A 40-year-old female presents to her gynecologist with dysmenorrhea, menorrhagia, and pelvic pain. The patient is not taking any medication and has no evidence of fever. Transvaginal sonogram reveals an enlarged, soft, and tender uterus, and uterine biopsy shows normal-appearing endometrial glands within the myometrium. Which of the following is the most likely diagnosis in this patient:
Q92
A 24-year-old woman comes to her primary care physician because she has not had a menstrual period for 6 months. She is a competitive runner and has been training heavily for the past year in preparation for upcoming races. She has no family or personal history of serious illness. She has not been sexually active for the past 9 months. Her temperature is 36.9°C (98.4° F), pulse is 51/min, respirations are 12/min, and blood pressure is 106/67 mm Hg. Her BMI is 18.1 kg/m2. Which of the following is the most likely cause of her amenorrhea?
Q93
A 23-year-old woman comes to the physician because of a 3-month history of pain during intercourse and vaginal dryness. The patient has also had intermittent hot flashes and fatigue during this time. Over the past year, her periods have become irregular. Her last menstrual period was over six months ago. She is sexually active with one partner and does not use protection or contraception. She has a history of acute lymphoblastic leukemia during childhood, which has remained in remission. Pelvic examination shows an atrophic cervix and vagina. A urinary pregnancy test is negative. A progestin challenge test is performed and shows no withdrawal bleeding. Further evaluation of this patient is most likely to show which of the following findings?
Q94
A 44-year-old woman with high blood pressure and diabetes presents to the outpatient clinic and informs you that she is trying to get pregnant. Her current medications include lisinopril, metformin, and sitagliptin. Her blood pressure is 136/92 mm Hg and heart rate is 79/min. Her physical examination is unremarkable. What should you do regarding her medication for high blood pressure?
Q95
A 30-year-old G1P0 woman at 26 weeks gestation presents to the obstetric emergency room for an evaluation after being involved in a motor vehicle accident. She was in the passenger seat of her car when the car was hit on the side by a drunk driver. She is currently in no acute distress but is worried about her pregnancy. The patient attended all her prenatal visits and took all her appropriate prenatal vitamins. Her past medical history is notable for diabetes mellitus, for which she takes metformin. Her temperature is 98.6°F (37°C), blood pressure is 135/75 mmHg, pulse is 109/min, and respirations are 22/min. A non-stress test is non-responsive, and a biophysical profile demonstrates abnormal fetal breathing, fetal activity, and fetal muscle tone. An amniotic fluid sample is taken which demonstrates a lecithin/sphingomyelin ratio of 1.9. Which of the following is the next best step in the management of this patient?
Q96
A 15-year-old girl is brought in by her parents to her pediatrician with concerns that their daughter still has not had her first menstrual cycle. The parents report that the patient has had no developmental issues in the past. She was born full term by vaginal delivery and has met all other milestones growing up. Based on chart review, the patient demonstrated breast bud development at 10 years of age. The patient is not self conscious of her appearance but is concerned that something may be wrong since she has not yet had her first period. The patient’s temperature is 97.9°F (36.6°C), blood pressure is 116/70 mmHg, pulse is 66/min, and respirations are 12/min. On exam, the patient appears her stated age and is of normal stature. She has Tanner 5 breast development but Tanner 2 pubic hair. On gynecologic exam, external genitalia appears normal, but the vagina ends in a blind pouch. Lab studies demonstrate that the patient has elevated levels of testosterone, estrogen, and luteinizing hormone. Which of the following is the most likely karyotype for this patient?
Q97
A 38-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the physician because of a 1-day history of dyspnea and left-sided chest pain that is worse when she breathes deeply. One week ago, she returned from a trip to Chile, where she had a 3-day episode of flu-like symptoms that resolved without treatment. Pregnancy and delivery of her first child were uncomplicated. She has no history of serious illness. Her temperature is 37.2°C (99°F), pulse is 118/min, respirations are 28/min and slightly labored, and blood pressure is 110/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. Examination shows jugular venous distention and bilateral pitting edema below the knees that is worse on the left-side. There is decreased breath sounds over the left lung base. The uterus is consistent in size with a 32-week gestation. The remainder of the examination shows no abnormalities. Further evaluation of this patient is most likely to show which of the following findings?
Q98
An obese 34-year-old primigravid woman at 20 weeks' gestation comes to the physician for a follow-up examination for a mass she found in her left breast 2 weeks ago. Until pregnancy, menses had occurred at 30- to 40-day intervals since the age of 11 years. Vital signs are within normal limits. Examination shows a 3.0-cm, non-mobile, firm, and nontender mass in the upper outer quadrant of the left breast. There is no palpable axillary lymphadenopathy. Pelvic examination shows a uterus consistent in size with a 20-week gestation. Mammography and core needle biopsy confirm an infiltrating lobular carcinoma. The pathological specimen is positive for estrogen and human epidermal growth factor receptor 2 (HER2) receptors and negative for progesterone receptors. Staging shows no distant metastatic disease. Which of the following is the most appropriate management?
Q99
A 19-year-old nulligravid woman comes to the physician because of irregular heavy menstrual bleeding since menarche at age 16 years. Menses occur at irregular 15- to 45-day intervals and last 7 to 10 days. She has also noted increased hair growth on her face. She has not been sexually active since she started taking isotretinoin for acne vulgaris 4 months ago. Her 70-year-old grandmother has breast cancer. She is 163 cm (5 ft 4 in) tall and weighs 74 kg (163 lb); BMI is 28 kg/m2. Pelvic examination shows copious cervical mucus and slightly enlarged irregular ovaries. If left untreated, this patient is at an increased risk for which of the following complications?
Q100
A primigravida, 29-year-old woman presents in her 28th week of pregnancy for evaluation of 3 hours of vaginal bleeding and abdominal pain. She denies any trauma and states that this is the first time she has had such symptoms. Her prenatal care has been optimal and all of her antenatal screenings have been within normal limits. Her vital signs are unremarkable. Physical examination reveals a small amount of blood in the vaginal canal and the cervical os is closed. Ultrasound imaging demonstrates positive fetal cardiac activity. What is the most likely diagnosis?
High-risk pregnancies US Medical PG Practice Questions and MCQs
Question 91: A 40-year-old female presents to her gynecologist with dysmenorrhea, menorrhagia, and pelvic pain. The patient is not taking any medication and has no evidence of fever. Transvaginal sonogram reveals an enlarged, soft, and tender uterus, and uterine biopsy shows normal-appearing endometrial glands within the myometrium. Which of the following is the most likely diagnosis in this patient:
A. Leiomyoma
B. Endometrial carcinoma
C. Endometriosis
D. Adenomyosis (Correct Answer)
E. Endometritis
Explanation: ***Adenomyosis***
- The classic presentation of **dysmenorrhea**, **menorrhagia**, and **pelvic pain** with a **tender, enlarged uterus** is highly suggestive of adenomyosis.
- The biopsy finding of **normal-appearing endometrial glands within the myometrium** is pathognomonic for adenomyosis, as it confirms the presence of endometrial tissue in the muscle wall of the uterus.
*Leiomyoma*
- While leiomyomas (fibroids) can cause **dysmenorrhea** and **menorrhagia**, they typically present with a **firm, irregularly enlarged uterus**, which contradicts the "soft and tender" description.
- Uterine biopsy in leiomyomas would show **benign smooth muscle tumors**, not endometrial glands within the myometrium.
*Endometrial carcinoma*
- Endometrial carcinoma primarily causes **abnormal uterine bleeding**, particularly in postmenopausal women, and may cause pelvic pain, but an **enlarged, soft, and tender uterus** is not a characteristic finding.
- Biopsy would reveal **malignant endometrial cells**, not normal-appearing endometrial glands within the myometrium.
*Endometriosis*
- Endometriosis causes **dysmenorrhea** and **pelvic pain**, but the tenderness and enlargement are typically due to **adnexal masses** (e.g., endometriomas) or diffuse peritoneal implants, not usually a globally enlarged, soft uterus.
- The diagnostic finding for endometriosis involves endometrial tissue **outside the uterus**, not within the myometrium as seen in the biopsy.
*Endometritis*
- Endometritis, especially chronic endometritis, can cause **pelvic pain** and **abnormal bleeding**, but it is often associated with **fever** and signs of infection, which are absent in this case.
- Biopsy would show **inflammatory infiltrates** (e.g., plasma cells) in the endometrium, not endometrial glands within the myometrium.
Question 92: A 24-year-old woman comes to her primary care physician because she has not had a menstrual period for 6 months. She is a competitive runner and has been training heavily for the past year in preparation for upcoming races. She has no family or personal history of serious illness. She has not been sexually active for the past 9 months. Her temperature is 36.9°C (98.4° F), pulse is 51/min, respirations are 12/min, and blood pressure is 106/67 mm Hg. Her BMI is 18.1 kg/m2. Which of the following is the most likely cause of her amenorrhea?
A. Decreased frequency of GnRH release from the hypothalamus (Correct Answer)
B. Poor synthetic response of ovarian cells to circulating LH and FSH
C. Increased prolactin secretion
D. Intrauterine adhesions
E. Increased LH release and increased ovarian androgen production
Explanation: ***Decreased frequency of GnRH release from the hypothalamus***
- This patient's profile (competitive runner, regular intense training, low **BMI** of 18.1 kg/m2, amenorrhea, and mild bradycardia) is classic for **hypothalamic amenorrhea**.
- **Intense physical activity** and **low body fat** can disrupt the pulsatile release of **gonadotropin-releasing hormone (GnRH)** from the hypothalamus, leading to reduced LH and FSH secretion and subsequent ovarian dysfunction.
*Poor synthetic response of ovarian cells to circulating LH and FSH*
- This scenario would suggest **primary ovarian insufficiency** or **premature ovarian failure**, which is less likely in a young, otherwise healthy athlete with no family history.
- While LH and FSH levels might be low in this patient due to hypothalamic suppression, the *ovaries themselves* are typically capable of responding if stimulated appropriately.
*Increased prolactin secretion*
- **Hyperprolactinemia** causes amenorrhea, but it would typically present with **galactorrhea** and is not directly linked to strenuous exercise or low BMI in this manner.
- While prolactin can suppress GnRH, the primary etiology in this athletic patient is more directly related to energy balance.
*Intrauterine adhesions*
- **Intrauterine adhesions (Asherman's syndrome)** typically occur after uterine trauma, such as D&C procedures, infection, or surgery.
- This patient has no history to suggest such an event, and her amenorrhea is more consistent with a hormonal imbalance.
*Increased LH release and increased ovarian androgen production*
- This describes **polycystic ovary syndrome (PCOS)**, which is characterized by obesity, hirsutism, and insulin resistance, none of which are present in this patient.
- In PCOS, there is often an increased LH:FSH ratio, leading to increased ovarian androgen production, which is the opposite of what would be expected with hypothalamic amenorrhea.
Question 93: A 23-year-old woman comes to the physician because of a 3-month history of pain during intercourse and vaginal dryness. The patient has also had intermittent hot flashes and fatigue during this time. Over the past year, her periods have become irregular. Her last menstrual period was over six months ago. She is sexually active with one partner and does not use protection or contraception. She has a history of acute lymphoblastic leukemia during childhood, which has remained in remission. Pelvic examination shows an atrophic cervix and vagina. A urinary pregnancy test is negative. A progestin challenge test is performed and shows no withdrawal bleeding. Further evaluation of this patient is most likely to show which of the following findings?
A. Increased FSH to LH ratio (Correct Answer)
B. Decreased LH levels
C. Decreased FSH to estrogen ratio
D. Decreased GnRH levels
E. Increased TSH levels
Explanation: ***Increased FSH to LH ratio***
- The patient's symptoms (pain during intercourse, vaginal dryness, hot flashes, fatigue, irregular periods, and prolonged amenorrhea in a 23-year-old) are consistent with **premature ovarian insufficiency** (POI), which is characterized by **elevated FSH** due to failed ovarian negative feedback.
- The history of childhood **acute lymphoblastic leukemia** (ALL) and its treatment, particularly chemotherapy or radiation, is a known risk factor for POI, leading to premature depletion of ovarian follicles.
*Decreased LH levels*
- In premature ovarian insufficiency, the **lack of ovarian estrogen production** removes the negative feedback on the hypothalamus and pituitary, leading to **increased, not decreased, LH and FSH levels**.
- A decreased LH level would typically be seen in **hypothalamic or pituitary insufficiency** (secondary or tertiary amenorrhea), which is less likely given the clinical picture of primary ovarian failure.
*Decreased FSH to estrogen ratio*
- In premature ovarian insufficiency, there is **decreased estrogen production** by the ovaries due to follicular depletion, while **FSH levels are elevated** because the pituitary is trying to stimulate the non-functional ovaries.
- This would result in an **increased, not decreased, FSH to estrogen ratio**, reflecting the underlying ovarian failure.
*Decreased GnRH levels*
- **Decreased GnRH levels** would indicate a central cause of amenorrhea (hypothalamic dysfunction), leading to low LH and FSH levels.
- In premature ovarian insufficiency, the problem lies within the ovaries, and the hypothalamus attempts to compensate by **increasing GnRH secretion** to stimulate the pituitary.
*Increased TSH levels*
- While **hypothyroidism** can cause irregular periods and fatigue, the other prominent symptoms like hot flashes, vaginal dryness, and dyspareunia are more specific to **estrogen deficiency**, not thyroid dysfunction.
- Although it's important to rule out thyroid issues, the constellation of symptoms strongly points to ovarian failure, not primary hypothyroidism.
Question 94: A 44-year-old woman with high blood pressure and diabetes presents to the outpatient clinic and informs you that she is trying to get pregnant. Her current medications include lisinopril, metformin, and sitagliptin. Her blood pressure is 136/92 mm Hg and heart rate is 79/min. Her physical examination is unremarkable. What should you do regarding her medication for high blood pressure?
A. Discontinue lisinopril and initiate aliskiren
B. Discontinue lisinopril and initiate labetalol (Correct Answer)
C. Continue her current regimen
D. Continue her current regimen and add a beta-blocker for increased control
E. Discontinue lisinopril and initiate candesartan
Explanation: ***Discontinue lisinopril and initiate labetalol***
- **Lisinopril**, an ACE inhibitor, is **teratogenic** and is contraindicated in pregnancy due to the risk of fetal renal dysfunction, oligohydramnios, and neonatal death.
- **Labetalol** is a **beta-blocker** commonly used in pregnancy for hypertension as it is considered safe and effective in this population.
*Discontinue lisinopril and initiate aliskiren*
- **Aliskiren**, a direct renin inhibitor, is also **teratogenic** and contraindicated in pregnancy due to similar risks as ACE inhibitors and ARBs.
- Replacing one teratogenic drug with another does not solve the primary concern of fetal safety.
*Continue her current regimen*
- **Continuing lisinopril** would expose the fetus to significant risks, as it is a known teratogen.
- The patient is actively trying to conceive, making it imperative to switch medications immediately.
*Continue her current regimen and add a beta-blocker for increased control*
- Adding a beta-blocker while continuing lisinopril is still inappropriate because **lisinopril itself is harmful during pregnancy**.
- The primary goal is to **discontinue teratogenic medications**, not simply to improve blood pressure control with an additional drug.
*Discontinue lisinopril and initiate candesartan*
- **Candesartan**, an **angiotensin receptor blocker (ARB)**, shares the same **teratogenic risks** as ACE inhibitors and is contraindicated in pregnancy.
- Replacing an ACE inhibitor with an ARB provides no benefit in terms of fetal safety.
Question 95: A 30-year-old G1P0 woman at 26 weeks gestation presents to the obstetric emergency room for an evaluation after being involved in a motor vehicle accident. She was in the passenger seat of her car when the car was hit on the side by a drunk driver. She is currently in no acute distress but is worried about her pregnancy. The patient attended all her prenatal visits and took all her appropriate prenatal vitamins. Her past medical history is notable for diabetes mellitus, for which she takes metformin. Her temperature is 98.6°F (37°C), blood pressure is 135/75 mmHg, pulse is 109/min, and respirations are 22/min. A non-stress test is non-responsive, and a biophysical profile demonstrates abnormal fetal breathing, fetal activity, and fetal muscle tone. An amniotic fluid sample is taken which demonstrates a lecithin/sphingomyelin ratio of 1.9. Which of the following is the next best step in the management of this patient?
A. Contraction stress test
B. Repeat biophysical profile
C. Emergent cesarean section
D. Immediate induction of labor
E. Betamethasone administration (Correct Answer)
Explanation: ***Betamethasone administration***
- The assessment indicates **fetal lung immaturity** (L:S ratio 1.9, abnormal BPP components), requiring **corticosteroid administration** to accelerate lung development.
- Given the patient's **gestational age** (26 weeks) and the concerning fetal status post-trauma, preparing for potential preterm delivery by optimizing fetal lung maturity is crucial.
*Contraction stress test*
- A contraction stress test is used to evaluate **fetal heart rate response to uterine contractions**, usually to assess **placental-fetal reserve**.
- While useful in some cases of fetal compromise, it is not the **immediate priority** given the clear evidence of **fetal lung immaturity** and the need for corticosteroids.
*Repeat biophysical profile*
- A repeat biophysical profile would only confirm the already established findings of **fetal compromise** and **lung immaturity**.
- This would delay the **necessary intervention** of administering corticosteroids, which is critical for fetal well-being.
*Emergent cesarean section*
- An emergent cesarean section would lead to a **preterm delivery** at 26 weeks, which carries significant risks of **neonatal morbidity and mortality** due to lung immaturity.
- The immediate priority is to administer **betamethasone** to improve fetal lung maturity before considering delivery, unless there's an immediate, life-threatening maternal or fetal indication.
*Immediate induction of labor*
- Similar to a cesarean section, immediately inducing labor would result in a **preterm birth** at 26 weeks, with an increased risk of complications due to **immature fetal lungs**.
- **Betamethasone administration** is the critical initial step to mitigate respiratory distress syndrome in the event of preterm delivery.
Question 96: A 15-year-old girl is brought in by her parents to her pediatrician with concerns that their daughter still has not had her first menstrual cycle. The parents report that the patient has had no developmental issues in the past. She was born full term by vaginal delivery and has met all other milestones growing up. Based on chart review, the patient demonstrated breast bud development at 10 years of age. The patient is not self conscious of her appearance but is concerned that something may be wrong since she has not yet had her first period. The patient’s temperature is 97.9°F (36.6°C), blood pressure is 116/70 mmHg, pulse is 66/min, and respirations are 12/min. On exam, the patient appears her stated age and is of normal stature. She has Tanner 5 breast development but Tanner 2 pubic hair. On gynecologic exam, external genitalia appears normal, but the vagina ends in a blind pouch. Lab studies demonstrate that the patient has elevated levels of testosterone, estrogen, and luteinizing hormone. Which of the following is the most likely karyotype for this patient?
A. 46, XX
B. 47, XXY
C. 45, XO
D. 46, XY (Correct Answer)
E. 47, XYY
Explanation: ***46, XY***
- This karyotype, coupled with the presentation, is classic for **Androgen Insensitivity Syndrome (AIS)**. Individuals with complete AIS are genetically male (**46, XY**) but have a female external phenotype due to a non-functional androgen receptor.
- The patient's **Tanner 5 breast development** (due to peripheral conversion of testosterone to estrogen) and **blind-ending vagina** are characteristic features of AIS, consistent with the lack of a uterus and fallopian tubes. Elevated testosterone, estrogen, and LH are also typical findings.
*46, XX*
- This karyotype represents a genotypically female individual. Failure of menstruation (primary amenorrhea) in this setting would suggest conditions like **Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome** (vaginal and uterine agenesis in a female karyotype), but this patient's hormonal profile (elevated testosterone) and blind-ending vagina in the presence of breast development without pubic hair are not typical for MRKH.
- In 46, XX individuals with primary amenorrhea, often there are issues with ovarian function, outflow tract obstruction, or hypothalamic-pituitary axis dysfunction, which do not fully align with the described hormonal and physical findings.
*47, XXY*
- This karyotype describes **Klinefelter syndrome**, which affects males. Individuals with Klinefelter syndrome typically present with a male phenotype, often with **hypogonadism, gynecomastia, and infertility**.
- This karyotype would not explain the patient's female external appearance and lack of menstruation; it's a condition affecting males.
*45, XO*
- This karyotype describes **Turner syndrome**, which affects females. Patients with Turner syndrome typically present with **gonadal dysgenesis**, leading to primary amenorrhea and a lack of secondary sexual characteristics (e.g., absent breast development).
- While patients with Turner syndrome can have a blind-ending vagina (if associated with Müllerian agenesis), the presence of **normal stature, Tanner 5 breast development**, and elevated testosterone levels are inconsistent with Turner syndrome.
*47, XYY*
- This karyotype describes **XYY syndrome**, which affects males. Individuals with XYY syndrome are typically phenotypically male and often present with increased height, but generally have normal fertility and sexual development.
- This karyotype would not be associated with a female external phenotype, breast development, or primary amenorrhea.
Question 97: A 38-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the physician because of a 1-day history of dyspnea and left-sided chest pain that is worse when she breathes deeply. One week ago, she returned from a trip to Chile, where she had a 3-day episode of flu-like symptoms that resolved without treatment. Pregnancy and delivery of her first child were uncomplicated. She has no history of serious illness. Her temperature is 37.2°C (99°F), pulse is 118/min, respirations are 28/min and slightly labored, and blood pressure is 110/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. Examination shows jugular venous distention and bilateral pitting edema below the knees that is worse on the left-side. There is decreased breath sounds over the left lung base. The uterus is consistent in size with a 32-week gestation. The remainder of the examination shows no abnormalities. Further evaluation of this patient is most likely to show which of the following findings?
A. Protein dipstick test of 2+ on urinalysis
B. Depression of the PR segment on electrocardiography
C. Decreased fibrinogen levels on serum analysis
D. Decreased myocardial perfusion on a cardiac PET scan
E. Noncompressible femoral vein on ultrasonography (Correct Answer)
Explanation: **Noncompressible femoral vein on ultrasonography**
- The patient's symptoms (dyspnea, pleuritic chest pain, tachypnea, tachycardia, hypoxemia, JVD, and unilateral leg edema) are highly suggestive of **pulmonary embolism (PE)**, especially given her recent travel and pregnancy. A noncompressible femoral vein on ultrasonography indicates a **deep vein thrombosis (DVT)**, which is the most common cause of PE.
- Pregnancy is a **hypercoagulable state**, increasing the risk of venous thromboembolism. The unilateral leg edema further supports the presence of a DVT.
*Protein dipstick test of 2+ on urinalysis*
- While preeclampsia can manifest with dyspnea due to pulmonary edema, her **blood pressure of 110/76 mm Hg is normal**, and she has no other signs of preeclampsia.
- **Proteinuria** would be a key finding in preeclampsia, but it is not directly linked to the acute pleuritic chest pain and hypoxemia seen here.
*Depression of the PR segment on electrocardiography*
- **PR segment depression** can be seen in **pericarditis**, which typically causes sharp, pleuritic chest pain that improves when leaning forward and is associated with a pericardial friction rub.
- The patient's presentation, particularly the unilateral leg edema and hypoxemia, is not typical for pericarditis.
*Decreased fibrinogen levels on serum analysis*
- **Decreased fibrinogen levels** are characteristic of **disseminated intravascular coagulation (DIC)**, which is a severe complication and would present with widespread bleeding or thrombotic events.
- While DIC can occur in pregnancy complications, it does not typically cause isolated acute PE symptoms and would not be the most likely initial finding in this scenario.
*Decreased myocardial perfusion on a cardiac PET scan*
- **Decreased myocardial perfusion** indicates **myocardial ischemia or infarction**, which usually presents with substernal chest pain, often radiating, and characteristic ECG changes.
- Although PE can cause right ventricular strain, the primary pathology is in the pulmonary vasculature, not directly in myocardial perfusion as the leading cause of her acute symptoms.
Question 98: An obese 34-year-old primigravid woman at 20 weeks' gestation comes to the physician for a follow-up examination for a mass she found in her left breast 2 weeks ago. Until pregnancy, menses had occurred at 30- to 40-day intervals since the age of 11 years. Vital signs are within normal limits. Examination shows a 3.0-cm, non-mobile, firm, and nontender mass in the upper outer quadrant of the left breast. There is no palpable axillary lymphadenopathy. Pelvic examination shows a uterus consistent in size with a 20-week gestation. Mammography and core needle biopsy confirm an infiltrating lobular carcinoma. The pathological specimen is positive for estrogen and human epidermal growth factor receptor 2 (HER2) receptors and negative for progesterone receptors. Staging shows no distant metastatic disease. Which of the following is the most appropriate management?
A. Surgical resection and chemotherapy (Correct Answer)
B. Surgical resection
C. Radiotherapy and chemotherapy
D. Radiotherapy only
E. Surgical resection and radiotherapy
Explanation: ***Surgical resection and chemotherapy***
- This patient has **infiltrating lobular carcinoma** with **positive estrogen and HER2 receptors** but **negative progesterone receptors**.
- Given the patient's **pregnancy status** and the tumor's receptor profile, chemotherapy is indicated in addition to surgical resection.
*Surgical resection*
- While surgical resection is a critical component of breast cancer treatment, it is insufficient alone for this patient given the tumor's aggressive features and receptor status, particularly the **HER2 positivity**.
- **HER2-positive cancers** benefit significantly from targeted chemotherapy, which would be missed with surgery alone.
*Radiotherapy and chemotherapy*
- **Radiotherapy** for breast cancer typically involves daily treatments over several weeks and is often **deferred until after delivery** in pregnant patients due to potential fetal risks.
- While chemotherapy is appropriate, initiation of radiotherapy is generally postponed or individualized based on gestational age and specific circumstances.
*Radiotherapy only*
- **Radiotherapy alone** is not an appropriate primary treatment for an invasive breast carcinoma in this context.
- It often follows surgery to reduce local recurrence but does not address the systemic nature of **HER2-positive cancer**.
*Surgical resection and radiotherapy*
- As mentioned, **radiotherapy** is generally avoided or delayed in pregnant patients due to concerns about **fetal exposure**.
- Moreover, this approach omits **chemotherapy**, which is crucial for **HER2-positive breast cancer** to prevent recurrence and improve survival.
Question 99: A 19-year-old nulligravid woman comes to the physician because of irregular heavy menstrual bleeding since menarche at age 16 years. Menses occur at irregular 15- to 45-day intervals and last 7 to 10 days. She has also noted increased hair growth on her face. She has not been sexually active since she started taking isotretinoin for acne vulgaris 4 months ago. Her 70-year-old grandmother has breast cancer. She is 163 cm (5 ft 4 in) tall and weighs 74 kg (163 lb); BMI is 28 kg/m2. Pelvic examination shows copious cervical mucus and slightly enlarged irregular ovaries. If left untreated, this patient is at an increased risk for which of the following complications?
A. Endometrial cancer (Correct Answer)
B. Breast cancer
C. Proximal myopathy
D. Thyroid lymphoma
E. Osteoporosis
Explanation: ***Endometrial cancer***
- This patient exhibits symptoms consistent with **polycystic ovary syndrome (PCOS)**, including irregular heavy menstrual bleeding, hirsutism, and enlarged irregular ovaries. The **anovulation** in PCOS leads to unopposed estrogen exposure, which causes **endometrial hyperplasia** and significantly increases the risk of endometrial cancer.
- Her **obesity (BMI 28 kg/m2)** further contributes to increased estrogen levels through peripheral aromatization of androgens, exacerbating the risk of endometrial hyperplasia and subsequent cancer.
*Breast cancer*
- While a family history of breast cancer exists, there is no direct link between the patient's current symptoms (PCOS, irregular menses) and an increased risk of breast cancer in her immediate future.
- **PCOS itself does not directly increase the risk of breast cancer**, although obesity, a common comorbidity, is a risk factor.
*Proximal myopathy*
- Proximal myopathy is characterized by **muscle weakness** predominantly affecting the hip and shoulder girdles.
- It is not a recognized complication of PCOS or the described symptoms and is more commonly associated with conditions like **thyroid dysfunction** or **Cushing's syndrome**.
*Thyroid lymphoma*
- Thyroid lymphoma is a rare malignancy of the thyroid gland, often associated with long-standing **Hashimoto's thyroiditis**.
- There are no clinical signs or symptoms in this patient's presentation that would suggest an increased risk for thyroid lymphoma.
*Osteoporosis*
- **Osteoporosis** is typically associated with **prolonged estrogen deficiency** or other conditions affecting bone density.
- In PCOS, the anovulation leads to **unopposed estrogen** exposure, which generally has a protective effect on bone density, making osteoporosis less likely.
Question 100: A primigravida, 29-year-old woman presents in her 28th week of pregnancy for evaluation of 3 hours of vaginal bleeding and abdominal pain. She denies any trauma and states that this is the first time she has had such symptoms. Her prenatal care has been optimal and all of her antenatal screenings have been within normal limits. Her vital signs are unremarkable. Physical examination reveals a small amount of blood in the vaginal canal and the cervical os is closed. Ultrasound imaging demonstrates positive fetal cardiac activity. What is the most likely diagnosis?
A. Inevitable abortion
B. Incomplete abortion
C. Complete abortion
D. Threatened abortion (Correct Answer)
E. Missed abortion
Explanation: ***Threatened abortion***
- Vaginal bleeding and abdominal pain in a viable pregnancy before 20 weeks indicate a threatened abortion. The **closed cervical os** and **positive fetal cardiac activity** are key diagnostic criteria, as they suggest the pregnancy is still salvageable.
- The symptoms occurring in the 28th week of pregnancy, although unusual for the classical definition which usually ends at 20 weeks, still fits the description of a threatened abortion due to the closed cervix and viable fetus, indicating that the pregnancy might still continue.
*Inevitable abortion*
- Characterized by **cervical dilation** and often rupture of membranes, in addition to bleeding and pain. In this case, the cervical os is closed, ruling out an inevitable abortion.
- Fetal membranes may be visible or palpable through the dilated cervix and cannot be stopped.
*Incomplete abortion*
- Involves **partial expulsion of pregnancy products** with retained tissue in the uterus, and an **open cervical os**. The closed cervix and positive fetal cardiac activity do not support this diagnosis.
- Patients typically experience heavy bleeding, severe cramping, and a palpable presence of tissue in the cervical canal.
*Complete abortion*
- Refers to the **complete expulsion of all pregnancy products** from the uterus, and the bleeding typically subsides. The presence of ongoing bleeding and fetal cardiac activity indicates this is not a complete abortion.
- The uterus is typically small and well-contracted, and the cervical os is usually closed after all tissue has passed.
*Missed abortion*
- Diagnosed when there is **fetal demise** but the products of conception are retained in the uterus, and there is no expulsion of tissue. This is ruled out by the presence of **positive fetal cardiac activity**.
- Patients may have absent fetal heart tones on ultrasound and often report a cessation of pregnancy symptoms such as morning sickness.
