A 29-year-old G1P0 presents to her obstetrician for her first prenatal care visit at 12 weeks gestation by last menstrual period. She states that her breasts are very tender and swollen, and her exercise endurance has declined. She otherwise feels well. She is concerned about preterm birth, as she heard that certain cervical procedures increase the risk. The patient has a gynecologic history of loop electrosurgical excision procedure (LEEP) for cervical dysplasia several years ago and has had negative Pap smears since then. She also has mild intermittent asthma that is well controlled with occasional use of her albuterol inhaler. At this visit, this patient’s temperature is 98.6°F (37.0°C), pulse is 69/min, blood pressure is 119/61 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and the uterine fundus is just palpable at the pelvic brim. Pelvic exam reveals normal female external genitalia, a closed and slightly soft cervix, a 12-week-size uterus, and no adnexal masses. Which of the following is the best method for evaluating for possible cervical incompetence in this patient?

Transvaginal ultrasound at 18 weeks gestation

Transabdominal ultrasound in the first trimester

Transvaginal ultrasound in the first trimester

Serial transvaginal ultrasounds starting at 16 weeks gestation

Transabdominal ultrasound at 18 weeks gestation

A 38-year-old G2P2 presents to her gynecologist to discuss the results of her diagnostic tests. She has no current complaints or concurrent diseases. She underwent a tubal ligation after her last pregnancy. Her last Pap smear showed a high-grade squamous intraepithelial lesion and a reflex HPV test was positive. Colposcopic examination reveals areas of thin acetowhite epithelium with diffuse borders and fine punctation. The biopsy obtained from the suspicious areas shows CIN 1. Note the discordancy between the cytology (HSIL) and histology (CIN 1) results. Which of the following is an appropriate next step in the management of this patient?

Repeat cytology and HPV co-testing in 6 months

A 28-year-old woman comes to the physician because she had a positive pregnancy test at home. She reports feeling nauseated and has vomited several times over the past week. During this period, she has also had increased urinary frequency. She is sexually active with her boyfriend and they use condoms inconsistently. Her last menstrual period was 5 weeks ago. Physical examination shows no abnormalities. A urine pregnancy test is positive. A pap smear is positive for a high-grade squamous intraepithelial lesion. Colposcopy shows cervical intraepithelial neoplasia grade II and III. Which of the following is the most appropriate next step in the management of this patient?

Reevaluation with cytology and colposcopy 6 weeks after birth

Perform loop electrosurgical excision

Diagnostic excisional procedure

Colposcopy and cytology at 6-month intervals for 12 months

A 27-year-old woman comes to the physician for a routine health maintenance examination. She feels well. She had a chlamydia infection at the age of 22 years that was treated. Her only medication is an oral contraceptive. She has smoked one pack of cigarettes daily for 6 years. She has recently been sexually active with 3 male partners and uses condoms inconsistently. Her last Pap test was 4 years ago and results were normal. Physical examination shows no abnormalities. A Pap test shows atypical squamous cells of undetermined significance. Which of the following is the most appropriate next step in management?

Perform loop electrosurgical excision procedure

A 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She said she initially had dull, generalized stomach pain about 6 hours prior, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of any serious illnesses. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most appropriate definitive treatment in the management of this patient?

Laparoscopic removal of ovarian cysts

Intramuscular ceftriaxone followed by cephalexin

A 54-year-old male carpenter accidentally amputated his right thumb while working in his workshop 30 minutes ago. He reports that he was cutting a piece of wood, and his hand became caught up in the machinery. He is calling the emergency physician for advice on how to transport his thumb and if it is necessary. Which of the following is the best information for this patient?

Wrap thumb in saline-moistened, sterile gauze and place in sterile bag

Place thumb in cup of cold milk

Wrap thumb in sterile gauze and submerge in a cup of saline

There is no need to save the thumb

Place thumb directly into cooler of ice

A 67-year-old woman with endometrial cancer undergoes robotic-assisted staging surgery. Final pathology reveals grade 2 endometrioid adenocarcinoma with 60% myometrial invasion, positive pelvic lymph nodes (2/15), negative para-aortic nodes (0/8), and lymphovascular space invasion. No cervical or adnexal involvement. The tumor care team debates adjuvant treatment. Evaluate which combination of pathologic features most significantly impacts treatment recommendations?

Positive pelvic nodes and negative para-aortic nodes

Grade 2 histology and depth of myometrial invasion

Number of positive nodes and total nodes removed

Lymphovascular space invasion and myometrial invasion depth

Absence of cervical involvement and patient age

A 29-year-old woman with stage IA1 cervical cancer (3 mm invasion, no LVSI) desires fertility preservation. She has one child and wants more children. Cone biopsy margins are positive. Imaging shows no lymph node involvement. Her oncologist recommends radical hysterectomy, while a fertility specialist suggests radical trachelectomy. The patient strongly desires future pregnancy. Evaluate the optimal management strategy balancing oncologic and reproductive outcomes.

Repeat cone biopsy followed by close surveillance

Radical hysterectomy given positive margins

Simple trachelectomy with sentinel lymph node biopsy

Radical trachelectomy with pelvic lymphadenectomy

Neoadjuvant chemotherapy followed by conservative surgery

Cervical procedures (LEEP for USMLE Step 1: High-Yield Surgery Lessons

🔪 The Cervical Scoop

LEEP (Loop Electrosurgical Excision Procedure): A "see and treat" method using a low-voltage, high-frequency electrical current via a wire loop. It simultaneously excises and cauterizes the cervical transformation zone for histology.
Indications: Primarily for high-grade squamous intraepithelial lesions (HSIL), confirmed as CIN 2 or CIN 3 on biopsy.

Complications:
- Immediate: Bleeding, infection.
- Long-term: Cervical stenosis.

⭐ High-Yield Risk: Excision of cervical tissue can lead to cervical incompetence, increasing the risk of preterm labor and second-trimester pregnancy loss.

LEEP procedure diagram showing excision of cervical cells

🔬 Anatomy - Transformation Zone Focus

Cervical Transformation Zone Anatomy Diagram

Transformation Zone (TZ): Dynamic area on the cervix between the original and new squamocolumnar junction (SCJ).
- Epithelium: Site of squamous metaplasia, where glandular (columnar) epithelium is replaced by squamous epithelium.
- Clinical Significance: High cellular turnover makes it the primary site for HPV infection and Cervical Intraepithelial Neoplasia (CIN).

⭐ The TZ's location is hormone-dependent. It everts onto the ectocervix in younger women and recedes into the endocervical canal post-menopause, impacting colposcopy.

⚡ Management - The LEEP Algorithm

LEEP (Loop Electrosurgical Excision Procedure) is a primary "see and treat" modality for cervical dysplasia. It is both diagnostic, providing a tissue specimen for histology, and therapeutic, by excising the entire transformation zone.

Indications: Confirmed CIN 2, CIN 3. Also used for unsatisfactory colposcopy when a high-grade lesion is suspected.
Complications:
- Immediate: Bleeding, infection, incomplete excision.
- Long-term: Cervical stenosis, ↑ risk of preterm delivery.

⭐ LEEP increases the risk of future pregnancy complications, including cervical insufficiency and preterm birth, due to the removal of cervical stroma.

LEEP procedure diagram

⚠️ Complications - Post-Procedure Pitfalls

Immediate (<4 weeks):
- Bleeding: Most common. Delayed bleeding can occur at 7-14 days. Manage with pressure, Monsel's solution, or sutures.
- Infection: Endometritis/cervicitis. Presents with fever, malodorous purulent discharge.
- Vaginal Discharge: Normal for weeks; often dark/"coffee-ground".
Long-Term:
- Cervical Stenosis: Can cause dysmenorrhea, amenorrhea, infertility.
- Cervical Insufficiency: ↑ risk of preterm birth & 2nd-trimester loss.
- Incomplete Excision: Positive margins require close follow-up (Pap/HPV co-testing at 6 months).

⭐ The most significant long-term obstetric risk is cervical insufficiency, leading to ↑ preterm delivery risk. Risk is proportional to excision depth.

⚡ Biggest Takeaways

LEEP is a diagnostic and therapeutic procedure for high-grade cervical dysplasia (CIN 2/3).

It excises the entire transformation zone using an electrified wire loop, providing a specimen for histologic analysis.

Unlike ablative methods, LEEP preserves tissue, allowing for crucial assessment of excision margins.

Immediate complications include bleeding (most common), infection, and cervical stenosis.

Long-term risks for future pregnancies include cervical incompetence and preterm delivery.

Post-procedure surveillance with co-testing (Pap + HPV) is essential to monitor for recurrence.

Continue reading on Oncourse

CONTINUE READING — FREE

or get the app

App Store|Google Play