A 24-year-old woman presents to the emergency department for evaluation of lower abdominal pain. She endorses 6 hours of progressively worsening pain. She denies any significant past medical history and her physical examination is positive for non-specific, diffuse pelvic discomfort. She denies the possibility of pregnancy given her consistent use of condoms with her partner. The vital signs are: blood pressure, 111/68 mm Hg; pulse, 71/min; and respiratory rate, 15/min. She is afebrile. Which of the following is the next best step in her management?
Q52
A 28-year-old woman comes to the physician because she is unable to conceive for 3 years. She and her partner are sexually active and do not use contraception. They were partially assessed for this complaint 6 months ago. Analysis of her husband's semen has shown normal sperm counts and hormonal assays for both partners were normal. Her menses occur at regular 28-day intervals and last 5 to 6 days. Her last menstrual period was 2 weeks ago. She had a single episode of urinary tract infection 4 years ago and was treated with oral antibiotics. Vaginal examination shows no abnormalities. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses. Rectal examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?
Q53
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?
Q54
A 62-year-old woman presents to the clinic for postmenopausal bleeding for the past month. She reports that the bleeding often occurs after intercourse with her husband. The patient denies fever, weight loss, chills, chest pain, abdominal pain, or shortness of breath but endorses mild dyspareunia and vaginal discharge. Her past medical history is significant for human papilloma virus and cervical cancer that was treated with surgical resection and radiation 5 years ago. Physical examination is unremarkable except for an irregular mass protruding from the vaginal wall. What is the most likely explanation for this patient’s condition?
Q55
A 25-year-old woman, gravida 2, para 1, at 25 weeks' gestation comes to the emergency department because of a 1-day history of fever and right-sided flank pain. During this period, she also had chills, nausea, vomiting, and burning on urination. Her last prenatal visit was 10 weeks ago. Pregnancy and delivery of her first child were uncomplicated. Her temperature is 39°C (102.2°F), pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows costovertebral angle tenderness on the right. The abdomen is soft and nontender, and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 25-week gestation. Fetal heart rate is 170/min. Laboratory studies show:
Leukocyte count 15,000/mm3
Urine
Nitrite 2+
Protein 1+
Blood 1+
RBC 5/hpf
WBC 500/hpf
Blood and urine samples are obtained for culture and drug sensitivity. Which of the following is the most appropriate next step in management?
Q56
A 29-year-old woman at 38 weeks gestation comes to the emergency room with regular contractions and spontaneous rupture of membranes. She subsequently delivers a 3500g (7lbs 7oz) newborn with ambiguous genitalia by spontaneous vaginal delivery. Her pregnancy and labor was uncomplicated. Examination of the newborn demonstrated no palpable gonads at the inguinal canal or perineum. Karyotype analysis demonstrated 46,XX. What is the best explanation for this patient’s presentation?
Q57
A 34-year-old G3P2 presents at 33 weeks gestation with several episodes of bloody spotting and mild vaginal bleeding over the past 2 weeks. The bleeding has no specific triggers and resolves spontaneously. She does not report abdominal pain or uterine contractions. She has had two cesarean deliveries. At 20 weeks gestation, the ultrasound examination showed the placental edge to be 5 cm away from the internal cervical os. On examination at this visit, the vital signs are as follows: blood pressure, 110/70 mm Hg; heart rate, 89/min; respiratory rate, 15/min; and temperature, 36.6℃ (97.9℉). The uterus is tender with no palpable contractions and streaks of blood are noted on the perineum, but there is no active bleeding. An ultrasound evaluation shows the placental edge 1 cm from the internal cervical os. Which of the following options best describes the placental position at each ultrasound?
Q58
A 25-year-old woman is brought to the emergency department by her roommate with severe right lower quadrant pain for the last 8 hours. The pain is progressively getting worse and is associated with vomiting. When you ask the patient about her last menstrual period, she tells you that although she stopped keeping track of her cycle after undergoing surgical sterilization 1 year ago, she recalls bleeding yesterday. The physical examination reveals a hemodynamically stable patient with a pulse of 90/min, respiratory rate of 14/min, blood pressure of 125/70 mm Hg, and temperature of 37.0°C (98.6°F). The abdomen is tender to touch (more tender in the lower quadrants), and tenderness at McBurney's point is absent. Which of the following is the best next step in the management of this patient?
Q59
A 32-year-old G1P0 woman at 27 weeks estimated gestational age presents for her first prenatal care appointment. She recently immigrated to the United States and didn’t receive any prenatal care in her country. Her blood pressure is 130/70 mm Hg, pulse is 85/min, and respirations are 16/min. Her BMI is 38.3 kg/m2. Physical examination is unremarkable except for normal pregnancy changes. Fetal ultrasound is performed and reveals fetal macrosomia. Which one of the following diagnostic tests is most likely to reveal the cause of this fetal abnormality?
Q60
A 25-year old woman is brought to the emergency department because of a 1-day history of lower abdominal pain and vaginal bleeding. Her last menstrual period was 6 weeks ago. She is sexually active and uses condoms inconsistently with her boyfriend. She had pelvic inflammatory disease at the age of 22 years. Her temperature is 37.2°C (99°F), pulse is 90/min, respirations are 14/min, and blood pressure is 130/70 mm Hg. The abdomen is soft, and there is tenderness to palpation in the left lower quadrant with guarding but no rebound. There is scant blood in the introitus. Her serum β-human chorionic gonadotropin (hCG) level is 1,600 mIU/mL. Her blood type is O, RhD negative. She is asked to return 4 days later. Her serum β-hCG level is now 1,900 mIU/ml. A pelvic ultrasound shows a normal appearing uterus with an empty intrauterine cavity and a minimal amount of free pelvic fluid. Which of the following is the most appropriate next step in management?
High-risk pregnancies US Medical PG Practice Questions and MCQs
Question 51: A 24-year-old woman presents to the emergency department for evaluation of lower abdominal pain. She endorses 6 hours of progressively worsening pain. She denies any significant past medical history and her physical examination is positive for non-specific, diffuse pelvic discomfort. She denies the possibility of pregnancy given her consistent use of condoms with her partner. The vital signs are: blood pressure, 111/68 mm Hg; pulse, 71/min; and respiratory rate, 15/min. She is afebrile. Which of the following is the next best step in her management?
A. Surgical consultation
B. Admission and observation
C. Obtain a pelvic ultrasound
D. Serum hCG (Correct Answer)
E. Abdominal CT scan
Explanation: ***Serum hCG***
- Despite the patient's claim of consistent condom use, **pregnancy must be ruled out** in any woman of reproductive age presenting with lower abdominal pain. **Ectopic pregnancy** is a life-threatening condition that can present this way.
- A **serum hCG** is more sensitive than a urine test and can detect very early pregnancies, which is crucial for prompt diagnosis and management.
*Surgical consultation*
- Surgical consultation would be premature without a definitive diagnosis or clear signs of an acute surgical abdomen, such as peritonitis or hemodynamic instability.
- Initial diagnostic steps are necessary to identify the cause of the pain before considering surgical intervention.
*Admission and observation*
- While observation might be necessary, it's not the immediate next best step. Without a diagnosis, observation alone may delay critical interventions for conditions like ectopic pregnancy.
- Admission for observation typically follows initial diagnostic workup when the diagnosis is uncertain but not immediately life-threatening.
*Obtain a pelvic ultrasound*
- A pelvic ultrasound is an important diagnostic tool for evaluating pelvic pain, but it should be performed only **after pregnancy has been ruled out** or confirmed.
- If the patient is pregnant, a pelvic ultrasound would be used to assess for intrauterine or ectopic pregnancy. If she is not pregnant, the ultrasound would help identify other gynecological causes of pain.
*Abdominal CT scan*
- An abdominal CT scan is less specific for gynecological causes of pain and exposes the patient to **ionizing radiation**, making it a less ideal initial step compared to ruling out pregnancy.
- It might be considered if the initial workup for gynecological causes is negative or if there are concerns for other intra-abdominal pathology.
Question 52: A 28-year-old woman comes to the physician because she is unable to conceive for 3 years. She and her partner are sexually active and do not use contraception. They were partially assessed for this complaint 6 months ago. Analysis of her husband's semen has shown normal sperm counts and hormonal assays for both partners were normal. Her menses occur at regular 28-day intervals and last 5 to 6 days. Her last menstrual period was 2 weeks ago. She had a single episode of urinary tract infection 4 years ago and was treated with oral antibiotics. Vaginal examination shows no abnormalities. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses. Rectal examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?
A. Postcoital testing
B. Hysteroscopy
C. Psychological counseling only
D. Hysterosalpingogram (Correct Answer)
E. Chromosomal karyotyping
Explanation: ***Hysterosalpingogram***
- A **hysterosalpingogram (HSG)** is the most appropriate next step to assess **fallopian tube patency** and uterine cavity abnormalities, which are common causes of infertility after male and ovulatory factors have been ruled out.
- The patient's history (3 years of infertility, normal male factors, regular menses suggesting ovulation) points to a need to investigate potential **tubal obstruction** or **uterine structural issues**.
*Postcoital testing*
- **Postcoital testing** evaluates sperm-mucus interaction and cervical factor infertility.
- While previously a common initial test, its **predictive value is low** and it is no longer routinely recommended as a primary diagnostic step in infertility workups.
*Hysteroscopy*
- **Hysteroscopy** is an invasive procedure that directly visualizes the uterine cavity.
- While it can identify **intrauterine pathologies** (e.g., polyps, fibroids, adhesions), it is generally performed *after* an HSG has suggested an abnormality or when initial workup points strongly to a uterine factor.
*Psychological counseling only*
- While infertility is a significant emotional stressor, **psychological counseling alone** is not a diagnostic step and does not address the underlying medical cause of infertility.
- Counseling can be offered as a supportive measure in conjunction with medical diagnostics and treatment.
*Chromosomal karyotyping*
- **Chromosomal karyotyping** is indicated in cases of **recurrent pregnancy loss**, severe male factor infertility (e.g., azoospermia), or suspected genetic syndromes.
- The patient's history does not suggest these indications, and her regular menses imply normal ovarian function, making genetic causes less likely as an initial diagnostic step.
Question 53: 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 54: A 62-year-old woman presents to the clinic for postmenopausal bleeding for the past month. She reports that the bleeding often occurs after intercourse with her husband. The patient denies fever, weight loss, chills, chest pain, abdominal pain, or shortness of breath but endorses mild dyspareunia and vaginal discharge. Her past medical history is significant for human papilloma virus and cervical cancer that was treated with surgical resection and radiation 5 years ago. Physical examination is unremarkable except for an irregular mass protruding from the vaginal wall. What is the most likely explanation for this patient’s condition?
A. Metastasis of cervical cancer via direct extension (Correct Answer)
B. Primary malignancy of endometrial cells
C. Atrophy of vaginal tissues secondary to old age
D. Metastasis of cervical cancer via hematogenous spread
E. Primary malignancy of vaginal squamous cells
Explanation: ***Metastasis of cervical cancer via direct extension***
- The patient has a history of **cervical cancer** and now presents with an **irregular mass protruding from the vaginal wall**, along with postmenopausal bleeding and dyspareunia. This clinical picture is highly suggestive of **local recurrence or direct extension** of the cervical cancer to the vagina.
- Cervical cancer commonly spreads to adjacent structures like the vagina, which would explain the symptoms of **postmenopausal bleeding, dyspareunia, and an irregular mass** in the vaginal wall.
*Primary malignancy of endometrial cells*
- While postmenopausal bleeding is a classic symptom of **endometrial cancer**, the presence of an **irregular mass protruding from the vaginal wall** makes this diagnosis less likely as the primary cause.
- Endometrial cancer usually causes bleeding directly from the uterus and typically presents with a uterine mass or thickening, not a visible vaginal mass unless it has already broadly metastasized.
*Atrophy of vaginal tissues secondary to old age*
- **Vaginal atrophy** can cause postmenopausal bleeding and dyspareunia, but it typically presents as **thin, pale, and dry vaginal tissues**, not an **irregular mass**.
- The presence of a palpable mass strongly points away from atrophy as the sole explanation.
*Metastasis of cervical cancer via hematogenous spread*
- While cervical cancer can metastasize hematogenously, **hematogenous spread** typically leads to distant metastases in organs like the lungs, liver, or bones, not usually to a localized, protruding vaginal mass.
- The presentation of a mass directly in the vagina points more towards **local extension** rather than distant hematogenous spread to a new primary site.
*Primary malignancy of vaginal squamous cells*
- Primary vaginal cancer is a possibility given the symptoms and a history of HPV, but the patient's prior diagnosis and treatment for **cervical cancer** 5 years ago make **recurrent or metastatic cervical cancer** a more likely explanation for a vaginal mass presenting in this manner.
- It is reasonable to assume a connection between the previous cervical cancer and the current vaginal lesion given the proximity and timing, suggesting recurrence or metastasis rather than a de novo primary vaginal cancer.
Question 55: A 25-year-old woman, gravida 2, para 1, at 25 weeks' gestation comes to the emergency department because of a 1-day history of fever and right-sided flank pain. During this period, she also had chills, nausea, vomiting, and burning on urination. Her last prenatal visit was 10 weeks ago. Pregnancy and delivery of her first child were uncomplicated. Her temperature is 39°C (102.2°F), pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows costovertebral angle tenderness on the right. The abdomen is soft and nontender, and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 25-week gestation. Fetal heart rate is 170/min. Laboratory studies show:
Leukocyte count 15,000/mm3
Urine
Nitrite 2+
Protein 1+
Blood 1+
RBC 5/hpf
WBC 500/hpf
Blood and urine samples are obtained for culture and drug sensitivity. Which of the following is the most appropriate next step in management?
A. Inpatient treatment with intravenous ceftriaxone (Correct Answer)
B. Perform a renal ultrasound
C. Outpatient treatment with oral ciprofloxacin
D. Inpatient treatment with intravenous ampicillin and gentamicin
E. Admit the patient and request an emergent obstetrical consult
Explanation: ***Inpatient treatment with intravenous ceftriaxone***
- The patient presents with classic signs of **pyelonephritis** (fever, flank pain, nausea, vomiting, CVA tenderness) in pregnancy, which warrants **inpatient admission** and **IV antibiotics** to prevent complications such as sepsis, preterm labor, and fetal compromise.
- **Ceftriaxone** is a broad-spectrum cephalosporin that is safe and effective in pregnancy for treating urinary tract infections, including pyelonephritis.
*Perform a renal ultrasound*
- While a **renal ultrasound** may be considered in cases of persistent fever after 48-72 hours of antibiotic therapy or if there's suspicion of obstruction or abscess, it is **not the immediate next step**.
- The priority is to initiate antibiotics promptly to treat the acute infection and prevent further complications.
*Outpatient treatment with oral ciprofloxacin*
- **Outpatient treatment** is inappropriate for **pyelonephritis in pregnancy** due to the high risk of complications for both the mother and the fetus.
- **Ciprofloxacin** (a fluoroquinolone) is generally **contraindicated in pregnancy** because of potential adverse effects on fetal cartilage development.
*Inpatient treatment with intravenous ampicillin and gentamicin*
- Although **ampicillin and gentamicin** are effective for many UTIs and safe in pregnancy, they are often reserved for cases where local resistance patterns favor this combination or as a second-line option.
- **Ceftriaxone** is a preferred first-line empiric choice for pyelonephritis in pregnancy due to its broad coverage and once-daily dosing.
*Admit the patient and request an emergent obstetrical consult*
- While admitting the patient is correct, **immediately requesting an emergent obstetrical consult** is premature as the primary issue is an acute infection requiring medical management.
- Obstetrics consultation is important in managing high-risk pregnancies or complications like preterm labor, but antibiotics for pyelonephritis should be initiated first, and then an obstetrician can be consulted for comanagement.
Question 56: A 29-year-old woman at 38 weeks gestation comes to the emergency room with regular contractions and spontaneous rupture of membranes. She subsequently delivers a 3500g (7lbs 7oz) newborn with ambiguous genitalia by spontaneous vaginal delivery. Her pregnancy and labor was uncomplicated. Examination of the newborn demonstrated no palpable gonads at the inguinal canal or perineum. Karyotype analysis demonstrated 46,XX. What is the best explanation for this patient’s presentation?
A. Ovarian dysgenesis
B. Deficiency of 5-alpha-reductase
C. Exposure to excessive androgenic steroids during gestation (Correct Answer)
D. Defective androgen receptors
E. Defective migration of gonadotropin-releasing hormone (GnRH) releasing neurons
Explanation: ***Exposure to excessive androgenic steroids during gestation***
- A 46,XX karyotype with ambiguous genitalia suggests **masculinization of a female fetus**, which occurs due to excessive androgen exposure during gestation. This often leads to clitoromegaly and labioscrotal fusion without palpable gonads.
- The most common cause is **untreated congenital adrenal hyperplasia (CAH)** in the infant, specifically **21-hydroxylase deficiency**, where cortisol synthesis is impaired, leading to an overproduction of androgens.
*Ovarian dysgenesis*
- This condition is characterized by **abnormal development of the ovaries**, which would typically lead to **female external genitalia** that might be underdeveloped but not masculinized.
- Ovarian dysgenesis is generally associated with **gonadal failure** and usually presents with primary amenorrhea and lack of secondary sexual characteristics later in life, not ambiguous genitalia at birth in a 46,XX individual.
*Deficiency of 5-alpha-reductase*
- This condition affects **46,XY individuals**, impairing the conversion of testosterone to the more potent **dihydrotestosterone (DHT)**, which is crucial for external male genital development.
- It would result in **under-masculinized male genitalia**, such as hypospadias and micropenis, but would not explain ambiguous genitalia in a 46,XX individual.
*Defective androgen receptors*
- This is characteristic of **androgen insensitivity syndrome (AIS)**, which affects **46,XY individuals**.
- Despite normal or elevated testosterone levels, the body cannot respond to androgens, leading to **female external genitalia** (complete AIS) or ambiguous genitalia (partial AIS), but in a genetic male, not a 46,XX female.
*Defective migration of gonadotropin-releasing hormone (GnRH) releasing neurons*
- This condition, known as **Kallmann syndrome**, primarily affects **pubertal development** due to hypogonadotropic hypogonadism and is often associated with anosmia (inability to smell).
- It does not cause **ambiguous genitalia at birth** and is usually diagnosed in adolescence due to delayed puberty.
Question 57: A 34-year-old G3P2 presents at 33 weeks gestation with several episodes of bloody spotting and mild vaginal bleeding over the past 2 weeks. The bleeding has no specific triggers and resolves spontaneously. She does not report abdominal pain or uterine contractions. She has had two cesarean deliveries. At 20 weeks gestation, the ultrasound examination showed the placental edge to be 5 cm away from the internal cervical os. On examination at this visit, the vital signs are as follows: blood pressure, 110/70 mm Hg; heart rate, 89/min; respiratory rate, 15/min; and temperature, 36.6℃ (97.9℉). The uterus is tender with no palpable contractions and streaks of blood are noted on the perineum, but there is no active bleeding. An ultrasound evaluation shows the placental edge 1 cm from the internal cervical os. Which of the following options best describes the placental position at each ultrasound?
A. Low-lying placenta → partial previa
B. Normally placed placenta → low-lying placenta
C. Normally lying placenta → marginal previa (Correct Answer)
D. Marginal previa → partial previa
E. Low-lying placenta → marginal previa
Explanation: ***Normally lying placenta → marginal previa***
- At 20 weeks, the placental edge was 5 cm from the internal cervical os, categorizing it as a **normally placed placenta** (greater than 2 cm from the os).
- At 33 weeks, the placental edge is 1 cm from the internal cervical os, which is consistent with a **marginal previa** (within 2 cm of the os but not covering it).
*Low-lying placenta → partial previa*
- A **low-lying placenta** is defined as one whose edge is within 2 cm of the internal cervical os but not covering it. At 20 weeks, the placenta was 5 cm away, so it was not low-lying.
- A **partial previa** implies the placenta partially covers the internal os, which is not indicated by the 1 cm distance from the os at 33 weeks.
*Normally placed placenta → low-lying placenta*
- The initial ultrasound at 20 weeks showed the placenta 5 cm away, which is indeed a **normally placed placenta**.
- However, at 33 weeks, the placental edge 1 cm from the os is more specifically defined as a **marginal previa**, not just a low-lying placenta.
*Marginal previa → partial previa*
- A **marginal previa** is defined as the placental edge being within 2 cm of the internal os but not covering it. At 20 weeks, the placenta was 5 cm away, so it was not a marginal previa.
- A **partial previa** means the placenta partially covers the os, which is not consistent with an edge 1 cm away.
*Low-lying placenta → marginal previa*
- The placenta was 5 cm away from the os at 20 weeks, which is a **normally placed placenta**, not a low-lying placenta.
- The 1 cm distance at 33 weeks is consistent with a **marginal previa**.
Question 58: A 25-year-old woman is brought to the emergency department by her roommate with severe right lower quadrant pain for the last 8 hours. The pain is progressively getting worse and is associated with vomiting. When you ask the patient about her last menstrual period, she tells you that although she stopped keeping track of her cycle after undergoing surgical sterilization 1 year ago, she recalls bleeding yesterday. The physical examination reveals a hemodynamically stable patient with a pulse of 90/min, respiratory rate of 14/min, blood pressure of 125/70 mm Hg, and temperature of 37.0°C (98.6°F). The abdomen is tender to touch (more tender in the lower quadrants), and tenderness at McBurney's point is absent. Which of the following is the best next step in the management of this patient?
A. Complete blood count
B. Urinalysis
C. FAST ultrasound scan
D. Appendectomy
E. Urinary human chorionic gonadotropin (hCG) (Correct Answer)
Explanation: ***Urinary human chorionic gonadotropin (hCG)***
- Despite surgical sterilization, a **low risk of ectopic pregnancy** still exists, especially with symptoms like **severe right lower quadrant pain** and **vomiting**.
- A positive urinary hCG would necessitate further evaluation for an **ectopic pregnancy**, which is a **life-threatening condition**.
*Complete blood count*
- While a CBC assesses for **leukocytosis** (suggesting infection/inflammation) or **anemia** (suggesting blood loss), it's not the immediate priority given the potential for ectopic pregnancy symptoms.
- A CBC alone would not rule out the most critical diagnosis in this scenario.
*Urinalysis*
- A urinalysis helps rule out **urinary tract infection (UTI)** or **nephrolithiasis** (kidney stones).
- While important for differential diagnosis, the severity of pain and reproductive history make ectopic pregnancy a more immediate concern.
*FAST ultrasound scan*
- An ultrasound is useful for identifying **free fluid** in the abdomen or assessing the **uterus and adnexa** for an ectopic pregnancy.
- However, in a female of reproductive age, a **positive hCG** is generally a prerequisite for a targeted pelvic ultrasound to confirm or exclude an early ectopic pregnancy.
*Appendectomy*
- While **appendicitis** is in the differential for right lower quadrant pain, the absence of **McBurney's point tenderness** and the patient's reproductive history make other diagnoses more likely first.
- Surgery should only be considered after a thorough diagnostic workup, especially to rule out time-sensitive conditions like ectopic pregnancy.
Question 59: A 32-year-old G1P0 woman at 27 weeks estimated gestational age presents for her first prenatal care appointment. She recently immigrated to the United States and didn’t receive any prenatal care in her country. Her blood pressure is 130/70 mm Hg, pulse is 85/min, and respirations are 16/min. Her BMI is 38.3 kg/m2. Physical examination is unremarkable except for normal pregnancy changes. Fetal ultrasound is performed and reveals fetal macrosomia. Which one of the following diagnostic tests is most likely to reveal the cause of this fetal abnormality?
A. Leptin
B. C-peptide
C. Oral glucose tolerance test (Correct Answer)
D. Glycated hemoglobin
E. Serum insulin
Explanation: ***Oral glucose tolerance test***
- The patient has several risk factors for **gestational diabetes mellitus (GDM)**, including **obesity (BMI 38.3)**, **late presentation to prenatal care**, and **fetal macrosomia**.
- An **oral glucose tolerance test (OGTT)** is the gold standard for diagnosing GDM, which is the most likely cause of fetal macrosomia in this context.
*Leptin*
- **Leptin** is a hormone involved in appetite and energy balance, and while it can be elevated in obesity, it is **not a primary diagnostic test for GDM** or fetal macrosomia.
- While leptin resistance is implicated in obesity and insulin resistance, directly measuring leptin levels is **not used for diagnosing diabetes** in pregnancy.
*C-peptide*
- **C-peptide** levels reflect endogenous insulin production, but measuring it directly is **not the initial diagnostic test for GDM**.
- While it can be used to assess residual beta-cell function in known diabetes, it's not the primary diagnostic tool for a new presentation with macrosomia.
*Glycated hemoglobin*
- **Glycated hemoglobin (HbA1c)** measures average blood glucose levels over the past 2-3 months and is used to diagnose **pre-existing diabetes** or monitor long-term glucose control.
- It is **not the preferred diagnostic test for GDM** due to its lower sensitivity during pregnancy and limitations in reflecting rapidly changing glucose levels.
*Serum insulin*
- Direct measurement of **serum insulin** is not used as a primary diagnostic test for GDM because insulin levels fluctuate significantly and **do not directly reflect glucose intolerance** as well as an OGTT.
- While insulin resistance is central to GDM, direct insulin levels are not part of the standard diagnostic criteria for GDM.
Question 60: A 25-year old woman is brought to the emergency department because of a 1-day history of lower abdominal pain and vaginal bleeding. Her last menstrual period was 6 weeks ago. She is sexually active and uses condoms inconsistently with her boyfriend. She had pelvic inflammatory disease at the age of 22 years. Her temperature is 37.2°C (99°F), pulse is 90/min, respirations are 14/min, and blood pressure is 130/70 mm Hg. The abdomen is soft, and there is tenderness to palpation in the left lower quadrant with guarding but no rebound. There is scant blood in the introitus. Her serum β-human chorionic gonadotropin (hCG) level is 1,600 mIU/mL. Her blood type is O, RhD negative. She is asked to return 4 days later. Her serum β-hCG level is now 1,900 mIU/ml. A pelvic ultrasound shows a normal appearing uterus with an empty intrauterine cavity and a minimal amount of free pelvic fluid. Which of the following is the most appropriate next step in management?
A. Administration of misoprostol
B. Administration of intramuscular methotrexate
C. Administration of anti-D immunoglobulin and intramuscular methotrexate (Correct Answer)
D. Repeat serum β-hCG and pelvic ultrasound in 2 days
E. Administration of anti-D immunoglobulin and oral misoprostol
Explanation: ***Administration of anti-D immunoglobulin and intramuscular methotrexate***
- The diagnosis is highly suggestive of an **ectopic pregnancy** due to increasing β-hCG levels (though not doubling) with an empty uterus, and the patient has **Rh-negative blood** type.
- **Intramuscular methotrexate** is indicated for stable ectopic pregnancies with β-hCG levels below 5,000 mIU/mL, and **anti-D immunoglobulin** is crucial to prevent Rh sensitization in Rh-negative women.
*Administration of misoprostol*
- **Misoprostol** is primarily used for medical abortion of intrauterine pregnancies or managing miscarriage, not for ectopic pregnancies.
- It would be ineffective in resolving an ectopic pregnancy and does not address the need for Rh prophylaxis.
*Administration of intramuscular methotrexate*
- While **intramuscular methotrexate** is appropriate for treating the ectopic pregnancy, it omits the critical step of administering **anti-D immunoglobulin**.
- Failure to administer anti-D immunoglobulin in an Rh-negative woman with an ectopic pregnancy can lead to **Rh sensitization**, posing risks for future pregnancies.
*Repeat serum β-hCG and pelvic ultrasound in 2 days*
- The current β-hCG trend (1600 to 1900 mIU/mL in 4 days) and empty uterus already strongly indicate an ectopic pregnancy or pregnancy of unknown location with a poor prognosis.
- Delaying treatment for another 2 days for repeat tests would postpone necessary intervention and potentially increase the risk of complications from a ruptured ectopic pregnancy.
*Administration of anti-D immunoglobulin and oral misoprostol*
- **Oral misoprostol** is not an appropriate treatment for an ectopic pregnancy; it is used for intrauterine gestations or miscarriage management.
- While **anti-D immunoglobulin** is correctly included due to her Rh-negative status, the choice of misoprostol makes this option incorrect for managing an ectopic pregnancy.
