A 21-year-old Caucasian woman presents to her gynecologist's office with a chief complaint of irregular periods. In the past 2 years, she has often gone > 3 months without menstruating. Menarche was at 13 years old, and prior to the past 2 years, she had regular periods every 28 days lasting 5 days with normal flow and no pain. She denies other symptoms of headache, vision changes, excessive fatigue or sweating, feelings of a racing heart, or hair loss. Since starting college, she has been bothered by weight gain and acne that she attributes to her habit of late night pizza and french fries. On exam she is well appearing with severe acne, and her temperature is 98.6°F (37°C), blood pressure is 120/80 mmHg, pulse is 60/min, and BMI is 30 kg/m^2. Lab work confirms the most likely diagnosis and includes a Hemoglobin A1c of 5.4. If she is not interested in child bearing at this time, what is the best initial medication to treat this disease?
Q172
A 25-year-old primigravid woman at 34-weeks' gestation comes to the physician because of an 8-day history of generalized pruritus. She has no history of rash. She has had standard prenatal care. Three weeks ago she was diagnosed with iron deficiency anemia. She traveled to Mexico for a vacation 3 months ago. She takes her multivitamin supplements inconsistently. Her blood pressure is 110/80 mm Hg. Examination shows pallor and mild scleral icterus. The uterus is soft, nontender, and consistent in size with a 34-week gestation. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 11 g/dL
Leukocyte count 8,000/mm3
Platelet 250,000/mm3
Prothrombin time 11 seconds
Serum
Total bilirubin 4 mg/dL
Direct bilirubin 3.2 mg/dL
Bile acid 15 μmol/L (N = 0.3–10)
AST 45 U/L
ALT 50 U/L
A peripheral blood smear is normal. There are no abnormalities on abdominopelvic ultrasonography. Which of the following is the most likely diagnosis?
Q173
An investigator is studying the relationship between fetal blood oxygen saturation and intrauterine growth restriction using MRI studies. The magnetic resonance transverse relaxation time (T2) is inversely related to the concentration of deoxyhemoglobin so that high concentrations of deoxyhemoglobin produce a low signal intensity on T2-weighted MRI. In a normal fetus, the T2 signal is most likely to be the highest in which of the following vessels?
Q174
A 36-year-old primigravid woman who recently immigrated to the United States presents to her gynecologist for the first time during the 28th week of her pregnancy. She hasn’t received any prenatal care or folic acid supplementation. The patient’s history reveals that she has received blood transfusions in the past due to “severe anemia.” Which of the following blood type situations would put the fetus at risk for hemolytic disease of the newborn?
Q175
A 29-year-old G2P1 woman presents at 24 weeks gestation with complaints of blurred vision and headaches. Her symptoms have increased in frequency over the past several weeks. Her medical history is significant only for occasional tension headaches. She takes no medications besides an oral folic acid supplement. The vital signs are: blood pressure, 159/90 mm Hg; pulse, 89/min; and respiratory rate, 18/min. She is afebrile. She states that her husband, a nurse, took her blood pressure 2 days earlier and found it to be 154/96 mm Hg at the time. Previously, her blood pressures have always been < 120/80 mm Hg. What is the next best step to solidify the diagnosis?
Q176
A 66-year-old woman presents to the primary care physician with complaints of involuntary loss of urine. This has been occurring over the past month for no apparent reason while suddenly feeling the need to urinate. History reveals triggers that stimulate the desire to pass urine, such as running water, handwashing, and cold weather. There is no family history of similar symptoms in her mother or any of her 8 children. Her blood pressure is 130/80 mm Hg, heart rate is 72/min, respiratory rate is 22/min, and temperature is 36.6°C (98.0°F). Physical examination is unremarkable. Urinalysis reveals the following:
Color Yellow
Clarity/turbidity Clear
pH 5.5
Specific gravity 1.015
Nitrites Negative
Leukocyte esterase Negative
Which of the following is the best next step in the management of this patient?
Q177
A 37-year-old G1P0 at 15 weeks gestation presents for an amniocentesis after a routine triple screen demonstrated a mildly elevated serum AFP. A chromosomal analysis revealed the absence of a second sex chromosome. Which of the following features will the infant most likely have?
Q178
A 35-year-old man attends an appointment with a fertility specialist together with his wife. The couple has been attempting to conceive for over 2 years but without success. She has recently undergone a comprehensive gynecological exam and all the results were normal. He states that he has no prior medical history to report. He says that he does have a low libido compared to other men of his age. On physical examination, he is observed to be of a lean build with a height of 6ft 3 inches with slight evidence of gynecomastia. His testes are small and underdeveloped. His lab tests show an elevation of LH and FSH, along with azoospermia. Which of the following is the most likely cause of this man’s infertility?
Q179
A 29-year-old primigravid woman at 24 weeks' gestation comes to the physician for a prenatal visit. She feels well. She has no personal history of serious illness. Medications include iron supplements and a multivitamin. Her temperature is 37.2°C (99°F) and blood pressure is 108/60 mm Hg. Pelvic examination shows a uterus consistent in size with a 24-week gestation. A 1-hour 50-g glucose challenge shows a glucose concentration of 155 mg/dL (N < 135 mg/dL). A 100-g oral glucose tolerance test shows glucose concentrations of 205 mg/dL (N < 180 mg/dL) and 154 mg/dL (N <140 mg/dL) at 1 and 3 hours, respectively. She refuses treatment with insulin. Which of the following complications is her infant at greatest risk of developing at birth?
Q180
A 34-year-old woman presents to her OB/GYN with complaints of missing her last 3 periods as well as intermittent spontaneous milky-white nipple discharge bilaterally for the past 3 months. Vital signs are stable and within normal limits. Neurologic examination is without abnormality, including normal visual fields. Serology and MRI of the brain are ordered, with results pending. Which of the following sets of laboratory results would be expected in this patient?
High-risk pregnancies US Medical PG Practice Questions and MCQs
Question 171: A 21-year-old Caucasian woman presents to her gynecologist's office with a chief complaint of irregular periods. In the past 2 years, she has often gone > 3 months without menstruating. Menarche was at 13 years old, and prior to the past 2 years, she had regular periods every 28 days lasting 5 days with normal flow and no pain. She denies other symptoms of headache, vision changes, excessive fatigue or sweating, feelings of a racing heart, or hair loss. Since starting college, she has been bothered by weight gain and acne that she attributes to her habit of late night pizza and french fries. On exam she is well appearing with severe acne, and her temperature is 98.6°F (37°C), blood pressure is 120/80 mmHg, pulse is 60/min, and BMI is 30 kg/m^2. Lab work confirms the most likely diagnosis and includes a Hemoglobin A1c of 5.4. If she is not interested in child bearing at this time, what is the best initial medication to treat this disease?
A. Leuprolide
B. Ethinyl estradiol - norgestimate (Correct Answer)
C. Simvastatin
D. Metformin
E. Spironolactone
Explanation: **Ethinyl estradiol - norgestimate**
- This patient's presentation with **oligomenorrhea**, **hirsutism** (acne and likely weight gain are surrogates), and lab findings (though not explicitly stated, the context suggests **PCOS**) points towards Polycystic Ovary Syndrome.
- **Combined oral contraceptives (COCs)** like ethinyl estradiol-norgestimate are the first-line treatment for managing PCOS symptoms in women not seeking fertility, as they regulate menstrual cycles, reduce androgen levels, and improve acne.
*Leuprolide*
- **Leuprolide** is a **GnRH agonist** that initially stimulates and then suppresses gonadotropin release, primarily used for conditions like endometriosis or uterine fibroids, and **central precocious puberty**.
- It would induce a menopausal state and is not indicated for the initial management of PCOS symptoms, especially in a young woman.
*Simvastatin*
- **Simvastatin** is an **HMG-CoA reductase inhibitor** used to lower cholesterol levels.
- While women with PCOS may have dyslipidemia, statins are not the primary treatment for the endocrine or menstrual irregularities of PCOS.
*Metformin*
- **Metformin** is an **insulin-sensitizing agent** used to treat type 2 diabetes and can be helpful in PCOS, particularly for improving insulin resistance and possibly aiding in weight loss and cycle regulation.
- However, for immediate symptom control of irregular periods and hyperandrogenism in a patient not seeking pregnancy, **COCs are generally preferred as initial therapy**.
*Spironolactone*
- **Spironolactone** is an **aldosterone antagonist** with anti-androgenic effects, often used to treat hirsutism and acne in PCOS.
- While it addresses the hyperandrogenic symptoms, it does not regulate menstrual cycles as effectively as COCs and is **often used as an add-on or second-line agent**, not the best initial monotherapy for the overall PCOS picture.
Question 172: A 25-year-old primigravid woman at 34-weeks' gestation comes to the physician because of an 8-day history of generalized pruritus. She has no history of rash. She has had standard prenatal care. Three weeks ago she was diagnosed with iron deficiency anemia. She traveled to Mexico for a vacation 3 months ago. She takes her multivitamin supplements inconsistently. Her blood pressure is 110/80 mm Hg. Examination shows pallor and mild scleral icterus. The uterus is soft, nontender, and consistent in size with a 34-week gestation. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 11 g/dL
Leukocyte count 8,000/mm3
Platelet 250,000/mm3
Prothrombin time 11 seconds
Serum
Total bilirubin 4 mg/dL
Direct bilirubin 3.2 mg/dL
Bile acid 15 μmol/L (N = 0.3–10)
AST 45 U/L
ALT 50 U/L
A peripheral blood smear is normal. There are no abnormalities on abdominopelvic ultrasonography. Which of the following is the most likely diagnosis?
A. Gilbert syndrome
B. Cholestasis of pregnancy (Correct Answer)
C. HELLP syndrome
D. Viral hepatitis A
E. Acute fatty liver of pregnancy
Explanation: **Cholestasis of pregnancy**
* The patient presents with **generalized pruritus without rash** in the third trimester, elevated **bile acids** (15 μmol/L, normal <10), and elevated **direct bilirubin** with mildly elevated transaminases, which are classic signs of intrahepatic cholestasis of pregnancy.
* This condition is characterized by impaired bile flow, leading to accumulation of bile acids in the liver and bloodstream, causing symptoms like itchiness and potential risks to the fetus.
*Gilbert syndrome*
* Characterized by **unconjugated hyperbilirubinemia** due to reduced UDP-glucuronosyltransferase activity, typically exacerbated by stress or fasting.
* It does not cause generalized pruritus, elevated bile acids, or significant elevations in direct bilirubin or liver enzymes as seen in this patient.
*HELLP syndrome*
* Defined by **Hemolysis**, **Elevated Liver enzymes**, and **Low Platelets**, none of which are observed in this patient (normal hemoglobin, platelet count, and mildly elevated liver enzymes that are not indicative of severe HELLP).
* Patients typically present with symptoms like right upper quadrant pain, headache, and visual disturbances, often associated with severe preeclampsia, which are absent here.
*Viral hepatitis A*
* Would typically present with more significant elevations in **AST and ALT** (often >500 U/L), along with fatigue, nausea, and dark urine, which are not described.
* While travel history is present, the specific symptom profile and lab values (especially the disproportionate elevation of bile acids and pruritus without severe inflammation) are less consistent with acute viral hepatitis.
*Acute fatty liver of pregnancy*
* A severe condition with more pronounced symptoms such as **nausea, vomiting, abdominal pain, jaundice, hypoglycemia**, and often **renal dysfunction** and **coagulopathy**.
* The patient's relatively mild symptoms, stable blood pressure, and absence of severe liver enzyme elevation, hypoglycemia, or renal impairment make this diagnosis less likely.
Question 173: An investigator is studying the relationship between fetal blood oxygen saturation and intrauterine growth restriction using MRI studies. The magnetic resonance transverse relaxation time (T2) is inversely related to the concentration of deoxyhemoglobin so that high concentrations of deoxyhemoglobin produce a low signal intensity on T2-weighted MRI. In a normal fetus, the T2 signal is most likely to be the highest in which of the following vessels?
A. Descending aorta
B. Superior vena cava
C. Ductus venosus (Correct Answer)
D. Pulmonary veins
E. Right atrium
Explanation: ***Ductus venosus***
- The **ductus venosus** shunts highly oxygenated blood directly from the **umbilical vein** to the inferior vena cava, bypassing the liver.
- This vessel carries the most oxygen-rich blood in the fetal circulation (lowest deoxyhemoglobin concentration), resulting in the **highest T2 signal intensity**.
*Descending aorta*
- The descending aorta receives a mixture of oxygenated blood from the left ventricle and deoxygenated blood from the **pulmonary artery** via the **ductus arteriosus**.
- This mixing reduces its overall oxygen saturation compared to the umbilical vein and ductus venosus.
*Superior vena cava*
- The superior vena cava carries **deoxygenated blood** from the upper body and head back to the right atrium.
- This vessel has a low oxygen saturation and high deoxyhemoglobin concentration, leading to a **low T2 signal**.
*Pulmonary veins*
- In a normal fetal circulation, the **lungs are not fully functional**, and pulmonary blood flow is relatively low.
- The pulmonary veins carry only a small amount of moderately oxygenated blood returning from the developing lungs, which is significantly less oxygenated than blood in the ductus venosus.
*Right atrium*
- The right atrium receives **mixed blood** from both the superior and inferior vena cava.
- While it receives some oxygenated blood from the inferior vena cava via the ductus venosus, this is diluted by deoxygenated blood, resulting in lower oxygen saturation than the blood within the ductus venosus itself.
Question 174: A 36-year-old primigravid woman who recently immigrated to the United States presents to her gynecologist for the first time during the 28th week of her pregnancy. She hasn’t received any prenatal care or folic acid supplementation. The patient’s history reveals that she has received blood transfusions in the past due to “severe anemia.” Which of the following blood type situations would put the fetus at risk for hemolytic disease of the newborn?
A. Mother is AB negative, father is O negative
B. Mother is O positive, father is B negative
C. Mother is O positive, father is AB negative
D. Mother is B positive, father is O negative
E. Mother is A negative, father is B positive (Correct Answer)
Explanation: ***Mother is A negative, father is B positive***
- This scenario presents a risk for **Rh incompatibility** because the mother is Rh-negative and the father is Rh-positive, meaning the fetus could inherit the Rh-positive antigen.
- The mother's history of blood transfusions for "severe anemia" could also indicate prior exposure to Rh-positive blood, which would have sensitized her system and led to the production of anti-Rh antibodies, putting the fetus at higher risk for **hemolytic disease of the newborn (HDN)** during a subsequent pregnancy.
*Mother is AB negative, father is O negative*
- In this case, both parents are **Rh-negative**, so there is no risk of Rh incompatibility.
- While ABO incompatibility can occur, it is generally **less severe** than Rh incompatibility and usually does not cause severe hemolytic disease requiring transfusions.
*Mother is O positive, father is B negative*
- The mother is **Rh-positive**, which means there is no risk of Rh incompatibility with an Rh-negative father.
- Although there is a potential for **ABO incompatibility**, this is typically less concerning for severe HDN compared to Rh incompatibility, and the Rh factor is the primary concern here.
*Mother is O positive, father is AB negative*
- The mother is **Rh-positive**, so Rh incompatibility is not a risk.
- While there is a potential for **ABO incompatibility** (mother is O, father has A and B antigens), this form of HDN is generally milder and rarely requires clinical intervention.
*Mother is B positive, father is O negative*
- The mother is **Rh-positive**, eliminating the risk of Rh incompatibility.
- Potential for **ABO incompatibility** exists, but the more severe forms of HDN are typically associated with Rh incompatibility.
Question 175: A 29-year-old G2P1 woman presents at 24 weeks gestation with complaints of blurred vision and headaches. Her symptoms have increased in frequency over the past several weeks. Her medical history is significant only for occasional tension headaches. She takes no medications besides an oral folic acid supplement. The vital signs are: blood pressure, 159/90 mm Hg; pulse, 89/min; and respiratory rate, 18/min. She is afebrile. She states that her husband, a nurse, took her blood pressure 2 days earlier and found it to be 154/96 mm Hg at the time. Previously, her blood pressures have always been < 120/80 mm Hg. What is the next best step to solidify the diagnosis?
A. 24-hour urine collection (Correct Answer)
B. Serum CBC and electrolytes
C. Electrocardiogram
D. Non-contrast enhanced head CT
E. Fetal ultrasound
Explanation: ***24-hour urine collection***
- The patient presents with **new-onset hypertension** (BP >140/90 mmHg on two occasions) and symptoms like **blurred vision** and **headaches**, highly suggestive of **preeclampsia**.
- A **24-hour urine collection** for protein is the gold standard to confirm the presence and quantify the severity of **proteinuria**, a diagnostic criterion for preeclampsia.
*Serum CBC and electrolytes*
- While a **CBC** and **renal function tests** (which include electrolytes) are part of the initial workup for preeclampsia to assess for complications like **HELLP syndrome** or renal impairment, they do not directly confirm the diagnosis of preeclampsia itself.
- These tests are typically ordered *after* proteinuria is evaluated or confirmed, or if there are signs of severe features.
*Electrocardiogram*
- An **ECG** is not indicated in the initial workup for suspected preeclampsia, as it does not provide diagnostic information for this condition.
- It would only be considered if there were specific cardiac concerns, which are not described here.
*Non-contrast enhanced head CT*
- A **head CT** is reserved for evaluating severe neurological symptoms such as **seizures**, focal neurological deficits, or severe, persistent headaches unresponsive to analgesia, to rule out complications like **hemorrhage** or **cerebral edema** in severe preeclampsia or eclampsia.
- The patient's blurred vision and headaches, while concerning, do not immediately warrant a CT before confirming preeclampsia.
*Fetal ultrasound*
- A **fetal ultrasound** is important for assessing fetal well-being, growth, and amniotic fluid volume in pregnancies complicated by preeclampsia to evaluate for **fetal growth restriction** or **oligohydramnios**.
- However, it does not confirm the maternal diagnosis of preeclampsia itself; it assesses the *impact* of the disease on the fetus.
Question 176: A 66-year-old woman presents to the primary care physician with complaints of involuntary loss of urine. This has been occurring over the past month for no apparent reason while suddenly feeling the need to urinate. History reveals triggers that stimulate the desire to pass urine, such as running water, handwashing, and cold weather. There is no family history of similar symptoms in her mother or any of her 8 children. Her blood pressure is 130/80 mm Hg, heart rate is 72/min, respiratory rate is 22/min, and temperature is 36.6°C (98.0°F). Physical examination is unremarkable. Urinalysis reveals the following:
Color Yellow
Clarity/turbidity Clear
pH 5.5
Specific gravity 1.015
Nitrites Negative
Leukocyte esterase Negative
Which of the following is the best next step in the management of this patient?
A. Surgery
B. Bladder training (Correct Answer)
C. Administer antimuscarinics
D. Administer antibiotics
E. Posterior tibial nerve stimulation
Explanation: ***Bladder training***
- The patient's symptoms are highly suggestive of **urge incontinence**, characterized by involuntary urine loss preceded by a sudden, strong desire to void. Triggers like running water and cold are classic.
- **Bladder training** is a first-line behavioral therapy for urge incontinence, involving scheduled voiding, delaying voiding, and urge suppression techniques.
*Surgery*
- **Surgery** is typically reserved for cases that fail conservative management, particularly for conditions like stress incontinence (e.g., sling procedures) or severe pelvic organ prolapse.
- It is not the initial recommended approach for uncomplicated urge incontinence given that behavioral therapies are less invasive and effective.
*Administer antimuscarinics*
- **Antimuscarinics** (e.g., oxybutynin, tolterodine) are pharmacological treatments that can help relax the bladder detrusor muscle, effective for urge incontinence.
- While a valid option, **behavioral therapies** like bladder training are generally recommended as first-line before initiating drug therapy due to potential side effects of medications (e.g., dry mouth, constipation).
*Administer antibiotics*
- The **urinalysis is negative** for signs of infection (negative nitrites and leukocyte esterase), ruling out a urinary tract infection (UTI).
- Administering **antibiotics** would be inappropriate as there is no evidence of bacterial infection, which is a common cause of new-onset urgency but not present here.
*Posterior tibial nerve stimulation*
- **Posterior tibial nerve stimulation (PTNS)** is a minimally invasive neuromodulation technique used for overactive bladder or urge incontinence that has failed other conservative treatments.
- It is considered a **second-line or third-line therapy** after behavioral and pharmacological interventions have been tried and failed.
Question 177: A 37-year-old G1P0 at 15 weeks gestation presents for an amniocentesis after a routine triple screen demonstrated a mildly elevated serum AFP. A chromosomal analysis revealed the absence of a second sex chromosome. Which of the following features will the infant most likely have?
A. Micrognathia
B. Streak ovaries (Correct Answer)
C. Cystic kidneys
D. Macroglossia
E. Intellectual disability
Explanation: **Streak ovaries**
- The absence of a second sex chromosome (45, X karyotype) is characteristic of **Turner syndrome**. This condition is marked by the complete or partial absence of an X chromosome in females.
- A hallmark feature of Turner syndrome is **gonadal dysgenesis**, where the ovaries fail to develop normally and are replaced by non-functional fibrous tissue, often referred to as "streak ovaries." This leads to primary amenorrhea and infertility.
*Micrognathia*
- **Micrognathia**, or an undersized jaw, is a feature more commonly associated with conditions like **Pierre Robin sequence** or other chromosomal abnormalities such as **Trisomy 18 (Edwards syndrome)**.
- While some facial anomalies can be present in Turner syndrome, micrognathia specifically is not a classic or prominent finding.
*Cystic kidneys*
- **Cystic kidneys** are seen in various genetic disorders, including **autosomal dominant polycystic kidney disease (ADPKD)** and **autosomal recessive polycystic kidney disease (ARPKD)**.
- Though renal anomalies (e.g., horseshoe kidney, absent kidney) can occur in Turner syndrome, cystic kidneys are not a typical feature.
*Macroglossia*
- **Macroglossia**, or an abnormally large tongue, is a characteristic feature of conditions like **Down syndrome (Trisomy 21)** and **Beckwith-Wiedemann syndrome**.
- It is not associated with Turner syndrome.
*Intellectual disability*
- While individuals with Turner syndrome may experience certain **cognitive challenges**, such as difficulties with nonverbal learning (e.g., spatial reasoning, mathematics), **frank intellectual disability is uncommon**.
- The cognitive profile in Turner syndrome is generally within the normal range, distinguishing it from conditions like Down syndrome where intellectual disability is a defining feature.
Question 178: A 35-year-old man attends an appointment with a fertility specialist together with his wife. The couple has been attempting to conceive for over 2 years but without success. She has recently undergone a comprehensive gynecological exam and all the results were normal. He states that he has no prior medical history to report. He says that he does have a low libido compared to other men of his age. On physical examination, he is observed to be of a lean build with a height of 6ft 3 inches with slight evidence of gynecomastia. His testes are small and underdeveloped. His lab tests show an elevation of LH and FSH, along with azoospermia. Which of the following is the most likely cause of this man’s infertility?
A. Absent GnRH production
B. Presence of Barr body (Correct Answer)
C. Primary ciliary dyskinesia
D. Absence of chloride channel
E. Androgen insensitivity
Explanation: ***Presence of Barr body***
- The constellation of **tall stature**, **gynecomastia**, **small, underdeveloped testes**, **azoospermia**, **elevated LH and FSH**, and infertility is highly characteristic of **Klinefelter syndrome (47, XXY)**.
- Individuals with Klinefelter syndrome possess an extra X chromosome, leading to the formation of a **Barr body** (inactivated X chromosome) in somatic cells, which is a key diagnostic feature.
*Absent GnRH production*
- **Absent GnRH production** (e.g., in **Kallmann syndrome**) would lead to **hypogonadotropic hypogonadism**, characterized by **low LH and FSH levels**, which contradicts the elevated levels seen in this patient.
- Although it causes infertility and low libido, the hormonal profile is inconsistent with the patient's presentation.
*Primary ciliary dyskinesia*
- **Primary ciliary dyskinesia (PCD)**, also known as **Kartagener syndrome**, is associated with **immotile sperm** (asthenozoospermia) and recurrent respiratory infections due to ciliary dysfunction.
- While it causes infertility, it does not explain the patient's specific physical features like **gynecomastia** or **elevated gonadotropins** and typically presents with a different clinical picture apart from infertility.
*Absence of chloride channel*
- The **absence of chloride channels**, specifically the **CFTR protein**, is characteristic of **Cystic Fibrosis**.
- This condition can cause male infertility due to **congenital bilateral absence of the vas deferens (CBAVD)**, leading to **obstructive azoospermia**, but it does not account for the patient's **gynecomastia**, **tall stature**, or **elevated LH and FSH**.
*Androgen insensitivity*
- **Androgen insensitivity syndrome (AIS)** results from a defect in androgen receptors, leading to varying degrees of feminization in genotypically male individuals (XY).
- While it can present with infertility and gynecomastia, individuals often have **normal to elevated testosterone levels** and may have **female external genitalia** or **undescended testes**, which does not align with the patient's described phenotype of small, underdeveloped testes and male appearance.
Question 179: A 29-year-old primigravid woman at 24 weeks' gestation comes to the physician for a prenatal visit. She feels well. She has no personal history of serious illness. Medications include iron supplements and a multivitamin. Her temperature is 37.2°C (99°F) and blood pressure is 108/60 mm Hg. Pelvic examination shows a uterus consistent in size with a 24-week gestation. A 1-hour 50-g glucose challenge shows a glucose concentration of 155 mg/dL (N < 135 mg/dL). A 100-g oral glucose tolerance test shows glucose concentrations of 205 mg/dL (N < 180 mg/dL) and 154 mg/dL (N <140 mg/dL) at 1 and 3 hours, respectively. She refuses treatment with insulin. Which of the following complications is her infant at greatest risk of developing at birth?
A. Respiratory distress syndrome
B. Hyperbilirubinemia (Correct Answer)
C. Birth trauma/shoulder dystocia
D. Macrosomia
E. Neonatal hypoglycemia
Explanation: ***Hyperbilirubinemia***
- Uncontrolled maternal diabetes leads to **fetal hyperglycemia**, causing fetal hyperinsulinemia.
- **Fetal hyperinsulinemia** contributes to accelerated breakdown of fetal red blood cells, leading to increased bilirubin production and, consequently, **neonatal hyperbilirubinemia**.
*Respiratory distress syndrome*
- While fetal hyperinsulinemia can delay fetal lung maturation and increase the risk of respiratory distress syndrome, it is typically due to **inhibition of surfactant production**.
- However, in term infants of diabetic mothers, the primary risk is often related to other metabolic complications like hypoglycemia or hyperbilirubinemia, and RDS is more characteristic of prematurity or poorly controlled diabetes overall, not the most direct or immediate risk over hyperbilirubinemia here.
*Birth trauma/shoulder dystocia*
- This complication is related to **macrosomia**, where the large size of the infant increases the risk during delivery.
- While severe macrosomia can increase the risk of birth trauma, fetal hyperinsulinemia also directly causes effects that raise the risk of hyperbilirubinemia.
*Macrosomia*
- Fetal hyperglycemia in uncontrolled diabetes leads to an increase in **fetal insulin production**, which acts as a growth factor, leading to excessive fetal growth or **macrosomia**.
- While macrosomia is a significant complication, the question asks for the greatest risk at birth, and macrosomia itself is a condition, while hyperbilirubinemia is a direct consequence that typically manifests shortly after birth.
*Neonatal hypoglycemia*
- After birth, the sudden cessation of maternal glucose supply, coupled with continued **fetal hyperinsulinemia**, can lead to a rapid drop in the neonate's blood glucose levels.
- Although neonatal hypoglycemia is a significant risk, the question asks for the greatest risk at birth, and hyperbilirubinemia is also a prominent and often more prolonged metabolic issue.
Question 180: A 34-year-old woman presents to her OB/GYN with complaints of missing her last 3 periods as well as intermittent spontaneous milky-white nipple discharge bilaterally for the past 3 months. Vital signs are stable and within normal limits. Neurologic examination is without abnormality, including normal visual fields. Serology and MRI of the brain are ordered, with results pending. Which of the following sets of laboratory results would be expected in this patient?
A. Decreased prolactin, decreased FSH, decreased LH
B. Increased prolactin, decreased FSH, decreased LH (Correct Answer)
C. Increased prolactin, decreased FSH, increased LH
D. Increased prolactin, increased FSH, increased LH
E. Decreased prolactin, increased FSH, increased LH
Explanation: ***Increased prolactin, decreased FSH, decreased LH***
- The patient's symptoms of **amenorrhea** and **galactorrhea** strongly suggest **hyperprolactinemia**.
- High prolactin levels suppress **gonadotropin-releasing hormone (GnRH)**, leading to decreased release of **FSH** and **LH** from the pituitary, which in turn causes menstrual irregularities.
*Decreased prolactin, decreased FSH, decreased LH*
- This profile would be consistent with central **hypogonadism**, but the presence of **galactorrhea** indicates an elevated prolactin level, making this option incorrect.
- A decrease in prolactin would not explain the milky-white nipple discharge.
*Increased prolactin, decreased FSH, increased LH*
- While increased prolactin is correct for the symptoms, a consistently **decreased FSH** with an **increased LH** is more characteristic of **polycystic ovary syndrome (PCOS)**, which does not typically present with galactorrhea in this manner.
- The elevated prolactin would usually suppress both FSH and LH.
*Increased prolactin, increased FSH, increased LH*
- This combination is inconsistent with the patient's presentation, as **hyperprolactinemia** typically **suppresses FSH and LH** due to its inhibitory effect on GnRH.
- Elevated gonadotropins (FSH and LH) with elevated prolactin would be a very unusual and specific endocrine disturbance not indicated here.
*Decreased prolactin, increased FSH, increased LH*
- Decreased prolactin does not explain **galactorrhea**, and increased FSH and LH would suggest **primary ovarian failure** (menopause), which is inconsistent with galactorrhea and would not typically occur in a 34-year-old woman with these symptoms.
- Ovarian failure would prevent menstruation, but not cause galactorrhea.
