A 24-year-old primigravida presents to her physician for regular prenatal care at 31 weeks gestation. She has no complaints and the antepartum course has been uncomplicated. Her pre-gestational history is significant for obesity (BMI = 30.5 kg/m2). She has gained a total of 10 kg (22.4 lb) during pregnancy, and 2 kg (4.48 lb) since her last visit 4 weeks ago. Her vital signs are as follows: blood pressure, 145/90 mm Hg; heart rate, 87/min; respiratory rate, 14/min; and temperature, 36.7℃ (98℉). The fetal heart rate is 153/min. The physical examination shows no edema and is only significant for a 2/6 systolic murmur best heard at the apex of the heart. A 24-hour urine is negative for protein. Which of the following options describe the best management strategy in this case?
Q2
A 29-year-old G2P2 female gives birth to a healthy baby boy at 39 weeks of gestation via vaginal delivery. Immediately after the delivery of the placenta, she experiences profuse vaginal hemorrhage. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She did not receive any prenatal care during either pregnancy. Her past medical history is notable for obesity and diabetes mellitus, which is well controlled on metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 95/50 mmHg, pulse is 125/min, and respirations are 22/min. On physical examination, the patient is in moderate distress. Her extremities are pale, cool, and clammy. Capillary refill is delayed. Which of the following is the most likely cause of this patient’s bleeding?
Q3
A 24-year-old woman comes to the physician for preconceptional advice. She has been married for 2 years and would like to conceive within the next year. Menses occur at regular 30-day intervals and last 4 days with normal flow. She does not smoke or drink alcohol and follows a balanced diet. She takes no medications. She is 160 cm (5 ft 3 in) tall and weighs 55 kg (121 lb); BMI is 21.5 kg/m2. Physical examination, including pelvic examination, shows no abnormalities. She has adequate knowledge of the fertile days of her menstrual cycle. Which of the following is most appropriate recommendation for this patient at this time?
Q4
A 30-year-old woman, gravida 2, para 1, at 42 weeks' gestation is admitted to the hospital in active labor. Pregnancy has been complicated by gestational diabetes, for which she has been receiving insulin injections. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 90/min, respirations are 18/min, and blood pressure is 135/80 mm Hg. The fetal heart rate tracing shows a baseline heart rate of 145/min and moderate variation with frequent accelerations and occasional early decelerations. She undergoes an elective repeat lower segment transverse cesarean section with complete removal of the placenta. Shortly after the operation, she starts having heavy uterine bleeding with passage of clots. Examination shows a soft uterus on palpation. Her bleeding continues despite fundal massage and the use of packing, oxytocin, misoprostol, and carboprost. Her pulse rate is now 120/min, respirations are 20/min, and blood pressure is 90/70 mm Hg. Her hemoglobin is 8 g/dL, hematocrit is 24%, platelet count is 120,000 mm3, prothrombin time is 11 seconds, and partial thromboplastin time is 30 seconds. Mass transfusion protocol is activated and a B-Lynch uterine compression suture is placed to control her bleeding. Which of the following is the mostly likely cause of her postpartum complication?
Q5
A 37-year-old woman presents to her physician with a newly detected pregnancy for the initial prenatal care visit. She is gravida 3 para 2 with a history of preeclampsia in her 1st pregnancy. Her history is also significant for arterial hypertension diagnosed 1 year ago for which she did not take any medications. The patient reports an 8-pack-year smoking history and states she quit smoking a year ago. On examination, the vital signs are as follows: blood pressure 140/90 mm Hg, heart rate 69/min, respiratory rate 14/min, and temperature 36.6°C (97.9°F). The physical examination is unremarkable. Which of the following options is the most appropriate next step in the management for this woman?
Q6
A 32-year-old G2P0A1 woman presents at 36 weeks of gestation for the first time during her pregnancy. The patient has no complaints, currently. However, her past medical history reveals seizure disorder, which is under control with valproic acid and lithium. She has not seen her neurologist during the past 2 years, in the absence of any complaints. She also reports a previous history of elective abortion. The physical examination is insignificant. Her blood pressure is 130/75 mm Hg and pulse is 80/min. The patient is scheduled to undergo regular laboratory tests and abdominal ultrasound. Given her past medical history, which of the following conditions is her fetus most likely going to develop?
Q7
A 26-year-old primigravid woman at 25 weeks' gestation comes to the physician for a prenatal visit. She has no history of serious illness and her only medication is a daily prenatal vitamin. A 1-hour 50-g glucose challenge shows a glucose concentration of 167 mg/dL (N < 135). A 100-g oral glucose tolerance test shows glucose concentrations of 213 mg/dL (N < 180) and 165 mg/dL (N < 140) at 1 and 3 hours, respectively. If she does not receive adequate treatment for her condition, which of the following complications is her infant at greatest risk of developing?
Q8
A 21-year-old female presents to her primary care doctor for prenatal counseling before attempting to become pregnant for the first time. She is an avid runner, and the physician notes her BMI of 17.5. The patient complains of chronic fatigue, which she attributes to her busy lifestyle. The physician orders a complete blood count that reveals a Hgb 10.2 g/dL (normal 12.1 to 15.1 g/dL) with an MCV 102 µm^3 (normal 78 to 98 µm^3). A serum measurement of a catabolic derivative of methionine returns elevated. Which of the following complications is the patient at most risk for if she becomes pregnant?
Q9
A 28-year-old woman comes to the physician because she has not had a menstrual period for 3 months. Menarche occurred at the age of 12 years and menses occurred at regular 30-day intervals until they became irregular 1 year ago. She is 160 cm (5 ft 3 in) tall and weighs 85 kg (187 lb); BMI is 33.2 kg/m2. Physical exam shows nodules and pustules along the jaw line and dark hair growth around the umbilicus. Pelvic examination shows a normal-sized, retroverted uterus. A urine pregnancy test is negative. Without treatment, this patient is at greatest risk for which of the following?
Q10
A 58-year-old woman presents to the physician’s office with vaginal bleeding. The bleeding started as a spotting and has increased and has become persistent over the last month. The patient is G3P1 with a history of polycystic ovary syndrome and type 2 diabetes mellitus. She completed menopause 4 years ago. She took cyclic estrogen-progesterone replacement therapy for 1 year at the beginning of menopause. Her weight is 89 kg (196 lb), height 157 cm (5 ft 2 in). Her vital signs are as follows: blood pressure 135/70 mm Hg, heart rate 78/min, respiratory rate 12/min, and temperature 36.7℃ (98.1℉). Physical examination is unremarkable. Transvaginal ultrasound reveals an endometrium of 6 mm thickness. Speculum examination shows a cervix without focal lesions with bloody discharge from the non-dilated external os. On pelvic examination, the uterus is slightly enlarged, movable, and non-tender. Adnexa is non-palpable. What is the next appropriate step in the management of this patient?
Obesity in pregnancy US Medical PG Practice Questions and MCQs
Question 1: A 24-year-old primigravida presents to her physician for regular prenatal care at 31 weeks gestation. She has no complaints and the antepartum course has been uncomplicated. Her pre-gestational history is significant for obesity (BMI = 30.5 kg/m2). She has gained a total of 10 kg (22.4 lb) during pregnancy, and 2 kg (4.48 lb) since her last visit 4 weeks ago. Her vital signs are as follows: blood pressure, 145/90 mm Hg; heart rate, 87/min; respiratory rate, 14/min; and temperature, 36.7℃ (98℉). The fetal heart rate is 153/min. The physical examination shows no edema and is only significant for a 2/6 systolic murmur best heard at the apex of the heart. A 24-hour urine is negative for protein. Which of the following options describe the best management strategy in this case?
A. Treatment in outpatient settings with labetalol
B. Treatment in the outpatient settings with nifedipine
C. Observation in the outpatient settings (Correct Answer)
D. Treatment in the inpatient settings with methyldopa
E. Admission to hospital for observation
Explanation: ***Observation in the outpatient settings***
- The patient's blood pressure is 145/90 mmHg, which meets the criteria for **gestational hypertension** according to ACOG (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg on two occasions at least 4 hours apart after 20 weeks gestation in a previously normotensive woman, without proteinuria).
- Since this is a single elevated blood pressure reading (not yet confirmed by a second reading after 4 hours) and there is no evidence of **proteinuria** or **severe features** (e.g., severe headache, visual disturbances, epigastric pain, elevated liver enzymes, thrombocytopenia, pulmonary edema), **close outpatient monitoring** is the appropriate initial step.
*Treatment in outpatient settings with labetalol*
- **Antihypertensive medication** is typically initiated for gestational hypertension if BP is consistently ≥160/110 mmHg, or if there are signs of severe features.
- While labetalol is a safe and common first-line agent, starting treatment based on a **single, non-severe elevated BP reading** without confirmed gestational hypertension or severe features is premature.
*Treatment in the outpatient settings with nifedipine*
- Similar to labetalol, **nifedipine** is an appropriate antihypertensive if medication is warranted for gestational hypertension.
- However, initiating medication is not the **first step** for an isolated, non-severe elevated blood pressure reading without confirmed diagnosis or severe features.
*Treatment in the inpatient settings with methyldopa*
- **Inpatient treatment** is reserved for patients with severe gestational hypertension, preeclampsia with severe features, or uncontrollable hypertension.
- While methyldopa is a safe antihypertensive in pregnancy, inpatient treatment is **not indicated** for this patient's presentation.
*Admission to hospital for observation*
- **Hospital admission** for observation is generally reserved for patients with more severe hypertension, suspected preeclampsia with severe features, or concerns about fetal well-being.
- Given the patient's **asymptomatic state**, normal fetal heart rate, and lack of proteinuria or severe features, inpatient admission is **unnecessary** at this stage.
Question 2: A 29-year-old G2P2 female gives birth to a healthy baby boy at 39 weeks of gestation via vaginal delivery. Immediately after the delivery of the placenta, she experiences profuse vaginal hemorrhage. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She did not receive any prenatal care during either pregnancy. Her past medical history is notable for obesity and diabetes mellitus, which is well controlled on metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 95/50 mmHg, pulse is 125/min, and respirations are 22/min. On physical examination, the patient is in moderate distress. Her extremities are pale, cool, and clammy. Capillary refill is delayed. Which of the following is the most likely cause of this patient’s bleeding?
A. Chorionic villi invading into the myometrium
B. Placental implantation over internal cervical os
C. Chorionic villi attaching to the decidua basalis
D. Chorionic villi invading into the serosa
E. Chorionic villi attaching to the myometrium (Correct Answer)
Explanation: ***Chorionic villi attaching to the myometrium***
- This describes **placenta accreta**, where the **chorionic villi adhere directly to the myometrium** without invading beyond it. This condition is strongly associated with a history of **prior C-sections**, as the scar tissue increases the risk of abnormal placental implantation.
- The profuse hemorrhage immediately following placental delivery, despite the placenta being delivered, suggests a problem with normal placental separation from the uterine wall. **Placenta accreta** can lead to massive postpartum hemorrhage when the placenta attempts to separate, tearing the maternal vessels.
*Chorionic villi invading into the myometrium*
- This describes **placenta increta**, where the **chorionic villi invade deeper into the myometrium**. While also causing severe hemorrhage, the term "attaching to the myometrium" (accreta) is a more common and slightly less severe form often seen with prior C-sections.
- Both accreta and increta present similarly with hemorrhage, but accreta is the initial and most common form of abnormal adherence to the myometrium.
*Placental implantation over internal cervical os*
- This describes **placenta previa**, which is characterized by **painless vaginal bleeding** typically in the **second or third trimester**, before delivery.
- While a prior C-section is a risk factor for placenta previa, the hemorrhage in this case occurred *after* the delivery of the placenta, not before or during labor, ruling out active previa.
*Chorionic villi invading into the serosa*
- This describes **placenta percreta**, the most severe form where **chorionic villi invade through the myometrium and into the uterine serosa**, potentially involving adjacent organs.
- While it causes massive hemorrhage, "attaching to" or even "invading into" the myometrium (accreta/increta) are more probable, given the description, than invasion *through* to the serosa, though all are part of the placenta accreta spectrum.
*Chorionic villi invading beyond the serosa*
- This is an alternative description for **placenta percreta**, indicating invasion through the uterus and potentially into surrounding structures like the bladder.
- While this is a severe cause of postpartum hemorrhage, the provided option "Chorionic villi attaching to the myometrium" (placenta accreta) is the most common form of abnormally adherent placenta in the spectrum and is highly consistent with the patient's history of prior C-section and the clinical presentation of hemorrhage after placental delivery.
Question 3: A 24-year-old woman comes to the physician for preconceptional advice. She has been married for 2 years and would like to conceive within the next year. Menses occur at regular 30-day intervals and last 4 days with normal flow. She does not smoke or drink alcohol and follows a balanced diet. She takes no medications. She is 160 cm (5 ft 3 in) tall and weighs 55 kg (121 lb); BMI is 21.5 kg/m2. Physical examination, including pelvic examination, shows no abnormalities. She has adequate knowledge of the fertile days of her menstrual cycle. Which of the following is most appropriate recommendation for this patient at this time?
A. Begin high-dose vitamin A supplementation
B. Begin vitamin B12 supplementation
C. Begin folate supplementation (Correct Answer)
D. Begin iron supplementation
E. Gain 2 kg prior to conception
Explanation: ***Begin folate supplementation***
- **Folate supplementation** of 400 mcg daily is recommended for all women of childbearing age to reduce the risk of **neural tube defects** (NTDs) in the fetus. This should ideally begin at least one month before conception and continue through the first trimester.
- The patient is planning to conceive, making preemptive folate supplementation critical for preventing serious birth defects.
*Begin high-dose vitamin A supplementation*
- **High-dose vitamin A** (more than 10,000 IU/day) can be **teratogenic** and is therefore contraindicated during preconception and pregnancy.
- While vitamin A is essential for fetal development, excessive amounts can lead to fetal abnormalities.
*Begin vitamin B12 supplementation*
- **Vitamin B12 supplementation** is generally not necessary unless the patient has a diagnosed deficiency, such as in strict vegetarians or those with malabsorption issues.
- There is no indication of B12 deficiency in this patient's history or presentation.
*Begin iron supplementation*
- Routine **iron supplementation** is not recommended preconception unless the patient is diagnosed with **iron deficiency anemia**.
- Excessive iron intake without a clear indication can cause gastrointestinal upset and has not been shown to improve pregnancy outcomes in non-anemic women.
*Gain 2 kg prior to conception*
- The patient has a **healthy BMI of 21.5 kg/m2**, which is within the normal range (18.5-24.9 kg/m2).
- There is no medical indication for her to gain weight prior to conception.
Question 4: A 30-year-old woman, gravida 2, para 1, at 42 weeks' gestation is admitted to the hospital in active labor. Pregnancy has been complicated by gestational diabetes, for which she has been receiving insulin injections. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 90/min, respirations are 18/min, and blood pressure is 135/80 mm Hg. The fetal heart rate tracing shows a baseline heart rate of 145/min and moderate variation with frequent accelerations and occasional early decelerations. She undergoes an elective repeat lower segment transverse cesarean section with complete removal of the placenta. Shortly after the operation, she starts having heavy uterine bleeding with passage of clots. Examination shows a soft uterus on palpation. Her bleeding continues despite fundal massage and the use of packing, oxytocin, misoprostol, and carboprost. Her pulse rate is now 120/min, respirations are 20/min, and blood pressure is 90/70 mm Hg. Her hemoglobin is 8 g/dL, hematocrit is 24%, platelet count is 120,000 mm3, prothrombin time is 11 seconds, and partial thromboplastin time is 30 seconds. Mass transfusion protocol is activated and a B-Lynch uterine compression suture is placed to control her bleeding. Which of the following is the mostly likely cause of her postpartum complication?
A. Adherent placenta to myometrium
B. Uterine inversion
C. Infection of the endometrial lining of the uterus
D. Uterine rupture
E. Lack of uterine muscle contraction (Correct Answer)
Explanation: ***Lack of uterine muscle contraction***
- The presentation of a **soft uterus** on palpation and continued severe bleeding despite fundal massage and uterotonics (**oxytocin, misoprostol, carboprost**) is highly indicative of **uterine atony**, which is a lack of effective uterine muscle contraction.
- Uterine atony is the most common cause of **postpartum hemorrhage**, and risk factors include **macrosomia** (due to gestational diabetes), **multiparity**, and a prolonged labor or rapid delivery, though the latter two are less clear here.
*Adherent placenta to myometrium*
- While a history of prior C-section and **macrosomia** (due to gestational diabetes) could increase the risk of an **abnormally adherent placenta** (accreta, increta, percreta), the description notes **complete removal of the placenta**.
- If the placenta were morbidly adherent and not completely removed, bleeding would likely stem from retained placental tissue, and this would typically be explicitly noted or suspected due to difficulty with manual removal.
*Uterine inversion*
- **Uterine inversion** involves the uterus turning inside out, which would present with a **mass protruding from the vagina** or a visible inversion of the fundus upon examination, along with sudden onset of severe pain and shock.
- The description of a **soft uterus** and an absence of a physical description of uterine inversion makes this diagnosis less likely.
*Infection of the endometrial lining of the uterus*
- **Endometritis** (infection of the endometrial lining) typically presents with fever, foul-smelling lochia, uterine tenderness, and prolonged postpartum bleeding, usually occurring a few days postpartum rather than immediately following delivery.
- The acute, massive hemorrhage immediately following delivery, coupled with a normal initial temperature, does not align with the typical presentation of endometritis.
*Uterine rupture*
- **Uterine rupture** is a serious complication, especially with a history of prior C-section, but it typically presents with **sudden severe abdominal pain**, fetal heart rate abnormalities (if it occurs before delivery), and **hemodynamic instability**, often with cessation of contractions.
- While the patient is hemodynamically unstable, the primary issue described is heavy uterine bleeding with a soft uterus, and no mention of severe abdominal pain or clear signs of rupture during the C-section make uterine atony a more direct explanation for the described symptoms.
Question 5: A 37-year-old woman presents to her physician with a newly detected pregnancy for the initial prenatal care visit. She is gravida 3 para 2 with a history of preeclampsia in her 1st pregnancy. Her history is also significant for arterial hypertension diagnosed 1 year ago for which she did not take any medications. The patient reports an 8-pack-year smoking history and states she quit smoking a year ago. On examination, the vital signs are as follows: blood pressure 140/90 mm Hg, heart rate 69/min, respiratory rate 14/min, and temperature 36.6°C (97.9°F). The physical examination is unremarkable. Which of the following options is the most appropriate next step in the management for this woman?
A. Methyldopa (Correct Answer)
B. Magnesium sulfate
C. Fosinopril
D. Labetalol
E. No medications needed
Explanation: ***Methyldopa***
- **Methyldopa** is a **centrally acting alpha-2 adrenergic agonist** that is considered a first-line agent for the treatment of **chronic hypertension in pregnancy**.
- Its **safety profile** and effectiveness in controlling blood pressure without significant fetal harm make it an appropriate choice.
*Magnesium sulfate*
- **Magnesium sulfate** is primarily used for the **prevention and treatment of seizures in preeclampsia** and **eclampsia**.
- It is not indicated for the chronic management of hypertension and is prescribed for specific acute indications during pregnancy.
*Fosinopril*
- **Fosinopril** is an **ACE inhibitor**, which is **contraindicated in pregnancy** due to its association with **fetal renal dysfunction**, **oligohydramnios**, and **malformations**, especially in the second and third trimesters.
- ACE inhibitors and ARBs should be avoided during pregnancy.
*Labetalol*
- **Labetalol** is an **alpha and beta-blocker that can be used for chronic hypertension in pregnancy**, but given the patient's history of asthma (implied through a history of smoking), **methyldopa** might be a slightly safer initial choice, although labetalol could also be considered.
- While generally safe, its use can be associated with **fetal growth restriction** and **neonatal bradycardia** if used indiscriminately, making methyldopa a preferred first-line agent in many cases.
*No medications needed*
- The patient has **chronic hypertension** (diagnosed 1 year ago) and previous **preeclampsia**, indicating a need for **antihypertensive management** to prevent adverse maternal and fetal outcomes.
- Not initiating treatment would put the patient at increased risk for **severe preeclampsia**, **placental abruption**, and other complications.
Question 6: A 32-year-old G2P0A1 woman presents at 36 weeks of gestation for the first time during her pregnancy. The patient has no complaints, currently. However, her past medical history reveals seizure disorder, which is under control with valproic acid and lithium. She has not seen her neurologist during the past 2 years, in the absence of any complaints. She also reports a previous history of elective abortion. The physical examination is insignificant. Her blood pressure is 130/75 mm Hg and pulse is 80/min. The patient is scheduled to undergo regular laboratory tests and abdominal ultrasound. Given her past medical history, which of the following conditions is her fetus most likely going to develop?
A. Neural tube defects (NTDs) (Correct Answer)
B. Intrauterine growth restriction
C. Iron deficiency anemia
D. Trisomy 21
E. Limb anomalies
Explanation: **Neural tube defects (NTDs)**
* The use of **valproic acid** during pregnancy is significantly associated with an increased risk of **neural tube defects (NTDs)**, such as spina bifida and anencephaly, in the fetus.
* Valproic acid interferes with **folate metabolism**, which is crucial for proper neural tube closure during early fetal development.
*Intrauterine growth restriction*
* While some medications and maternal conditions can cause **intrauterine growth restriction (IUGR)**, valproic acid and lithium are **not primary causes** of IUGR.
* Other factors, such as **placental insufficiency**, severe maternal hypertension, or infections, are more commonly associated with IUGR.
*Iron deficiency anemia*
* **Iron deficiency anemia** is a common maternal condition in pregnancy, but it is **not a direct fetal outcome** of maternal valproic acid or lithium use.
* Fetal anemia might occur due to other causes like **Rh incompatibility** or parvovirus infection.
*Trisomy 21*
* **Trisomy 21 (Down syndrome)** is a **chromosomal anomaly** caused by the presence of an extra copy of chromosome 21.
* It is not related to maternal medication use like valproic acid or lithium; its incidence is primarily correlated with **advanced maternal age**.
*Limb anomalies*
* Although several teratogenic medications can cause **limb anomalies**, **valproic acid** is more strongly linked to **neural tube defects** and certain **cardiac anomalies**.
* **Thalidomide**, for example, is notoriously associated with severe limb malformations.
Question 7: A 26-year-old primigravid woman at 25 weeks' gestation comes to the physician for a prenatal visit. She has no history of serious illness and her only medication is a daily prenatal vitamin. A 1-hour 50-g glucose challenge shows a glucose concentration of 167 mg/dL (N < 135). A 100-g oral glucose tolerance test shows glucose concentrations of 213 mg/dL (N < 180) and 165 mg/dL (N < 140) at 1 and 3 hours, respectively. If she does not receive adequate treatment for her condition, which of the following complications is her infant at greatest risk of developing?
A. Elevated calcium levels
B. Decreased hematocrit
C. Decreased amniotic fluid production
D. Islet cell hyperplasia (Correct Answer)
E. Omphalocele
Explanation: ***Islet cell hyperplasia***
- The patient's glucose tolerance test results indicate **gestational diabetes mellitus (GDM)**, which leads to increased fetal glucose exposure.
- In response to chronic hyperglycemia, the fetal beta cells undergo **hyperplasia** and hypertrophy to increase insulin production, predisposing the infant to **hypoglycemia** after birth.
*Elevated calcium levels*
- **Hypocalcemia** is a more common electrolyte disturbance in infants of diabetic mothers due to prematurity, asphyxia, or parathyroid hormone suppression.
- **Hypercalcemia** is not typically associated with gestational diabetes.
*Decreased hematocrit*
- Infants of diabetic mothers are at increased risk for **polycythemia** (elevated hematocrit) due to increased erythropoietin production in response to fetal hypoxia.
- **Decreased hematocrit** (anemia) is less common and usually related to other causes.
*Decreased amniotic fluid production*
- Uncontrolled gestational diabetes often leads to **polyhydramnios** (excess amniotic fluid) due to fetal hyperglycemia-induced polyuria.
- **Oligohydramnios** (decreased amniotic fluid) is not a typical complication of GDM.
*Omphalocele*
- **Omphalocele** is a **ventral wall defect** associated with chromosomal abnormalities or other genetic syndromes, not primarily with gestational diabetes.
- While GDM can increase the risk of various birth defects, omphalocele is not one of the more commonly cited or direct consequences.
Question 8: A 21-year-old female presents to her primary care doctor for prenatal counseling before attempting to become pregnant for the first time. She is an avid runner, and the physician notes her BMI of 17.5. The patient complains of chronic fatigue, which she attributes to her busy lifestyle. The physician orders a complete blood count that reveals a Hgb 10.2 g/dL (normal 12.1 to 15.1 g/dL) with an MCV 102 µm^3 (normal 78 to 98 µm^3). A serum measurement of a catabolic derivative of methionine returns elevated. Which of the following complications is the patient at most risk for if she becomes pregnant?
A. Placenta abruptio (Correct Answer)
B. Placenta previa
C. Placenta accreta
D. Neural tube defects
E. Gestational diabetes
Explanation: **Placenta abruptio**
* The patient presents with several risk factors for **placental abruption**, including **low BMI**, **anemia** (Hgb 10.2), and **elevated homocysteine** (indicated by elevated catabolic derivative of methionine, implying **folate or B12 deficiency**, which leads to high homocysteine).
* **Anemia** and **folate deficiency** are associated with an increased risk of placental abruption.
*Placenta previa*
* **Placenta previa** is characterized by the placenta covering the cervical os, typically associated with risk factors like **previous C-section**, **multiparity**, and **advanced maternal age**.
* The patient's profile (first pregnancy, young) does not align with the typical risk factors for placenta previa.
*Placenta accreta*
* **Placenta accreta** involves abnormal placental adherence to the uterine wall, most commonly linked to **prior uterine surgery** (especially C-sections) and **placenta previa**.
* The patient has no history of uterine surgery, making placenta accreta an unlikely primary risk.
*Neural tube defects*
* **Neural tube defects** are associated with **folate deficiency**, which is likely present given the **macrocytic anemia** (MCV 102) and elevated homocysteine.
* However, the question asks for the complication the patient is *most* at risk for due to her overall profile including her low BMI and anemia, and while NTDs are a risk, the combination of factors points more strongly to placental abruption.
*Gestational diabetes*
* **Gestational diabetes** is linked to risk factors like **obesity**, **family history of diabetes**, and **advanced maternal age**.
* The patient's **low BMI** (17.5) and young age make gestational diabetes an unlikely significant risk.
Question 9: A 28-year-old woman comes to the physician because she has not had a menstrual period for 3 months. Menarche occurred at the age of 12 years and menses occurred at regular 30-day intervals until they became irregular 1 year ago. She is 160 cm (5 ft 3 in) tall and weighs 85 kg (187 lb); BMI is 33.2 kg/m2. Physical exam shows nodules and pustules along the jaw line and dark hair growth around the umbilicus. Pelvic examination shows a normal-sized, retroverted uterus. A urine pregnancy test is negative. Without treatment, this patient is at greatest risk for which of the following?
A. Choriocarcinoma
B. Mature cystic teratoma
C. Endometrial carcinoma (Correct Answer)
D. Endometrioma
E. Cervical carcinoma
Explanation: ***Endometrial carcinoma***
- The patient's presentation including **amenorrhea**, **obesity** (BMI 33.2 kg/m²), **hirsutism** (dark hair around the umbilicus), and **acne** (nodules and pustules along the jawline) strongly suggests **Polycystic Ovary Syndrome (PCOS)**.
- In PCOS, chronic anovulation leads to unopposed **estrogen stimulation** of the endometrium, increasing the risk of **endometrial hyperplasia** and subsequently **endometrial carcinoma**.
*Choriocarcinoma*
- This is a rare, aggressive form of **gestational trophoblastic disease** that typically develops after a **hydatidiform mole** or pregnancy.
- The patient's negative pregnancy test and lack of prior abnormal pregnancy rule out this condition.
*Mature cystic teratoma*
- This is a common **benign ovarian tumor** that contains mature tissues from all three germ layers.
- It does not typically cause **amenorrhea** or symptoms of **hyperandrogenism** like those described.
*Endometrioma*
- This is a type of **endometriosis** where endometrial tissue grows on the ovaries, forming blood-filled "chocolate cysts."
- While it can cause pelvic pain and dysmenorrhea, it is not associated with **amenorrhea** or the **hyperandrogenic** features seen in this patient.
*Cervical carcinoma*
- This type of cancer is primarily caused by **Human Papillomavirus (HPV) infection** and is usually diagnosed through Pap smears.
- The patient's symptoms are not characteristic of cervical cancer, which typically presents with abnormal vaginal bleeding or postcoital bleeding.
Question 10: A 58-year-old woman presents to the physician’s office with vaginal bleeding. The bleeding started as a spotting and has increased and has become persistent over the last month. The patient is G3P1 with a history of polycystic ovary syndrome and type 2 diabetes mellitus. She completed menopause 4 years ago. She took cyclic estrogen-progesterone replacement therapy for 1 year at the beginning of menopause. Her weight is 89 kg (196 lb), height 157 cm (5 ft 2 in). Her vital signs are as follows: blood pressure 135/70 mm Hg, heart rate 78/min, respiratory rate 12/min, and temperature 36.7℃ (98.1℉). Physical examination is unremarkable. Transvaginal ultrasound reveals an endometrium of 6 mm thickness. Speculum examination shows a cervix without focal lesions with bloody discharge from the non-dilated external os. On pelvic examination, the uterus is slightly enlarged, movable, and non-tender. Adnexa is non-palpable. What is the next appropriate step in the management of this patient?
A. Endometrial biopsy (Correct Answer)
B. Hysteroscopy with targeted biopsy
C. Hysteroscopy with dilation and curettage
D. Saline infusion sonography
E. Medroxyprogesterone acetate therapy
Explanation: ***Endometrial biopsy***
- **Postmenopausal bleeding** warrants an endometrial biopsy to rule out endometrial hyperplasia or carcinoma, especially with risk factors like obesity, PCOS, and a history of unopposed estrogen exposure.
- An endometrial thickness of 6mm in a postmenopausal woman, along with persistent bleeding, is concerning enough to necessitate **histological evaluation**.
*Hysteroscopy with targeted biopsy*
- While hysteroscopy allows for direct visualization and targeted biopsy, it is generally considered after an initial **blind endometrial biopsy** proves inconclusive or insufficient, or if focal lesions are suspected.
- In this case, there is no indication of focal lesions, and a initial endometrial biopsy is the more appropriate first step to broadly sample the endometrium.
*Hysteroscopy with dilation and curettage*
- **Dilation and curettage** (D&C) is a more invasive procedure, usually reserved for cases where an endometrial biopsy is insufficient, technically difficult to perform, or when significant bleeding requires therapeutic intervention.
- It is not the initial diagnostic step for postmenopausal bleeding given the availability of less invasive options.
*Saline infusion sonography*
- **Saline infusion sonography** (SIS) helps visualize the endometrial cavity more clearly than transvaginal ultrasound, particularly for identifying polyps or fibroids.
- However, SIS is primarily a diagnostic imaging tool; it does not provide tissue for histological diagnosis, which is crucial for evaluating postmenopausal bleeding.
*Medroxyprogesterone acetate therapy*
- **Medroxyprogesterone acetate** is used to treat endometrial hyperplasia without atypia or as a component of hormone replacement therapy.
- It should not be initiated without a **definitive histological diagnosis** to rule out malignancy, especially in the context of postmenopausal bleeding.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
