mass, and a live ectopic may have various tissues in it when examined microscopically. However, this patient has a negative hCG, which effectively rules out ectopic pregnancy unless there is a laboratory error. Also, this cyst has tissues that are found in struma ovarii. Gastric carcinoma (choice C) can metastasize to the ovary. In fact, 5% of all ovarian malignancies are metastases from other sites. The cancers that most frequently metastasize to the ovary are colon, breast, stomach, and pancreas. When a gastric carcinoma metastasizes to the ovary, it is termed a Krukenberg tumor and has the pathognomonic “signet-ring” cells. Thyroid carcinoma (choice E) rarely metastasizes to the ovary and rarely would be found in combination with the other tissue elements that this patient’s cyst has.

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5) Explanation:

The correct answer is

D. Breast cancer accounts for the greatest number of new cancer cases in women each year. In 1997, there were 180,200 new breast cancer cases. However, lung cancer is the major cause of cancer death in women. In 1997, lung cancer accounted for 66,000 cancer deaths in women, compared with the 43,900 female deaths caused by breast cancer. There is currently no test used to screen for lung cancer. Smoking cessation is the most effective way to reduce mortality from lung cancer. As stated above, breast cancer (choice A) accounts for the most number of cancer cases in women each year in the U.S., but not the highest number of cancer deaths. Mammography is the screening method used to detect subclinical breast cancer-the stage at which breast cancer is least likely to have spread. Cervical cancer (choice B) is the gynecologic type that causes the fewest number of cancer deaths, partly because of the success of Pap test screening. Pap testing allows preinvasive lesions to be identified and treated, which prevents the progression to invasive disease. Endometrial cancer (choice C) is the most common gynecologic cancer in women older than 45. There is no proven screening test available for endometrial cancer. Ovarian cancer (choice E) is a major cause of cancer death in women. More women die of ovarian cancer than of cervical or endometrial cancer combined. There is no proven screening test available for ovarian cancer.

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6) Explanation:

The correct answer is

E. This patient has a presentation and findings that are most consistent with a benign cystic teratoma (dermoid). Dermoids are a type of ovarian germ cell tumor. Germ cell tumors are the most common type of ovarian neoplasm in females under the age of 20 and dermoids are the most common benign ovarian neoplasm. Dermoids can range in size from small masses that are noted incidentally on ultrasound and cause no symptoms, to large cysts that cause pain and pressure, as this patient has. Laparotomy is the most appropriate next step in the management of this patient because, as adnexal masses enlarge–especially when they become greater than 5 cm–the risk of ovarian torsion increases. Thus, laparotomy with removal of the dermoid is indicated to prevent torsion. Also, this patient’s mass is causing her symptoms of pain and pressure and, on that basis, should be removed. Finally, while the mass most likely is a dermoid, this is not certain without pathologic diagnosis and, therefore, the cyst should be removed and evaluated by a pathologist. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. To repeat pelvic examination in 1 year (choice A) would not be correct management. This patient is symptomatic with a 6 cm ovarian mass that is at risk for torsion. She should, therefore, be managed surgically. To repeat pelvic ultrasound in 6 weeks choice B) is appropriate for some adnexal masses. For example, in a young woman with a small complex cyst that appears consistent with a corpus luteum, it may be most prudent to recheck an ultrasound in 6 weeks to see if the cyst has resolved. This patient, however, is symptomatic with a 6 cm cyst that appears to be a dermoid, which will not resolve spontaneously. She, therefore, requires surgery. To prescribe the oral contraceptive pill (choice C) may help to prevent future ovarian cysts but it will not resolve this cyst, which requires surgical management. To perform hysteroscopy (choice D) would not be indicated. Hysteroscopy is used to evaluate the uterine cavity and would not be used for management of an adnexal mass.

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7) Explanation:

The correct answer is

A. In the U.S., hepatitis C virus (HCV) is the most common blood-borne infection. HCV is a single-stranded RNA virus that is transmitted by blood-borne transmission or through sexual contact. With the disease being so prevalent-it affects 3.9 million Americans-it is not rare to find a pregnant patient with hepatitis

C. In fact, it appears to infect as much as 0.6% of the pregnant population. Studies that have been performed so far show that the rate of infection of infants born to hepatitis C-positive, HIV-negative mothers is about 5%. Hepatitis C transmission through breast milk has not been clearly proven. Breast-fed and bottle-fed infants have a rate of infection that is approximately 4%. Therefore, the patient should be told that casual contact is permitted and that currently there is no evidence that breast-feeding increases HCV transmission to the baby. To state that there is strong evidence that breast-feeding increases HCV transmission to the baby (choice B) is incorrect. As explained above, the available studies do not demonstrate that breast-feeding increases HCV transmission. To state that complete isolation is not needed but breast-feeding is prohibited (choice C) is incorrect for the reasons detailed above. To state that the patient should be completely isolated from the baby (choice D), or that casual contact with the baby is prohibited (choice E) are both incorrect for the reasons detailed above. If patients with hepatitis C were not allowed contact with their infants, they would have to give them up, because hepatitis C is a chronic disease. Fifty percent of patients with HCV develop biochemical evidence of chronic liver disease. Hepatitis C is not like varicella-zoster (chickenpox), where a neonate can be isolated from the mother until she is no longer infectious.

________________________________________

Explanation:

The correct answer is

B. The most common medical complication of pregnancy is infection of the urinary tract. Because of the anatomic and physiologic changes that occur during pregnancy, asymptomatic bacteriuria is more likely to become symptomatic and there is also an increased progression to pyelonephritis during pregnancy. Escherichia coli is the causative organism in approximately 80% of cases of UTI while other gram-negative organisms (e.g., Klebsiella, Enterobacter, and Proteus species) and gram-positive cocci (e.g. enterococci and group B streptococci) are responsible for the remainder. UTI in pregnancy can be treated with a 3-day course of antibiotics including trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. It is essential to document successful treatment with a follow-up urine culture 10 days after treatment. All women who are treated for UTI during pregnancy should have periodic rescreening for infection with urine cultures or urine dipstick for nitrites or leukocyte esterase. If a woman develops a second infection, as this patient has, she should be retreated and then placed on chronic suppression with prophylactic antibiotics. The drug of choice for such prophylaxis is nitrofurantoin once a day or sulfisoxazole once a day. To state that no further treatment or diagnostic study is necessary (choice A) is incorrect. Women with bacteriuria during pregnancy are at increased risk of developing pyelonephritis and are at higher risk for low birth weight and preterm deliveries. Therefore, this patient should be placed on prophylactic antibiotics for the remainder of the pregnancy. To place the patient on intravenous antibiotics for the remainder of the pregnancy (choice C) would not be indicated. Once a day oral therapy is usually sufficient to prevent recurrence of the infection. Intravenous pyelogram (choice D) and abdominal CT scan (choice E) result in significant fetal exposure to radiation. They should only be performed when absolutely necessary. This patient has a second UTI, which does not require that either of these studies be performed.

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9) Explanation:

The correct answer is

C. This patient has signs and symptoms that are most consistent with endometritis. Postpartum endometritis is believed to result from organisms ascending from the vagina and causing a polymicrobial infection of the endometrium. Infection may also involve the myometrium and parametrial tissues. Patients with endometritis typically present with fever and chills, lower abdominal pain, a foul-smelling vaginal discharge, and malaise. Examination is significant for fever, abdominal tenderness, and uterine tenderness. Cesarean section is the major risk factor for postpartum endometritis. Patients undergoing cesarean section have a several-fold higher risk of developing endometritis compared with those having a vaginal delivery. The treatment of choice for endometritis following a cesarean section must include anaerobic coverage, along with gram-positive and gram-negative coverage. Therefore, the treatment of choice is clindamycin and gentamicin. Ampicillin (choice A) and ampicillin-gentamicin (choice B) fail to cover the anaerobic organisms that play an important role in the pathophysiology of post-cesarean section endometritis. Clindamycin-metronidazole (choice D) and metronidazole (choice E) have good activity against anaerobic organisms, but fail to cover gram-negative organisms.

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10) Explanation:

The correct answer is

A. In the current era of medical cost containment, postoperative hospital stays tend to be significantly shorter than they were in the past. Therefore, it is more essential than ever to make sure that patients who are discharged postoperatively are, in fact, ready for discharge. Discharge criteria generally include that the patient should be alert, able to ambulate (if this was her preoperative level of function), able to tolerate adequate oral intake, have stable vital signs, and have satisfactory bowel and urinary tract function. This patient is 2 days status post total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). Although this is a major procedure, it is not uncommon for patients to be ready for discharge at this time. However, this patient has not had adequate oral intake. Therefore, this patient should not be discharged until she shows evidence of being able to tolerate oral intake. Postoperative infection is frequently seen following TAH-BSO and it is often a reason to delay discharge in order to treat the infection with antibiotics and ensure that there is no abscess formation. This patient, however, shows no evidence of infection (choice B). Therefore, she does not need to be kept hospitalized longer on this basis. Low hematocrit (choice C) is a concern in a postoperative patient because it may make the patient symptomatic and it may be a sign of continued bleeding. This patient, however, has a hematocrit of 36%, which is well within the expected range after TAH-BSO. It is important to make sure that a postoperative patient is able to urinate normally. Many patients have difficulty with urination secondary to general anesthesia, use of the Foley catheter, or bladder denervation. This patient’s urinary tract function (choice D), however, is normal. Unstable vital signs are a very good reason to keep a postoperative patient hospitalized for a longer period of time. However, this patient’s vital signs (choice E) are normal.

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11) Explanation:

The correct answer is

B. Chorioamnionitis is an infection that can develop at any time before and during delivery. The most common findings in patients with chorioamnionitis are a fever and uterine tenderness. An elevated fetal heart rate is also often seen. This patient has a temperature elevation and uterine tenderness, which make the diagnosis of chorioamnionitis. It is essential that antibiotics be started immediately because prompt initiation of antibiotics, once the diagnosis of chorioamnionitis is made, results in better maternal and neonatal outcomes than if therapy is delayed. It is also essential that broad-spectrum antibiotic therapy be chosen because a mixture of organisms is usually involved including aerobes and anaerobes. The most frequently used regimen is ampicillin or penicillin with gentamicin. In terms of the mode of delivery, vaginal delivery is acceptable in patients with chorioamnionitis. While it is desirable to have an expeditious delivery, chorioamnionitis is not an indication for cesarean delivery. To wait to administer antibiotics to the mother after vaginal delivery (choice A) would not be correct, as the delay would deprive both the mother and the fetus of the beneficial effects of the antibiotics. To perform cesarean delivery (choice C) or to perform cesarean delivery and then administer antibiotics to the mother (choice D) would not be indicated. As explained above, when a woman has chorioamnionitis, it is desirable to expedite delivery, but cesarean delivery should be performed only for obstetric indications. To perform intra-amniotic injection of antibiotics (choice E) would not be indicated. Intra-amniotic injection of antibiotics during labor is not a therapy used to treat chorioamnionitis during labor.

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12) Explanation:

The correct answer is

D. Asymptomatic bacteriuria is present in 2 to 9% of pregnant women. An association between asymptomatic bacteriuria and preterm delivery/low birth weight has been demonstrated. Therefore, all pregnant women should be screened for asymptomatic bacteriuria early in the pregnancy, and women who demonstrate bacteriuria (defined as a clean-catch, midstream urine specimen with 25,000 to 100,000 colony forming units per milliliter of a single organism) should be treated.

E. Coli is the organism that is isolated in roughly 80% of cases while other gram-negative organisms (e.g., Klebsiella, Enterobacter, and Proteus species) and gram-positive cocci (e.g. enterococci and group B streptococci) are responsible for the remainder. Antibiotic sensitivities are often available at the time of diagnosis of the asymptomatic bacteriuria, which will allow for correct choice of medications. A 3-day course of antibiotics may be given. Possible choices include trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. Ampicillin and amoxicillin can also be used, but up to 1/3 of

E. Coli isolates will be resistant to these drugs. Therefore, these drugs should be chosen only if the organism is sensitive. 10 days after completing the medication, the patient should have a follow-up urine culture as a test-of-cure. Waiting to see if symptoms develop (choice A) is not appropriate. Bacteriuria, even without symptoms, has been shown to be associated with preterm labor and low birth weight. Asymptomatic bacteriuria should, therefore, be treated. Resending another urine culture (choice B) would not be the most appropriate next step. This patient already has demonstrable bacteriuria and treatment should be instituted. Admitting for intravenous antibiotics (choice E) or obtaining a renal ultrasound (choice C) would not be necessary. This patient has asymptomatic bacteriuria and not pyelonephritis; therefore, a 3-day course of oral antibiotics followed by a repeat culture 10 days later is all that is necessary.

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13) Explanation:

The correct answer is

C. Gestational diabetes is defined as glucose intolerance that either has its onset or its first recognition during pregnancy. Gestational diabetes is usually diagnosed by means of oral glucose tolerance testing. Patients with gestational diabetes and normal fasting glucose levels have two major risks. The first is fetal macrosomia. Women with gestational diabetes are known to have larger babies, and this creates an increased risk of complications of delivery including shoulder dystocia and cesarean delivery. The second risk is of the eventual development of overt diabetes. Fifty percent of women with gestational diabetes will go on to develop overt diabetes within the next 20 years. Patients with gestational diabetes and abnormal fasting glucose levels do have an increased risk of stillbirth. To state that gestational diabetes is associated with fetal anomalies (choice A) is incorrect. However, patients with overt diabetes do have an increased risk of fetal anomalies. To state that gestational diabetes is associated with intrauterine growth restriction (choice B) is not correct. Gestational diabetes is associated with macrosomia. To state that gestational diabetes is not associated with future diabetes is incorrect (choice D), as explained above. To state that gestational diabetes with normal fasting glucose is associated with stillbirth (choice E) is incorrect. However, overt diabetes and gestational diabetes with abnormal fasting glucose levels (class A2) are associated with stillbirth.

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14) Explanation:

The correct answer is

D. Mitral valve stenosis is one of the more common valvular lesions seen in pregnancy. The most common cause of mitral stenosis is rheumatic endocarditis. During normal pregnancy there is an increase in the cardiac output and an increase in preload and circulating volume. Patients with mitral stenosis have a fixed, decreased valve area, which places them at risk for the development of pulmonary hypertension and pulmonary edema. Control of arrhythmias is absolutely essential in these patients because they are at increased risk, given the left atrial enlargement that often goes along with their mitral stenosis. Labor and delivery can be a particularly dangerous time for these patients. Therefore, patients with significant mitral stenosis should be monitored invasively using a Swan-Ganz catheter. It is recommended that the second stage of labor be shortened using forceps or vacuum to prevent excess maternal Valsalva efforts and maternal tachycardia. Asthma (choice A) is not an indication for forceps-assisted vaginal delivery. In terms of mode of delivery, asthmatic patients may be managed like any other patient in the second stage of labor. Group B Streptococcus colonization (choice B) is an indication for intravenous penicillin or clindamycin (if the patient has an allergy to penicillin). These antibiotics are given to prevent GBS sepsis in the neonate. GBS colonization is not an indication for forceps-assisted vaginal delivery. Herpes (choice C) can be transmitted to the fetus at the time of delivery. Therefore, when lesions are present in the birth canal, most obstetricians recommend cesarean delivery. A history of herpes outbreaks, as this patient has, is not an indication for forceps. To state that this patient would not benefit from a forceps-assisted vaginal delivery (choice E) is incorrect. As explained above, given this patient’s mitral stenosis, forceps-assisted vaginal delivery would be recommended.

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15) Explanation:

The correct answer is

B. A significant body of evidence has developed that transmission rates of HIV from mother to infant can be decreased through the use of medications and cesarean delivery. The Pediatric AIDS Clinical Trials Group (PACTG) 076 Zidovudine Regimen was shown to decrease the rate of transmission from 25% to 8%. This regimen consisted of ZDV being given antepartum and intrapartum to the mother and postpartum to the infant. More recent evidence is accumulating that the mode of delivery also affects transmission rates. The combination of ZDV therapy and cesarean delivery decreases the risk of transmission to approximately 2%. But, the decrease in transmission with cesarean delivery occurs regardless of whether the patient is receiving antiretroviral therapy. Thus, cesarean delivery should be offered to HIV-positive women to prevent transmission. Delivery at 38 weeks is recommended to reduce the chances that the patient will go into labor or rupture her membranes. Once these occur, the benefit of cesarean delivery is reduced. To offer elective c-section after amniocentesis to determine lung maturity (choice A) is incorrect. Amniocentesis should be avoided, if possible, in the HIV-positive woman. To offer elective c-section at 34 weeks (choice C) is incorrect. To perform a cesarean delivery at 34 weeks risks iatrogenic prematurity in the neonate. Cesarean delivery prior to the onset of labor or rupture of membranes is the preference, and this can be accomplished at 38 weeks with a lower risk of iatrogenic prematurity. To recommend forceps-assisted vaginal delivery (choice D) or vaginal delivery (choice E) is incorrect. The decision of which mode of delivery to choose ultimately belongs to the patient. But, vaginal delivery would not be recommended, as cesarean delivery has been shown to decrease transmission rates.

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16) Explanation:

The correct answer is

A. Constitutional delay is normal pubertal progression at a delayed rate or onset. The average age at menarche is 12 1/2 years, but it may be delayed until 16 or may begin as early as age 10. Dysfunctional uterine bleeding (choice B) results when the endometrium has proliferated under estrogen stimulation, and then begins to slough and causes irregular painless bleeding. This is common in younger adolescents who have not been menstruating long. Dysmenorrhea (choice C) is pain associated with menstrual cycles, and this adolescent is not menstruating yet. Primary amenorrhea (choice D) is a delay in menarche with no menstrual cycles or secondary sex characteristics by 14 years of age or no menses with secondary sex characteristics by 16 years of age. This adolescent has secondary characteristics but is not yet 16 years of age. Secondary amenorrhea (choice E) is the absence of menses for at least three cycles after regular cycles have been present.

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17) Explanation:

The correct answer is

A. Hyperprolactinemia is the cause in approximately 10 to 20% of cases of amenorrhea. It is known that elevated prolactin levels alter the hypothalamic-pituitary-ovarian axis such that ovulation is suppressed and menses do not occur. This patient has amenorrhea, galactorrhea (i.e., a milky discharge from the breasts), and an elevated prolactin level. All of these findings are consistent with hyperprolactinemia, likely coming from a pituitary microadenoma. The fact that no mass is seen on the head MRI is also consistent with a pituitary microadenoma, as small microadenomas may not be visualized. The treatment of choice for this patient is with bromocriptine. Bromocriptine is a dopamine agonist that has been shown to decrease prolactin levels and bring about a return of ovulation and menses. The re-establishment of ovulation is especially important for this patient who wishes to conceive. Dicloxacillin (choice B) is often used to treat a breast infection, which can occur in a nursing mother. This patient, however, does not have findings consistent with breast infection. Rather, the nipple discharge is secondary to the patient’s elevated prolactin levels. Magnesium sulfate (choice C) is used in obstetrics to prevent seizures in patients with pre-eclampsia and to stop the uterus from contracting in patients with preterm labor. It is not indicated for the treatment of hyperprolactinemia. The oral contraceptive pill (choice D) would not be appropriate as this is a young woman who wishes to become pregnant. If she did not desire pregnancy, the oral contraceptive pill would be appropriate therapy. One of the major concerns in young women with microadenomas is that decreased levels of estrogen will lead to bone loss and the eventual development of osteoporosis. The oral contraceptive pill, by providing daily estrogen and progestin, will help to prevent bone loss. Thyroxine (choice E) is used in patients with hypothyroidism. This patient has a normal TSH and no evidence of hypothyroidism, and would, therefore, not need thyroxine.

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18) Explanation:

The correct answer is

A. Influenza pneumonia during pregnancy can be a severe illness. Normally “the flu” is a self-limited illness that lasts 3-4 days and produces few major sequelae. However, patients with influenza pneumonia during pregnancy can develop high fever, malaise, cough, and headache. In some cases a bacterial superinfection will occur (often with Staphylococcus aureus), which can lead to peribronchial infiltrates, cavitation, and a pleural effusion. Current recommendations are that pregnant women who will be in the second or third trimester during the flu epidemic season should be given the influenza vaccination. Also, pregnant women with significant medical problems should be given the vaccination before the influenza season, regardless of trimester. The measles (choice B), mumps (choice C), and rubella (choice D) vaccines are live attenuated vaccines. Their use during pregnancy is contraindicated. The varicella (choice E) vaccination is used to prevent chickenpox. It is a live-virus vaccine; therefore, its use during pregnancy is also contraindicated.

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19) Explanation:

The correct answer is

B. This patient is demonstrating an abnormal labor pattern with arrest of dilation. The normal pattern of labor is one of continued progression. Whether a patient is in the latent phase or the active phase, there should be a gradual progression with an increase in the amount of cervical dilation. This patient, however, has stopped dilating and has had her contractions space out considerably. An arrest of labor like this can be caused by several reasons: contractions may not be adequate; the fetus may have a malpresentation; or the maternal pelvis may not be able to accommodate the fetus. In this case it appears that the contractions are not adequate, so at this point, it would be reasonable to give intravenous oxytocin in an effort to re-establish a contraction pattern that can effect a vaginal delivery. Expectant management (choice A) would not be the most appropriate next step. The patient is clearly demonstrating a dysfunctional labor pattern at this point. To “watch and wait” in the face of insufficient uterine contractions is to place the patient at risk of an even longer labor and the correspondingly higher risk of infection. Cesarean delivery (choice C) would not be the most appropriate next step in management. This patient may very well need a cesarean delivery if she is truly unable to progress in labor. However, it is worth attempting a vaginal delivery in this multiparous patient who has already had two vaginal deliveries. To attempt a forceps-assisted vaginal delivery (choice D) or a vacuum-assisted vaginal delivery (choice E) would be contraindicated. This patient’s cervix is only 5 centimeters dilated. Forceps and vacuum cannot be attempted in patients unless they are fully dilated and at +2 station or lower.

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20) Explanation:

The correct answer is

D. The cesarean delivery rate in the U.S. is roughly 25%. Much effort has been put into trying to lower this rate. One third of all cesarean births are a result of elective repeat cesarean delivery. Therefore, much attention has been focused on vaginal birth after cesarean (VBAC). A few decades ago, there was an obstetric dictum that “once a cesarean, always a cesarean.” This is no longer the case. Some women are allowed to attempt vaginal birth after a prior cesarean delivery. And, in fact, the attempt is often successful. Estimates are that approximately 70% of all women that attempt VBAC will be successful. This patient has had one prior cesarean delivery, and it was through a low transverse uterine hysterotomy. Right now, she has no contraindications to VBA

C. Therefore, a VBAC attempt may be tried. If the success rate of VBAC were 0% (choice A) or even 25% (choice B), the topic would be a non-issue. The fact that the success rate of VBAC is so high is what makes the choice between repeat cesarean and VBAC more complicated. 50% (choice C) is approximately the success rate in women who attempt VBAC who had a prior cesarean for dystocia. Women with a prior cesarean delivery for dystocia have a VBAC success rate of approximately 50% to 70%. Although this rate is still good, it is consistently lower than the rate for women with non-recurring indications, such as a non-reassuring fetal tracing. Attempts at vaginal delivery are not 100% (choice E) successful even in women who have never had a cesarean delivery. In fact, the success rate for vaginal delivery in women who have not undergone previous cesarean delivery is about 70%–the same success rate as women attempting VBAC with a non-recurring indication.

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21) Explanation:

The correct answer is

E. Endometrial cancer is the most common gynecologic cancer in women ages 45 and older. The main factor that predisposes a woman to the development of endometrial cancer is exposure to unopposed estrogen, whether endogenous or exogenous. Endogenous factors include, early menarche, late menopause, chronic anovulation, estrogen-secreting ovarian tumors, and obesity. Exogenous factors include the ingestion of unopposed estrogen (as with estrogen replacement therapy). Hypertension and diabetes have also been associated with endometrial cancer, though this relationship may likely be related to obesity. This patient has endometrial cancer on the basis of her endometrial biopsy result. The correct management for this patient is with total abdominal hysterectomy, bilateral adnexectomy, and possible lymph node sampling. Chemotherapy (choice A) would not be the most appropriate next step in management. If the patient were not a surgical candidate, because of her obesity, for example, then radiation therapy could be administered. Cone biopsy (choice B) is used in the diagnosis and management of cervical cancer. It would not be used for this patient with an endometrial biopsy showing endometrial cancer. Dilation and curettage (choice C) or hysteroscopy (choice D) would not be the most appropriate next step in management. The diagnosis of endometrial cancer has been made on the basis of the endometrial biopsy. Therefore, the most appropriate next step in management is to treat the patient through hysterectomy or, if hysterectomy is not possible because of obesity or medical disease, radiation.

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22) Explanation:

The correct answer is

A. This patient has a face presentation. Typically, a fetus in labor is as an occiput presentation. In certain rare instances (roughly 1 in 500 deliveries), however, the fetus is in a face presentation. Causes of face presentation include an anencephalic fetus, pelvic contraction, and high parity. A vaginal delivery is possible when the fetus is in a mentum anterior position (i.e., the fetal chin is oriented toward the maternal pubic symphysis.) The fetus can flex its head, thereby allowing delivery. This patient is in active labor with contractions every 2 minutes and 5 cm of cervical dilation. The fetus is in mentum anterior position. Therefore, expectant management is the most appropriate next step. Oxytocin augmentation (choice B) is not indicated. This patient is in active labor on her own and therefore does not need oxytocin to augment it. Forceps delivery (choice C) would not be indicated. Forceps are not used prior to full dilation of the cervix. Also, with a non-vertex presentation, forceps would be contraindicated. Vacuum delivery (choice D) is not indicated. As with forceps, vacuum delivery is not performed prior to full dilation of the cervix. With a face presentation, vacuum delivery would be contraindicated. Cesarean section (choice E) would not be indicated. Vaginal delivery is possible with face presentation.

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23) Explanation:

The correct answer is

A. The presence of a classic uterine scar is an absolute contraindication to a vaginal birth after cesarean (VBAC). A classic uterine scar is a vertical incision into the uterus that extends from the lower uterine segment up into the active myometrial portion toward the fundus of the uterus. Patients with a previous classic cesarean delivery have roughly a 10% risk of uterine rupture. Therefore, these patients should have an elective repeat cesarean delivery when the fetus is mature. Group B Streptococcus (GBS) urine infection (choice B) is not a contraindication to vaginal delivery. Patients with GBS urine infection are allowed to have a vaginal delivery but must receive IV antibiotics during labor to prevent GBS invasive disease of the newborn. Previous appendectomy (choice C), or other intra-abdominal surgery, is not a contraindication to vaginal delivery. Prior cesarean delivery for non-reassuring fetal tracing (choice D) is not a contraindication to vaginal delivery. Patients with this indication for primary cesarean delivery have approximately a 70% rate of success with VBA

C. Women with two prior cesarean deliveries (choice E) may undergo a trial of labor (VBAC). This is the case if the two prior cesarean deliveries were low-transverse hysterotomies. However, the patient should be cautioned that the risk of rupture does increase with the number of previous cesarean deliveries.

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24) Explanation:

The correct answer is

A. Tamoxifen is known to act as an estrogen agonist at the level of the endometrium. Numerous studies have shown that women on tamoxifen develop changes in the endometrium including polyps, hyperplasia, and cancer. Hyperplasia runs a continuum from cystic glandular hyperplasia to atypical hyperplasia. Patients with atypical hyperplasia are at significantly increased risk for the eventual development of endometrial cancer. Thus, in a patient who is taking tamoxifen for breast cancer prevention and develops atypical endometrial hyperplasia, the tamoxifen should be stopped. If there is a need to continue the tamoxifen, then hysterectomy should be considered. To increase the tamoxifen dose (choice B) would be contraindicated. This patient has atypical hyperplasia, likely caused by the tamoxifen. Increasing the dose will only exacerbate the problem. To repeat the endometrial biopsy (choice C) would not be the most appropriate next step in management. The next step should be to discontinue the tamoxifen. The patient should then have a repeat endometrial biopsy in several months to ensure that there is no progression of the hyperplasia. To schedule a pelvic ultrasound (choice D) would not be the most appropriate next step in management. This patient has known atypical hyperplasia; thus, the tamoxifen should be stopped first. Pelvic ultrasound can be used to evaluate the endometrium; however, in this case, regardless of what the ultrasound shows, the pathology reveals atypical hyperplasia. To switch the patient to estrogen (choice E) would be absolutely contraindicated. Unopposed estrogen would worsen the endometrial changes.

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25) Explanation:

The correct answer is

C. The Pap smear has been shown to be a highly effective screening test for cervical cancer. The Pap test was introduced in the U.S. roughly 50 years ago, and since that time the mortality rate from cervical cancer has decreased by 70%. The main drawbacks to Pap testing are that many women do not get a regular (or any) Pap smear and that the test has a high false-negative rate. That is, a given Pap smear may be read as negative when, in fact, the woman has abnormal cytology. The reason for this false negative rate is that there may be errors in sampling, preparation, screening, and interpretation, such that abnormal cells are missed. Yet, if a woman has a yearly Pap test, it is assumed that these abnormal cells will eventually be discovered. Because the natural history of most cervical cancers is believed to be a gradual progression over many years, then annual screening (even with a high false-negative rate) will lead to lesions eventually being discovered and appropriate treatment being given. Women should have an annual Pap test when they begin having sexual intercourse or at the age of 18, whichever comes first. Colonoscopy (choice A) is used to screen for colon cancer in some at-risk patients. This patient is not high-risk and therefore, at age 18, does not need to have a colonoscopy. The mammogram (choice B) is used to screen for breast cancer. Women should begin having regular mammograms at age 40. Pelvic ultrasound (choice D) is not used as a screening test. Certain studies have been done to evaluate whether pelvic ultrasound is a good screening test for ovarian cancer. On the basis of these studies, however, pelvic ultrasound is not recommended for this purpose. Sigmoidoscopy (choice E) is also used to screen for colon cancer. As explained above, this patient is not high-risk and therefore does not need a sigmoidoscopy.

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http://www.4shared.com/file/96059890/475c866f/4ufamily_1.html

http://www.4shared.com/file/96163818/621fcd44/instrument_2_-4ufamily.html

http://rapidshare.com/files/176045048/Obstetics_Simplified.rar