uworld OBGY question thread - ck_hue

[ArchivalUser]

2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors.

A group of 47 experts representing 23 professional societies, national and international health organizations, and federal agencies met in Bethesda, MD, September 14-15, 2012, to revise the 2006 American Society for Colposcopy and Cervical Pathology Consensus Guidelines. The group's goal was to provide revised evidence-based consensus guidelines for managing women with abnormal cervical cancer screening tests, cervical intraepithelial neoplasia (CIN) and adenocarcinoma in situ (AIS) following adoption of cervical cancer screening guidelines incorporating longer screening intervals and co-testing. In addition to literature review, data from almost 1.4 million women in the Kaiser Permanente Northern California Medical Care Plan provided evidence on risk after abnormal tests. Where data were available, guidelines prescribed similar management for women with similar risks for CIN 3, AIS, and cancer. Most prior guidelines were reaffirmed. Examples of updates include: Human papillomavirus-negative atypical squamous cells of undetermined significance results are followed with co-testing at 3 years before return to routine screening and are not sufficient for exiting women from screening at age 65 years; women aged 21-24 years need less invasive management, especially for minor abnormalities; postcolposcopy management strategies incorporate co-testing; endocervical sampling reported as CIN 1 should be managed as CIN 1; unsatisfactory cytology should be repeated in most circumstances, even when HPV results from co-testing are known, while most cases of negative cytology with absent or insufficient endocervical cells or transformation zone component can be managed without intensive follow-up.

[ArchivalUser]

q id 4124

A 22-year-old woman comes to your office at 1 0 weeks gestation for her first prenatal visit. Her obstetrical
history is significant for a spontaneous abortion at 12 weeks gestation one year ago. She states that her
mother has hypothyroidism. and she asks you to order thyroid function tests for her. She denies any
symptoms. and her physical examination is unremarkable. Ultrasound reveals an intrauterine gestation with
normal fetal cardiac activity. Which of the following results is most likely to be expected in this patient?

r A. Normal total T4. normal TSH
r B. Decreased free T 4. decreased TSH
r C.lncreased total T4. normal TSH
r D. Increased free T 4. decreased TSH
r E. Decreased total T 4. increased TSH

[ArchivalUser]

this question is updated ...

[ArchivalUser]

Thyroid disease in pregnancy: (Women's Health Series).

Pregnancy is a state of many hormonal changes that can make interpretation of thyroid function tests difficult. Measuring trimester-specific reference values of thyrotropin and free thyroxine is recommended. Because overt maternal hypothyroidism negatively affects the fetus, timely recognition and treatment are important. Women taking levothyroxine prepregnancy require a ≤50% dose increase during pregnancy. Hyperthyroidism can result from excessive human chorionic gonadotropin or Graves disease. Radioactive scanning should be avoided during pregnancy. Antithyroidal drug therapy should consist of propylthiouracil during the first trimester and methimazole thereafter. If indicated, beta blockers can be administered under obstetrical supervision. Iodine deficiency is a known goitrogen and stimulus for thyroid nodular growth. Thyroid nodules may enlarge, but the incidence of thyroid cancer is not increased during pregnancy. Suspicious nodules should be biopsied and, if necessary, removed during the second trimester; otherwise, follow-up can safely be conducted postpartum. Thyroid-stimulating hormone suppression for any preexisting thyroid cancer or suspicious nodules should achieve free or total T4 in the upper normal range for pregnancy. Postpartum thyroiditis occurs more frequently in antithyroid peroxidase-positive women, who should be screened by measuring serum thyrotropin at 6 to 12 weeks' gestation and at 3 and 6 months postpartum.

http://sma.org/southern-medical-journal/...th-series/

[ArchivalUser]

Q id 4162

A healthy. 32-year-old. primigravid woman at 12 weeks of gestation comes to the physician for a routine
prenatal visit. She has no complaints. She does not use tobacco or alcohol. She has blood group 0.
Rh(D)+. and her husband has blood group AB. Rh(D)+. She is concerned about the risk of alloimmunization
because her mother had that problem during her second pregnancy. Although the child will have a different
blood group from the patient. alloimmunization is of little concern due to which of the following?

r A. Immune response is depressed in pregnancy
r B. ABO antigens are weakly antigenic
r C. The mother is tolerant to the child·s ABO antigens
r D. Antibodies to ABO antigens cause mild disease in most newborns
r E. Antibodies to ABO antigens are not hemolytic

[ArchivalUser]

Explanation:

The four common blood types are 0. A. B. and AB. Patients missing a blood type have antibodies to the
missing antigens as shown below.

Blood Type Antibodies Against
A B
B A
0 Both A and B
AB None

A mother with blood group 0 and a father with blood group AB will have a child with either blood group A or
blood group B (both differ from the mother's blood group). Hemolytic disease of the newborn (HDN) is mainly
seen in a group 0 mother who has a group A orB baby. The A and B antigens are antigenic and cause the
mother to form lgG antibodies to A or B that can cross the placenta (can also form some lgM antibodies to the
A antigen and other minor antigens) (Choices A, B, and C). Only the lgG antibodies can cross the placenta.
but varying titer levels result in HDN. which is mild in most patients. with neonatal jaundice successfully
treated with phototherapy (Choice E). However. the titers can be higher in certain populations (e.g .. Africans
and African Americans) and lead to more severe HDN.
ABO incompatibility reactions can occur in the first pregnancy because both A and B antigens are found in
food and bacteria in the environment. These antigens can induce various degrees of antibody production in
group 0 individuals. In contrast. Rh(D) alloimmunization reactions typically occur in the second pregnancy
onwards. with greater severity. Also. Rh(D) antibodies are typically alllgG at higher titers that cross the
placenta and cause more significant disease.
Exposure during the first pregnancy is usually required before causing disease in the second pregnancy. This
patient has low risk of alloimmunization because both she and her husband are Rh(D)+.

Educational objective:
ABO incompatibility generally occurs in a group 0 mother with a group A orB baby. but ABO incompatibility
causes less severe hemolytic disease of the newborn than does Rh(D) incompatibility. Affected infants are
usually asymptomatic at birth with absent or mild anemia and develop neonatal jaundice. which is usually
successfully treated with phototherapy.

[ArchivalUser]

Q id 3273

A 25-year-old woman at 28 weeks gestation comes to the ER because of strong. regular and painful uterine
contractions that started 4 hours earlier with the passage of clear fluid from her vagina. She denies any
vaginal bleeding. She has had no prenatal care. Vital signs are normal. A sterile speculum examination
shows pooling of amniotic fluid within the vagina. and a cervix that is 4 em dilated and 80percent effaced.
Ultrasonogram in the emergency department shows an amniotic fluid index of 4 and bilateral renal agenesis in the fetus. Which of the following is the most appropriate next step in management?
r A. Allow spontaneous vaginal delivery
r B. Consent for cesarean section
r C. Administer corticosteroids
r D. Amnioinfusion and tocolysis

Explanation:
This patient has preterm labor with rupture of the membranes. In this case. the fetus has a severe congenital
anomaly incompatible with life. so labor should be allowed to proceed. Patients with bilateral renal agenesis
will not survive outside the uterus because of the severe pulmonary hypoplasia associated with renal
agenesis. They will survive in utero because the placenta oxygenates the fetal blood and removes waste
products from the fetal circulation.
(Choice B) There is no need for a cesarean section. which increases maternal morbidity. as the fetus can be
evacuated vaginally.
(Choices C & D) Since the fetal anomaly is not compatible with life. all attempts to prolong pregnancy will not
improve fetal mortality. and delivery should be allowed to proceed.
Educational objective:
Labor should be allowed to proceed in patients where the fetus has been diagnosed with a severe congenital
anomaly incompatible with life.

[ArchivalUser]

Q id 3682

A 30-year-old female comes to the office complaining of vaginal discharge. dyspareunia and vulvar pruritus.
She has a history of hypothyroidism and takes thyroid replacement therapy. She uses tobacco and alcohol
every day. On examination. you notice a thin. grayish vaginal discharge and erythema and edema of the vulva
and vaginal mucosa. The pH of the discharge is 6.0 and wet-mount examination reveals pear-shaped motile
organisms. First line treatment is prescribed for both the patient and her partner. The patient must avoid
which of the following during the treatment period?
r A. Grapefruit juice
r B. Alcohol use
r C. Midday sun exposure
r D. Thyroid supplements
r E. Tobacco use

Explanation: User ld:
The findings of thin vaginal discharge. erythematous vaginal mucosa. and motile pear-shaped organisms on
wet-mount. are all characteristic of trichomonal vaginitis. Metronidazole is the treatment of choice for this
condition. If alcohol is taken during metronidazole therapy. a disulfiram-like reaction may result in which
acetaldehyde accumulates in the blood stream. This causes flushing. nausea. vomiting and hypotension. For
this reason. all patients who take metronidazole should abstain from drinking alcohol.
(Choice A) Grapefruit juice is known to inhibit the P450 system. Intake of grapefruit juice should be limited in
patients taking medications which are processed by the P450 system (e.g. cyclosporine).
(Choice C) Sun exposure should be limited while taking tetracycline. as this antibiotic can cause
photosensitivity.
(Choice D) There is no adverse interaction between thyroid supplements and metronidazole.
(Choice E) Despite the myriad negative health consequences of tobacco use. it does not interfere with
metronidazole therapy.
Educational objective:
All patients who take metronidazole should abstain from drinking alcohol. as it is associated with a
disulfiram-like reaction.

[ArchivalUser]

Q id 3110

A 28-year-old woman. gravida 3. para 2. at 32 weeks gestation comes to the physician because she has only
felt 2-3 fetal movements in the past 12 hours. As in her previous pregnancies. she has gestational diabetes.
which is under good control with diet and mild exercise. She does not use tobacco. alcohol or drugs. Vital
signs are normal. Physical examination is unremarkable. F eta I heart tones are heard. Which of the following
is the next most appropriate step in management?
r A. Non-stress test
r B. Biophysical profile
r C. Contraction stress test
r D. Ultrasonography
r E. Deliver the baby immediately

Explanation: User ld:
In the presence of decreased fetal movements. fetal compromise should be suspected and the best next step
in management is a nonstress test (NST). NST is usually performed in high risk pregnancies starting at 32-34
weeks gestation or when there is a loss of perception of fetal movements in any pregnancy. NST is carried
out by recording the fetal heart rate while monitoring for spontaneous perceived fetal movements. A test is
considered reactive (normal) if in 20 minutes 2 accelerations of the fetal heart rate of at least 15 beats per
minute above the baseline lasting at least 15 seconds each are noted. If less than 2 accelerations are noted
in 20 min. the test is considered nonreactive (abnormal) and further assessment is required. The most
common cause of a nonreactive NST is a sleeping baby. not a diseased baby. so vibroacoustic stimulation is
used to wake the baby up and allow a timely test.
(Choice B) A biophysical profile (BPP) is a scoring system designed to evaluate fetal well-being. It is
indicated in high risk pregnancies and in cases of maternal or physician concern. decreased fetal movements
or a non-reactive NST.
(Choice C) In a contraction stress test (Oxytocin challenge test). the mother is given an infusion of oxytocin
sufficientto result in 3 contractions per 1 0 minutes. and the effectthese contractions have on fetal heart
activity is recorded. If a late deceleration is noted at each contraction. the test is positive and delivery is
usually recommended. Because this is a more invasive test. it is not used as an initial examination.
(Choice D) Ultrasonography is not as sensitive as NST or BPP for evaluation of decreased fetal movements
and fetal well-being. It is. however. the first step if fetal demise is suspected as it can document the presence
or absence of fetal heart movement.
(Choice E) Delivery is indicated when significant signs of fetal distress or maternal deterioration are present.
Educational objective:
If fetal movement decreases or becomes imperceptible by the mother. then a nonstress test should be
carried out to document fetal well-being.

( options are slightly chnaged in the new q bank )

[ArchivalUser]

Q id 2561

A 21-year-old woman at 36 weeks gestation is admitted for delivery. She has severe preeclampsia. Her blood
pressure is 190/11 0 mmHg. pulse is 80/min and respirations are 16/min. Physical examination shows 3+
pitting edema of the legs and brisk deep tendon reflexes. Fundoscopic examination shows no abnormalities.
Laboratory studies show elevated BUN. serum creatinine and serum transaminases. Urinalysis shows 4+
proteinuria. Intravenous hydralazine and magnesium sulfate was initiated on admission. After stabilization.
intravenous oxytocin and artificial rupture of membranes (AROM) was administered for induction of labor.
Two hours later. her blood pressure is 150/90 mmHg. pulse is 78/min and respirations are 9/min. Repeat
examination shows hyporeflexia and a completely effaced cervix that is 5 em dilated. Which of the following is the most appropriate next step in management?
r A. Stop hydralazine and do an emergency caesarian section
r B. Stop magnesium sulfate and give calcium gluconate
r C. Stop hydralazine and monitor serum cyanide level
r D. Stop intravenous oxytocin and intubate the patient
r E. Continue currenttreatment and proceed with delivery

Explanation: User ld:
The second neurologic exam performed in this patient shows depressed deep tendon reflexes. which is the
earliest sign of magnesium sulfate toxicity. Magnesium causes toxicity by acting as a CNS depressant and by
blocking neuromuscular transmission. It is very important for patients on magnesium sulfate to be closely
observed with regular examination of their deep tendon reflexes. The second sign of toxicity is respiratory
depression. The treatment of magnesium sulfate toxicity is immediate discontinuation of the infusion and
administration of calcium gluconate.
(Choice A) There is no need to stop hydralazine as her BP is stable. Stopping hydralazine would be indicated
if the BP dropped abruptly.
(Choice C) Monitoring a cyanide level is irrelevant because the patient is not being treated with nitroprusside.
(Choice D) The patient may necessitate artificial ventilation due to respiratory depression related to
magnesium toxicity. but stopping magnesium sulfate and administration of calcium gluconate is the more
urgent intervention. Oxytocin is not responsible for her condition; it is analogous to ADH and therefore. may
be responsible for hyponatremia and water intoxication.
(Choice E) If magnesium sulfate infusion is not stopped immediately there is a risk of death due to cardiac or
respiratory arrest.
Educational objective:
Depression of the deep tendon reflexes is the earliest sign of magnesium sulfate toxicity. Treatment requires
stopping the magnesium sulfate infusion and administration of calcium gluconate