A 33-year-old nulliparous woman comes to the physician because of a 5-month history of increased flow and duration of her menses. Menses previously occurred at regular 32-day intervals and lasted 4 days with normal flow. They now last 10 days and the flow is heavy with the passage of clots. During this period, she has also had dyspareunia and cyclical lower abdominal pain. Her mother died of cervical cancer at the age of 58 years. Her BMI is 31 kg/m2. Her temperature is 37°C (98.6°F), pulse is 86/min, and blood pressure is 110/70 mm Hg. Pelvic examination shows an asymmetrically enlarged, nodular uterus consistent in size with a 12-week gestation. A urine pregnancy test is negative. Which of the following is the most likely cause of this patient's findings?
Q82
A 38-year-old primigravid woman at 34 weeks' gestation comes to the emergency department because of progressive shortness of breath for 3 hours. At a prenatal visit 2 weeks earlier, she was diagnosed with gestational hypertension. Amniocentesis with chromosomal analysis was performed at 16 weeks' gestation and showed no abnormalities. The patient has been otherwise healthy, except for a deep venous thrombosis 2 years ago that was treated with low molecular weight heparin. Her current medications include methyldopa and a multivitamin. She appears anxious. Her pulse is 90/min, respirations are 24/min, and blood pressure is 170/100 mm Hg. Crackles are heard over both lung bases. Pelvic examination shows a uterus consistent in size with a 32-week gestation. Examination of the heart, abdomen, and extremities shows no abnormalities. Which of the following is the most likely cause of this patient's shortness of breath?
Q83
A 30-year-old woman comes to the primary care physician because she has felt nauseous and fatigued for 3 weeks. Menses occur at irregular 24- to 33-day intervals and last for 4–6 days. Her last menstrual period was 7 weeks ago. Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 100/70 mm Hg. Pelvic examination shows an enlarged uterus. Her serum β-hCG concentration is 96,000 mIU/mL (N < 5). An abdominal ultrasound is shown. Which of the following is the most likely diagnosis?
Q84
A 22-year-old woman presents to the gynecologist for evaluation of amenorrhea and dyspareunia. The patient states that she recently got married and has been worried about getting pregnant. The patient states that she has never had a period and that sex has always been painful. On examination, the patient is Tanner stage 5 with no obvious developmental abnormalities. The vaginal exam is limited with no identified vaginal canal. What is the most likely cause of this patient’s symptoms?
Q85
A 57-year-old female presents to general gynecology clinic for evaluation of a pelvic mass. The mass was detected on a routine visit to her primary care doctor during abdominal palpation. In the office, she receives a transvaginal ultrasound, which reveals a mass measuring 11 cm in diameter. In the evaluation of this mass, elevation of which tumor marker would be suggestive of an ovarian cancer?
Q86
A 54-year-old woman comes to the physician because she has not had her menstrual period for the last 5 months. Menarche occurred at the age of 11 years, and menses occurred at regular 28-day intervals until they became irregular at 30- to 45-day intervals with light flow 2 years ago. She does not have vaginal dryness or decreased libido. She had four successful pregnancies and breastfed all her children until the age of 2 years. There is no personal or family history of serious illness. Except when she was pregnant, she has smoked one pack of cigarettes daily for 30 years. She does not drink alcohol. She is 167 cm (5 ft 5 in) tall and weighs 92 kg (203 lb); BMI is 33 kg/m2. Her vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following best explains this patient's lack of symptoms other than amenorrhea?
Q87
A 20-year-old woman is brought to the emergency department 6 hours after the onset of colicky lower abdominal pain that has been progressively worsening. The pain is associated with nausea and vomiting. She has stable inflammatory bowel disease treated with 5-aminosalicylic acid. She is sexually active with her boyfriend and they use condoms inconsistently. She was diagnosed with chlamydia one year ago. Her temperature is 38.1°C (100.6°F), pulse is 94/min, respirations are 22/min, and blood pressure is 120/80 mm Hg. Examination shows right lower quadrant guarding and rebound tenderness. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?
Q88
A 36-year-old G4P1021 woman comes to the emergency room complaining of intense abdominal pain and vaginal bleeding. She is 9 weeks into her pregnancy and is very concerned as she experienced similar symptoms during her past pregnancy losses. Her pain is described as “stabbing, 10/10 pain that comes and goes.” When asked about her vaginal bleeding, she reports that “there were some clots initially, similar to my second day of menstruation.” She endorses joint pains that is worse in the morning, “allergic” rashes at her arms, and fatigue. She denies weight loss, chills, fever, nausea/vomiting, diarrhea, or constipation. Physical examination reveals an enlarged and irregularly shaped uterus with a partially open external os and a flesh-colored bulge. Her laboratory findings are shown below:
Serum:
Hemoglobin: 11.8 g/dL
Hematocrit: 35%
Leukocyte count:7,600 /mm^3 with normal differential
Platelet count: 200,000/mm^3
Bleeding time: 4 minutes (Normal: 2-7 minutes)
Prothrombin time: 13 seconds (Normal: 11-15 seconds)
Partial thromboplastin time (activated): 30 seconds (Normal: 25-40 seconds)
What is the most likely cause of this patient’s symptoms?
Q89
A 43-year-old woman presents to her physician’s office complaining of fatigue and light headedness for one month. She has regular periods but notes that they have become heavier in the last year. She endorses increased urination and feels that she has gained weight in her abdomen, but review of systems is otherwise negative. She is a daycare teacher and has a first cousin with von Willebrand disease. Temperature is 98.4°F (36.9°C), pulse is 92/min, blood pressure is 109/72 mmHg, and respirations are 14/min.
A CBC demonstrates:
Hemoglobin: 9.9 g/dL
Leukocyte count: 6,300/mm^3
Platelet count: 180,000/mm^3
Which of the following is the best next step to evaluate the etiology of this patient’s findings?
Q90
A 23-year-old G1P0 primigravid woman at 28 weeks estimated gestational age presents for a prenatal checkup. She says she has been having occasional headaches but is otherwise fine. The patient says she feels regular fetal movements and mild abdominal pain at times. Her past medical history is unremarkable. Current medications are a prenatal multivitamin and the occasional acetaminophen. Her blood pressure is 148/110 mm Hg today. On her last visit at 24 weeks of gestation, her blood pressure was 146/96 mm Hg. On physical exam, the fundus measures 28 cm above the pubic symphysis. Laboratory findings are significant for the following:
Serum Glucose (fasting) 88 mg/dL
Sodium 142 mEq/L
Potassium 3.9 mEq/L
Chloride 101 mEq/L
Serum Creatinine 0.9 mg/dL
Blood Urea Nitrogen 10 mg/dL
Alanine aminotransferase (ALT) 18 U/L
Aspartate aminotransferase (AST) 16 U/L
Mean Corpuscular Volume (MCV) 85 fL
Leukocyte count 4,200/mm3
Reticulocyte count 1%
Erythrocyte count 5.1 million/mm3
Platelet count 95,000mm3
Urinalysis show:
Proteins 2+
Glucose negative
Ketones negative
Leucocytes negative
Nitrites negative
Red Blood Cells (RBCs) negative
Casts negative
Which of the following medications would be the next best step in the treatment of this patient?
High-risk pregnancies US Medical PG Practice Questions and MCQs
Question 81: A 33-year-old nulliparous woman comes to the physician because of a 5-month history of increased flow and duration of her menses. Menses previously occurred at regular 32-day intervals and lasted 4 days with normal flow. They now last 10 days and the flow is heavy with the passage of clots. During this period, she has also had dyspareunia and cyclical lower abdominal pain. Her mother died of cervical cancer at the age of 58 years. Her BMI is 31 kg/m2. Her temperature is 37°C (98.6°F), pulse is 86/min, and blood pressure is 110/70 mm Hg. Pelvic examination shows an asymmetrically enlarged, nodular uterus consistent in size with a 12-week gestation. A urine pregnancy test is negative. Which of the following is the most likely cause of this patient's findings?
A. Benign tumor of the myometrium (Correct Answer)
B. Abnormal thickening of endometrial tissue
C. Malignant transformation of endometrial tissue
D. Endometrial tissue within the ovaries
E. Pedunculated endometrial mass
Explanation: ***Benign tumor of the myometrium***
- This presentation is highly suggestive of **uterine fibroids** (leiomyomas), which are **benign tumors of the myometrium**. They commonly cause **menorrhagia** (heavy and prolonged menstrual bleeding), **dyspareunia**, **cyclical lower abdominal pain**, and an **asymmetrically enlarged, nodular uterus**.
- The patient's age and nulliparity are consistent with increased risk for fibroids, and her BMI also presents an indirect risk due to potential **estrogen excess**.
*Abnormal thickening of endometrial tissue*
- This description typically refers to **endometrial hyperplasia**, which can cause heavy bleeding but usually presents with a **symmetrically enlarged uterus** or an endometrial stripe thickening on ultrasound.
- It does not typically cause the **nodular uterine enlargement** or **dyspareunia** described.
*Malignant transformation of endometrial tissue*
- **Endometrial carcinoma** is less likely in a 33-year-old nulliparous woman, although obesity is a risk factor.
- While it can cause abnormal uterine bleeding, it presents with a higher likelihood of **postmenopausal bleeding** or a symmetrically enlarged uterus, and less commonly with the distinct **nodular asymmetry** seen in fibroids.
*Endometrial tissue within the ovaries*
- This describes an **endometrioma** (a type of endometriosis), which is a cyst of endometrial tissue in the ovary.
- While endometriomas can cause **dyspareunia** and pelvic pain, they do not typically cause an **asymmetrically enlarged, nodular uterus** or **menorrhagia** as the primary symptom.
*Pedunculated endometrial mass*
- This typically refers to an **endometrial polyp**, which can cause heavy or irregular bleeding.
- However, polyps are less likely to cause a diffusely **enlarged, nodular uterus**, or significant **dyspareunia** unless very large and prolapsed.
Question 82: A 38-year-old primigravid woman at 34 weeks' gestation comes to the emergency department because of progressive shortness of breath for 3 hours. At a prenatal visit 2 weeks earlier, she was diagnosed with gestational hypertension. Amniocentesis with chromosomal analysis was performed at 16 weeks' gestation and showed no abnormalities. The patient has been otherwise healthy, except for a deep venous thrombosis 2 years ago that was treated with low molecular weight heparin. Her current medications include methyldopa and a multivitamin. She appears anxious. Her pulse is 90/min, respirations are 24/min, and blood pressure is 170/100 mm Hg. Crackles are heard over both lung bases. Pelvic examination shows a uterus consistent in size with a 32-week gestation. Examination of the heart, abdomen, and extremities shows no abnormalities. Which of the following is the most likely cause of this patient's shortness of breath?
A. Pulmonary edema (Correct Answer)
B. Pulmonary metastases
C. Idiopathic pulmonary fibrosis
D. Pulmonary thromboembolism
E. Amniotic fluid embolism
Explanation: ***Pulmonary edema***
- The patient presents with **gestational hypertension** and new-onset **shortness of breath** with **bilateral basal crackles**, a classic presentation for pulmonary edema, often precipitated by conditions like preeclampsia in pregnancy.
- Her elevated blood pressure (170/100 mm Hg) and rapid respiratory rate (24/min) further support increased **pulmonary hydrostatic pressure**, leading to fluid extravasation into the lung alveoli.
*Pulmonary metastases*
- This is unlikely given her young age, lack of a prior cancer diagnosis, and acute onset of symptoms.
- **Pulmonary metastases** typically present with a more gradual onset of symptoms and are less commonly associated with bilateral basal crackles in isolation.
*Idiopathic pulmonary fibrosis*
- **Idiopathic pulmonary fibrosis** is a chronic, progressive interstitial lung disease, typically affecting older individuals, and has a much slower, gradual onset of symptoms.
- The acute presentation of severe shortness of breath in a young, previously healthy pregnant woman does not fit the typical course of this disease.
*Pulmonary thromboembolism*
- While the patient has a history of **DVT** and is pregnant (a hypercoagulable state), the primary presentation with **bilateral crackles** and **hypertension** makes pulmonary edema more likely.
- A pulmonary embolism might cause sudden shortness of breath and an elevated pulse, but significant bilateral crackles are less typical unless there's associated right heart failure leading to pulmonary congestion.
*Amniotic fluid embolism*
- **Amniotic fluid embolism** is a rare but catastrophic event, typically presenting with sudden, severe respiratory distress, hemodynamic collapse, and coagulopathy, often occurring during labor or soon after delivery.
- This patient is not in labor, does not show signs of hemodynamic collapse or coagulopathy, and the onset is progressive over several hours rather than sudden.
Question 83: A 30-year-old woman comes to the primary care physician because she has felt nauseous and fatigued for 3 weeks. Menses occur at irregular 24- to 33-day intervals and last for 4–6 days. Her last menstrual period was 7 weeks ago. Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 100/70 mm Hg. Pelvic examination shows an enlarged uterus. Her serum β-hCG concentration is 96,000 mIU/mL (N < 5). An abdominal ultrasound is shown. Which of the following is the most likely diagnosis?
A. Partial hydatidiform mole
B. Bicornuate uterus pregnancy
C. Abdominal pregnancy
D. Complete hydatid mole (Correct Answer)
E. Dichorionic-diamniotic twins
Explanation: ***Complete hydatid mole***
- The ultrasound image shows a **\"snowstorm\" appearance** with multiple anechoic cysts, typical of a complete hydatidiform mole, consistent with **grape-like vesicles**.
- The significantly elevated **β-hCG level (96,000 mIU/mL)** and symptoms like nausea in conjunction with an enlarged uterus and irregular menses, are highly indicative of gestational trophoblastic disease.
*Partial hydatidiform mole*
- A partial mole typically shows evidence of **fetal tissue** or a **fetus** with associated placental changes, which is absent in this image and clinical presentation.
- While β-hCG levels can be elevated, they are often lower than in complete moles and less likely to show the classic **\"snowstorm\" appearance** in the absence of fetal parts.
*Bicornuate uterus pregnancy*
- A bicornuate uterus is a **uterine anomaly** where the uterus has two horns, and pregnancy would typically occur in one of these horns, appearing as a normal or atypical intrauterine pregnancy on ultrasound.
- The ultrasound image does not show a normally developing pregnancy within a horn of a bicornuate uterus, but rather a characteristic vesicular pattern within the uterus.
*Abdominal pregnancy*
- Abdominal pregnancy involves an **ectopic implantation** outside the uterus, in the abdominal cavity, often showing abnormal fetal presentation and placental attachment to abdominal organs.
- The ultrasound clearly shows an **intrauterine mass** with the characteristic vesicular pattern, ruling out an abdominal pregnancy.
*Dichorionic-diamniotic twins*
- This refers to a **twin pregnancy** with two separate placentas and two separate amniotic sacs, which would be visible as two distinct gestational sacs and two fetuses on ultrasound.
- The image shows a **single mass** with a vesicular pattern, not two separate gestational sacs or fetuses, nor two distinct placentas.
Question 84: A 22-year-old woman presents to the gynecologist for evaluation of amenorrhea and dyspareunia. The patient states that she recently got married and has been worried about getting pregnant. The patient states that she has never had a period and that sex has always been painful. On examination, the patient is Tanner stage 5 with no obvious developmental abnormalities. The vaginal exam is limited with no identified vaginal canal. What is the most likely cause of this patient’s symptoms?
A. Exposure to DES in utero
B. Turner syndrome
C. PCOS
D. Hyperprolactinemia
E. Mullerian agenesis (Correct Answer)
Explanation: ***Mullerian agenesis***
- **Mullerian agenesis** (also known as Mayer-Rokitansky-Küster-Hauser syndrome) is characterized by the **absence or hypoplasia of the uterus and the upper two-thirds of the vagina**, leading to **primary amenorrhea** and **dyspareunia**.
- The patient's normal secondary sexual characteristics (Tanner stage 5) indicate functioning ovaries and normal hormone production, which is consistent with this diagnosis, as Mullerian structures develop independently of ovarian function.
*Exposure to DES in utero*
- In utero exposure to **DES (diethylstilbestrol)** can lead to various structural abnormalities of the female reproductive tract, such as a **T-shaped uterus**, vaginal adenosis, and clear cell adenocarcinoma of the vagina or cervix.
- While it can cause anatomical abnormalities, it does not typically result in agenesis of the entire vaginal canal or uterus, which would manifest as complete primary amenorrhea and absence of the vaginal canal during examination.
*Turner syndrome*
- **Turner syndrome (45, XO)** is characterized by the absence of one X chromosome, leading to **gonadal dysgenesis** and **ovarian failure**.
- Patients typically present with **primary amenorrhea** due to streak gonads and lack of estrogen production, which also results in **delayed or absent pubertal development** (e.g., lack of breast development), contradicting the patient's Tanner stage 5.
*PCOS*
- **Polycystic Ovary Syndrome (PCOS)** is an endocrine disorder characterized by **anovulation**, **hyperandrogenism**, and polycystic ovaries on ultrasound.
- While PCOS often causes **oligomenorrhea or amenorrhea**, it does not cause an absent vaginal canal or uterus, and patients typically have normal vaginal anatomy.
*Hyperprolactinemia*
- **Hyperprolactinemia** is an excess of prolactin in the blood, which can inhibit GnRH pulsatility, leading to **anovulation** and **amenorrhea**.
- However, hyperprolactinemia does not cause an absent vaginal canal or uterus, and the patient's primary complaint of dyspareunia due to an absent vaginal canal cannot be explained by this condition.
Question 85: A 57-year-old female presents to general gynecology clinic for evaluation of a pelvic mass. The mass was detected on a routine visit to her primary care doctor during abdominal palpation. In the office, she receives a transvaginal ultrasound, which reveals a mass measuring 11 cm in diameter. In the evaluation of this mass, elevation of which tumor marker would be suggestive of an ovarian cancer?
A. Alpha fetoprotein
B. CA-125 (Correct Answer)
C. CA-19-9
D. Beta-hCG
E. S-100
Explanation: ***CA-125***
- **CA-125** is the most widely used tumor marker for the detection and monitoring of **epithelial ovarian cancer**.
- Elevated levels in a postmenopausal woman with a large pelvic mass are highly suggestive of **ovarian malignancy**.
*Alpha fetoprotein*
- **Alpha fetoprotein (AFP)** is primarily associated with **germ cell tumors** of the ovary (e.g., endodermal sinus tumor) or **hepatocellular carcinoma**.
- It is not typically elevated in common epithelial ovarian cancers, which are more prevalent in older women.
*CA-19-9*
- **CA-19-9** is a tumor marker commonly elevated in **pancreatic cancer** and sometimes in **cholangiocarcinoma** or other gastrointestinal malignancies.
- While it can be elevated in some mucinous ovarian tumors, it is not the primary marker for general ovarian cancer evaluation.
*Beta-hCG*
- **Beta-hCG (Human Chorionic Gonadotropin)** is a marker for **choriocarcinoma** and other **gestational trophoblastic diseases**, as well as some germ cell tumors.
- It would not be expected to be elevated in a typical epithelial ovarian cancer in a 57-year-old female.
*S-100*
- **S-100 protein** is a marker primarily associated with **melanoma** and neural tissue tumors.
- It has no significant role in the diagnosis or monitoring of ovarian cancer.
Question 86: A 54-year-old woman comes to the physician because she has not had her menstrual period for the last 5 months. Menarche occurred at the age of 11 years, and menses occurred at regular 28-day intervals until they became irregular at 30- to 45-day intervals with light flow 2 years ago. She does not have vaginal dryness or decreased libido. She had four successful pregnancies and breastfed all her children until the age of 2 years. There is no personal or family history of serious illness. Except when she was pregnant, she has smoked one pack of cigarettes daily for 30 years. She does not drink alcohol. She is 167 cm (5 ft 5 in) tall and weighs 92 kg (203 lb); BMI is 33 kg/m2. Her vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following best explains this patient's lack of symptoms other than amenorrhea?
A. Obesity (Correct Answer)
B. Early menarche
C. Smoking
D. Multiparity
E. Breastfeeding
Explanation: ***Obesity***
- **Adipose tissue** (fat) is capable of converting adrenal androgens into **estrone**, a form of estrogen, via the enzyme **aromatase**.
- This elevated estrone level can provide a degree of **estrogenic activity**, thereby preventing symptoms like vaginal dryness and decreased libido, despite the cessation of ovarian estrogen production.
*Early menarche*
- The age of menarche (first menstruation) does not directly influence the severity or presence of menopausal symptoms in later life.
- While earlier menarche might be associated with a slightly longer reproductive lifespan, it doesn't explain the absence of symptoms after menopause.
*Smoking*
- **Smoking** is generally associated with an **earlier onset of menopause** and can actually **worsen menopausal symptoms** due to its anti-estrogenic effects.
- It does not protect against or explain the absence of symptoms like vaginal dryness.
*Multiparity*
- The number of previous pregnancies (**multiparity**) does not have a protective effect against menopausal symptoms.
- While lactation can cause temporary amenorrhea, multiparity itself does not explain the lack of menopausal symptoms after the cessation of menses.
*Breastfeeding*
- **Breastfeeding** causes **prolactin-induced amenorrhea**, but this effect is temporary and resolves once breastfeeding ceases.
- It does not affect the long-term presentation or severity of menopausal symptoms after the cessation of ovarian function.
Question 87: A 20-year-old woman is brought to the emergency department 6 hours after the onset of colicky lower abdominal pain that has been progressively worsening. The pain is associated with nausea and vomiting. She has stable inflammatory bowel disease treated with 5-aminosalicylic acid. She is sexually active with her boyfriend and they use condoms inconsistently. She was diagnosed with chlamydia one year ago. Her temperature is 38.1°C (100.6°F), pulse is 94/min, respirations are 22/min, and blood pressure is 120/80 mm Hg. Examination shows right lower quadrant guarding and rebound tenderness. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?
A. Urine culture
B. Erect abdominal x-ray
C. Serum β-hCG concentration (Correct Answer)
D. Transvaginal ultrasound
E. CT scan of the abdomen
Explanation: ***Serum β-hCG concentration***
- The patient is a **sexually active woman** with colicky lower abdominal pain, nausea, and vomiting, raising suspicion for an **ectopic pregnancy**.
- A **serum β-hCG concentration test** is crucial to **rule out pregnancy** as a cause of her symptoms, especially given her inconsistent condom use.
*Urine culture*
- While a urinary tract infection (UTI) can cause lower abdominal pain, the presentation of **guarding and rebound tenderness** in the right lower quadrant is **less typical for a simple UTI** and suggests a more acute abdominal process.
- Although ruling out a UTI is important, it is **not the most immediate priority** given the potential for a life-threatening ectopic pregnancy.
*Erect abdominal x-ray*
- An erect abdominal x-ray is primarily used to detect **free air under the diaphragm** in cases of **bowel perforation** or to identify **bowel obstruction**.
- While helpful in some abdominal emergencies, it is **less sensitive for diagnosing the differential diagnoses** pertinent to this patient's presentation (e.g., appendicitis, ectopic pregnancy).
*Transvaginal ultrasound*
- A **transvaginal ultrasound** would be an important next step **after confirming pregnancy** to determine if it is intrauterine or ectopic.
- However, performing an ultrasound **before confirming pregnancy** with β-hCG is not the most efficient initial approach for evaluating acute abdominal pain in a sexually active woman.
*CT scan of the abdomen*
- A CT scan of the abdomen would be highly useful for diagnosing conditions like **appendicitis** or complications of inflammatory bowel disease.
- However, in a **woman of childbearing age**, a CT scan should generally be performed **after ruling out pregnancy** due to radiation exposure risks to a potential fetus.
Question 88: A 36-year-old G4P1021 woman comes to the emergency room complaining of intense abdominal pain and vaginal bleeding. She is 9 weeks into her pregnancy and is very concerned as she experienced similar symptoms during her past pregnancy losses. Her pain is described as “stabbing, 10/10 pain that comes and goes.” When asked about her vaginal bleeding, she reports that “there were some clots initially, similar to my second day of menstruation.” She endorses joint pains that is worse in the morning, “allergic” rashes at her arms, and fatigue. She denies weight loss, chills, fever, nausea/vomiting, diarrhea, or constipation. Physical examination reveals an enlarged and irregularly shaped uterus with a partially open external os and a flesh-colored bulge. Her laboratory findings are shown below:
Serum:
Hemoglobin: 11.8 g/dL
Hematocrit: 35%
Leukocyte count:7,600 /mm^3 with normal differential
Platelet count: 200,000/mm^3
Bleeding time: 4 minutes (Normal: 2-7 minutes)
Prothrombin time: 13 seconds (Normal: 11-15 seconds)
Partial thromboplastin time (activated): 30 seconds (Normal: 25-40 seconds)
What is the most likely cause of this patient’s symptoms?
A. Polycystic ovarian syndrome
B. Adenomyosis
C. Chromosomal abnormality
D. Leiomyomata uteri
E. Anti-phospholipid syndrome (Correct Answer)
Explanation: ***Anti-phospholipid syndrome***
- The patient's history of **recurrent pregnancy losses**, combined with **joint pains**, **rashes**, and the current presentation of **abdominal pain** and **vaginal bleeding** during early pregnancy, is highly suggestive of anti-phospholipid syndrome (APS). APS is an **autoimmune disorder** characterized by **thrombosis** and **pregnancy morbidity**.
- The partial opening of the external os and a flesh-colored bulge indicates an ongoing miscarriage, which is a common manifestation of APS due to **placental thrombosis**.
*Polycystic ovarian syndrome*
- **Polycystic ovarian syndrome (PCOS)** is primarily characterized by **irregular periods**, **hirsutism**, **acne**, and **polycystic ovaries** on ultrasound.
- It is not typically associated with acute, severe abdominal pain and vaginal bleeding with clots in early pregnancy, nor with joint pains or allergic rashes.
*Adenomyosis*
- **Adenomyosis** is a condition where **endometrial tissue grows into the muscular wall of the uterus**, leading to **heavy, painful periods (menorrhagia and dysmenorrhea)** and an **enlarged, boggy uterus**.
- While it can cause an enlarged uterus and pain, acute severe pain and vaginal bleeding with clots in early pregnancy are not its primary presentation, nor are joint pains or rashes.
*Chromosomal abnormality*
- **Chromosomal abnormalities** are a common cause of **first-trimester miscarriages** and can present with vaginal bleeding and abdominal pain.
- However, they do not explain the systemic symptoms such as **joint pains** and **allergic rashes**, which point towards an underlying **autoimmune condition**.
*Leiomyomata uteri*
- **Leiomyomata uteri (uterine fibroids)** are **benign tumors of the uterine muscle** that can cause an **enlarged, irregularly shaped uterus**, **heavy menstrual bleeding**, and **pelvic pain**.
- While fibroids can cause pain and bleeding in pregnancy, they typically do not cause **recurrent pregnancy losses** and are not associated with **joint pains** or **allergic rashes**.
Question 89: A 43-year-old woman presents to her physician’s office complaining of fatigue and light headedness for one month. She has regular periods but notes that they have become heavier in the last year. She endorses increased urination and feels that she has gained weight in her abdomen, but review of systems is otherwise negative. She is a daycare teacher and has a first cousin with von Willebrand disease. Temperature is 98.4°F (36.9°C), pulse is 92/min, blood pressure is 109/72 mmHg, and respirations are 14/min.
A CBC demonstrates:
Hemoglobin: 9.9 g/dL
Leukocyte count: 6,300/mm^3
Platelet count: 180,000/mm^3
Which of the following is the best next step to evaluate the etiology of this patient’s findings?
A. von Willebrand factor antigen
B. TSH
C. Parvovirus B19 IgM and IgG
D. Hysteroscopy
E. Pelvic ultrasound (Correct Answer)
Explanation: ***Pelvic ultrasound***
- This patient presents with **heavy menstrual bleeding (menorrhagia)**, symptoms of **anemia** (fatigue, lightheadedness), and abdominal distension/weight gain. These symptoms, particularly the abdominal weight gain and increased urination, strongly suggest a pelvic mass or uterine pathology, such as **leiomyomas (fibroids)**.
- A pelvic ultrasound is the initial, **non-invasive imaging modality** of choice to evaluate for uterine or adnexal pathology in women presenting with menorrhagia, pelvic pain, or suspected masses.
*von Willebrand factor antigen*
- While the patient has a **first cousin with von Willebrand disease** and experiences menorrhagia, a bleeding disorder is less likely to fully explain the **abdominal weight gain** and **increased urination**, which point more towards a mass effect.
- Labs for von Willebrand disease (vWF antigen, ristocetin cofactor activity, factor VIII activity) would be considered if a structural cause for bleeding is ruled out, or if there's a strong personal history of bleeding.
*TSH*
- **Hypothyroidism** can cause menorrhagia and fatigue, but it does not typically lead to significant **abdominal weight gain** attributable to an anatomical mass or increased urination from uterine pressure.
- While thyroid dysfunction can cause menstrual irregularities, the compressive symptoms make a primary uterine cause more likely.
*Parvovirus B19 IgM and IgG*
- **Parvovirus B19 infection** can cause anemia (particularly in individuals with underlying hematologic conditions) and fatigue, but it **does not explain menorrhagia** or the abdominal symptoms like weight gain and increased urination.
- This evaluation would be considered in cases of unexplained anemia, especially with known exposure or aplastic crisis, not as a primary evaluation for heavy menstrual bleeding and mass effect.
*Hysteroscopy*
- **Hysteroscopy** is a procedure to visualize the inside of the uterus and is often used to evaluate for **intrauterine pathologies** such as polyps or submucosal fibroids after initial imaging, like ultrasound, has identified or suggested such findings.
- It is an **invasive procedure** and not the **best initial step** compared to a non-invasive pelvic ultrasound to broadly evaluate the uterus and adnexa.
Question 90: A 23-year-old G1P0 primigravid woman at 28 weeks estimated gestational age presents for a prenatal checkup. She says she has been having occasional headaches but is otherwise fine. The patient says she feels regular fetal movements and mild abdominal pain at times. Her past medical history is unremarkable. Current medications are a prenatal multivitamin and the occasional acetaminophen. Her blood pressure is 148/110 mm Hg today. On her last visit at 24 weeks of gestation, her blood pressure was 146/96 mm Hg. On physical exam, the fundus measures 28 cm above the pubic symphysis. Laboratory findings are significant for the following:
Serum Glucose (fasting) 88 mg/dL
Sodium 142 mEq/L
Potassium 3.9 mEq/L
Chloride 101 mEq/L
Serum Creatinine 0.9 mg/dL
Blood Urea Nitrogen 10 mg/dL
Alanine aminotransferase (ALT) 18 U/L
Aspartate aminotransferase (AST) 16 U/L
Mean Corpuscular Volume (MCV) 85 fL
Leukocyte count 4,200/mm3
Reticulocyte count 1%
Erythrocyte count 5.1 million/mm3
Platelet count 95,000mm3
Urinalysis show:
Proteins 2+
Glucose negative
Ketones negative
Leucocytes negative
Nitrites negative
Red Blood Cells (RBCs) negative
Casts negative
Which of the following medications would be the next best step in the treatment of this patient?
A. Magnesium sulfate (Correct Answer)
B. Phenobarbital
C. Valproic acid
D. Ethosuximide
E. Diazepam
Explanation: ***Magnesium sulfate***
- The patient presents with **gestational hypertension**, **proteinuria (2+)**, **thrombocytopenia (platelets 95,000/mm³)**, and **headaches at 28 weeks gestation**, indicating severe preeclampsia.
- **Magnesium sulfate** is the drug of choice for the prevention and treatment of **eclampsia-related seizures** in women with severe preeclampsia.
*Phenobarbital*
- **Phenobarbital** is an anticonvulsant but is generally reserved for refractory seizures or in situations where magnesium sulfate is contraindicated.
- It has a risk of **fetal respiratory depression** and neonatal withdrawal symptoms if used close to delivery.
*Valproic acid*
- **Valproic acid** is an anticonvulsant that carries a significant risk of **teratogenicity**, including **neural tube defects**, especially if used in early pregnancy.
- It is not the preferred agent for acute seizure prophylaxis in preeclampsia.
*Ethosuximide*
- **Ethosuximide** is primarily used for **absence seizures** and has no role in the management or prevention of seizures in preeclampsia.
- It would not address the underlying pathology or provide seizure prophylaxis in this patient.
*Diazepam*
- While **diazepam** can be used to abort an active seizure, it is not recommended for routine seizure prophylaxis in preeclampsia due to its **sedative effects** and potential for **fetal depression**.
- Magnesium sulfate is more effective and has a better safety profile for seizure prevention in preeclampsia.
