Prenatal Care — MCQs

Q: A 34-year-old woman presents at 6 weeks of delivery. She wants contraception for the next 3 years. What will be the best contraceptive method in this case?

Copper T. ***Copper T*** - A **Copper T intrauterine device (IUD)** is an excellent choice for long-term contraception (up to 10 years), making it suitable for her 3-year requirement. - It's **non-hormonal**, making it safe for breastfeeding mothers and avoiding potential hormonal side effects. *Nothing besides lactation amenorrhea* - **Lactational amenorrhea method (LAM)** is effective for only the first six months postpartum, provided the mother is exclusively breastfeeding and her periods have not returned. - It is not a reliable method for contraception beyond six months postpartum or for the requested 3-year duration. *IUCD with progesterone* - An **intrauterine device (IUD) with progesterone** (e.g., Mirena) can be a good long-term option, but it releases hormones which can potentially affect breastfeeding, especially if initiated very early postpartum. - While generally safe for breastfeeding, a non-hormonal option like the copper T is often preferred if there are concerns about hormonal exposure or side effects. *Injectable progesterone* - **Injectable progesterone** (e.g., Depo-Provera) is an effective contraceptive, but it needs to be administered every 3 months. - While safe for breastfeeding, it's not considered as convenient for a 3-year duration as a single-insertion IUD, and some women experience side effects like irregular bleeding or weight gain.

Q: What is the typical time between fertilization and implantation?

8 days. ***8 days*** - **Fertilization** typically occurs in the **fallopian tube**, and the resulting **zygote** then undergoes several cell divisions while migrating towards the uterus. - Implantation, the process by which the **blastocyst embeds into the uterine wall**, usually begins around day 6 post-fertilization and is completed by day 8-10. *2 days* - At 2 days post-fertilization, the embryo is typically in the **2-cell to 4-cell stage** and is still located within the fallopian tube, far from the implantation site. - This stage is too early for implantation to occur, as the embryo has not yet reached the **blastocyst stage** or the uterus. *14 days* - By 14 days post-fertilization, implantation would have long been completed, and the initial stages of **trophoblast development** and formation of the **placenta** would be underway. - This time frame represents a more advanced stage of pregnancy, whereas implantation is an early event. *16 days* - Sixteen days post-fertilization is well past the window for initial implantation; at this point, significant embryonic development has occurred, and the woman might even be experiencing early signs of **pregnancy**, such as a missed period. - Implantation is a much earlier process, concluding by day 10 at the latest.

Q: A 31-year-old woman, gravida 1, para 0, at 28 weeks' gestation comes to the obstetrician for a prenatal visit. She has had a tingling pain in the thumb, index finger, and middle finger of her right hand for the past 6 weeks. Physical examination shows decreased sensation to pinprick touch on the thumb, index finger, middle finger, and lateral half of the ring finger of the right hand. The pain is reproduced when the dorsal side of each hand is pressed against each other. Which of the following additional findings is most likely in this patient?

Thenar atrophy. ***Thenar atrophy*** - The patient's symptoms (tingling pain in the **thumb, index, and middle fingers**, decreased sensation in these digits, and pain reproduced by pressing the dorsal sides of the hands together - **Phalen's sign**) are classic for **carpal tunnel syndrome (CTS)**. - As **carpal tunnel syndrome** progresses, **median nerve** compression can lead to **atrophy of the thenar muscles** (which are innervated by the median nerve) due to chronic denervation. *Palmar nodule* - A **palmar nodule** is characteristic of **Dupuytren's contracture**, a fibrotic condition of the palmar fascia. - This condition is not associated with the nerve compression symptoms described in the patient. *Wrist drop* - **Wrist drop** is a clinical manifestation of **radial nerve injury**, typically affecting the extensor muscles of the wrist and fingers. - The patient's symptoms localize to the median nerve distribution, not the radial nerve. *Hypothenar weakness* - **Hypothenar weakness** indicates **ulnar nerve compression** or injury, affecting the muscles responsible for the movement of the little finger and some intrinsic hand muscles. - The symptoms described are clearly within the **median nerve distribution**, not the ulnar nerve. *Interosseus wasting* - **Interosseus wasting** is primarily a sign of **ulnar nerve damage**, affecting the small muscles between the metacarpals that help with finger abduction and adduction. - Again, the patient's symptoms of carpal tunnel syndrome are due to **median nerve compression**, not ulnar nerve pathology.

Q: A 36-year-old Asian G4P3 presents to her physician with a recently diagnosed pregnancy for a first prenatal visit. The estimated gestational age is 5 weeks. She had 2 vaginal deliveries and 1 medical abortion. Her children had birth weights of 4100 g and 4560 g. Her medical history is significant for gastroesophageal reflux disease, for which she takes pantoprazole. The pre-pregnancy weight is 78 kg (172 lb), and the weight at the time of presentation is 79 kg (174 lb). Her height is 157 cm (5 ft 1 in). Her vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 75/min, respiratory rate 13/min, and temperature 36.7℃ (98℉). Her physical examination is unremarkable except for increased adiposity. Which of the following tests is indicated in this woman?

Glucose oral tolerance test. ***Glucose oral tolerance test*** - This patient has several risk factors for **gestational diabetes mellitus (GDM)**, including advanced maternal age (>25, she is 36), high pre-pregnancy BMI (31.6 kg/m$^2$), and two prior deliveries with **macrosomic infants** (**>4000g**). - Given these risk factors, an **early screening for GDM** with a glucose oral tolerance test is indicated. *Serology for CMV* - **Cytomegalovirus (CMV) serology** is generally not routinely recommended for all pregnant women unless there is specific clinical suspicion or exposure. - While CMV can cause congenital infection, the patient's history does not suggest any particular risk for CMV beyond the general population. *Coagulogram* - A **coagulogram** (e.g., PT, aPTT, fibrinogen) is not routinely performed in healthy pregnant women at their initial prenatal visit. - It would only be indicated if there was a history of **bleeding disorders**, recurrent pregnancy loss, or other specific medical conditions suggesting a coagulopathy. *Liver enzyme assessment* - **Liver enzyme assessment** is not a routine screening test for all pregnant women. - It would be indicated for conditions like **preeclampsia** with severe features, intrahepatic cholestasis of pregnancy, or concerns about drug-induced liver injury, none of which are suggested by the current presentation. *Human chorionic gonadotropin and pregnancy-associated plasma protein-A* - These are markers used in **first-trimester screening for aneuploidy** (e.g., Down syndrome), often combined with nuchal translucency ultrasound. - While aneuploidy screening is offered to all pregnant women, the question specifically asks for a test indicated due to her medical and obstetric history, pointing more towards metabolic risks.

Q: A 17-year-old woman with no significant past medical history presents to the outpatient OB/GYN clinic with her parents for concerns of primary amenorrhea. She denies any symptoms and appears relatively unconcerned about her presentation. The review of systems is negative. Physical examination demonstrates an age-appropriate degree of development of secondary sexual characteristics, and no significant abnormalities on heart, lung, or abdominal examination. Her vital signs are all within normal limits. Her parents are worried and request that the appropriate laboratory tests are ordered. Which of the following tests is the best next step in the evaluation of this patient’s primary amenorrhea?

Serum beta hCG. ***Serum beta hCG*** - It is crucial to rule out **pregnancy** as a cause of amenorrhea in any patient of reproductive age, even in the absence of intercourse history. - A positive result would immediately explain the amenorrhea and necessitate further obstetric care. *Pelvic ultrasound* - While useful for evaluating uterine and ovarian anatomy, it is not the *first* step when pregnancy has not been ruled out. - It would be more appropriate if there were concerns for **structural abnormalities** after initial lab work. *Serum prolactin* - This test is indicated if there are symptoms suggesting **hyperprolactinemia**, such as galactorrhea or headaches, which are absent here. - High prolactin can inhibit GnRH release, leading to amenorrhea, but it's not the initial screening test. *Serum FSH* - FSH levels are important for assessing **ovarian function** and diagnosing conditions like primary ovarian insufficiency. - However, in a patient with normal secondary sexual characteristics, other more common causes should be ruled out first. *Left hand radiograph* - A left hand radiograph is used to assess **bone age**, primarily in cases of delayed puberty or growth concerns. - This patient has age-appropriate secondary sexual characteristics, suggesting **bone age** is likely consistent with her chronological age.

Q: A 28-year-old G1P0 woman who is 30 weeks pregnant presents to the women's health center for a prenatal checkup. She is concerned that her baby is not moving as much as usual over the past five days. She thinks she only felt the baby move eight times over an hour long period. Her prenatal history was notable for morning sickness requiring pyridoxine. Her second trimester ultrasound revealed no abnormal placental attachment. She takes a multivitamin daily. Her temperature is 98.6°F (37°C), blood pressure is 120/70 mmHg, pulse is 80/min, and respirations are 16/min. The patient's physical exam is unremarkable. Her fundal height is 28 cm, compared to 26 cm two weeks ago. The fetal pulse is 140/min. The patient undergoes external fetal monitoring. With vibroacoustic stimulation, the patient feels eight movements over two hours. What is the best next step in management?

Biophysical profile. ***Biophysical profile*** - The patient reports **decreased fetal movement** and a non-reassuring modified count, requiring further evaluation of fetal well-being. - A **biophysical profile** combines a non-stress test with an ultrasound assessment of fetal breathing, movement, tone, and amniotic fluid volume to provide a comprehensive picture of fetal health. *Induction of labor* - **Induction of labor** is typically reserved for cases with confirmed fetal distress or when the risks of continuing the pregnancy outweigh the benefits, which is not yet established. - While fetal well-being is a concern, there is no immediate indication for delivery before further diagnostic tests. *Inpatient monitoring* - **Inpatient monitoring** may be considered if initial outpatient assessments like a non-stress test or biophysical profile are non-reassuring, but it is not the immediate next step. - The patient’s current vital signs and fundal height are within normal limits, and the most recent fetal heart rate is reassuring, so continuous inpatient monitoring is premature. *Reassurance* - **Reassurance** alone is insufficient given the patient's concern about decreased fetal movement and the non-reassuring result of 8 movements in 2 hours with vibroacoustic stimulation. - Decreased fetal movement can be a sign of fetal compromise, necessitating objective assessment rather than just reassurance. *Oxytocin challenge* - An **oxytocin challenge test** (also known as a contraction stress test) is used to evaluate uteroplacental function by observing fetal heart rate response to contractions. - It is typically performed if a non-stress test or biophysical profile is equivocal or non-reassuring, it is not the initial test of choice for decreased fetal movement.

A 31-year-old woman, gravida 1, para 0, at 28 weeks' gestation comes to the obstetrician for a prenatal visit. She has had a tingling pain in the thumb, index finger, and middle finger of her right hand for the past 6 weeks. Physical examination shows decreased sensation to pinprick touch on the thumb, index finger, middle finger, and lateral half of the ring finger of the right hand. The pain is reproduced when the dorsal side of each hand is pressed against each other. Which of the following additional findings is most likely in this patient?

A 36-year-old Asian G4P3 presents to her physician with a recently diagnosed pregnancy for a first prenatal visit. The estimated gestational age is 5 weeks. She had 2 vaginal deliveries and 1 medical abortion. Her children had birth weights of 4100 g and 4560 g. Her medical history is significant for gastroesophageal reflux disease, for which she takes pantoprazole. The pre-pregnancy weight is 78 kg (172 lb), and the weight at the time of presentation is 79 kg (174 lb). Her height is 157 cm (5 ft 1 in). Her vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 75/min, respiratory rate 13/min, and temperature 36.7℃ (98℉). Her physical examination is unremarkable except for increased adiposity. Which of the following tests is indicated in this woman?

A 17-year-old woman with no significant past medical history presents to the outpatient OB/GYN clinic with her parents for concerns of primary amenorrhea. She denies any symptoms and appears relatively unconcerned about her presentation. The review of systems is negative. Physical examination demonstrates an age-appropriate degree of development of secondary sexual characteristics, and no significant abnormalities on heart, lung, or abdominal examination. Her vital signs are all within normal limits. Her parents are worried and request that the appropriate laboratory tests are ordered. Which of the following tests is the best next step in the evaluation of this patient’s primary amenorrhea?

A 36-year-old primigravid woman at 8 weeks' gestation comes to the emergency department because of vaginal bleeding and mild suprapubic pain 1 hour ago. The bleeding has subsided and she has mild, brown spotting now. Her medications include folic acid and a multivitamin. She smoked one pack of cigarettes daily for 10 years and drank alcohol occasionally but stopped both 6 weeks ago. Her temperature is 37°C (98.6°F), pulse is 92/min, and blood pressure is 116/77 mm Hg. Pelvic examination shows a closed cervical os and a uterus consistent in size with an 8-week gestation. Ultrasonography shows an intrauterine pregnancy and normal fetal cardiac activity. Which of the following is the most appropriate next step in management?

A 23-year-old woman presents to a medical office for a check-up. The patient has a 5-year history of epilepsy with focal-onset motor seizures and currently is seizure-free on 50 mg of lamotrigine 3 times a day. She does not have any concurrent illnesses and does not take other medications, except oral contraceptive pills. She is considering pregnancy and seeks advice on possible adjustments or additions to her therapy. Which of the following changes should be made?

Q10

A 28-year-old G1P0 woman who is 30 weeks pregnant presents to the women's health center for a prenatal checkup. She is concerned that her baby is not moving as much as usual over the past five days. She thinks she only felt the baby move eight times over an hour long period. Her prenatal history was notable for morning sickness requiring pyridoxine. Her second trimester ultrasound revealed no abnormal placental attachment. She takes a multivitamin daily. Her temperature is 98.6°F (37°C), blood pressure is 120/70 mmHg, pulse is 80/min, and respirations are 16/min. The patient's physical exam is unremarkable. Her fundal height is 28 cm, compared to 26 cm two weeks ago. The fetal pulse is 140/min. The patient undergoes external fetal monitoring. With vibroacoustic stimulation, the patient feels eight movements over two hours. What is the best next step in management?

Prenatal Care US Medical PG Practice Questions and MCQs

Question 1: A 34-year-old woman presents at 6 weeks of delivery. She wants contraception for the next 3 years. What will be the best contraceptive method in this case?

A. Nothing besides lactation amenorrhea
B. IUCD with progesterone
C. Injectable progesterone
D. Copper T (Correct Answer)

Explanation: ***Copper T*** - A **Copper T intrauterine device (IUD)** is an excellent choice for long-term contraception (up to 10 years), making it suitable for her 3-year requirement. - It's **non-hormonal**, making it safe for breastfeeding mothers and avoiding potential hormonal side effects. *Nothing besides lactation amenorrhea* - **Lactational amenorrhea method (LAM)** is effective for only the first six months postpartum, provided the mother is exclusively breastfeeding and her periods have not returned. - It is not a reliable method for contraception beyond six months postpartum or for the requested 3-year duration. *IUCD with progesterone* - An **intrauterine device (IUD) with progesterone** (e.g., Mirena) can be a good long-term option, but it releases hormones which can potentially affect breastfeeding, especially if initiated very early postpartum. - While generally safe for breastfeeding, a non-hormonal option like the copper T is often preferred if there are concerns about hormonal exposure or side effects. *Injectable progesterone* - **Injectable progesterone** (e.g., Depo-Provera) is an effective contraceptive, but it needs to be administered every 3 months. - While safe for breastfeeding, it's not considered as convenient for a 3-year duration as a single-insertion IUD, and some women experience side effects like irregular bleeding or weight gain.

Question 2: A GSP4 woman comes for routine sonography for the first time. She has four daughters and expresses a desire for a boy this time, asking for sex determination. To abide by ethical guidelines, what should you do?

A. Check routine ANC and sex for developmental abnormalities and do not reveal gender to the patient (Correct Answer)
B. Check routine ANC and sex for developmental abnormalities and do reveal gender to the patient
C. Do reveal gender if a girl
D. Check only routine ANC, do not check sex

Explanation: ***Check routine ANC and sex for developmental abnormalities and do not reveal gender to the patient*** - It is **illegal** and **unethical** to reveal the sex of the fetus in many countries, including India, to prevent **sex-selective abortions**. - The primary purpose of a routine antenatal ultrasound is to assess fetal **health** and **developmental abnormalities**, not to determine sex for parental preference. *Check routine ANC and sex for developmental abnormalities and do reveal gender to the patient* - Revealing the gender to the patient directly facilitates **sex-selective abortion**, which is medically unethical and illegal due to the potential for harm to the fetus and society. - This practice would violate the **Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act** in India, which prohibits gender determination. *Do reveal gender if a girl* - Revealing the gender, regardless of whether it is a boy or a girl, can lead to **gender-biased selective abortions**, particularly in cultures with a strong preference for male offspring. - This action undermines the ethical principles of **non-maleficence** and **justice** by potentially facilitating harm based on gender preference. *Check only routine ANC, do not check sex* - While the primary focus is routine antenatal care, avoiding the assessment of fetal sex entirely could lead to **missing potential developmental abnormalities** that might be identifiable through observation of external genitalia. - A thorough ultrasound examination routinely includes a visual check of fetal anatomy, which can incidentally reveal gender, but this information should not be shared with the parents for selection purposes.

Question 3: What is the typical time between fertilization and implantation?

A. 2 days
B. 8 days (Correct Answer)
C. 14 days
D. 16 days

Explanation: ***8 days*** - **Fertilization** typically occurs in the **fallopian tube**, and the resulting **zygote** then undergoes several cell divisions while migrating towards the uterus. - Implantation, the process by which the **blastocyst embeds into the uterine wall**, usually begins around day 6 post-fertilization and is completed by day 8-10. *2 days* - At 2 days post-fertilization, the embryo is typically in the **2-cell to 4-cell stage** and is still located within the fallopian tube, far from the implantation site. - This stage is too early for implantation to occur, as the embryo has not yet reached the **blastocyst stage** or the uterus. *14 days* - By 14 days post-fertilization, implantation would have long been completed, and the initial stages of **trophoblast development** and formation of the **placenta** would be underway. - This time frame represents a more advanced stage of pregnancy, whereas implantation is an early event. *16 days* - Sixteen days post-fertilization is well past the window for initial implantation; at this point, significant embryonic development has occurred, and the woman might even be experiencing early signs of **pregnancy**, such as a missed period. - Implantation is a much earlier process, concluding by day 10 at the latest.

Question 4: A female patient missed her oral contraceptive pill (OCP) on four different days during the first two weeks of her menstrual cycle. What is the most appropriate advice for her?

A. Adopt another method of contraception
B. Continue taking the pill
C. Continue current pack, consider additional contraceptive method for remaining days (Correct Answer)
D. Take all 4 pills at once and continue taking pills

Explanation: **Continue current pack, consider additional contraceptive method for remaining days** - Missing four pills in the first two weeks significantly compromises contraceptive efficacy, necessitating the use of **backup contraception** (like condoms) for the remainder of the cycle. - Continuing the current pack is important to maintain hormonal rhythm and prevent unscheduled bleeding, but it won't immediately restore full protection. *Adopt another method of contraception* - While a backup method is needed, she doesn't necessarily need to **completely abandon** OCPs, especially if she has previously tolerated them well. - The immediate concern is the current cycle's protection; a long-term change in method might be considered if adherence is a persistent issue. *Continue taking the pill* - Simply continuing the pill without additional measures is **insufficient** as the contraceptive effectiveness has been significantly compromised by missing multiple doses. - This approach would leave her at a **high risk of pregnancy** during the current cycle. *Take all 4 pills at once and continue taking pills* - Taking multiple missed pills at once is **not recommended** and can lead to **nausea, vomiting**, or irregular bleeding due to a sudden high dose of hormones. - This strategy would not restore contraceptive efficacy effectively and would increase side effects without providing better protection.

Question 5: A 31-year-old woman, gravida 1, para 0, at 28 weeks' gestation comes to the obstetrician for a prenatal visit. She has had a tingling pain in the thumb, index finger, and middle finger of her right hand for the past 6 weeks. Physical examination shows decreased sensation to pinprick touch on the thumb, index finger, middle finger, and lateral half of the ring finger of the right hand. The pain is reproduced when the dorsal side of each hand is pressed against each other. Which of the following additional findings is most likely in this patient?

A. Palmar nodule
B. Wrist drop
C. Hypothenar weakness
D. Interosseus wasting
E. Thenar atrophy (Correct Answer)

Explanation: ***Thenar atrophy*** - The patient's symptoms (tingling pain in the **thumb, index, and middle fingers**, decreased sensation in these digits, and pain reproduced by pressing the dorsal sides of the hands together - **Phalen's sign**) are classic for **carpal tunnel syndrome (CTS)**. - As **carpal tunnel syndrome** progresses, **median nerve** compression can lead to **atrophy of the thenar muscles** (which are innervated by the median nerve) due to chronic denervation. *Palmar nodule* - A **palmar nodule** is characteristic of **Dupuytren's contracture**, a fibrotic condition of the palmar fascia. - This condition is not associated with the nerve compression symptoms described in the patient. *Wrist drop* - **Wrist drop** is a clinical manifestation of **radial nerve injury**, typically affecting the extensor muscles of the wrist and fingers. - The patient's symptoms localize to the median nerve distribution, not the radial nerve. *Hypothenar weakness* - **Hypothenar weakness** indicates **ulnar nerve compression** or injury, affecting the muscles responsible for the movement of the little finger and some intrinsic hand muscles. - The symptoms described are clearly within the **median nerve distribution**, not the ulnar nerve. *Interosseus wasting* - **Interosseus wasting** is primarily a sign of **ulnar nerve damage**, affecting the small muscles between the metacarpals that help with finger abduction and adduction. - Again, the patient's symptoms of carpal tunnel syndrome are due to **median nerve compression**, not ulnar nerve pathology.

Question 6: A 36-year-old Asian G4P3 presents to her physician with a recently diagnosed pregnancy for a first prenatal visit. The estimated gestational age is 5 weeks. She had 2 vaginal deliveries and 1 medical abortion. Her children had birth weights of 4100 g and 4560 g. Her medical history is significant for gastroesophageal reflux disease, for which she takes pantoprazole. The pre-pregnancy weight is 78 kg (172 lb), and the weight at the time of presentation is 79 kg (174 lb). Her height is 157 cm (5 ft 1 in). Her vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 75/min, respiratory rate 13/min, and temperature 36.7℃ (98℉). Her physical examination is unremarkable except for increased adiposity. Which of the following tests is indicated in this woman?

A. Serology for CMV
B. Coagulogram
C. Glucose oral tolerance test (Correct Answer)
D. Liver enzyme assessment
E. Human chorionic gonadotropin and pregnancy-associated plasma protein-A

Explanation: ***Glucose oral tolerance test*** - This patient has several risk factors for **gestational diabetes mellitus (GDM)**, including advanced maternal age (>25, she is 36), high pre-pregnancy BMI (31.6 kg/m$^2$), and two prior deliveries with **macrosomic infants** (**>4000g**). - Given these risk factors, an **early screening for GDM** with a glucose oral tolerance test is indicated. *Serology for CMV* - **Cytomegalovirus (CMV) serology** is generally not routinely recommended for all pregnant women unless there is specific clinical suspicion or exposure. - While CMV can cause congenital infection, the patient's history does not suggest any particular risk for CMV beyond the general population. *Coagulogram* - A **coagulogram** (e.g., PT, aPTT, fibrinogen) is not routinely performed in healthy pregnant women at their initial prenatal visit. - It would only be indicated if there was a history of **bleeding disorders**, recurrent pregnancy loss, or other specific medical conditions suggesting a coagulopathy. *Liver enzyme assessment* - **Liver enzyme assessment** is not a routine screening test for all pregnant women. - It would be indicated for conditions like **preeclampsia** with severe features, intrahepatic cholestasis of pregnancy, or concerns about drug-induced liver injury, none of which are suggested by the current presentation. *Human chorionic gonadotropin and pregnancy-associated plasma protein-A* - These are markers used in **first-trimester screening for aneuploidy** (e.g., Down syndrome), often combined with nuchal translucency ultrasound. - While aneuploidy screening is offered to all pregnant women, the question specifically asks for a test indicated due to her medical and obstetric history, pointing more towards metabolic risks.

Question 7: A 17-year-old woman with no significant past medical history presents to the outpatient OB/GYN clinic with her parents for concerns of primary amenorrhea. She denies any symptoms and appears relatively unconcerned about her presentation. The review of systems is negative. Physical examination demonstrates an age-appropriate degree of development of secondary sexual characteristics, and no significant abnormalities on heart, lung, or abdominal examination. Her vital signs are all within normal limits. Her parents are worried and request that the appropriate laboratory tests are ordered. Which of the following tests is the best next step in the evaluation of this patient’s primary amenorrhea?

A. Pelvic ultrasound
B. Serum beta hCG (Correct Answer)
C. Serum prolactin
D. Serum FSH
E. Left hand radiograph

Explanation: ***Serum beta hCG*** - It is crucial to rule out **pregnancy** as a cause of amenorrhea in any patient of reproductive age, even in the absence of intercourse history. - A positive result would immediately explain the amenorrhea and necessitate further obstetric care. *Pelvic ultrasound* - While useful for evaluating uterine and ovarian anatomy, it is not the *first* step when pregnancy has not been ruled out. - It would be more appropriate if there were concerns for **structural abnormalities** after initial lab work. *Serum prolactin* - This test is indicated if there are symptoms suggesting **hyperprolactinemia**, such as galactorrhea or headaches, which are absent here. - High prolactin can inhibit GnRH release, leading to amenorrhea, but it's not the initial screening test. *Serum FSH* - FSH levels are important for assessing **ovarian function** and diagnosing conditions like primary ovarian insufficiency. - However, in a patient with normal secondary sexual characteristics, other more common causes should be ruled out first. *Left hand radiograph* - A left hand radiograph is used to assess **bone age**, primarily in cases of delayed puberty or growth concerns. - This patient has age-appropriate secondary sexual characteristics, suggesting **bone age** is likely consistent with her chronological age.

Question 8: A 36-year-old primigravid woman at 8 weeks' gestation comes to the emergency department because of vaginal bleeding and mild suprapubic pain 1 hour ago. The bleeding has subsided and she has mild, brown spotting now. Her medications include folic acid and a multivitamin. She smoked one pack of cigarettes daily for 10 years and drank alcohol occasionally but stopped both 6 weeks ago. Her temperature is 37°C (98.6°F), pulse is 92/min, and blood pressure is 116/77 mm Hg. Pelvic examination shows a closed cervical os and a uterus consistent in size with an 8-week gestation. Ultrasonography shows an intrauterine pregnancy and normal fetal cardiac activity. Which of the following is the most appropriate next step in management?

A. Reassurance and follow-up ultrasonography (Correct Answer)
B. Progestin therapy
C. Complete bed rest
D. Low-dose aspirin therapy
E. Cervical cerclage

Explanation: ***Reassurance and follow-up ultrasonography*** - The patient's symptoms of **mild vaginal bleeding** at 8 weeks' gestation with a **closed cervical os**, a uterus consistent with gestational age, and **normal fetal cardiac activity** on ultrasound indicate a **threatened abortion** which has largely resolved. - In such cases, the current management involves reassuring the patient that the pregnancy is likely to continue and scheduling a follow-up ultrasound to confirm continued fetal well-being, as there is no intervention proven to alter the outcome. *Progestin therapy* - While progesterone has a role in maintaining pregnancy, routine progestin therapy for resolved or mild threatened abortion is **not universally recommended** unless there is a documented **progesterone deficiency** or specific risk factors like a history of recurrent miscarriage. - In this case, the bleeding has subsided and fetal viability is confirmed. *Complete bed rest* - Historically, bed rest was a common recommendation for threatened abortion, but studies have demonstrated **no benefit** in preventing miscarriage and it can even lead to complications such as **thrombophlebitis** and **muscle atrophy**. - Current evidence-based guidelines do not support complete bed rest for threatened abortion. *Low-dose aspirin therapy* - Low-dose aspirin is primarily used in pregnancy for conditions like **antiphospholipid syndrome** or for the prevention of **preeclampsia** in high-risk women. - There is **no indication** for low-dose aspirin in the management of threatened abortion without these specific risk factors. *Cervical cerclage* - **Cervical cerclage** is a procedure used to reinforce an incompetent cervix, typically for women with a history of **recurrent second-trimester losses** or a **shortened cervical length** identified on ultrasound. - It is **not indicated** for threatened abortion in the first trimester, especially when the cervical os is closed and no signs of cervical insufficiency are present.

Question 9: A 23-year-old woman presents to a medical office for a check-up. The patient has a 5-year history of epilepsy with focal-onset motor seizures and currently is seizure-free on 50 mg of lamotrigine 3 times a day. She does not have any concurrent illnesses and does not take other medications, except oral contraceptive pills. She is considering pregnancy and seeks advice on possible adjustments or additions to her therapy. Which of the following changes should be made?

A. Recommend 5 mg of folic acid daily with no changes to antiepileptic therapy (Correct Answer)
B. Recommend 100 μg of vitamin K daily with no changes to antiepileptic therapy
C. Decrease the dose of lamotrigine to 50 mg 2 times a day
D. No changes or additions to the patient’s regimen are indicated
E. Change lamotrigine to oxcarbazepine prior to conception

Explanation: ***Recommend 5 mg of folic acid daily with no changes to antiepileptic therapy*** - All women of childbearing age taking antiepileptic drugs (AEDs) who are planning pregnancy should take **high-dose folic acid (4-5 mg daily)** to reduce the risk of **neural tube defects**. - **Lamotrigine** is generally considered one of the safer AEDs during pregnancy, and changing a well-controlled regimen can lead to breakthrough seizures, posing risks to both mother and fetus. *Recommend 100 μg of vitamin K daily with no changes to antiepileptic therapy* - **Vitamin K supplementation** is primarily recommended in the **third trimester** for women taking AEDs (especially enzyme-inducing ones like carbamazepine, phenytoin, and phenobarbital) to prevent **neonatal coagulopathy**. - While lamotrigine is not a potent enzyme inducer, a general recommendation for vitamin K can be considered, but **folic acid supplementation is a more immediate and critical consideration** *before* conception and throughout the first trimester. *Decrease the dose of lamotrigine to 50 mg 2 times a day* - **Decreasing the lamotrigine dosage** without clinical indication could lead to a **breakthrough seizure**, which poses a significant risk to both the mother and the developing fetus. - **Seizure control** is paramount during pregnancy, and dose adjustments should only be made if clinically necessary due to side effects or if lamotrigine levels decrease, which often requires *increasing* the dose due to hormonal changes. *No changes or additions to the patient’s regimen are indicated* - This is incorrect as **folic acid supplementation** is strongly recommended for all women taking AEDs who are planning pregnancy due to the increased risk of neural tube defects. - Failure to initiate folic acid supplementation would expose the fetus to preventable risks, despite the patient being otherwise healthy and seizure-free. *Change lamotrigine to oxcarbazepine prior to conception* - **Changing an effective AED** when the patient is seizure-free can destabilize seizure control, potentially leading to breakthrough seizures. - While oxcarbazepine is an alternative AED, there is no compelling reason to switch from lamotrigine, which is generally considered **relatively safe in pregnancy** and is effectively controlling this patient's seizures.

Question 10: A 28-year-old G1P0 woman who is 30 weeks pregnant presents to the women's health center for a prenatal checkup. She is concerned that her baby is not moving as much as usual over the past five days. She thinks she only felt the baby move eight times over an hour long period. Her prenatal history was notable for morning sickness requiring pyridoxine. Her second trimester ultrasound revealed no abnormal placental attachment. She takes a multivitamin daily. Her temperature is 98.6°F (37°C), blood pressure is 120/70 mmHg, pulse is 80/min, and respirations are 16/min. The patient's physical exam is unremarkable. Her fundal height is 28 cm, compared to 26 cm two weeks ago. The fetal pulse is 140/min. The patient undergoes external fetal monitoring. With vibroacoustic stimulation, the patient feels eight movements over two hours. What is the best next step in management?

A. Biophysical profile (Correct Answer)
B. Induction of labor
C. Inpatient monitoring
D. Reassurance
E. Oxytocin challenge

Explanation: ***Biophysical profile*** - The patient reports **decreased fetal movement** and a non-reassuring modified count, requiring further evaluation of fetal well-being. - A **biophysical profile** combines a non-stress test with an ultrasound assessment of fetal breathing, movement, tone, and amniotic fluid volume to provide a comprehensive picture of fetal health. *Induction of labor* - **Induction of labor** is typically reserved for cases with confirmed fetal distress or when the risks of continuing the pregnancy outweigh the benefits, which is not yet established. - While fetal well-being is a concern, there is no immediate indication for delivery before further diagnostic tests. *Inpatient monitoring* - **Inpatient monitoring** may be considered if initial outpatient assessments like a non-stress test or biophysical profile are non-reassuring, but it is not the immediate next step. - The patient’s current vital signs and fundal height are within normal limits, and the most recent fetal heart rate is reassuring, so continuous inpatient monitoring is premature. *Reassurance* - **Reassurance** alone is insufficient given the patient's concern about decreased fetal movement and the non-reassuring result of 8 movements in 2 hours with vibroacoustic stimulation. - Decreased fetal movement can be a sign of fetal compromise, necessitating objective assessment rather than just reassurance. *Oxytocin challenge* - An **oxytocin challenge test** (also known as a contraction stress test) is used to evaluate uteroplacental function by observing fetal heart rate response to contractions. - It is typically performed if a non-stress test or biophysical profile is equivocal or non-reassuring, it is not the initial test of choice for decreased fetal movement.

Question 11: A 25-year-old G1P0 woman at 14 weeks estimated gestational age presents for prenatal care. She has no complaints. No significant past medical history. The patient is afebrile and vital signs are within normal limits. Physical examination is unremarkable. Laboratory findings are significant for the following: Thyroid-stimulating hormone (TSH) 0.3 mIU/L (0.4–4.2 mIU/L) Total T4 11.4 µg/dL (5.4–11.5 µg/dL) Free total T4 0.7 ng/dL (0.7–1.8 ng/dL) Which of the following is the most likely etiology of this patient’s laboratory findings?

A. Estrogen regulation of thyroxine-binding globulin secretion (TBG) (Correct Answer)
B. Estrogen mediated thyroid hyperplasia
C. Human chorionic gonadotropin (hCG) regulation of TBG
D. Progesterone regulation of TBG
E. Placental production of thyroxine

Explanation: ***Estrogen regulation of thyroxine-binding globulin secretion (TBG)*** - During pregnancy, **elevated estrogen levels** lead to increased synthesis of **thyroxine-binding globulin (TBG)** in the liver. - This rise in TBG increases the total amount of thyroid hormones (**Total T4**) bound in the blood, maintaining a normal **free T4** despite a slightly lower **TSH** in early pregnancy, which is a normal physiological adaptation. *Estrogen mediated thyroid hyperplasia* - While estrogen does influence thyroid function, its primary effect is on **TBG synthesis**, not direct thyroid hyperplasia leading to these specific lab findings. - **Thyroid hyperplasia** might occur in response to iodine deficiency or certain autoimmune conditions, not typically as a direct estrogen effect presenting with these labs. *Human chorionic gonadotropin (hCG) regulation of TBG* - **hCG** does have a weak TSH-like activity, which can suppress TSH and slightly increase free T4, particularly in the first trimester. - However, hCG's primary interaction is with the TSH receptor, not direct regulation of **TBG secretion**. *Progesterone regulation of TBG* - **Progesterone** plays a crucial role in maintaining pregnancy but does not directly or significantly influence the synthesis or regulation of **TBG**. - Its effects are more related to uterine and cervical changes. *Placental production of thyroxine* - The placenta does produce some hormones, but it does **not produce thyroxine** (T4). - The primary source of thyroxine for both mother and fetus is the maternal thyroid gland.

Question 12: A 13-year-old girl presents to her pediatrician with vaginal bleeding and abdominal pain. The patient states that this has happened sporadically over the past 4 months. She is currently experiencing these symptoms and has soaked through 1 pad today. She denies being sexually active or using any illicit substances. Her vitals are within normal limits, and physical exam is notable for a healthy young girl with a non-focal abdominal and pelvic exam. Which of the following is the best next step in management?

A. Administer azithromycin and ceftriaxone
B. Perform hysteroscopy and biopsy
C. Perform a CT scan of the abdomen
D. Reassurance and discharge
E. Order a coagulation profile (Correct Answer)

Explanation: ***Order a coagulation profile*** - **Abnormal uterine bleeding (AUB)** in an adolescent often suggests an underlying **coagulopathy**, with **von Willebrand disease** being the most common cause. - Given the patient's age, sporadic heavy bleeding, and lack of other obvious causes, investigating **bleeding disorders** is a critical next step. *Administer azithromycin and ceftriaxone* - This treatment targets **sexually transmitted infections (STIs)**, specifically **gonorrhea** and **chlamydia**. - The patient explicitly denies being **sexually active**, making STIs an unlikely cause in this context, and there are no signs of infection. *Perform hysteroscopy and biopsy* - **Hysteroscopy** and **biopsy** are invasive procedures typically reserved for evaluating **structural abnormalities** or **malignancy** in cases of AUB. - Given the patient's age and the sporadic nature of her bleeding, it is not the initial investigation. *Perform a CT scan of the abdomen* - A **CT scan of the abdomen** is a sophisticated imaging modality that might be used to identify **structural abnormalities** or **masses** in the abdomen or pelvis. - However, it carries radiation risks and is not the first-line investigation for AUB, especially with a non-focal physical exam. *Reassurance and discharge* - Reassurance alone is inappropriate given the patient's persistent and heavy **vaginal bleeding** (soaking through a pad). - This symptom requires further investigation to rule out significant underlying medical conditions, such as a **coagulopathy**.

Question 13: A 30-year-old woman, gravida 3, para 1, at 25 weeks' gestation comes to the physician because of mild itching of the vulva and anal region for 2 weeks. She has a history of 2 episodes of vulvovaginal candidiasis last year that both subsided following 1 week of treatment with butoconazole. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 25-week gestation. There are no signs of vulvar or perianal erythema, edema, or fissures. Microscopy of an adhesive tape that was applied to the perianal region shows multiple ova. Which of the following is the most appropriate next step in management?

A. Ivermectin
B. Albendazole
C. Supportive therapy
D. Praziquantel
E. Pyrantel pamoate (Correct Answer)

Explanation: ***Pyrantel pamoate*** - The patient's symptoms (perianal itching) and the finding of **ova on adhesive tape** are classic for **pinworm infection** (enterobiasis). Pyrantel pamoate is a safe and effective treatment for pinworms during pregnancy. - It is preferred over other antihelminthics due to its **poor systemic absorption**, minimizing exposure to the fetus, and its documented safety profile in pregnancy. *Ivermectin* - Ivermectin is primarily used for **strongyloidiasis** and **onchocerciasis**, not pinworms. - Its safety in pregnancy is less established compared to pyrantel pamoate, and it is generally avoided during gestation unless absolutely necessary. *Albendazole* - Albendazole is an effective treatment for pinworms, but it is generally **contraindicated in the first trimester** of pregnancy due to potential teratogenicity and is only used in the second and third trimesters if the benefits outweigh the risks. - Given the availability of safer alternatives like pyrantel pamoate, albendazole is not the most appropriate first-line choice for pinworms in pregnancy. *Supportive therapy* - While supportive therapy (e.g., hygiene measures) is important in managing pinworm infection, it is insufficient as the **sole treatment** for eradicating the parasites, especially with confirmed ova. - **Pharmacological treatment** is necessary to kill the worms and prevent reinfection. *Praziquantel* - Praziquantel is the drug of choice for treating **schistosomiasis** and **tapeworm infections**. - It is not effective against **pinworms**.

Question 14: A 20-year-old G1P0 woman at 12 weeks estimated gestational age presents to the obstetric clinic for the first prenatal visit. She admits to being unsure of whether to keep or abort the pregnancy but now has finally decided to keep it. She says she is experiencing constant fatigue. Physical examination reveals conjunctival pallor. Her hemoglobin level is 10.1 g/dL. Which of the following additional features would likely be present in this patient?

A. Decreased TIBC
B. Decreased exercise tolerance
C. Increased Transferrin Saturation
D. Pica (Correct Answer)
E. Onychorrhexis

Explanation: ***Pica*** - The patient's fatigue, conjunctival pallor, and hemoglobin of 10.1 g/dL at 12 weeks gestation are highly suggestive of **iron deficiency anemia**. **Pica** (cravings for non-nutritive substances like ice, dirt, or clay) is a common symptom of severe iron deficiency. - This symptom reflects a compensatory mechanism or an attempt to replenish depleted iron stores. *Decreased TIBC* - In **iron deficiency anemia**, the total iron-binding capacity (**TIBC**) is typically **increased** as the body tries to maximize iron uptake due to low iron stores. - A decreased TIBC would be characteristic of **anemia of chronic disease**, not iron deficiency. *Increased Transferrin Saturation* - **Transferrin saturation** measures the percentage of transferrin that is bound to iron. In **iron deficiency anemia**, iron stores are low, leading to **decreased transferrin saturation**. - Increased transferrin saturation is seen in conditions like **hemochromatosis** or iron overload, which are not suggested by the patient's presentation. *Decreased exercise tolerance* - While **decreased exercise tolerance** is a common symptom of **anemia** due to reduced oxygen-carrying capacity, it is a general symptom of anemia and not as specific for iron deficiency as pica. - The question asks for *additional features* likely to be present, and pica is a highly specific and often recognized symptom of iron deficiency. *Onychorrhexis* - **Onychorrhexis**, or longitudinal ridging and brittleness of the nails, can occur in **iron deficiency anemia**, but it is less specific than pica and often associated with more chronic or severe cases. - **Koilonychia** (spoon nails) is a highly specific nail finding for chronic iron deficiency but onychorrhexis is a more general finding.

Question 15: A 28-year-old woman, gravida 2, para 1, at 14 weeks' gestation, comes to the physician with a 3-day history of abnormal vaginal discharge. She has not had fever, chills, or abdominal pain. One week ago, her 2-year-old daughter had a urinary tract infection that quickly resolved after antibiotic therapy. The patient reports that she is sexually active with one male partner and they do not use condoms. Vital signs are within normal limits. Pelvic examination shows an inflamed and friable cervix. There is mucopurulent, foul-smelling discharge from the cervical os. There is no uterine or cervical motion tenderness. Vaginal pH measurement shows a pH of 3.5. Which of the following is the most appropriate initial step in management?

A. Wet mount preparation
B. Nucleic acid amplification test (Correct Answer)
C. Amine test
D. Urine analysis and culture
E. Potassium hydroxide preparation

Explanation: ***Nucleic acid amplification test*** - The patient's symptoms of **inflamed, friable cervix** and **mucopurulent discharge**, along with a normal vaginal pH (3.5), are highly suggestive of **cervicitis**, commonly caused by *Chlamydia trachomatis* or *Neisseria gonorrhoeae*. - **NAATs** are the most sensitive and specific tests for detecting these organisms, which is crucial for prompt diagnosis and treatment, especially in pregnancy, to prevent adverse outcomes. *Wet mount preparation* - A **wet mount** would be useful for identifying *Trichomonas vaginalis* or *Candida* species and diagnosing **bacterial vaginosis**, but the patient's normal vaginal pH makes these diagnoses less likely. - While it can help rule out other common causes of vaginal discharge, it is **not sensitive enough** to reliably detect *Chlamydia* or *Gonorrhea*. *Amine test* - The **amine test** (or whiff test) is used to detect the release of amines in the presence of **bacterial vaginosis**, typically indicated by a **vaginal pH >4.5**. - The patient's vaginal pH of 3.5 makes **bacterial vaginosis highly unlikely**, so an amine test would not be beneficial in this scenario. *Urine analysis and culture* - While the patient's daughter recently had a **urinary tract infection (UTI)**, the patient's symptoms are localized to the cervix (cervicitis) with **no fever, chills, or abdominal pain** indicative of a UTI. - A urine analysis and culture would be appropriate if bladder symptoms were present, but it **will not diagnose cervicitis** or the specific sexually transmitted infections causing it. *Potassium hydroxide preparation* - A **KOH preparation** is primarily used to identify **fungal elements (hyphae and spores)**, indicating a *Candida* infection, which typically presents with thick, white, "cottage cheese" discharge and itching. - This test is **not useful for diagnosing cervicitis** or bacterial causes of vaginal discharge, and the patient's symptoms are not consistent with candidiasis.

Question 16: A 20-year-old woman comes to the physician for contraceptive counseling. She has recently become sexually active with her boyfriend and expresses concerns because approximately 10 days ago the condom broke during intercourse. Her medical history is significant for deep vein thrombosis and pulmonary embolism. Urine pregnancy test is negative. After discussing different contraceptive options, the patient says, “I'd like to try the most effective method that works without hormones and would allow me to become pregnant at a later time.” The contraceptive method that best meets the patient's wishes has which of the following mechanisms?

A. Avoiding sex during fertile period
B. Preventing ovulation
C. Thickening of cervical mucus
D. Inducing endometrial inflammation (Correct Answer)
E. Closing off the fallopian tubes

Explanation: ***Inducing endometrial inflammation*** - The patient's desire for a **non-hormonal**, **highly effective**, and **reversible** contraceptive method that avoids her history of **deep vein thrombosis (DVT) and pulmonary embolism (PE)** strongly points to the **copper intrauterine device (IUD)**. - The primary mechanism of the copper IUD is to induce a **sterile inflammatory reaction** in the endometrium, which is toxic to sperm and ova, preventing fertilization and implantation. *Avoiding sex during fertile period* - This describes **fertility awareness methods**, which are generally **less effective** than the patient desires. - These methods require careful tracking of the menstrual cycle and abstinence, making them prone to **user error**. *Preventing ovulation* - This is the primary mechanism of **hormonal contraceptives**, which the patient wishes to avoid due to her history of DVT/PE and preference for a **non-hormonal option**. - Hormonal contraceptives (e.g., combined oral contraceptives, patches, rings) are contraindicated or used with caution in individuals with a history of **thromboembolism**. *Thickening of cervical mucus* - This is a common mechanism of **progestin-only hormonal contraceptives** (e.g., progestin-only pills, hormonal IUDs, implants), which the patient also wants to avoid. - While hormonal IUDs have lower systemic absorption than other hormonal methods, the patient specifically asked for a **non-hormonal method**. *Closing off the fallopian tubes* - This describes **surgical sterilization** (e.g., tubal ligation), which is generally considered **permanent** and would not allow the patient to become pregnant at a later time, contrary to her stated wishes. - This method is also invasive and not a reversible form of contraception.

Question 17: A 28-year-old primigravida presents to the office with complaints of heartburn while lying flat on the bed at night and mild constipation that started a couple of weeks ago. She is 10 weeks pregnant, as determined by her last menstrual period. Her first menstruation was at 13 years of age and she has always had regular 28-day cycles. Her past medical history is insignificant. She does not smoke cigarettes or drink alcohol and does not take any medications. Her father died of colon cancer at 70 years of age, while her mother has diabetes and hypertension. Her vital signs include: temperature 36.9℃ (98.4℉), blood pressure 98/52 mm Hg, pulse 113/minute, oxygen saturation 99%, and respiratory rate 12 /minute. The physical examination was unremarkable, except for a diastolic murmur heard over the apex. Which of the following is considered abnormal in this woman?

A. Decreased vascular resistance
B. Diastolic murmur (Correct Answer)
C. Tachycardia
D. Increased cardiac output
E. Low blood pressure

Explanation: ***Diastolic murmur*** - Diastolic murmurs in pregnancy are **never normal** and always require further investigation to rule out significant **cardiac pathology**, such as valvular stenosis or regurgitation. - While physiological changes in pregnancy can lead to systolic murmurs, **diastolic murmurs** are considered pathological. *Decreased vascular resistance* - **Peripheral vasodilation** due to hormonal changes (**progesterone**) is a normal physiological adaptation in early pregnancy, leading to decreased systemic vascular resistance. - This decrease helps accommodate the **increased blood volume** and cardiac output, contributing to a slight drop in blood pressure. *Tachycardia* - An **increased heart rate** is a normal physiological response in pregnancy, typically seen as early as the first trimester. - This compensatory mechanism helps maintain **cardiac output** in the face of decreased systemic vascular resistance and increased blood volume. *Increased cardiac output* - **Cardiac output increases** significantly during pregnancy, primarily due to increases in both heart rate and stroke volume, to meet the metabolic demands of the mother and fetus. - This increase begins in the **first trimester** and peaks in the second trimester, remaining elevated until delivery. *Low blood pressure* - A **mild decrease in blood pressure**, particularly the diastolic pressure, is common in early pregnancy due to generalized vasodilation. - The given blood pressure (98/52 mm Hg) is within the expected physiological range for a healthy pregnant woman in her first trimester.

Question 18: A 52-year-old female presents with a primary complaint of amenorrhea for the past 6 months. She also reports dyspareunia, recurrent headache, and infrequent episodes of night sweats. Diagnostic work-up reveals increased serum FSH levels. Which additional laboratory findings would most likely be seen in this patient?

A. Increased serum progesterone and increased serum LH
B. Decreased serum estradiol and increased serum progesterone
C. Decreased serum estradiol and increased serum LH (Correct Answer)
D. Increased serum estradiol and decreased serum LH
E. Decreased serum progesterone and increased serum testosterone

Explanation: ***Decreased serum estradiol and increased serum LH*** - **Amenorrhea**, **dyspareunia**, **headaches**, and **night sweats** in a 52-year-old female, along with **increased serum FSH**, are classic signs of **menopause**. - During menopause, the ovaries decrease **estrogen** (estradiol) production; this lack of negative feedback to the pituitary causes a compensatory **increase in LH** and FSH. *Increased serum progesterone and increased serum LH* - **Increased progesterone** is typically seen after ovulation or during pregnancy, neither of which is consistent with the patient's symptoms of amenities and menopausal signs. - While **LH is increased in menopause**, the elevation of progesterone would indicate active ovarian function, contrasting with the overall clinical picture. *Decreased serum estradiol and increased serum progesterone* - While **decreased estradiol** is appropriate for menopause, **increased progesterone** would be contradictory. - **Progesterone levels** generally fall during menopause due to the cessation of ovulation. *Increased serum estradiol and decreased serum LH* - **Increased serum estradiol** would contradict the symptoms of menopause, as it would imply continued ovarian function. - **Decreased LH** would also be inconsistent with ovarian failure, as LH levels rise to stimulate non-responsive ovaries. *Decreased serum progesterone and increased serum testosterone* - While **decreased serum progesterone** is expected in menopause, **increased testosterone** is not a primary diagnostic marker for menopause. - Although testosterone levels can fluctuate, a significant increase is not a typical and consistent finding.

Question 19: A 31-year-old female presents to her primary care physician with mild anxiety and complaints of mood swings lasting several months. The patient reports that the mood swings affect her work and personal relationships. In addition, she complains of increased irritability, breast tenderness, bloating, fatigue, binge-eating, and difficulty concentrating for 10 days prior to her menstrual period. The patient's symptoms increase in severity with the approach of menses but resolve rapidly on the first day of menses. She states that she is very sensitive to criticism of her work by others. She also snaps at her children and her husband. She has tried yoga to unwind, but with limited improvement. She is concerned that her behavior is affecting her marriage. The patient has no past medical history, and has regular periods every 24 days. She has had two normal vaginal deliveries. She uses condoms for contraception. Her mother has major depressive disorder. The physical exam is unremarkable. What is the most appropriate next step in the treatment of this patient?

A. Nonserotonergic antidepressants
B. Selective serotonin reuptake inhibitors (SSRIs) (Correct Answer)
C. Oral contraceptive and nonsteroidal anti-inflammatory drugs (NSAIDs)
D. Gonadotropin-releasing hormone (GnRH) agonists
E. Anxiolytic therapy

Explanation: ***Selective serotonin reuptake inhibitors (SSRIs)*** - This patient presents with symptoms highly suggestive of **Premenstrual Dysphoric Disorder (PMDD)**, including mood swings, irritability, physical symptoms (bloating, breast tenderness), and functional impairment, all occurring cyclically in the **luteal phase** and resolving with menses. - **SSRIs** are considered first-line pharmacological treatment for PMDD due to their efficacy in reducing both psychological and physical symptoms. They can be prescribed continuously or intermittently (only during the luteal phase). *Nonserotonergic antidepressants* - While some antidepressants can be used for mood disorders, **nonserotonergic agents** (e.g., bupropion) are generally not considered first-line for PMDD. - The efficacy of these agents specifically for the range of PMDD symptoms, particularly cyclical ones, is less well established compared to SSRIs. *Oral contraceptive and nonsteroidal anti-inflammatory drugs (NSAIDs)* - **Oral contraceptives** can sometimes alleviate PMDD symptoms in some women by suppressing ovulation and stabilizing hormonal fluctuations, but they are not the primary pharmacological treatment for the mood and anxiety symptoms of PMDD. - **NSAIDs** are effective for physical symptoms like cramps or headaches, but they do not address the primary mood and psychiatric symptoms of PMDD. *Gonadotropin-releasing hormone (GnRH) agonists* - **GnRH agonists** induce a temporary pharmacological menopause, effectively stopping ovarian hormone production, which can alleviate severe PMDD symptoms. - However, due to significant side effects (hot flashes, bone loss) and their more aggressive nature, they are typically reserved for **severe cases of PMDD refractory to first-line treatments**, not as an initial step. *Anxiolytic therapy* - **Anxiolytics** (e.g., benzodiazepines) can help manage **anxiety symptoms** but do not address the full spectrum of PMDD, including mood swings, irritability, and physical symptoms. - They also carry risks of dependence and are generally reserved for short-term use or as adjuncts in specific situations, not as a primary treatment for PMDD.

Question 20: A 23-year-old G1P0 female presents to her OB/GYN for her routine 36-week visit. Her current complaints include increased fatigue at the end of the day, and edema in her ankles. The patient’s physical examination is unremarkable except for inguinal adenopathy. Upon pelvic examination for cervical changes, the OB/GYN notices a vaginal chancre. The patient states that it is not painful when touched. Which of the following is the most likely diagnosis?

A. Secondary syphilis
B. Cardiovascular syphilis
C. Primary syphilis (Correct Answer)
D. Gummatous syphilis
E. Neurosyphilis

Explanation: ***Primary syphilis*** - A **painless chancre** is the hallmark lesion of primary syphilis, which develops at the site of initial inoculation. - While fatigue and edema are common in pregnancy, the presence of a **painless vaginal chancre** and **inguinal adenopathy** is highly indicative of primary syphilis. *Secondary syphilis* - This stage is characterized by a **disseminated skin rash** (often involving palms and soles), **condyloma lata**, and generalized lymphadenopathy, not a solitary chancre. - Symptoms usually appear several weeks or months after the chancre of primary syphilis has healed. *Cardiovascular syphilis* - This is a form of **tertiary syphilis** that affects the heart and great vessels, typically resulting in **aortitis**, aneurysms, or aortic regurgitation. - It develops years to decades after the initial infection and would not present with a chancre. *Gummatous syphilis* - This is another manifestation of **tertiary syphilis**, characterized by the formation of **gummas**—soft, non-cancerous granulomas that can affect any organ. - Like cardiovascular syphilis, it occurs many years after initial infection and does not involve a primary chancre. *Neurosyphilis* - This involves the **central nervous system** and can occur at any stage of syphilis, but is usually a late complication. - Symptoms vary widely but include **meningitis**, strokes, or psychiatric manifestations, none of which are consistent with a chancre or the acute presentation described.

Question 21: A 27-year-old primigravid woman at 32 weeks' gestation comes to the physician for a prenatal visit. She has had swollen legs, mild shortness of breath, and generalized fatigue for the past 2 weeks. Medications include iron supplements and a multivitamin. Her temperature is 37.2°C (99°F), pulse is 93/min, respirations are 20/min, and blood pressure is 108/60 mm Hg. There is 2+ pitting edema of the lower extremities, but no erythema or tenderness. The lungs are clear to auscultation. Cardiac examination shows an S3 gallop. Pelvic examination shows a uterus consistent in size with a 32-week gestation. Which of the following is the most appropriate next step in management for this patient's symptoms?

A. Ventilation-perfusion scan
B. Urinalysis
C. Echocardiography (Correct Answer)
D. Lower extremity doppler
E. Reassurance and monitoring

Explanation: ***Echocardiography*** - The patient presents with classic signs of **peripartum cardiomyopathy**, including **new-onset heart failure** symptoms (dyspnea, fatigue, edema) in the late stages of pregnancy (32 weeks) with an **S3 gallop**. - **Echocardiography** is the definitive diagnostic tool to visualize cardiac function, assess ventricular size, and measure the **ejection fraction** to confirm cardiomyopathy. *Ventilation-perfusion scan* - This test is primarily used to diagnose **pulmonary embolism**, which typically presents with sudden onset dyspnea, pleuritic chest pain, and sometimes hypoxemia, none of which are prominent here. - While shortness of breath is present, the **S3 gallop** and widespread edema are more indicative of cardiac dysfunction than pulmonary embolism. *Urinalysis* - A urinalysis is used to screen for kidney issues or **preeclampsia** (proteinuria), which can present with edema and hypertension. - However, this patient's blood pressure is normal, and her symptoms point more directly to cardiac rather than renal pathology. *Lower extremity doppler* - This is used to diagnose **deep vein thrombosis (DVT)**, which would typically cause unilateral leg swelling, warmth, and tenderness. - The patient has **bilateral pitting edema** with no erythema or tenderness, making DVT less likely as the primary cause of her symptoms. *Reassurance and monitoring* - Given the patient's significant and worsening symptoms (**dyspnea, S3 gallop, widespread edema**), simply reassuring her and monitoring would be inappropriate and could lead to delayed diagnosis and treatment of a serious cardiac condition. - These symptoms are beyond the normal physiological changes of pregnancy and warrant urgent investigation.

Question 22: A 20-year-old primigravid woman comes to the physician in October for her first prenatal visit. She has delayed the visit because she wanted a “natural birth” but was recently convinced to get a checkup after feeling more tired than usual. She feels well. Menarche was at the age of 12 years and menses used to occur at regular 28-day intervals and last 3–7 days. The patient emigrated from Mexico 2 years ago. Her immunization records are unavailable. Pelvic examination shows a uterus consistent in size with a 28-week gestation. Laboratory studies show: Hemoglobin 12.4 g/dL Leukocyte count 8,000/mm3 Blood group B negative Serum Glucose 88 mg/dL Creatinine 1.1 mg/dL TSH 3.8 μU/mL Rapid plasma reagin negative HIV antibody negative Hepatitis B surface antigen negative Urinalysis shows no abnormalities. Urine culture is negative. Chlamydia and gonorrhea testing are negative. A Pap smear is normal. Administration of which of the following vaccines is most appropriate at this time?

A. Varicella and influenza
B. Varicella and Tdap
C. Influenza only
D. Tdap and influenza (Correct Answer)
E. Hepatitis B and MMR

Explanation: ***Tdap and influenza*** - The **Tdap vaccine** is recommended for pregnant women during each pregnancy, preferably between **27 and 36 weeks gestation**, to provide passive immunity to the newborn against pertussis. The patient is at 28 weeks gestation. - The **influenza vaccine** is recommended for all pregnant women, regardless of trimester, during flu season (October in this case) to protect both the mother and the newborn. *Varicella and influenza* - The **varicella vaccine is contraindicated in pregnancy** because it is a live attenuated vaccine. - While influenza vaccine is appropriate, administering varicella vaccine is not. *Varicella and Tdap* - As mentioned, the **varicella vaccine is contraindicated in pregnancy** due to its live attenuated nature. - Although Tdap is appropriate, varicella is not. *Influenza only* - While the **influenza vaccine is appropriate**, the **Tdap vaccine** is also indicated for this patient given her gestational age and the benefits for the newborn. - Administering only influenza would miss an opportunity to provide crucial pertussis protection. *Hepatitis B and MMR* - The **Hepatitis B vaccine** is safe in pregnancy if indicated, but the patient tested **Hepatitis B surface antigen negative**, suggesting no current infection and no immediate need for vaccination based on the provided information. - The **MMR vaccine is contraindicated in pregnancy** because it is a live attenuated vaccine.

Question 23: A 29-year-old man presents to an STD clinic complaining of a painful lesion at the end of his penis. The patient says it started as a tiny red bump and grew over several days. He has no history of a serious illness and takes no medications. He has had several sexual partners in the past few months. At the clinic, his temperature is 38.2℃ (100.8℉), the blood pressure is 115/70 mm Hg, the pulse is 84/min, and the respirations are 14/min. Examination of the inguinal area shows enlarged and tender lymph nodes, some of which are fluctuant. There is an ulcerated and weeping sore with an erythematous base and ragged edges on the end of his penis. The remainder of the physical examination shows no abnormalities. The result of the Venereal Disease Research Laboratory (VDRL) is negative. Which of the following diagnoses best explains these findings?

A. Chancre
B. Chancroid (Correct Answer)
C. Condyloma latum
D. Lymphogranuloma venereum
E. Condyloma acuminatum

Explanation: ***Chancroid*** - This diagnosis is characterized by a **painful genital ulcer** with **ragged edges** and an **erythematous base**, accompanied by **painful, enlarged, and fluctuant inguinal lymph nodes** (buboes). - The causative agent is *Haemophilus ducreyi*, and the patient's symptoms, including fever and recent multiple sexual partners, are consistent with this infection. *Chancre* - A chancre, characteristic of **primary syphilis**, is typically a **painless ulcer** with a clean base and firm, raised borders, which contrasts with the painful and ragged ulcer described here. - While syphilis can cause lymphadenopathy, it's usually bilateral and non-tender, unlike the painful and fluctuant nodes seen in chancroid; the **negative VDRL** also rules out active syphilis. *Condyloma latum* - **Condyloma latum** are moist, flat-topped, wart-like lesions associated with **secondary syphilis**, and they are typically **painless** and do not ulcerate or weep. - This presentation does not match the described painful, ulcerated lesion, and the negative VDRL further discredits active syphilis. *Lymphogranuloma venereum* - **Lymphogranuloma venereum (LGV)**, caused by specific serovars of *Chlamydia trachomatis*, presents with a usually **painless, transient papule or ulcer** followed by severe, often unilateral, inguinal lymphadenopathy that can coalesce into buboes. - While LGV can cause painful buboes, the initial lesion is often inconspicuous and painless, unlike the prominent painful ulcer described here. *Condyloma acuminatum* - **Condyloma acuminatum**, or **genital warts**, are caused by the **human papillomavirus (HPV)** and present as cauliflower-like, flesh-colored growths that are typically **painless** and **non-ulcerative**. - This presentation does not involve an ulcerated, weeping lesion or associated painful lymphadenopathy, making it an unlikely diagnosis.

Question 24: A 34-year-old woman, gravida 2, para 0, at 28 weeks' gestation comes to the physician for a prenatal visit. She has not had regular prenatal care. Her most recent ultrasound at 20 weeks of gestation confirmed accurate fetal dates and appropriate fetal development. She takes levothyroxine for hypothyroidism. She used to work as a nurse before she emigrated from Brazil 13 years ago. She lost her immunization records during the move and cannot recall all of her vaccinations. She appears well. Vital signs are within normal limits. Physical examination shows a fundal height of 26 cm and no abnormalities. An ELISA test for HIV is negative. Serology testing shows hepatitis B surface antibody positive, hepatitis B core antibody and surface antigen negative, and hepatitis A antibody negative. Hepatitis C antibody is positive with detectable RNA. Given her incomplete vaccination history and current serologic results, which of the following vaccinations is most appropriate to recommend at this time?

A. Undergo liver biopsy
B. Schedule a cesarean delivery
C. Start combination therapy with interferon α and ribavirin
D. Counsel about transmission risks and plan postpartum treatment
E. Hepatitis A vaccination (Correct Answer)

Explanation: ***Hepatitis A vaccination*** - The patient has no prior immunity to **Hepatitis A**, as indicated by the **negative Hepatitis A antibody** serology. - Vaccination against **Hepatitis A** is crucial in this patient, especially given her increased risk of exposure due to being a former healthcare worker and a positive hepatitis C infection. *Undergo liver biopsy* - A **liver biopsy** is an invasive procedure and is generally not recommended during pregnancy, especially when other diagnostic or management strategies are available. - While it can assess the degree of liver damage, it is usually reserved for specific indications and is not the most appropriate immediate step for vaccine recommendation. *Schedule a cesarean delivery* - **Hepatitis C viral transmission** to the fetus is primarily vertical during birth, but a **cesarean delivery** has not been shown to significantly reduce this risk compared to vaginal delivery. - The decision regarding delivery method is typically made based on obstetric indications rather than solely for Hepatitis C prevention. *Start combination therapy with interferon α and ribavirin* - **Interferon α** and **ribavirin** are contraindicated during pregnancy due to their **teratogenic effects** and severe side effects. - Antiviral treatment for Hepatitis C is generally deferred until **postpartum**. *Counsel about transmission risks and plan postpartum treatment* - While counseling about **transmission risks** and planning **postpartum treatment** for Hepatitis C is essential, it addresses the existing Hepatitis C infection rather than prescribing a vaccination, which is the direct question. - It is an important part of comprehensive care for this patient but not the most appropriate *vaccination* recommendation.

Question 25: An 18-year-old woman presents to the medical clinic 4 days after her boyfriend's condom broke during sexual intercourse. The patient states "I do not wish to get pregnant at this point in my life." She has no other medical conditions and takes no prescription medications. Her family history is negative. She is a social drinker, drinking approximately 3–4 days every month. She is currently in a monogamous relationship with her boyfriend and she believes her boyfriend is monogamous as well. The heart rate is 104/min, and the blood pressure is 124/80 mm Hg. On physical examination, she appears tired and nervous. Heart auscultation reveals no murmur, and the lungs are clear to auscultation bilaterally. Her ovaries and uterus are palpable. Speculum exam shows no signs of trauma and a closed cervical os. Based on her history and physical examination, which of the following management strategies would you recommend?

A. Ethinyl estradiol
B. Mifepristone
C. Copper-IUD (Correct Answer)
D. Ulipristal acetate
E. Levonorgestrel

Explanation: ***Copper-IUD*** - A **copper IUD** is the most effective form of emergency contraception, with a failure rate of less than 0.1%. It can be inserted up to 5 days after unprotected intercourse. - It works by causing a **spermicidal inflammatory reaction** in the uterus, preventing fertilization and implantation. *Ethinyl estradiol* - **Ethinyl estradiol** is an estrogen component typically used in combined oral contraceptives, but not as effective as dedicated emergency contraception methods. - Using estrogen alone for emergency contraception would require a very high dose, leading to significant side effects like **nausea and vomiting**, and its efficacy is lower compared to other options. *Mifepristone* - **Mifepristone** is an antiprogestin primarily used for medical abortion within the first 10 weeks of pregnancy, not as a standalone emergency contraceptive. - It would not be the first-line choice for emergency contraception in a patient seeking to prevent pregnancy *after* intercourse, but rather to terminate an established pregnancy. *Ulipristal acetate* - **Ulipristal acetate** is an effective oral emergency contraceptive that can be taken up to 5 days (120 hours) after unprotected intercourse. - While effective, its efficacy is slightly lower than a copper IUD, especially as time from intercourse increases, and the patient has no contraindications for IUD insertion. *Levonorgestrel* - **Levonorgestrel** (Plan B One-Step) is an oral emergency contraceptive most effective when taken within 72 hours, though it can be somewhat effective up to 120 hours. - Its efficacy decreases significantly after 72 hours, and it is less effective than a copper IUD, especially considering the patient is already 4 days post-intercourse.

Question 26: A 29-year-old G1P0 woman at 24 weeks gestation presents to her physician with complaints of burning with urination, and she reports that she has been urinating much more frequently than usual over the past several days. She otherwise is doing well and has experienced no complications with her pregnancy or vaginal discharge. Her temperature is 97.5°F (36.4°C), blood pressure is 112/82 mmHg, pulse is 89/min, respirations are 19/min, and oxygen saturation is 98% on room air. Examination is significant for suprapubic discomfort upon palpation and a gravid uterus. There is no costovertebral angle tenderness. Urinalysis shows increased leukocyte esterase, elevated nitrites, 55 leukocytes/hpf, and bacteria. The physician prescribes a 7-day course of nitrofurantoin. Which of the following is the next best step in management?

A. Test for gonorrhea and chlamydia
B. Send a urine culture (Correct Answer)
C. Perform a renal ultrasound
D. Add ciprofloxacin to antibiotic regimen
E. Add penicillin to antibiotic regimen

Explanation: ***Send a urine culture*** - A urine culture is crucial for confirming the diagnosis of a **urinary tract infection (UTI)**, identifying the specific pathogen, and determining its **antibiotic susceptibility** in pregnant patients. - This step ensures that the prescribed antibiotic, nitrofurantoin, is effective against the causative organism, which is essential to prevent complications like pyelonephritis and preterm birth in pregnancy. *Test for gonorrhea and chlamydia* - While sexually transmitted infections (STIs) can cause dysuria, the patient's urinalysis findings (leukocyte esterase, nitrites, leukocytes, bacteria) are highly suggestive of a **bacterial UTI**, not primarily an STI. - Furthermore, the absence of vaginal discharge makes **gonorrhea** and **chlamydia** less likely as the primary cause of her symptoms. *Perform a renal ultrasound* - A renal ultrasound is generally reserved for patients with **recurrent UTIs**, suspected **urinary tract obstruction**, or signs of **pyelonephritis** (e.g., fever, flank pain), which are not present here. - This patient's symptoms are consistent with a routine cystitis, and there's no indication for imaging at this initial presentation. *Add ciprofloxacin to antibiotic regimen* - **Ciprofloxacin** is a **fluoroquinolone**, which is generally **contraindicated in pregnancy** due to potential adverse effects on fetal cartilage development. - The standard first-line antibiotics for UTIs in pregnancy, like nitrofurantoin, are preferred and typically effective. *Add penicillin to antibiotic regimen* - While penicillin is generally safe in pregnancy, it is not a first-line agent for typical uncomplicated UTIs, which are often caused by **gram-negative bacteria** like *E. coli* that may not be susceptible to penicillin alone. - The patient is already on nitrofurantoin, an appropriate choice, and adding penicillin without a culture result is not indicated.

Question 27: A 23-year-old woman presents with a 4-week menstrual delay. She also complains of irritability, increased somnolence, and occasional nausea. She had her first menarche at the age of 13, and her menstrual cycle became regular at the age of 15. She has been sexually active since the age of 20 but has had the same sexual partner since then. They stopped using birth control protection approximately 6 months ago. She does not smoke and consumes alcohol occasionally. Her blood pressure is 120/80 mm Hg, heart rate is 71/min, respiratory rate is 14/min, and temperature is 36.6℃ (98.2℉). Physical examination is significant only for slight breast engorgement and nipple pigmentation. Gynecologic examination reveals cervical softening and cyanosis. Which of the following drugs would be recommended for this patient?

A. Progesterone
B. Vitamin A
C. Folic acid (Correct Answer)
D. Combination of natural estrogen and progestin
E. Biphasic oral contraceptive

Explanation: **Folic acid** - The patient's symptoms (menstrual delay, breast engorgement, nipple pigmentation, cervical softening, and cyanosis) strongly suggest **early pregnancy**. - **Folic acid supplementation** is crucial in early pregnancy to prevent **neural tube defects** in the fetus. *Progesterone* - While progesterone supports pregnancy, it is not typically prescribed as a routine supplement to confirmed pregnant women without specific indications like a history of recurrent miscarriage or threatened abortion. - Its primary role in normal early pregnancy is maintained by the corpus luteum, and exogenous supplementation isn't universally recommended. *Vitamin A* - **Excessive intake of Vitamin A** during pregnancy can be teratogenic, causing congenital malformations. - Routine high-dose supplementation is generally avoided, and daily requirements are typically met through prenatal vitamins. *Combination of natural estrogen and progestin* - This combination constitutes **hormone replacement therapy** or some forms of contraception, which are contraindicated in pregnancy. - Introducing exogenous sex hormones could interfere with the natural hormonal balance essential for a healthy pregnancy. *Biphasic oral contraceptive* - Oral contraceptives are **contraindicated during pregnancy** as they are used to prevent conception. - Continuing or initiating them would be inappropriate and potentially harmful given the signs of pregnancy.

Question 28: A 28-year-old woman, gravida 2, para 1, at 24 weeks gestation comes to the physician for a prenatal visit. She reports dull aching pain and paresthesia over her left hand during the last few weeks. The pain radiates to her shoulder and is worse at night. Her hand feels numb upon waking up in the morning. She has a sister who has multiple sclerosis. Her current medications include iron supplements and a multivitamin. Vital signs are within normal limits. When the wrist is passively held in full flexion, aggravation of paresthesia is perceived immediately. Which of the following is the most likely explanation for this patient's symptoms?

A. Demyelinating disease of peripheral nerves
B. Ulnar nerve compression
C. Demyelinating disease of CNS
D. Median nerve compression (Correct Answer)
E. Cervical radiculopathy

Explanation: ***Median nerve compression*** - The patient's symptoms of **dull aching pain**, **paresthesia** in the hand radiating to the shoulder, and **nocturnal worsening** relieved by activity are classic for **carpal tunnel syndrome (CTS)**. - The **Phalen's maneuver** (passive wrist flexion causing paresthesia) is a positive sign for CTS, indicating compression of the **median nerve** at the wrist, which is often exacerbated during pregnancy due to fluid retention and swelling. *Demyelinating disease of peripheral nerves* - While it can cause paresthesia, it typically presents with more diffuse and progressive sensory or motor deficits, and the specific pattern of hand symptoms and a positive Phalen's test are not characteristic. - The symptoms are more localized and directly reproduced by a maneuver that specifically impinges the median nerve. *Ulnar nerve compression* - Compression of the ulnar nerve (e.g., at the **cubital tunnel**) would cause symptoms primarily in the **fourth and fifth digits**, which is not described here. - A positive Phalen's maneuver specifically implicates the median nerve, not the ulnar nerve. *Demyelinating disease of CNS* - A demyelinating disease of the CNS, like **multiple sclerosis**, which runs in her family, would present with more widespread, fluctuating neurological deficits, often involving vision, balance, or motor weakness. - The symptoms described are strictly localized to the hand and arm distribution, consistent with a peripheral nerve entrapment. *Cervical radiculopathy* - Cervical radiculopathy, caused by nerve root compression in the neck, would typically present with neck pain, and the pain and paresthesia would follow a **dermatomal pattern** corresponding to the affected nerve root. - While it can radiate to the shoulder and arm, the positive Phalen's maneuver points specifically to a wrist-level median nerve compression, and the lack of neck pain makes it less likely.

Question 29: A 27-year-old African-American woman, gravida 1, para 0, at 11 weeks' gestation comes to her physician for a prenatal visit. She feels more fatigued than usual but has no other symptoms. She has no history of serious illness. She takes no medications. Her mother has systemic lupus erythematosus. Her temperature is 37.2°C (98.9°F), pulse is 80/min, respirations are 18/min, and blood pressure is 120/75 mm Hg. Examination shows no abnormalities. Laboratory studies show: Hemoglobin 9.2 g/dL Hematocrit 27.5% Leukocyte count 6,000/mm3 Platelet Count 180,000/mm3 MCV 74 μm3 MCH 24 pg/cell Serum Na+ 138 mEq/L K+ 4.5 mEq/L Cl- 100 mEq/L HCO3- 25 mEq/L Urea Nitrogen 15 mg/dL Creatinine 1.0 mg/dL Total Bilirubin 0.4 mg/dL Iron 67 U/L Ferritin 98 ng/mL Which of the following is the most appropriate next step in management?

A. Measure LDH and haptoglobin
B. Hemoglobin electrophoresis (Correct Answer)
C. Perform direct Coombs test
D. Measure anticardiolipin antibody titers
E. Amniocentesis

Explanation: **Hemoglobin electrophoresis** - The patient's **microcytic anemia** (MCV 74) with normal ferritin suggests a diagnosis other than iron deficiency, such as a **hemoglobinopathy**, particularly given her African-American ethnicity and the possibility of **thalassemia** or **sickle cell trait**. - **Prenatal screening for hemoglobinopathies** is crucial, and hemoglobin electrophoresis is the definitive test to identify different hemoglobin variants and diagnose conditions like **alpha and beta thalassemia traits** or **sickle cell trait**, which are important for genetic counseling and management during pregnancy. *Measure LDH and haptoglobin* - These tests are used to evaluate for **hemolytic anemia** (elevated LDH, low haptoglobin). - While the patient has anemia, there are no other signs of hemolysis (e.g., elevated bilirubin, reticulocytosis, jaundice), and a primary focus should be on identifying the cause of the microcytic anemia before investigating hemolysis. *Perform direct Coombs test* - A direct Coombs test is used to detect **autoimmune hemolytic anemia**. - There is no clinical or laboratory evidence to suggest an autoimmune hemolytic process (e.g., no spherocytes, no significant reticulocytosis, normal bilirubin). *Measure anticardiolipin antibody titers* - This test screens for **antiphospholipid syndrome**, which is associated with recurrent pregnancy loss and thrombosis. - While her mother has SLE, which can be associated with antiphospholipid syndrome, the patient's primary presenting problem is unexplained microcytic anemia, not a history of pregnancy complications or thrombotic events. *Amniocentesis* - Amniocentesis is an invasive procedure used for **fetal genetic testing** and is typically performed later in pregnancy (15-20 weeks). - There is no medical indication for amniocentesis at 11 weeks' gestation based on the current presentation; the immediate concern is diagnosing and managing the maternal anemia.

Question 30: A 26-year-old woman presents to the women’s health clinic with a 9-week delay in menses. The patient has a history of grand mal seizures, and was recently diagnosed with acute sinusitis. She is prescribed lamotrigine and amoxicillin. The patient smokes one-half pack of cigarettes every day for 10 years, and drinks socially a few weekends every month. Her mother died of breast cancer when she was 61 years old. The vital signs are stable during the current office visit. Physical examination is grossly normal. The physician orders a urine beta-hCG that comes back positive. Abdominal ultrasound shows an embryo consistent in dates with the first day of last menstrual period. Given the history of the patient, which of the following would most likely decrease congenital malformations in the newborn?

A. Decrease alcohol consumption
B. Switching to cephalexin
C. Folic acid supplementation (Correct Answer)
D. Smoking cessation
E. Switching to another antiepileptic medication

Explanation: ***Folic acid supplementation*** - **Folic acid** (vitamin B9) is crucial in early pregnancy for **neural tube development** and significantly reduces the risk of **neural tube defects** and other congenital malformations. - Given the patient’s history of **lamotrigine** use, which can increase the risk of neural tube defects, folic acid supplementation is even more critical. *Decrease alcohol consumption* - While **alcohol cessation** is important to prevent **fetal alcohol syndrome** and other alcohol-related developmental issues, it primarily affects neurological development and facial dysmorphology rather than primarily preventing - The effects of alcohol are typically more pronounced with **chronic heavy consumption**, and while any reduction is beneficial, it is not the most likely intervention to decrease general congenital malformations. *Switching to cephalexin* - **Amoxicillin** is considered **safe in pregnancy** and is a penicillin-class antibiotic, while **cephalexin** is a cephalosporin. - Switching antibiotics from one safe drug to another without a clear medical indication (e.g., allergy, resistance) would **not decrease the risk of congenital malformations**. *Smoking cessation* - **Smoking cessation** is vital during pregnancy as it reduces the risk of **low birth weight**, **preterm birth**, and other complications like placental abruption. - However, the primary link of smoking is not directly with **congenital malformations** like neural tube defects, but rather with growth restriction and adverse perinatal outcomes. *Switching to another antiepileptic medication* - This patient is on **lamotrigine**, which is considered one of the **safer antiepileptic drugs (AEDs)** in pregnancy, especially compared to others like **valproic acid**. - Switching to an alternative AED might even carry a **higher risk for congenital malformations** and is generally not recommended unless lamotrigine is ineffective or contraindicated.

Question 31: A 23-year-old woman comes to the emergency department because of a 5-day history of nausea and vomiting. There is no associated fever, abdominal pain, constipation, diarrhea, or dysuria. She is sexually active and uses condoms inconsistently. Her last menstrual period was 10 weeks ago. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 18/min, and blood pressure is 110/70 mm Hg. There is no rebound tenderness or guarding. A urine pregnancy test is positive. Ultrasonography shows an intrauterine pregnancy consistent in size with an 8-week gestation. The hormone that was measured in this patient's urine to detect the pregnancy is also directly responsible for which of the following processes?

A. Hypertrophy of the uterine myometrium
B. Fetal angiogenesis
C. Maintenance of the corpus luteum (Correct Answer)
D. Inhibition of ovulation
E. Stimulation of uterine contractions at term

Explanation: ***Maintenance of the corpus luteum*** - The hormone measured in the urine pregnancy test is **human chorionic gonadotropin (hCG)**. hCG's primary role early in pregnancy is to **maintain the corpus luteum**, which in turn produces progesterone to support the uterine lining. - The **corpus luteum** is essential for progesterone production until the placenta is sufficiently developed to take over this function, typically around 8-10 weeks gestation. *Hypertrophy of the uterine myometrium* - **Estrogen** and **progesterone** are primarily responsible for the hypertrophy and hyperplasia of the uterine myometrium during pregnancy. - While hCG indirectly supports this by maintaining the corpus luteum (which produces estrogen and progesterone), it does not directly cause myometrial hypertrophy itself. *Fetal angiogenesis* - **Vascular endothelial growth factor (VEGF)** and **fibroblast growth factor (FGF)** are key factors directly involved in fetal angiogenesis (the formation of new blood vessels in the fetus). - While proper placental function, supported by hCG, is critical for fetal growth, hCG itself is not the direct mediator of fetal angiogenesis. *Inhibition of ovulation* - High levels of **estrogen** and **progesterone** (produced by the corpus luteum, maintained by hCG) provide **negative feedback** to the hypothalamus and pituitary, thus inhibiting the release of GnRH, FSH, and LH, which prevents further ovulation. - hCG itself does not directly inhibit ovulation; rather, it sets in motion the hormonal cascade that leads to its inhibition. *Stimulation of uterine contractions at term* - **Oxytocin** is the primary hormone responsible for stimulating uterine contractions, particularly at term, often in conjunction with prostaglandins. - hCG levels peak early in pregnancy and then decline, and it plays no direct role in stimulating labor contractions.

Question 32: An 18-year-old G1P0 woman who is 10 weeks pregnant presents for her first prenatal visit. She reports nausea with occasional vomiting but denies bleeding, urinary symptoms, or abdominal pain. She just graduated high school and works at the local grocery store. She does not take any medications and has no known drug allergies. Physical examination is unremarkable. Initial laboratory studies reveal the following: Serum: Na+: 140 mEq/L Cl-: 100 mEq/L K+: 4.0 mEq/L HCO3-: 24 mEq/L BUN: 10 mg/dL Glucose: 100 mg/dL Creatinine: 1.0 mg/dL Thyroid-stimulating hormone: 2.5 µU/mL Ca2+: 9.5 mg/dL AST: 25 U/L ALT: 20 U/L Leukocyte count: 10,000 cells/mm^3 with normal differential Hemoglobin: 14 g/dL Hematocrit: 42% Platelet count: 200,000 /mm^3 Urine: Epithelial cells: few Glucose: negative WBC: 20/hpf Bacterial: > 100,000 cfu / E. coli pan-sensitive What is the best next step in management?

A. Levofloxacin for three days
B. Nitrofurantoin for duration of pregnancy
C. Observation and treatment if symptoms develop
D. Observation and repeat cultures in one week
E. Nitrofurantoin for seven days (Correct Answer)

Explanation: ***Nitrofurantoin for seven days*** - The patient has **asymptomatic bacteriuria** (ABU) in pregnancy, indicated by the positive urine culture (>100,000 cfu/mL *E. coli*) without urinary symptoms. - Timely treatment of ABU in pregnancy with an appropriate antibiotic like **nitrofurantoin** for 7 days is essential to prevent complications such as pyelonephritis and preterm birth. *Levofloxacin for three days* - **Fluoroquinolones** such as levofloxacin are generally **contraindicated in pregnancy** due to potential adverse effects on fetal cartilage development. - A 3-day course is also typically too short for adequate treatment of ABU in pregnancy, where a 7-day course is usually recommended. *Nitrofurantoin for duration of pregnancy* - While nitrofurantoin is a safe and effective treatment for ABU in pregnancy, continuous treatment for the **entire duration of pregnancy** is typically reserved for women with recurrent UTIs or a history of pyelonephritis, not initial ABU. - A 7-day course is sufficient for initial treatment of ABU. *Observation and treatment if symptoms develop* - **Asymptomatic bacteriuria in pregnancy** is a significant risk factor for developing symptomatic urinary tract infections, including pyelonephritis, which can lead to serious maternal and fetal complications. - Therefore, ABU identified during pregnancy **must be treated**, even in the absence of symptoms, and observation is not appropriate. *Observation and repeat cultures in one week* - As with the previous option, ABU in pregnancy carries significant risks and requires **immediate antibiotic treatment**, not delayed observation. - Waiting to repeat cultures simply prolongs the presence of bacteriuria, increasing the risk of ascending infection and complications.

Question 33: A 5-year-old boy presents for a regularly scheduled check-up. The child is wheelchair bound due to lower extremity paralysis and suffers from urinary incontinence. At birth, it was noted that the child had lower limbs of disproportionately small size in relation to the rest of his body. Radiograph imaging at birth also revealed several abnormalities in the spine, pelvis, and lower limbs. Complete history and physical performed on the child's birth mother during her pregnancy would likely have revealed which of the following?

A. Maternal use of nicotine
B. Maternal use of tetracyclines
C. Maternal hyperthyroidism
D. Maternal use of lithium
E. Uncontrolled maternal diabetes mellitus (Correct Answer)

Explanation: ***Uncontrolled maternal diabetes mellitus*** - **Maternal diabetes** is a significant risk factor for **caudal regression syndrome**, which presents with **lower limb paralysis**, **urinary incontinence**, and **spinal/pelvic abnormalities**. - The combination of disproportionately small lower limbs and the associated neurological and skeletal issues strongly points to a congenital anomaly linked to **poor glycemic control** during pregnancy. *Maternal use of nicotine* - Maternal nicotine use is associated with a range of adverse pregnancy outcomes, including **low birth weight**, **premature birth**, and **respiratory problems**, but not typically caudal regression syndrome. - While concerning, it does not directly explain the specific constellation of skeletal, neurological, and urological abnormalities described. *Maternal use of tetracyclines* - **Tetracycline exposure** during pregnancy can lead to **tooth discoloration** and **bone growth inhibition**, particularly in the developing fetus. - It is not known to cause the severe spinal and lower limb malformations, paralysis, or urinary incontinence seen in this case. *Maternal hyperthyroidism* - Uncontrolled maternal hyperthyroidism can lead to complications such as **fetal tachycardia**, **goiter**, and **preterm birth**. - It is not directly associated with congenital malformations like caudal regression syndrome that affect the lower spine and limbs. *Maternal use of lithium* - Maternal lithium use is most notably associated with an increased risk of **Ebstein's anomaly**, a congenital **heart defect**. - It does not explain the specific musculoskeletal, neurological, and urological abnormalities presented in the case.

Question 34: A 26-year-old primigravida woman presents to her obstetrician for her first prenatal visit. Her last menstrual cycle was 12 weeks ago. She denies tobacco, alcohol, illicit drug use, or history of sexually transmitted infections. She denies recent travel outside the country but is planning on visiting her family in Canada for Thanksgiving in 3 days. Her past medical and family history is unremarkable. Her temperature is 97.5°F (36.3°C), blood pressure is 119/76 mmHg, pulse is 90/min, and respirations are 20/min. BMI is 22 kg/m^2. Fetal pulse is 136/min. The patient's blood type is B-negative. Mumps and rubella titers are non-reactive. Which of the following is the most appropriate recommendation at this visit?

A. Measles-mumps-rubella vaccination
B. Rh-D immunoglobulin
C. One hour glucose challenge
D. PCV23 vaccination
E. Influenza vaccination (Correct Answer)

Explanation: ***Influenza vaccination*** - The patient is in her **first trimester** and should receive an **inactivated influenza vaccine (IIV)** because she will be traveling during the flu season. - The **Centers for Disease Control and Prevention (CDC)** recommends that all pregnant women receive the influenza vaccine, regardless of the trimester of pregnancy. *Measles-mumps-rubella vaccination* - The **MMR vaccine** is a **live attenuated vaccine** and is **contraindicated in pregnancy** due to the theoretical risk of congenital rubella syndrome. - Since the patient's **rubella titers are non-reactive**, she should defer vaccination until **after delivery**. *Rh-D immunoglobulin* - **Rh-D immunoglobulin** is administered to Rh-negative mothers to prevent alloimmunization, but it is typically given at **28 weeks' gestation** and again postpartum if the baby is Rh-positive. - This patient is only **12 weeks pregnant**, making prophylaxis unnecessary at this time. *One hour glucose challenge* - The **one-hour glucose challenge test** for **gestational diabetes mellitus** is routinely performed between **24 and 28 weeks' gestation**. - Performing this test at **12 weeks' gestation** would be premature and not provide accurate results. *PCV23 vaccination* - The **pneumococcal polysaccharide vaccine (PPSV23)** is generally recommended for pregnant women only if they have risk factors like chronic medical conditions (e.g., asthma, diabetes, heart disease) or are immunocompromised. - This patient has **no risk factors** indicating a need for **PCV23 vaccination** at this time.

Question 35: A 34-year-old primigravid woman at 8 weeks' gestation comes to the emergency department 4 hours after the onset of vaginal bleeding and crampy lower abdominal pain. She has passed multiple large and small blood clots. The vaginal bleeding and pain have decreased since their onset. Her temperature is 37°C (98.6°F), pulse is 98/min, and blood pressure is 112/76 mm Hg. Pelvic examination shows mild vaginal bleeding and a closed cervical os. An ultrasound of the pelvis shows minimal fluid in the endometrial cavity and no gestational sac. Which of the following is the most likely diagnosis?

A. Complete abortion (Correct Answer)
B. Incomplete abortion
C. Threatened abortion
D. Missed abortion
E. Inevitable abortion

Explanation: ***Complete abortion*** - The patient's history of **vaginal bleeding**, **crampy abdominal pain**, passage of **blood clots**, and subsequent *decrease* in bleeding and pain are classic signs. - A **closed cervical os** and **empty endometrial cavity** on ultrasound confirm that all products of conception have been expelled. *Incomplete abortion* - This would involve the *partial expulsion* of products of conception, meaning some tissue would still be retained in the uterus. - The ultrasound would show **retained products of conception** within the endometrial cavity, and the os might be open. *Threatened abortion* - Characterized by **vaginal bleeding** with a **closed cervical os** and a *viable pregnancy* (gestational sac with or without fetal pole) on ultrasound. - There would typically be *no passage of tissue* or clots, and the pregnancy would still be ongoing. *Missed abortion* - Involves a **non-viable pregnancy** where the embryo or fetus has died but there is *no expulsion of tissue* or significant bleeding. - The ultrasound would show a gestational sac or fetus without cardiac activity, and the cervical os would be closed. *Inevitable abortion* - Presents with **vaginal bleeding** and an **open cervical os**, indicating that abortion is in progress and cannot be stopped. - While there is bleeding and pain, the key differentiating factor from a complete abortion is the *open cervical os* and often *ongoing expulsion* of tissue.

Question 36: A 30-year old G2P1 woman, currently at 38 weeks estimated gestational age, presents with contractions. She says that she did not have any prenatal care, because she does not have health insurance. Upon delivery, the infant appears jaundiced and has marked hepatosplenomegaly. Serum hemoglobin is 11.6 g/dL and serum bilirubin is 8 mg/dL. The direct and indirect Coombs tests are both positive. The mother has never had a blood transfusion. Her previous child was born healthy with no complications. Which of the following is most consistent with this neonate’s most likely condition?

A. The neonate developed IgM autoantibodies to its own red blood cells
B. This condition could have been prevented with the administration of glucocorticoids
C. Vitamin K deficiency has led to hemolytic anemia
D. The mother generated IgM antibodies against fetal red blood cells
E. The mother generated IgG antibodies against fetal red blood cells (Correct Answer)

Explanation: ***The mother generated IgG antibodies against fetal red blood cells*** - The positive direct and indirect **Coombs test** in a jaundiced neonate with **hepatosplenomegaly** and **anemia** (elevated bilirubin, normal hemoglobin for full term is 14-24 g/dL, 11.6 is borderline to low) suggests **hemolytic disease of the newborn (HDN)**. This is typically caused by maternal **IgG antibodies** crossing the placenta and targeting fetal red blood cells, as IgG is the only antibody class capable of crossing the placenta. - The history of a healthy first child suggests that the mother was likely sensitized during the first pregnancy, and in the second pregnancy, a more robust immune response led to the production of these IgG antibodies. *The neonate developed IgM autoantibodies to its own red blood cells* - **IgM antibodies** do not cross the placenta, therefore any hemolytic disease caused by IgM from the mother would not affect the fetus. - While autoimmune hemolytic anemia can occur in neonates, the positive indirect Coombs test (detecting antibodies in the mother's serum) points more strongly to maternal antibodies. *This condition could have been prevented with the administration of glucocorticoids* - Glucocorticoids are used to enhance fetal **lung maturity** in cases of preterm labor, and are not indicated for the prevention or treatment of hemolytic disease of the newborn. - Prevention of HDN due to Rh incompatibility typically involves the administration of **RhoGAM (anti-D immunoglobulin)** to Rh-negative mothers. *Vitamin K deficiency has led to hemolytic anemia* - **Vitamin K deficiency** in neonates primarily causes **coagulopathy** (bleeding disorders) due to impaired synthesis of clotting factors. - It does not cause hemolytic anemia, hepatosplenomegaly, or positive Coombs tests. *The mother generated IgM antibodies against fetal red blood cells* - **IgM antibodies** are **pentameric** and too large to cross the **placental barrier**. - Therefore, maternal IgM antibodies cannot cause hemolytic disease of the newborn.

Question 37: A 23-year-old woman presents to the outpatient OB/GYN clinic as a new patient who wishes to begin contraception. She has no significant past medical history, family history, or social history. The review of systems is negative. Her vital signs are: blood pressure 118/78 mm Hg, pulse 73/min, and respiratory rate 16/min. She is afebrile. Physical examination is unremarkable. She has researched multiple different contraceptive methods, and wants to know which is the most efficacious. Which of the following treatments should be recommended?

A. Withdrawal
B. Male condoms
C. Intrauterine device (IUD) (Correct Answer)
D. Diaphragm with spermicide
E. NuvaRing

Explanation: ***Intrauterine device (IUD)*** - **IUDs** are among the most **efficacious** reversible contraceptive methods, with typical use pregnancy rates less than 1% per year. - They offer long-term contraception (3-10 years depending on the type) and do not require daily adherence, which contributes to their high effectiveness. *Withdrawal* - The withdrawal method is **highly user-dependent** and has a typical failure rate of about 20-22% per year. - Its effectiveness relies completely on perfect timing and self-control, making it one of the **least efficacious** methods. *Male condoms* - While effective when used perfectly, **male condoms** have a typical use failure rate of about 13-18% per year. - Their efficacy is significantly reduced by inconsistent or incorrect use. *Diaphragm with spermicide* - The **diaphragm with spermicide** has a typical use failure rate of about 12-17% per year, similar to condoms. - Its effectiveness depends on proper fit, correct insertion before intercourse, and consistent use of spermicide. *NuvaRing* - The **NuvaRing**, an estrogen-progestin ring, has a typical use failure rate of about 7-9% per year. - While more effective than barrier methods, its efficacy is still lower than that of IUDs or implants, often due to user adherence issues like forgetting to replace the ring.

Question 38: A 34-year-old gravida 5, para 4 presents to the physician for prenatal care at 32 weeks of pregnancy. She comes from a rural region of Ethiopia and did not have appropriate prenatal care during previous pregnancies. She has no complaints of swelling, contractions, loss of fluid, or bleeding from the vagina. During her current pregnancy, she has received proper care and has completed the required laboratory and instrumental tests, which did not show any pathology. Her blood pressure is 130/70 mm Hg, heart rate is 77/min, respiratory rate is 15/min, and temperature is 36.6°C (97.8°F). Her examination is consistent with a normal 32-weeks’ gestation. The patient tells the physician that she is going to deliver her child at home, without any medical aid. The physician inquires about her tetanus vaccination status. The patient reports that she had tetanus 1 year after her first delivery at the age of 16, and it was managed appropriately. She had no tetanus vaccinations since then. Which of the following statements is true?

A. The patient should receive at least 2 doses of tetanus toxoid within the 4-week interval to ensure that she and her baby will both have immunity against tetanus. (Correct Answer)
B. The antibodies from tetanus immune globulin vaccine, if given to a pregnant woman, would not cross the placental barrier.
C. Even if the patient receives appropriate tetanus vaccination, it will be necessary to administer toxoid to the newborn.
D. The patient is protected against tetanus due to her past medical history, so only the child is at risk of developing tetanus after an out-of-hospital delivery.
E. The patient does not need vaccination because she has developed natural immunity against tetanus and will pass it to her baby.

Explanation: ***The patient should receive at least 2 doses of tetanus toxoid within the 4-week interval to ensure that she and her baby will both have immunity against tetanus.*** - For unvaccinated or incompletely vaccinated pregnant women, the **CDC recommends a series of at least two doses of tetanus toxoid-containing vaccine (Tdap or Td)**. These doses should be given at least 4 weeks apart to provide sufficient maternal protection and ensure the transfer of **passive immunity** to the newborn. - This regimen ensures that both the mother and the baby receive protection against tetanus, particularly crucial in settings of **home delivery without medical aid** where the risk of exposure is higher. *The antibodies from tetanus immune globulin vaccine, if given to a pregnant woman, would not cross the placental barrier.* - **Tetanus immune globulin (TIG)** provides immediate, but short-lived, passive immunity and its antibodies **do cross the placental barrier**. - However, TIG is not routinely used for prenatal vaccination; **tetanus toxoid (Tdap/Td)** is administered to stimulate active antibody production in the mother and subsequent passive transfer to the fetus. *Even if the patient receives appropriate tetanus vaccination, it will be necessary to administer toxoid to the newborn.* - If the mother receives **appropriate tetanus vaccination (Tdap/Td) during pregnancy**, sufficient **maternal antibodies are transferred to the newborn** via the placenta, protecting the infant during the first few months of life. - Therefore, the newborn typically does not require immediate tetanus toxoid administration at birth if the mother was adequately vaccinated during pregnancy; their primary series of vaccinations begins later. *The patient is protected against tetanus due to her past medical history, so only the child is at risk of developing tetanus after an out-of-hospital delivery.* - While prior tetanus infection can provide some immunity, it is **not always long-lasting or fully protective**, and it does not guarantee protection for future pregnancies or the newborn. - Therefore, the mother should still be vaccinated to ensure both her and the baby's protection, especially when delivering in a high-risk environment. *The patient does not need vaccination because she has developed natural immunity against tetanus and will pass it to her baby.* - **Natural immunity to tetanus following infection is often insufficient and may not be long-lasting**, unlike immunity conferred by vaccination. - Therefore, vaccination is still recommended to ensure adequate immunity for the mother and to facilitate the transfer of protective antibodies to the baby.

Question 39: A 20-year-old woman presents with nausea, fatigue, and breast tenderness. She is sexually active with two partners and occasionally uses condoms during intercourse. A β-hCG urinary test is positive. A transvaginal ultrasound reveals an 8-week fetus in the uterine cavity. The patient is distressed by this news and requests an immediate abortion. Which of the following is the most appropriate step in management?

A. Explain the risk and potential harmful effects of the procedure. (Correct Answer)
B. Ask the patient to reconsider and refer her to a social worker.
C. Ask the patient to obtain consent from legal guardians.
D. Ask the patient to obtain consent from the baby’s father.
E. Conduct a psychiatric evaluation for mental competence.

Explanation: ***Explain the risk and potential harmful effects of the procedure.*** - It is crucial to **inform the patient fully** about the medical procedure, including its risks and benefits, as part of the **informed consent** process. - This ensures the patient makes an autonomous, well-considered decision, which is a fundamental ethical principle in medicine. *Ask the patient to reconsider and refer her to a social worker.* - While it's important to ensure the patient has considered all aspects, **directly asking the patient to reconsider** can be perceived as coercive and may undermine her autonomy. - Referring to a social worker might be appropriate if the patient expresses uncertainty or needs support, but it should not be a replacement for proper medical counseling about the procedure itself. *Ask the patient to obtain consent from legal guardians.* - At 20 years old, the patient is an **adult** and legally capable of making her own medical decisions, including consent for abortion. - Forcing her to obtain consent from legal guardians would infringe upon her **autonomy and legal rights**. *Ask the patient to obtain consent from the baby’s father.* - In most jurisdictions, a woman's decision to have an abortion is **her legal right**, and the consent of the father is **not required**. - Requiring paternal consent would violate her **personal autonomy** and could create unnecessary barriers to care. *Conduct a psychiatric evaluation for mental competence.* - There is **no indication** in the patient's presentation (nausea, fatigue, breast tenderness, distress about pregnancy) that suggests she lacks the mental competence to make her own medical decisions. - Requesting a psychiatric evaluation without clinical grounds would be **unethical and inappropriate**.

Question 40: A 27-year-old G3P2002 presents to the clinic for follow up after her initial prenatal visit. Her last period was 8 weeks ago. Her medical history is notable for obesity, hypertension, type 2 diabetes, and eczema. Her current two children are healthy. Her current pregnancy is with a new partner after she separated from her previous partner. Her vaccinations are up to date since the delivery of her second child. Her temperature is 98°F (37°C), blood pressure is 110/60 mmHg, pulse is 85/min, and respirations are 18/min. Her physical exam is unremarkable. Laboratory results are shown below: Hemoglobin: 14 g/dL Hematocrit: 41% Leukocyte count: 9,000/mm^3 with normal differential Platelet count: 210,000/mm^3 Blood type: O Rh status: Negative Urine: Epithelial cells: Rare Glucose: Positive WBC: 5/hpf Bacterial: None Rapid plasma reagin: Negative Rubella titer: > 1:8 HIV-1/HIV-2 antibody screen: Negative Gonorrhea and Chlamydia NAAT: negative Pap smear: High-grade squamous intraepithelial lesion (HGSIL) What is the best next step in management?

A. Repeat Pap smear
B. Colposcopy and biopsy now (Correct Answer)
C. Colposcopy and biopsy after delivery
D. Loop electrosurgical excision procedure (LEEP)
E. Cryosurgical excision

Explanation: **Colposcopy and biopsy now** - A finding of **high-grade squamous intraepithelial lesion (HGSIL)** during pregnancy warrants immediate **colposcopy** to evaluate the extent of the cervical abnormality. - **Biopsy** should be performed if indicated during colposcopy to rule out **invasive cancer**, as delaying diagnosis could worsen prognosis. *Repeat Pap smear* - Repeating the Pap smear is not appropriate because a **HGSIL** result indicates a significant abnormality requiring further diagnostic evaluation, not just re-screening. - Delaying definitive diagnosis could lead to progression of a high-grade lesion or missing an **invasive cancer**. *Colposcopy and biopsy after delivery* - While some procedures can be deferred, delaying colposcopy and biopsy for a **HGSIL** until after delivery is not recommended due to the risk of **progression to invasive cancer** during pregnancy. - Close monitoring with colposcopy and biopsy for suspected high-grade lesions or cancer is **safe** during pregnancy. *Loop electrosurgical excision procedure (LEEP)* - **LEEP** is an excisional procedure that removes cervical tissue and is typically used for diagnosed **cervical intraepithelial neoplasia (CIN) 2/3 or AIS**, not as the initial diagnostic step for HGSIL during pregnancy. - It carries a risk of obstetric complications, such as **preterm delivery**, and is generally deferred until after pregnancy unless invasive cancer is suspected. *Cryosurgical excision* - **Cryosurgery** is an ablative treatment used for low-grade cervical lesions (CIN 1) or in some cases of CIN 2, but it is not indicated for **HGSIL** as an initial step, especially during pregnancy where tissue diagnosis is crucial. - It is an ablative treatment that destroys tissue without obtaining a specimen for histopathological evaluation, which is necessary to rule out **invasive malignancy**.

Question 41: A 25-year-old female comes to her obstetrician’s office for a prenatal visit. She has a transvaginal ultrasound that correlates with her last menstrual period and dates her pregnancy at 4 weeks. She has no complaints except some nausea during the morning that is improving. She comments that she has had some strange food cravings, but has no issues with eating a balanced diet. Her BMI is 23 kg/m^2 and she has gained 1 pound since the start of her pregnancy. She is curious about her pregnancy and asks the physician what her child is now able to do. Which of the following developments is expected of the fetus during this embryological phase?

A. Formation of male genitalia
B. Closure of the neural tube (Correct Answer)
C. Movement of limbs
D. Creation of the notochord
E. Cardiac activity visible on ultrasound

Explanation: ***Closure of the neural tube*** - At **4 weeks gestation**, the **neural tube** is in the process of closing, forming the precursor for the brain and spinal cord, making this a critical developmental milestone. - This period is vital for the prevention of neural tube defects like **spina bifida** and **anencephaly**. *Formation of male genitalia* - The differentiation of **external genitalia** (male or female) occurs much later, typically around weeks **9-12 of gestation**, much later than the 4-week mark discussed here. - Prior to this, the genital ridges are bipotential and do not yet show sex-specific characteristics. *Movement of limbs* - While limb buds begin to appear around 4-5 weeks, coordinated **limb movements** are typically observed much later, around **10-12 weeks** of gestation, as muscular and neurological systems further develop. - Early movements are typically subtle and reflex-like, rather than purposeful. *Creation of the notochord* - The **notochord** is formed during **gastrulation**, which occurs predominantly in the **third week of gestation**, prior to the 4-week mark. - It serves as the primary axial support for the embryo and induces the formation of the neural tube. *Cardiac activity visible on ultrasound* - **Cardiac activity** typically becomes detectable on transvaginal ultrasound between **5 and 6 weeks gestation**, shortly after the 4-week mark. - At 4 weeks, the heart tube may have started to form, but discernible beating is usually not yet evident.

Question 42: A 25-year-old G1P0000 presents to her obstetrician’s office for her first prenatal visit. She had a positive pregnancy test 6 weeks ago, and her last period was about two months ago, though at baseline her periods are irregular. Aside from some slight nausea in the mornings, she feels well. Which of the following measurements would provide the most accurate dating of this patient’s pregnancy?

A. Crown-rump length (Correct Answer)
B. Femur length
C. Abdominal circumference
D. Biparietal diameter
E. Serum beta-hCG

Explanation: ***Crown-rump length*** - This measurement, typically obtained via **transvaginal ultrasound** in the first trimester (up to 13 weeks 6 days), provides the **most accurate gestational age dating**. - It's highly precise because fetal growth is very consistent during this early period, minimizing variability. *Femur length* - This is a biometric measurement typically used for dating in the **second and third trimesters**. - Its accuracy for dating is lower than CRL in the first trimester and becomes more variable in later pregnancy due to individual fetal growth differences. *Abdominal circumference* - This measurement is primarily used in the **late second and third trimetes**r to assess fetal growth and weight, rather than for accurate dating. - It is highly susceptible to variations based on fetal nutrition and health, making it a poor choice for initial dating. *Biparietal diameter* - This is a reliable measurement for dating from the **late first trimester through the second trimester**, but it is less accurate than CRL in the very early first trimester. - After the first trimester, its accuracy declines compared to earlier measurements as individual variations in head size become more prominent. *Serum beta-hCG* - While a **positive beta-hCG test** confirms pregnancy and quantitative levels can suggest gestational age ranges, it's not a precise dating tool. - Levels vary widely among individuals and with different types of pregnancies (e.g., multiples), making it unsuitable for accurate dating.

Question 43: A 21-year-old gravida 1, para 0 woman presents to the family medicine clinic for her first prenatal appointment. She states that she has been taking folic acid supplements daily as directed by her mother. She smokes a few cigarettes a day and has done so for the last 5 years. Pediatric records indicate the patient is measles, mumps, and rubella non-immune. Her heart rate is 78/min, respiratory rate is 14/min, temperature is 36.5°C (97.7°F), and blood pressure is 112/70 mm Hg. Her calculated BMI is approximately 26 kg/m2. Her heart is without murmurs and lung sounds are clear bilaterally. Standard prenatal testing is ordered. Which of the following is the next best step for this patient’s prenatal care?

A. MMR vaccine during pregnancy
B. Serology, then vaccine postpartum
C. MMR vaccine postpartum (Correct Answer)
D. Serology, then vaccine during pregnancy
E. MMR vaccine and immune globulin postpartum

Explanation: ***MMR vaccine postpartum*** - The **MMR vaccine is a live attenuated vaccine** and therefore **contraindicated during pregnancy** due to the theoretical risk of fetal infection and congenital rubella syndrome. - Vaccinating postpartum ensures the mother develops immunity without any risk to the current pregnancy, and it's also safe for breastfeeding. *MMR vaccine during pregnancy* - Administering a **live attenuated vaccine** like MMR during pregnancy is generally avoided due to the **theoretical risk of teratogenicity**. - While documented cases of congenital rubella syndrome from the vaccine are rare, the risk is not zero, making it unsafe for routine administration during gestation. *Serology, then vaccine postpartum* - The patient's records already indicate she is **MMR non-immune**, rendering additional serology unnecessary to determine her immune status. - The crucial step is the timing of vaccination, which should be postpartum, regardless of repeat serology findings. *Serology, then vaccine during pregnancy* - As explained, **MMR vaccination is contraindicated during pregnancy**, making immediate vaccination during gestation an inappropriate course of action. - While serology can confirm non-immunity, it doesn't change the recommendation to delay vaccination until after delivery. *MMR vaccine and immune globulin postpartum* - **Immune globulin** is typically given for passive immunity following exposure to certain diseases if the patient is non-immune (e.g., RhoGAM for Rh-negative mothers). - It is **not routinely administered with the MMR vaccine postpartum** for healthy, non-immune individuals, as the vaccine itself stimulates active immunity.

Question 44: A 23-year-old woman presents to her primary care physician for a wellness checkup. She has been treated for gonorrhea and chlamydia 3 times in the past 6 months but is otherwise healthy. She smokes cigarettes, drinks alcohol regularly, and wears a helmet while riding her bicycle. The patient is generally healthy and has no acute complaints. Her vitals and physical exam are unremarkable. She is requesting advice regarding contraception. The patient is currently taking oral contraceptive pills. Which of the following would be the most appropriate recommendation for this patient?

A. Intrauterine device
B. Tubal ligation
C. Etonogestrel implant
D. Condoms (Correct Answer)
E. Pull out method

Explanation: ***Condoms*** - The patient has a history of **recurrent STIs**, indicating a need for barrier protection in addition to contraception to prevent future infections. - **Condoms** are the only contraceptive method listed that provides significant protection against STIs, making them the most appropriate recommendation for this patient's overall health and sexual practices. *Intrauterine device* - While a highly effective contraceptive, an **IUD** does not protect against sexually transmitted infections (STIs), and the patient's history suggests a high risk for contracting STIs. - Additionally, some IUDs (like copper IUDs) can **increase menstrual bleeding**, and hormonal IUDs have their own systemic effects. *Tubal ligation* - This is a permanent sterilization method that, while highly effective for contraception, offers **no protection against STIs**. - It is generally considered for women who have completed childbearing or are certain they do not desire future pregnancies, which may not be the case for a 23-year-old. *Etonogestrel implant* - The **etonogestrel implant** is an effective form of contraception but offers **no protection against STIs**. - The patient's history of recurrent STIs indicates that a method also providing STI prevention is crucial. *Pull out method* - The **pull-out method** is an unreliable form of contraception with a high failure rate, offering minimal protection against pregnancy and **no protection against STIs**. - Given the patient's history of STIs and desire for effective contraception, this method is entirely inappropriate.

Question 45: A 23-year-old woman, gravida 1 para 0, at 16 weeks’ gestation presents to the physician because of swelling of her right breast for 1 month. She has no personal or family history of any serious illnesses. She has taken contraceptive pills over the past few years. Vital signs are within normal limits. Physical examination shows asymmetric breasts with the right breast being enlarged. The palpation of the breast shows a 4 x 5 cm (1.5 x 1.9 in) mass under the skin in the upper outer quadrant. It is nontender and mobile with a rubbery consistency and regular borders. A breast ultrasound shows a round and solid homogeneous mass with well-defined borders and low echogenicity, measuring 5 cm (1.9 in) in diameter. Which of the following is the most likely diagnosis?

A. Fibroadenoma (Correct Answer)
B. Invasive ductal carcinoma
C. Lobular carcinoma
D. Medullary carcinoma
E. Fibrocystic changes

Explanation: ***Fibroadenoma*** - The patient's age (23 years old), pregnancy status, and the description of the mass—**rubbery, mobile, nontender, with regular borders**, and **low echogenicity on ultrasound**—are highly characteristic of a fibroadenoma. - Fibroadenomas are **benign tumors** common in young women and can grow during pregnancy due to hormonal stimulation. *Invasive ductal carcinoma* - This typically presents as a **hard, fixed, irregular mass** that is often **nontender** but may cause skin dimpling or nipple retraction, none of which are described. - While it is the most common form of breast cancer, its characteristics **do not match** the highly mobile and rubbery nature of the described mass. *Lobular carcinoma* - Often presents as a **diffuse thickening** rather than a well-defined mass and can be multifocal or bilateral. - It's **less common** than invasive ductal carcinoma and its presentation is inconsistent with the clear, round mass described. *Medullary carcinoma* - This is a **rare subtype of invasive ductal carcinoma** that can appear well-circumscribed on imaging, mimicking a benign lesion. - However, it typically presents as a **firm, fixed mass** and is less likely in a young woman with a classic fibroadenoma presentation. *Fibrocystic changes* - Characterized by **multiple cysts, tenderness, and fluctuating size** with menstrual cycles; often described as "lumpy" breasts rather than a single, well-defined mass. - While common, the description of a **single, discrete, rubbery, mobile mass** is not typical for fibrocystic changes.

Question 46: A 19-year-old woman comes to the physician because of recent weight gain. She started a combined oral contraceptive for dysmenorrhea and acne six months ago. She has been taking the medication consistently and experiences withdrawal bleeding on the 4th week of each pill pack. Her acne and dysmenorrhea have improved significantly. The patient increased her daily exercise regimen to 60 minutes of running and weight training three months ago. She started college six months ago. She has not had any changes in her sleep or energy levels. Her height is 162 cm and she weighs 62 kg; six months ago she weighed 55 kg. Examination shows clear skin and no other abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A. Measure serum testosterone concentration
B. Perform a low-dose dexamethasone suppression test
C. Measure serum TSH level
D. Switch contraceptive to a non-hormonal contraceptive method
E. Reassure the patient (Correct Answer)

Explanation: ***Reassure the patient*** - The patient's **weight gain of 7 kg (BMI 23.6 kg/m²) over six months is within the normal range** and is likely due to the combination of starting college (lifestyle changes) and increased muscle mass from her intensified exercise regimen. - Her improved acne and dysmenorrhea, consistent withdrawal bleeding, and lack of other concerning symptoms (e.g., changes in sleep, energy, or examination abnormalities) suggest the oral contraceptive is well-tolerated and effective for its intended purposes. *Measure serum testosterone concentration* - Although **PCOS** can cause weight gain and acne, the patient's acne has significantly improved with combined oral contraceptives, and her menstrual cycles are regular (withdrawal bleeding). - There are no other signs of hyperandrogenism (e.g., hirsutism, clitoromegaly) to warrant testosterone measurement. *Perform a low-dose dexamethasone suppression test* - This test is used to diagnose **Cushing syndrome**, which can cause weight gain and acne. - However, the patient does not exhibit other classic features of Cushing syndrome such as central obesity, moon facies, striae, or proximal muscle weakness, and her skin is described as clear. *Measure serum TSH level* - **Hypothyroidism** can lead to weight gain, but the patient reports no changes in her sleep or energy levels, and increased exercise suggests she is not experiencing fatigue. - Other common symptoms of hypothyroidism, such as cold intolerance or constipation, are not mentioned. *Switch contraceptive to a non-hormonal contraceptive method* - While some women experience weight gain with hormonal contraceptives, the **evidence for significant weight gain directly attributable to oral contraceptives is mixed and often minimal**. - Given that her primary concerns (dysmenorrhea and acne) have significantly improved without other adverse effects, and her weight gain can be otherwise explained, switching contraception is not the most appropriate first step.

Question 47: A 29-year-old G1P0 presents to her obstetrician for her first prenatal care visit at 12 weeks gestation by last menstrual period. She states that her breasts are very tender and swollen, and her exercise endurance has declined. She otherwise feels well. She is concerned about preterm birth, as she heard that certain cervical procedures increase the risk. The patient has a gynecologic history of loop electrosurgical excision procedure (LEEP) for cervical dysplasia several years ago and has had negative Pap smears since then. She also has mild intermittent asthma that is well controlled with occasional use of her albuterol inhaler. At this visit, this patient’s temperature is 98.6°F (37.0°C), pulse is 69/min, blood pressure is 119/61 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and the uterine fundus is just palpable at the pelvic brim. Pelvic exam reveals normal female external genitalia, a closed and slightly soft cervix, a 12-week-size uterus, and no adnexal masses. Which of the following is the best method for evaluating for possible cervical incompetence in this patient?

A. Transabdominal ultrasound in the first trimester
B. Transvaginal ultrasound in the first trimester
C. Serial transvaginal ultrasounds starting at 16 weeks gestation
D. Transabdominal ultrasound at 18 weeks gestation
E. Transvaginal ultrasound at 18 weeks gestation (Correct Answer)

Explanation: ***Transvaginal ultrasound at 18 weeks gestation*** - A history of **LEEP** is a risk factor for **cervical incompetence** and warrants screening with transvaginal ultrasound. - The optimal timing for **cervical length** screening in women with a history of cervical procedures is typically between **18 and 24 weeks gestation**, as the risk of cervical shortening usually manifests during this period. *Transabdominal ultrasound in the first trimester* - **Transabdominal ultrasound** is generally not ideal for precise **cervical length measurement** due to potential shadowing from the fetus or maternal obesity. - **First-trimester cervical length measurement** is not typically recommended for routine screening of cervical incompetence, as changes are less pronounced early in pregnancy. *Transvaginal ultrasound in the first trimester* - While more accurate than transabdominal, **first-trimester transvaginal ultrasound** for cervical length is not standard for predicting cervical incompetence. - Significant cervical shortening due to incompetence often occurs later in the second trimester, so early screening may miss the condition. *Serial transvaginal ultrasounds starting at 16 weeks gestation* - While **serial transvaginal ultrasounds** starting at 16 weeks can be part of a management plan for high-risk patients, the most critical single assessment typically occurs at **18-24 weeks**. - Starting serial scans too early may not be necessary if the cervix is long and closed at the initial key screening, unless there are other strong indications. *Transabdominal ultrasound at 18 weeks gestation* - Similar to first-trimester transabdominal ultrasound, **transabdominal imaging** at 18 weeks is generally **less accurate** than transvaginal for measuring cervical length. - **Transvaginal ultrasound** offers a clearer and more precise view of the cervix, which is crucial for assessing potential shortening or funneling.

Question 48: A 25-year-old G2P1 woman at 12 weeks gestational age presents to the office to discuss the results of her routine prenatal screening labs, which were ordered during her 1st prenatal visit. She reports taking a daily prenatal vitamin but no other medications. She complains of mild fatigue and appears pale on exam. Her complete blood count (CBC) shows the following: Hemoglobin (Hb) 9.5 g/dL Hematocrit 29% Mean corpuscular volume (MCV) 75 µm3 Which of the following are the most likely hematologic states of the patient and her fetus?

A. Iron deficiency anemia in both the mother and the fetus
B. Iron deficiency anemia in the mother; normal Hb levels in the fetus (Correct Answer)
C. Pernicious anemia in the mother; normal Hb levels in the fetus
D. Physiologic anemia in the mother; normal Hb levels in the fetus
E. Folate deficiency anemia in both the mother and the fetus

Explanation: ***Iron deficiency anemia in the mother; normal Hb levels in the fetus*** - The mother's lab values (Hb 9.5 g/dL, MCV 75 µm3) indicate **microcytic, hypochromic anemia**, consistent with **iron deficiency anemia**. - The fetus prioritizes iron uptake, even in cases of severe maternal iron deficiency, meaning the **fetal hemoglobin levels** are typically normal unless maternal iron deficiency is profound and prolonged. *Iron deficiency anemia in both the mother and the fetus* - While the mother clearly has **iron deficiency anemia**, the fetus generally maintains **normal hemoglobin levels** by actively drawing iron from the mother, even at her expense. - Fetal iron deficiency leading to anemia is rare unless maternal deficiency is extremely severe and prolonged, which is not indicated here. *Pernicious anemia in the mother; normal Hb levels in the fetus* - **Pernicious anemia** (vitamin B12 deficiency) typically presents as **macrocytic anemia** (high MCV), which contradicts the patient's MCV of 75 µm3 (microcytic). - Although the fetus would likely have normal Hb levels in maternal pernicious anemia, the mother's lab findings do not support this diagnosis. *Physiologic anemia in the mother; normal Hb levels in the fetus* - **Physiologic anemia of pregnancy** is caused by a disproportionate increase in plasma volume compared to red blood cell mass, resulting in **dilutional anemia**, but usually with a **normal MCV**. - The patient's **low MCV (75 µm3)** indicates a microcytic anemia, which is not characteristic of physiologic anemia of pregnancy. *Folate deficiency anemia in both the mother and the fetus* - **Folate deficiency anemia** is a type of **macrocytic anemia** (high MCV), which is inconsistent with the patient's MCV of 75 µm3. - While severe maternal folate deficiency can affect the fetus, the maternal blood picture does not support this diagnosis.

Question 49: A 23-year-old woman presents to the emergency department with burning and increased urinary frequency. The patient states that her symptoms started yesterday and have been worsening despite hydrating well. The patient is generally healthy, does not smoke or drink alcohol, and is 10 weeks pregnant. She is currently taking folate, iron, and a multivitamin. Her temperature is 98.1°F (36.7°C), blood pressure is 122/83 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for an absence of costovertebral angle tenderness and mild discomfort to palpation of the lower abdomen. An initial urine dipstick is notable for the presence of leukocytes, bacteria, and nitrates. Which of the following is the best treatment for this patient?

A. Doxycycline
B. Ceftriaxone
C. Trimethoprim-sulfamethoxazole
D. Amoxicillin-clavulanate (Correct Answer)
E. Ciprofloxacin

Explanation: ***Amoxicillin-clavulanate*** - This patient presents with symptoms and urine dipstick findings consistent with a **urinary tract infection (UTI)**. Given her **pregnancy**, treatment must be safe for the fetus. **Amoxicillin-clavulanate** is a penicillin-class antibiotic that is generally considered safe during pregnancy (Category B). - The presence of **leukocytes, bacteria, and nitrites** on urine dipstick strongly supports the diagnosis of UTI, and amoxicillin-clavulanate effectively targets common uropathogens like *E. coli*. *Doxycycline* - **Doxycycline** is a **tetracycline antibiotic** that is **contraindicated in pregnancy** (Category D) due to the risk of fetal teeth discoloration and inhibition of bone growth. - While effective against many bacteria, its teratogenic potential makes it an inappropriate choice for this pregnant patient. *Ceftriaxone* - **Ceftriaxone** is a broad-spectrum cephalosporin that is generally safe in pregnancy (Category B) but is typically reserved for more severe infections, such as pyelonephritis, or when oral antibiotics are not tolerated. - For a simple cystitis in pregnancy, an oral antibiotic is preferred, and ceftriaxone is usually given parenterally. *Trimethoprim-sulfamethoxazole* - **Trimethoprim-sulfamethoxazole** (TMP-SMX) is contraindicated in the **first trimester** of pregnancy due to its **folate antagonist** effects, which can increase the risk of neural tube defects. - Although it is generally safe in the second and early third trimesters, this patient is in her first trimester (10 weeks pregnant), making it an inappropriate choice. *Ciprofloxacin* - **Ciprofloxacin** is a **fluoroquinolone antibiotic** that is generally **contraindicated in pregnancy** (Category C) due to theoretical concerns of cartilage damage in the fetus, though human data are reassuring. - It is usually avoided unless other safer antibiotics are ineffective or contraindicated.

Question 50: A 29-year-old, gravida 1 para 0, at 10 weeks' gestation comes to the physician for progressively worsening emesis, nausea, and a 2-kg (4.7-lb) weight loss over the past 2 weeks. The most recent bouts of vomiting occur around 3–4 times a day, and she is stressed that she had to take a sick leave from work the last 2 days. She is currently taking ginger and vitamin B6 with limited relief. Her pulse is 80/min, blood pressure is 100/60 mmHg, and respiratory rate is 13/min. Orthostatic vital signs are within normal limits. The patient is alert and oriented. Her abdomen is soft and nontender. Urinalysis shows no abnormalities. Her hematocrit is 40%. Venous blood gas shows: pH 7.43 pO2 42 mmHg pCO2 54 mmHg HCO3- 31 mEq/L SO2 80% In addition to oral fluid resuscitation, which of the following is the most appropriate next step in management?

A. Addition of doxylamine (Correct Answer)
B. Monitoring and stress counseling
C. Administration of supplemental oxygen
D. Trial of metoclopramide
E. IV fluid resuscitation

Explanation: ***Addition of doxylamine*** - The patient exhibits features of **hyperemesis gravidarum**, including significant **weight loss**, frequent vomiting despite home remedies, and mild **alkalosis** (elevated pH, pCO2, HCO3- suggesting metabolic alkalosis from vomiting with respiratory compensation; typically, hyperemesis might lead to metabolic alkalosis, but here, the pCO2 is high indicating some respiratory compensation or mild respiratory acidosis might be overshadowed by metabolic alkalosis). - Given that she has tried ginger and vitamin B6 with limited success for her severe symptoms, the next appropriate step is to add **doxylamine**, an antihistamine with antiemetic properties, typically combined with pyridoxine (vitamin B6) for hyperemesis gravidarum. *Monitoring and stress counseling* - This patient's symptoms are beyond typical "morning sickness," given the **2-kg weight loss** and frequent vomiting impacting her work, indicating significant physiological distress. - While stress can exacerbate symptoms, the primary issue is a severe physical condition requiring medical intervention rather than just counseling. *Administration of supplemental oxygen* - The patient's **pO2 is 42 mmHg**, which is a normal venous pO2 and does not indicate hypoxemia requiring supplemental oxygen. **Arterial pO2** is typically much higher. - Her **respiratory rate is 13/min**, and she is alert and oriented, suggesting adequate oxygenation and ventilation clinically. *Trial of metoclopramide* - Metoclopramide is an **antiemetic** that can be used in hyperemesis gravidarum, but it is typically reserved for cases where **doxylamine/pyridoxine** combinations are insufficient. - It also carries a risk of **extrapyramidal side effects**, making it a second-line or third-line agent after safer options have been tried. *IV fluid resuscitation* - While the patient has significant vomiting and weight loss, her vital signs are relatively stable (no orthostatic changes, BP 100/60 mmHg), and her hematocrit is 40%, indicating **no severe dehydration** requiring immediate intravenous fluids. - The question specifically asks for the *next step* in addition to *oral fluid resuscitation*, implying that oral rehydration is already being considered or attempted, and a pharmaceutical intervention is needed.

Question 51: A 31-year-old G2P1001 presents to the labor floor for external cephalic version (ECV) due to breech presentation at 37 weeks gestation. Her pregnancy has been complicated by an episode of pyelonephritis at 14 weeks gestation, treated with intravenous ceftriaxone. The patient has not had urinary symptoms since that time. Otherwise, her prenatal care has been routine and she tested Rh-negative with negative antibodies at her first prenatal visit. She has a history of one prior spontaneous vaginal delivery without complications. She also has a medical history of anemia. Current medications include nitrofurantoin for urinary tract infection suppression and iron supplementation. The patient’s temperature is 98.5°F (36.9°C), pulse is 75/min, blood pressure is 122/76 mmHg, and respirations are 13/min. Physical exam is notable for a fundal height of 37 centimeters and mild pitting edema in both lower extremities. Cardiopulmonary exams are unremarkable. Bedside ultrasound confirms that the fetus is still in breech presentation. Which of the following should be performed in this patient as a result of her upcoming external cephalic version?

A. Fibrinogen level
B. Urinalysis
C. Urine protein to creatinine ratio
D. Complete blood count
E. Rhogam administration (Correct Answer)

Explanation: ***Rhogam administration*** - An **external cephalic version (ECV)** carries a risk of **fetal-maternal hemorrhage** due to manipulation of the uterus and fetus. - For **Rh-negative mothers**, Rhogam (anti-D immune globulin) administration is crucial to prevent **Rh alloimmunization** if fetal blood enters maternal circulation. *Fibrinogen level* - A fibrinogen level is typically checked in cases of suspected **disseminated intravascular coagulation (DIC)** or significant bleeding risk, such as in patients with **placental abruption** or severe pre-eclampsia. - While bleeding is a potential complication of any obstetric procedure, routine fibrinogen levels are not indicated prior to an ECV in an otherwise healthy patient with no signs of bleeding dyscrasia. *Urinalysis* - Although the patient has a history of pyelonephritis and is on nitrofurantoin, she has been **asymptomatic** and a urinalysis was likely performed recently as part of her routine prenatal care. - While urinary tract infections can be a concern in pregnancy, a urinalysis is not a direct requirement for an ECV unless new urinary symptoms arise. *Urine protein to creatinine ratio* - A urine protein to creatinine ratio is used to screen for or confirm **preeclampsia**, a condition characterized by **hypertension and proteinuria**. - The patient's blood pressure is normal (122/76 mmHg) and there is no mention of proteinuria, so this test is not indicated for the ECV. *Complete blood count* - While a complete blood count (CBC) would confirm her known anemia and assess for infection, it is **not directly necessitated by the ECV procedure itself** as a preventive measure against Rh incompatibility. - The primary concern for an Rh-negative mother undergoing ECV is feto-maternal hemorrhage, making Rhogam the critical intervention.

Question 52: A 15-year-old girl is brought to the clinic by her mother for an annual well-exam. She is relatively healthy with an unremarkable birth history. She reports no specific concerns except for the fact that her friends “already got their periods and I still haven’t gotten mine.” Her mom reports that she also had her menarche late and told her not to worry. When alone, the patient denies any pain, fevers, weight changes, vaginal discharge, or psychosocial stressors. Physical examination demonstrates a healthy female with a Tanner 4 stage of development of breast, genitalia, and pubic hair. What findings would you expect in this patient?

A. Formation of breast mound
B. Flat chest with raised nipples
C. Formation of breast bud
D. Raised areola
E. Coarse hair across pubis and medial thigh (Correct Answer)

Explanation: ***Coarse hair across pubis and medial thigh*** - A healthy 15-year-old girl with **Tanner 4 stage development** of pubic hair will exhibit adult-type hair that is **coarse, curly, and abundant**, extending over the mons pubis and spreading to the medial thighs. - This stage indicates near-complete sexual maturation in terms of pubic hair growth, consistent with a patient who has developed secondary sexual characteristics but has not yet experienced menarche. *Formation of breast mound* - The **formation of a breast mound** is characteristic of Tanner Stage 4 breast development where the areola and papilla form a secondary mound above the general contour of the breast, which is consistent with the patient's overall Tanner 4 stage development. - However, the question asks specifically about findings in a healthy 15-year-old with Tanner 4 development across **all categories (breast, genitalia, pubic hair)**, not just the breasts. The correct answer focuses on the specific visual changes of the pubic hair itself at this stage. *Flat chest with raised nipples* - A **flat chest with raised nipples** (nipple elevation) describes Tanner Stage 2 breast development, which is an earlier stage than the patient's reported Tanner Stage 4. - This stage precedes significant breast enlargement and the development of a distinct breast mound. *Formation of breast bud* - The **formation of a breast bud** (small, tender lump under the nipple) is the defining characteristic of Tanner Stage 2 breast development, indicating the very beginning of breast growth. - This is an earlier stage than the Tanner Stage 4 described for this patient. *Raised areola* - **Raised areola** with a flattened breast contour is characteristic of Tanner Stage 3 breast development, where the breast and areola enlarge further, but the areola typically lies on the same contour as the breast. - In Tanner Stage 4, the areola and papilla elevate above the general breast contour, forming a secondary mound.

Question 53: A 54-year-old woman comes to the office complaining of increased urinary frequency and dysuria. She is accompanied by her husband. The patient reports that she goes to the bathroom 6-8 times a day. Additionally, she complains of pain at the end of her urinary stream. She denies fever, abdominal pain, vaginal discharge, or hematuria. Her husband adds, “we also don’t have sex as much as we used to.” The patient reports that even when she is “in the mood,” sex is “no longer pleasurable.” She admits feeling guilty about this. The patient’s last menstrual period was 15 months ago. Her medical history is significant for hyperlipidemia and coronary artery disease. She had a non-ST elevation myocardial infarction (NSTEMI) 3 months ago, and she has had multiple urinary tract infections (UTIs) in the past year. She smokes 1 pack of cigarettes a day and denies alcohol or illicit drug use. Body mass index is 32 kg/m^2. Pelvic examination reveals vaginal dryness and vulvar tissue thinning. A urinalysis is obtained as shown below: Urinalysis Glucose: Negative WBC: 25/hpf Bacterial: Many Leukocyte esterase: Positive Nitrites: Positive The patient is prescribed a 5-day course of nitrofurantoin. Which of the following is the most appropriate additional management for the patient’s symptoms?

A. Venlafaxine
B. Antibiotic prophylaxis
C. Combination oral contraceptives
D. Topical clobetasol
E. Topical estrogen (Correct Answer)

Explanation: ***Topical estrogen*** - The patient's symptoms of **vaginal dryness**, **dyspareunia**, **recurrent UTIs**, and **urinary frequency** are highly suggestive of **genitourinary syndrome of menopause (GSM)**, previously known as vulvovaginal atrophy. Vaginal examination findings of **vaginal tissue thinning** further support this diagnosis. - **Topical estrogen** directly addresses the underlying **estrogen deficiency**, restoring vaginal and urethral tissue health, thereby alleviating both sexual and urinary symptoms. Given her history of CAD and an NSTEMI, topical estrogen is preferred over systemic estrogen due to its minimal systemic absorption. *Venlafaxine* - **Venlafaxine** is a serotonin-norepinephrine reuptake inhibitor (SNRI) that can be used to treat **vasomotor symptoms of menopause** (e.g., hot flashes) or depression. - It does not directly address the **urogenital symptoms of GSM** such as vaginal dryness, dyspareunia, or recurrent UTIs, and therefore would not be the most appropriate primary treatment for these specific complaints. *Antibiotic prophylaxis* - While the patient experiences **recurrent UTIs**, treating the underlying cause of these infections, which is likely **vaginal atrophy** due to menopause, should be prioritized. - **Antibiotic prophylaxis** would only temporarily prevent infections without addressing the fundamental tissue changes that predispose her to UTIs. *Combination oral contraceptives* - **Combination oral contraceptives** contain both estrogen and progestin, but they are primarily used for contraception and often to manage **perimenopausal symptoms** in younger women. - They are generally contraindicated in women over 35 who smoke or have a history of CAD due to increased risk of thrombotic events, and are not the primary treatment for **urogenital atrophy** in postmenopausal women, especially with her clinical history. *Topical clobetasol* - **Topical clobetasol** is a high-potency corticosteroid used to treat inflammatory dermatoses, such as **lichen sclerosus** or severe eczema. - It would not be appropriate for treating **vaginal dryness**, **dyspareunia**, or **recurrent UTIs** caused by **estrogen deficiency**, and its prolonged use can lead to skin atrophy.

Question 54: A 27-year-old G1P0 at 12 weeks gestation presents to her obstetrician for her first prenatal visit. She and her husband both have achondroplasia, and she is curious what are the chances that they will have a child of average height. What percent of pregnancies between two individuals with achondroplasia that result in a live birth will be expected to be offspring that are unaffected by this condition?

A. 0%
B. 50%
C. 75%
D. 33% (Correct Answer)
E. 25%

Explanation: ***33%*** - Achondroplasia is an **autosomal dominant** condition, meaning only one copy of the mutated gene is needed to express the trait. However, individuals with achondroplasia are typically **heterozygous (Aa)** because the homozygous dominant state (AA) is **lethal in utero** or shortly after birth. - When two heterozygous (Aa) parents mate, a Punnett square shows 25% AA, 50% Aa, and 25% aa. Since AA is a lethal genotype that is not viable for live birth, the surviving offspring will be 1/3 aa (unaffected) and 2/3 Aa (affected), meaning 33% will be of average height. *0%* - This would be true if all offspring were affected or if the condition was recessive and both parents were homozygous dominant, which is not the case for achondroplasia. - The possibility of having an unaffected child exists because affected individuals are generally heterozygous. *50%* - This would be the percentage of affected offspring if one parent was homozygous dominant and the other was homozygous recessive, or if one parent was homozygous dominant and the other heterozygous. - However, autosomal dominant traits typically result in a 2:1 ratio of affected to unaffected live births when both parents are heterozygous. *75%* - This would be the percentage of affected offspring if the homozygous dominant state were not lethal, resulting in 25% aa, 50% Aa, and 25% AA. - Achondroplasia, however, has a **lethal homozygous dominant genotype**, which alters the observed phenotypic ratios in live births. *25%* - This percentage represents the chance of having an unaffected offspring (aa) before considering the lethality of the homozygous dominant genotype (AA). - When accounting for the non-viability of AA genotypes, the proportion of unaffected offspring among live births increases.

Question 55: A 16-year-old girl comes to the physician for a regular health visit. She feels healthy. She lives with her parents at home. She says that the relationship with her parents has been strained lately because they ""do not approve"" of her new boyfriend. She recently became sexually active with her boyfriend and requests a prescription for an oral contraception. She does not want her parents to know. She smokes half-a-pack of cigarettes per day and does not drink alcohol. She appears well-nourished. Physical examination shows no abnormalities. Urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A. Recommend an oral contraceptive pill
B. Discuss all effective contraceptive options (Correct Answer)
C. Conduct HIV screening
D. Inform patient that her smoking history disqualifies her for oral contraceptives
E. Ask patient to obtain parental consent before discussing any contraceptive options

Explanation: ***Discuss all effective contraceptive options*** - It is crucial to discuss all available and **effective contraceptive options** with the patient, including their benefits, risks, and suitability for her lifestyle, before recommending a specific method. - This ensures **informed consent** and shared decision-making, empowering the patient to choose the best method for her needs. *Recommend an oral contraceptive pill* - Recommending only one method without discussing alternatives limits the patient's choices and does not provide a **comprehensive approach** to contraception. - While oral contraceptives are effective, other methods like **long-acting reversible contraceptives (LARCs)** may be more suitable or preferred by the patient. *Conduct HIV screening* - While **HIV screening** is important for sexually active individuals, it is not the immediate next step in management when the patient's primary concern is contraception. - Addressing the patient's immediate request for contraception takes precedence, though **STI/HIV counseling** should be part of comprehensive sexual health discussions. *Inform patient that her smoking history disqualifies her for oral contraceptives* - A smoking history in adolescent patients **does not automatically disqualify** them from all types of oral contraceptives, especially progestin-only pills. - The risk of **thromboembolism** with combined oral contraceptives is increased in smokers over 35, but a 16-year-old's risk needs careful assessment and discussion, not an outright disqualification. *Ask patient to obtain parental consent before discussing any contraceptive options* - In many jurisdictions, including the US, minors have the right to **confidential reproductive healthcare services**, including contraception, without parental consent. - Requiring parental consent would violate her **confidentiality rights** and could deter her from seeking necessary care, potentially leading to unintended pregnancy.

Question 56: A 29-year-old G1P0 female at 32 weeks gestation presents to the emergency department with vaginal bleeding. She has had minimal prenatal care to-date with only an initial visit with an obstetrician after a positive home pregnancy test. She describes minimal spotting that she noticed earlier today that has progressed to larger amounts of blood; she estimates 30 mL of blood loss. She denies any cramping, pain, or contractions, and she reports feeling continued movements of the baby. Ultrasound and fetal heart rate monitoring confirm the presence of a healthy fetus without any evidence of current or impending complications. The consulted obstetrician orders blood testing for Rh-status of both the mother as well as the father, who brought the patient to the hospital. Which of the following represents the best management strategy for this situation?

A. After 28 weeks gestation, administration of RhoGAM will have no benefit
B. If mother is Rh-positive and father is Rh-negative then administer RhoGAM
C. If mother is Rh-negative and father is Rh-negative then administer RhoGAM
D. If mother is Rh-negative and father is Rh-positive, RhoGAM administration is not needed
E. If mother is Rh-negative and father is Rh-positive then administer RhoGAM (Correct Answer)

Explanation: ***If mother is Rh-negative and father is Rh-positive then administer RhoGAM*** - This combination creates a risk for **Rh incompatibility**, meaning the fetus could be Rh-positive and the mother's immune system could form antibodies against fetal red blood cells, which can harm the fetus in future pregnancies. - **RhoGAM (Rh immunoglobulin)** administration prevents the mother from forming these antibodies when there's a risk of maternal-fetal blood mixing, as indicated by vaginal bleeding. *After 28 weeks gestation, administration of RhoGAM will have no benefit* - This statement is incorrect; **RhoGAM is routinely administered around 28 weeks gestation** as prophylaxis in Rh-negative mothers, even without bleeding episodes, to prevent sensitization. - In cases of potential fetal-maternal hemorrhage, such as vaginal bleeding, RhoGAM is indicated regardless of gestational age beyond the first trimester. *If mother is Rh-positive and father is Rh-negative then administer RhoGAM* - This scenario does not pose a risk for **Rh incompatibility hemolytic disease of the newborn**, as the mother already possesses the Rh antigen. - RhoGAM is specifically given to Rh-negative mothers to prevent their immune system from reacting to an Rh-positive fetus. *If mother is Rh-negative and father is Rh-negative then administer RhoGAM* - In this case, both parents are **Rh-negative**, meaning the fetus will also be Rh-negative. - There is no risk of **Rh incompatibility** or sensitization, so RhoGAM administration is not indicated. *If mother is Rh-negative and father is Rh-positive, RhoGAM administration is not needed* - This statement is incorrect and represents a critical misunderstanding of **Rh incompatibility prophylaxis**. - This specific genetic combination creates the highest risk for **Rh sensitization** during pregnancy, especially with events like vaginal bleeding, making RhoGAM administration essential.

Question 57: A 27-year-old woman comes to the physician because of a 1-month history of progressive shortness of breath. She can no longer walk one block without stopping to catch her breath. Her last menstrual period was 3 months ago. Menarche occurred at the age of 12 years, and menses had occurred at regular 28-day intervals. Cardiac examination shows a grade 3/6, rumbling diastolic murmur at the apex. Laboratory studies show an elevated β-hCG concentration. Which of the following is the most likely explanation for this patient's worsening dyspnea?

A. Decreased minute ventilation
B. Increased peripheral vascular resistance
C. Increased right ventricular afterload
D. Increased intravascular volume (Correct Answer)
E. Decreased right ventricular preload

Explanation: ***Increased intravascular volume*** - Pregnancy causes a significant **increase in plasma volume** (up to 50%) and **cardiac output**, which can exacerbate pre-existing cardiac conditions like mitral stenosis. - The elevated intravascular volume leads to increased pressure in the **left atrium** and **pulmonary circulation**, causing pulmonary congestion and dyspnea. *Decreased minute ventilation* - **Minute ventilation** actually increases during pregnancy due to increased tidal volume and respiratory rate to meet higher oxygen demands. - A *decrease* in minute ventilation would lead to **hypercapnia** and respiratory acidosis, which is not consistent with the typical presentation of worsening dyspnea in pregnancy-exacerbated mitral stenosis. *Increased peripheral vascular resistance* - Pregnancy is associated with a **decrease in systemic vascular resistance (SVR)**, primarily due to the effects of progesterone and the low-resistance placental circulation. - An *increase* in SVR would typically lead to increased **afterload** on the left ventricle and hypertension, which is not the primary mechanism for dyspnea in this context. *Increased right ventricular afterload* - While **pulmonary hypertension** can increase right ventricular afterload in severe mitral stenosis, the primary hemodynamic stressor in pregnancy is the **volume overload**. - The *initial* and most direct impact of increased intravascular volume leading to dyspnea is on the left heart and pulmonary circulation, not primarily increased right ventricular afterload. *Decreased right ventricular preload* - **Right ventricular preload** generally increases in pregnancy due to the elevated blood volume, reflecting increased venous return to the heart. - A *decrease* in right ventricular preload would typically lead to reduced cardiac output and hypotension, rather than exacerbated dyspnea from pulmonary congestion.

Question 58: A 21-year-old woman, gravida 1, para 0, at 39 weeks' gestation comes to the physician for a prenatal visit. She has some mild edema and tiredness but generally feels well. She recently had a nephew visiting for 1 week who became ill and was diagnosed with the chickenpox. She has no history of chickenpox and is not vaccinated against the varicella zoster virus. Current medications include folic acid supplements and a prenatal vitamin. Her temperature is 37°C (98.6°F), pulse is 82/min, respirations are 15/min, and blood pressure is 116/64 mm Hg. Pelvic examination shows a uterus consistent in size with 39 weeks' gestation. IgG antibody titers for varicella zoster virus are negative. Which of the following is the most appropriate next step in management?

A. Reassurance
B. Serial ultrasounds
C. Varicella vaccine
D. Varicella zoster immune globulin (Correct Answer)
E. Ganciclovir therapy

Explanation: ***Varicella zoster immune globulin*** - The patient has been exposed to **chickenpox** (via her nephew), has no history of the disease, and is **not vaccinated**, indicating she is susceptible. Her negative **IgG antibody titers** confirm her lack of immunity. - Due to her **39 weeks' gestation**, there is a risk of severe maternal varicella and congenital varicella syndrome, making **varicella zoster immune globulin (VZIG)** an appropriate post-exposure prophylaxis to mitigate the severity of infection. *Reassurance* - Reassurance alone is insufficient given the patient's **non-immune status** and recent **exposure to varicella**, which places her and the fetus at risk. - Varicella infection during pregnancy can lead to serious complications, including **congenital varicella syndrome** or **neonatal varicella**. *Serial ultrasounds* - While ultrasounds may be used to monitor for fetal complications if **maternal infection** occurs, they are not a prophylactic measure to prevent or reduce the severity of the infection itself. - The immediate priority is to prevent or attenuate the infection after exposure in a **non-immune pregnant woman**. *Varicella vaccine* - The **live attenuated varicella vaccine** is **contraindicated** during pregnancy due to the theoretical risk of fetal infection. - Vaccination should ideally occur **before pregnancy** or postpartum. *Ganciclovir therapy* - **Ganciclovir** is an antiviral medication primarily used for **cytomegalovirus (CMV)** infections and is generally not the first-line treatment for varicella, especially in a prophylactic setting. - For varicella, **acyclovir** or **valacyclovir** might be considered for treatment of active infection, but VZIG is the recommended post-exposure prophylaxis in non-immune pregnant women.

Question 59: A 26-year-old G1P0 woman presents for her first prenatal visit. Past medical history reveals the patient is blood type O negative, and the father is type A positive. The patient refuses Rho(D) immune globulin (RhoGAM), because it is derived from human plasma, and she says she doesn’t want to take the risk of contracting HIV. Which of the following is correct regarding the potential condition her baby may develop?

A. The injection can be avoided because the risk of complications of this condition is minimal
B. She should receive Rho(D) immune globulin to prevent the development of Rh(D) alloimmunization (Correct Answer)
C. The Rho(D) immune globulin will also protect the baby against other Rh antigens aside from Rh(D)
D. She should receive Rho(D) immune globulin to prevent the development of ABO incompatibility
E. Rho(D) immune globulin is needed both before and immediately after delivery to prevent maternal sensitization for future pregnancies

Explanation: ***She should receive Rho(D) immune globulin to prevent the development of Rh(D) alloimmunization*** - The patient is **Rh-negative** and her partner is **Rh-positive**, creating a risk for **Rh incompatibility** where the mother can develop antibodies against fetal Rh-positive red blood cells. - **Rho(D) immune globulin** prevents the mother from becoming sensitized to the **Rh(D) antigen** if fetal blood enters her circulation, thus preventing **hemolytic disease of the newborn** in this or future pregnancies. *The injection can be avoided because the risk of complications of this condition is minimal* - This statement is incorrect; **Rh alloimmunization** can lead to severe consequences for the fetus, including **hemolytic disease of the newborn**, which can cause **fetal hydrops**, severe anemia, and even death. - The risk of complications is not minimal, and prevention with **Rho(D) immune globulin** is a standard and critical part of prenatal care for Rh-negative mothers. *The Rho(D) immune globulin will also protect the baby against other Rh antigens aside from Rh(D)* - **Rho(D) immune globulin** is specifically formulated to target the **Rh(D) antigen** and will not protect against alloimmunization to other **Rh antigens** (e.g., C, c, E, e). - While other Rh antigens can cause incompatibility, the **D antigen** is by far the most immunogenic and clinically significant. *She should receive Rho(D) immune globulin to prevent the development of ABO incompatibility* - **ABO incompatibility** is a different condition that can occur when the mother is **type O** and the baby is type A or B (as is the case here with an A-positive father), but it is generally **less severe** than Rh incompatibility and usually does not require **Rho(D) immune globulin** for prevention. - **Rho(D) immune globulin** specifically targets the **Rh(D) antigen** and plays no role in preventing or treating **ABO incompatibility**. *Rho(D) immune globulin is needed both before and immediately after delivery to prevent maternal sensitization for future pregnancies* - For **Rh-negative** mothers, **Rho(D) immune globulin** is administered around **28 weeks of gestation** and again within **72 hours after delivery** if the baby is Rh-positive. - This dual administration strategy covers potential fetal-maternal hemorrhages during pregnancy and at birth, but it's not "both before and immediately after delivery" as a blanket statement for *all* exposures; the prenatal dose is crucial.

Question 60: An otherwise healthy 18-year-old girl comes to the physician because of a 1-year history of severe acne vulgaris over her face, upper back, and arms. Treatment with oral antibiotics and topical combination therapy with benzoyl peroxide and retinoid has not completely resolved her symptoms. Examination shows oily skin with numerous comedones, pustules, and scarring over the face and upper back. Long-term therapy is started with combined oral contraceptives. This medication significantly reduces the risk of developing which of the following conditions?

A. Endometrial cancer (Correct Answer)
B. Hepatic adenoma
C. Hypertension
D. Malignant melanoma
E. Deep vein thrombosis

Explanation: ***Endometrial cancer*** - Combined oral contraceptives (COCs) reduce the risk of **endometrial cancer** by suppressing chronic **estrogen-induced endometrial proliferation** through progesterone's anti-proliferative effects. - The protective effect increases with the **duration of COC use** and persists for several years after discontinuation. *Hepatic adenoma* - **Hepatic adenomas** are a recognized, though rare, complication of combined oral contraceptive use. - The risk increases with **higher estrogen doses** and **longer duration of use**. *Hypertension* - COCs can cause a **slight increase in blood pressure** in some women, particularly due to the estrogen component, and are therefore a risk factor for hypertension, not protective against it. - This effect is generally mild, but blood pressure monitoring is recommended for women on COCs. *Malignant melanoma* - There is **no clear evidence** that combined oral contraceptives significantly reduce the risk of malignant melanoma. - Some studies have suggested a possible *increased risk* or no association, but protective effects are not established. *Deep vein thrombosis* - COCs, especially those containing higher estrogen doses, are associated with an **increased risk of deep vein thrombosis (DVT)** due to their effects on coagulation factors. - This is a well-known adverse effect, not a condition prevented by COC use.

Question 61: A 26-year-old woman comes to the emergency department because of a 3-day history of nausea and vomiting. Her last menstrual period was 9 weeks ago. A urine pregnancy test is positive. Ultrasonography shows an intrauterine pregnancy consistent in size with a 7-week gestation. The hormone that was measured in this patient's urine to detect the pregnancy is also directly responsible for which of the following processes?

A. Development of breast tissue
B. Preparation of the uterine endometrium for implantation
C. Inhibition of preterm uterine contractions
D. Maintenance of the corpus luteum (Correct Answer)
E. Inhibition of ovulation

Explanation: ***Maintenance of the corpus luteum*** - The hormone measured in the urine pregnancy test is **human chorionic gonadotropin (hCG)**. - **hCG** acts like **luteinizing hormone (LH)** to maintain the **corpus luteum** in early pregnancy, ensuring continued progesterone production until the placenta takes over. *Development of breast tissue* - **Estrogen** and **progesterone** are the primary hormones responsible for the development of breast tissue during pregnancy, preparing the breasts for lactation. - While hCG indirectly supports these hormones, it does not directly cause breast tissue development. *Preparation of the uterine endometrium for implantation* - The **preparation of the uterine endometrium** for implantation is primarily driven by **progesterone**, produced by the corpus luteum initially and later by the placenta. - hCG’s role is to maintain the corpus luteum, thus indirectly supporting progesterone production. *Inhibition of preterm uterine contractions* - **Progesterone** is the main hormone responsible for **inhibiting uterine contractions** during pregnancy to prevent preterm labor. - While hCG supports progesterone production, it does not directly inhibit uterine contractions itself. *Inhibition of ovulation* - High levels of **estrogen** and **progesterone** during pregnancy suppress the hypothalamic-pituitary-gonadal axis, thereby **inhibiting ovulation**. - While hCG maintains the corpus luteum which produces these hormones, hCG itself is not the direct inhibitor of ovulation.

Question 62: A 26-year-old woman, gravida 2, para 1, at 9 weeks' gestation comes to the physician with her 16-month-old son for her first prenatal visit. Her son has had low-grade fever, headache, and arthralgia for 5 days. He has also had a generalized rash that started on the cheeks 2 days ago and has since spread to his body. The woman has some mild nausea but is feeling well. Her first pregnancy was uneventful. Her son was delivered at 40 weeks' gestation via lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Current medications include prenatal vitamins with folic acid. Preconception rubella and varicella titers were recorded as adequate. His immunizations are up-to-date. His temperature is 36.8°C (98.2°F), pulse is 85/min, respirations are 13/min, and blood pressure is 114/65 mm Hg. Pelvic examination of the woman shows a uterus consistent in size with a 9-week gestation. An image of the woman's son is shown. A complete blood cell count is within normal limits. Which of the following is the most appropriate next step in management?

A. Antibiotics for the child
B. Serial fetal ultrasounds
C. Report the disease to health authorities
D. Maternal serologic assays for virus-specific IgG and IgM (Correct Answer)
E. Isolation precautions for the child

Explanation: **Maternal serologic assays for virus-specific IgG and IgM** - The child's symptoms (low-grade fever, headache, arthralgia, and a rash starting on the cheeks and spreading to the body, often described as a "slapped cheek" appearance) are highly suggestive of **Erythema Infectiosum** (fifth disease), caused by **Parvovirus B19**. - Since the mother is pregnant and has been exposed, assessing her **immune status** (IgG) and recent infection (IgM) with Parvovirus B19 is crucial due to the potential for significant fetal complications, such as **hydrops fetalis**, anemia, and even fetal death. *Antibiotics for the child* - Erythema Infectiosum is a **viral infection**, therefore, antibiotics are **ineffective** and inappropriate for treatment. - The clinical presentation clearly points away from a bacterial cause for the rash and systemic symptoms. *Serial fetal ultrasounds* - While **serial fetal ultrasounds** would be indicated if the mother tested positive for acute Parvovirus B19 infection to monitor for **fetal hydrops**, this is not the immediate **first step**. - The first step is to confirm maternal infection status before initiating these more invasive and resource-intensive monitoring measures. *Report the disease to health authorities* - **Parvovirus B19 infection** is generally not a **nationally notifiable disease** that requires immediate reporting to public health authorities, unlike conditions such as measles or rubella. - The primary concern here is the potential **vertical transmission** and fetal risk, which is managed clinically rather than through public health reporting. *Isolation precautions for the child* - By the time the characteristic rash of Erythema Infectiosum appears, the child is typically **no longer contagious**. - Therefore, isolation precautions for the child at this stage would be unnecessary and would not prevent further spread.

Question 63: A 26-year-old G1P0 woman comes to her maternal and fetal medicine doctor at 15 weeks of gestation in order to be evaluated for fetal developmental abnormalities. Her family has a history of congenital disorders leading to difficulty walking so she was concerned about her child. Amniocentesis shows normal levels of all serum proteins and circulating factors. Despite this, the physician warns that there is a possibility that there may be a neural tube abnormality in this child even though the normal results make it less likely. If this child was born with a neural tube closure abnormality, which of the following findings would most likely be seen in the child?

A. Protrusion of the meninges and spinal cord through a bony defect
B. Protrusion of the meninges through a bony defect
C. Spinal cord able to be seen externally
D. Tuft of hair or skin dimple on lower back (Correct Answer)
E. Absence of the brain and calvarium

Explanation: ***Tuft of hair or skin dimple on lower back*** - This finding, particularly a **tuft of hair**, **skin dimple**, or **subcutaneous lipoma** on the lower back, is characteristic of **spina bifida occulta**. - **Spina bifida occulta** is the least severe form of neural tube defect, where there is a bony defect in the vertebrae but the spinal cord and meninges remain within the spinal canal and are not externally evident. *Protrusion of the meninges and spinal cord through a bony defect* - This describes a **myelomeningocele**, which is a more severe form of spina bifida where the **spinal cord** and **meninges** protrude through a bony defect. - Myelomeningocele typically presents with a visible sac on the back containing neural tissue, often leading to neurological deficits. *Protrusion of the meninges through a bony defect* - This describes a **meningocele**, where only the **meninges** protrude through a defect in the vertebral column, forming a fluid-filled sac. - While it involves a visible sac, it does not contain neural tissue, and neurological symptoms are often absent or less severe compared to myelomeningocele. *Spinal cord able to be seen externally* - This is characteristic of **myeloschisis** or **rachischisis**, the most severe open neural tube defects where the **spinal cord** is open and exposed to the environment. - This condition is often incompatible with life or leads to profound neurological impairment. *Absence of the brain and calvarium* - This describes **anencephaly**, a severe neural tube defect resulting from failure of closure of the anterior neural tube. - Anencephaly is a lethal condition where the forebrain and cranial vault are absent, which is distinctly different from a spinal defect.

Question 64: A 17-year-old girl comes to the physician because she had unprotected sexual intercourse the previous day. Menses have occurred at regular 28-day intervals since menarche at the age of 13 years. Her last menstrual period was 12 days ago. Physical examination shows no abnormalities. A urine pregnancy test is negative. She does not wish to become pregnant until after college and does not want her parents to be informed of this visit. Which of the following is the most appropriate step in management?

A. Administer ulipristal acetate
B. Insert copper-containing intra-uterine device (Correct Answer)
C. Administer mifepristone
D. Insert progestin-containing intra-uterine device
E. Administer combined oral contraceptive

Explanation: ***Insert copper-containing intra-uterine device*** - This is the **most effective form of emergency contraception**, offering >99% effectiveness and can be inserted up to 5 days after unprotected intercourse. - It also provides highly effective long-term contraception, aligning with the patient's desire not to become pregnant until after college. *Administer ulipristal acetate* - While effective as emergency contraception, **ulipristal acetate** is less effective than the copper IUD, especially five days after intercourse. - It provides only **short-term contraception** and would require the patient to return for long-term birth control. *Administer mifepristone* - **Mifepristone** is primarily an abortion pill used to terminate an existing pregnancy, not for emergency contraception. - It would be inappropriate for a situation where pregnancy has not been confirmed and the goal is prevention. *Insert progestin-containing intra-uterine device* - **Progestin-containing IUDs** are excellent for long-term contraception but are **not approved or effective as emergency contraception**. - Their mechanism of action primarily involves thickening cervical mucus and thinning the uterine lining, which takes time to become effective. *Administer combined oral contraceptive* - Combined oral contraceptives can be used as emergency contraception (the **Yuzpe method**) but are **less effective** than the copper IUD or ulipristal acetate. - This method is associated with more side effects like nausea and vomiting, and requires multiple doses, which decreases compliance.

Question 65: A 14-year-old girl is brought to the pediatrician by her mother. The girl's mother states that she began having her period 6 months ago. The patient states that after her first period she has had a period every 10 to 40 days. Her menses have ranged from very light flow to intense and severe symptoms. Otherwise, the patient is doing well in school, is on the track team, and has a new boyfriend. Her temperature is 98.1°F (36.7°C), blood pressure is 97/58 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam demonstrates an obese girl but is otherwise within normal limits. Which of the following is the most likely diagnosis?

A. Normal development (Correct Answer)
B. Pregnancy
C. Polycystic ovarian syndrome
D. Premenstrual tension
E. Premenstrual dysphoric disorder

Explanation: ***Normal development*** - In the first 1-2 years after **menarche**, menstrual cycles are often **irregular** due to the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, leading to anovulatory cycles. - The patient's presentation of varied cycle lengths (10-40 days) and flow intensity within 6 months of menarche is consistent with this common physiological phenomenon. *Pregnancy* - Although **amenorrhea** is a hallmark of pregnancy, the patient is experiencing periods, albeit irregular. - There are no other signs or symptoms suggestive of pregnancy like nausea, breast tenderness, or abdominal enlargement. *Polycystic ovarian syndrome* - While **irregular menses** and **obesity** are features of PCOS, the patient's symptoms have only been present for a short time (6 months post-menarche). - PCOS typically involves additional signs of **hyperandrogenism** (e.g., hirsutism, acne, alopecia) or characteristic ovarian morphology on ultrasound, which are not mentioned here. *Premenstrual tension* - **Premenstrual tension (PMT)**, often referred to as PMS, involves a constellation of emotional and physical symptoms that cyclically occur in the late luteal phase of the menstrual cycle and resolve with menses. - The primary concern in this case is the **irregularity of her periods** and menstrual symptoms, rather than a consistent pattern of premenstrual mood or physical complaints separate from the flow itself. *Premenstrual dysphoric disorder* - **Premenstrual dysphoric disorder (PMDD)** is a severe form of PMS characterized by significant mood disturbances such as irritability, depression, and anxiety that profoundly affect daily functioning. - The patient's reported symptoms focus on variability in her menstrual cycle and flow, not on severe, debilitating mood shifts occurring consistently before her menses, and she is otherwise noted to be "doing well."

Question 66: A 26-year-old woman, G1P0, at 22 weeks of gestation presents to the clinic for a prenatal visit. Her recent pregnancy scan shows a single live intrauterine fetus with adequate fetal movements. Facial appearance shows the presence of a cleft lip. The rest of the fetal development is within normal limits. The fetal heart rate is 138/min. Her prenatal screening tests for maternal serum α-fetoprotein (MSAFP) concentration, pregnancy-associated plasma protein-A (PAPP-A), and free β-human chorionic gonadotropin (β-hCG) are within normal ranges respectively. Her past medical and surgical histories are negative. She is worried about the health of her baby. The baby is at increased risk for which of the following birth defects?

A. Down syndrome
B. Neural tube abnormalities
C. Ocular abnormalities
D. Trisomy 13
E. Cleft palate (Correct Answer)

Explanation: ***Cleft palate*** - A **cleft lip** may occur in isolation or with a **cleft palate**, as both result from incomplete fusion of facial structures during embryonic development. - The presence of a cleft lip strongly increases the likelihood of an associated cleft palate, forming a **cleft lip and palate (CLP)** spectrum of defects. *Down syndrome* - **Down syndrome (Trisomy 21)** is associated with facial dysmorphia but not typically isolated cleft lip. - Additionally, maternal serum markers (MSAFP, PAPP-A, free β-hCG) were reported as **normal**, making Down syndrome less likely. *Neural tube abnormalities* - **Neural tube defects (NTDs)**, like **spina bifida** or **anencephaly**, are primarily associated with abnormal MSAFP levels, which are normal in this case. - They involve defects of the brain or spinal cord and are not directly linked to cleft lip. *Ocular abnormalities* - While some genetic syndromes can involve both facial and ocular abnormalities, an isolated **cleft lip** does not specifically point to a higher risk of ocular defects compared to other associated anomalies. - There is no direct anatomical or developmental connection between isolated cleft lip and increased risk of ocular abnormalities. *Trisomy 13* - **Trisomy 13 (Patau syndrome)** is often associated with a **cleft lip** and palate, but it also presents with severe multi-organ anomalies like **microphthalmia**, **polydactyly**, and significant developmental delays. - The fetal development, apart from the cleft lip, is described as **otherwise normal**, and the maternal serum markers would likely be abnormal in Trisomy 13, making this diagnosis less probable.

Question 67: A 19-year-old female complains of abnormal facial hair growth. This has been very stressful for her, especially in the setting of not being happy with her weight. Upon further questioning you learn she has a history of type 2 diabetes mellitus. Her height is 61 inches, and weight is 185 pounds (84 kg). Physical examination is notable for facial hair above her superior lip and velvety, greyish thickened hyperpigmented skin in the posterior neck. Patient is started on a hormonal oral contraceptive. Which of the following is a property of the endometrial protective hormone found in this oral contraceptive?

A. Enhances tubal motility
B. Thickens cervical mucus (Correct Answer)
C. Increases bone fractures
D. Decreases LDL
E. Decreases thyroid binding globulin

Explanation: ***Thickens cervical mucus*** - The endometrial protective hormone in this oral contraceptive is **progestin**, which acts by **thickening cervical mucus**, making it impenetrable to sperm and thus preventing fertilization. - This action is a key mechanism by which combined oral contraceptives prevent pregnancy, along with inhibiting ovulation. *Enhances tubal motility* - **Estrogen**, found in combined oral contraceptives, generally enhances tubal motility, but progestin's primary action for contraception is not tubal enhancement but rather making the cervical mucus inhospitable. - Increased tubal motility could theoretically aid sperm transport or ovum capture, which is counterproductive to contraception. *Increases bone fractures* - **Hormonal contraceptives**, particularly combined oral contraceptives, are not typically associated with an **increased risk of bone fractures**; in fact, some studies suggest a protective or neutral effect on bone mineral density. - **Estrogen** in combined oral contraceptives generally has a protective effect on bone density. *Decreases LDL* - While some hormonal therapies can impact lipid profiles, **oral contraceptives**, particularly those with certain progestins, can sometimes lead to a **slight increase in LDL** (low-density lipoprotein) and triglycerides, while estrogen components can elevate HDL. - The net effect on LDL is not typically a decrease; therefore, this is not a property of the progestin component providing endometrial protection. *Decreases thyroid binding globulin* - **Estrogen** in oral contraceptives **increases the synthesis of thyroid-binding globulin (TBG)**, leading to higher total thyroid hormone levels, although free thyroid hormone levels usually remain normal. - Progestins do not decrease TBG; therefore, this statement is incorrect.

Question 68: A 25-year-old G1P0 woman at 22 weeks’ gestation presents to the emergency department with persistent vomiting over the past 8 weeks which has resulted in 5.5 kg (12.1 lb) of unintentional weight loss. She has not received any routine prenatal care to this point. She reports having tried diet modification and over-the-counter remedies with no improvement. The patient's blood pressure is 103/75 mm Hg, pulse is 93/min, respiratory rate is 15/min, and temperature is 36.7°C (98.1°F). Physical examination reveals an anxious and fatigued-appearing young woman, but whose findings are otherwise within normal limits. What is the next and most important step in her management?

A. Begin treatment with vitamin B6
B. Begin treatment with metoclopramide
C. Obtain a basic electrolyte panel
D. Obtain a beta hCG and pelvic ultrasound
E. Admit and begin intravenous rehydration (Correct Answer)

Explanation: ***Admit and begin intravenous rehydration*** - The patient exhibits signs of **hyperemesis gravidarum**, including persistent vomiting, **significant weight loss** (5.5 kg), and inability to maintain hydration orally. - **Intravenous rehydration** is crucial to correct dehydration and electrolyte imbalances, which can lead to serious complications if left untreated. *Begin treatment with vitamin B6* - While **pyridoxine (vitamin B6)** is a first-line treatment for **mild to moderate nausea and vomiting of pregnancy**, it is insufficient for severe cases involving significant weight loss and dehydration. - This patient's symptoms are beyond what can be effectively addressed with vitamin B6 alone and require more aggressive management. *Begin treatment with metoclopramide* - **Metoclopramide** is an antiemetic that can be used for nausea and vomiting in pregnancy, but it is typically reserved for cases where first-line therapies (like vitamin B6) are ineffective. - Before starting medication, especially in a severely dehydrated patient, addressing the immediate fluid and electrolyte deficits is paramount. *Obtain a basic electrolyte panel* - While obtaining an **electrolyte panel** is an important diagnostic step to assess the degree of electrolyte disturbance, it is not the *most important first step* in management. - The patient's clinical presentation of persistent vomiting and weight loss clearly indicates the need for immediate intravenous rehydration regardless of initial electrolyte results. *Obtain a beta hCG and pelvic ultrasound* - A **beta hCG level** and **pelvic ultrasound** might be indicated later to rule out other causes of hyperemesis, such as **multiple gestation** or **molar pregnancy**. - However, given the patient's acute symptoms of dehydration and weight loss, immediate stabilization with intravenous fluids takes precedence over diagnostic imaging.

Question 69: A 28-year-old primigravid woman comes to the physician at 27 weeks' gestation with increased urinary frequency, a burning sensation when urinating, flank pain, and nausea. Her pregnancy has been uncomplicated. Glucose tolerance testing performed at 25 weeks' gestation was normal. She is sexually active with her husband. Her only medication is a prenatal vitamin. Her pulse is 90/min, respirations are 16/min, and blood pressure is 125/75 mm Hg. Physical examination shows marked tenderness in the right costovertebral area. Pelvic examination shows a uterus consistent with 27 weeks' gestation. Her urine dipstick is positive for leukocyte esterase and nitrites. The urine is sent for bacterial culture. Which of the following changes most likely contributed to this patient's condition?

A. Increased body temperature
B. Decreased ureteral smooth muscle tone (Correct Answer)
C. Decreased urine volume
D. Increased urinary pH
E. Decreased urine glucose concentration

Explanation: ***Decreased ureteral smooth muscle tone*** - Hormonal changes during pregnancy, particularly elevated **progesterone**, lead to **relaxation of smooth muscle** in the ureters. This causes **ureteral dilation** and **stasis of urine**, increasing the risk of ascending infection. - The resulting **hydroureteronephrosis** allows bacteria to ascend more easily from the bladder to the kidneys, predisposing the patient to **pyelonephritis**, as suggested by her symptoms of flank pain, fever (implied by symptoms), and costovertebral angle tenderness. *Increased body temperature* - While an increased body temperature (fever) is a symptom of infection, it is a **result** of the pyelonephritis, not a predisposing factor for it. - An underlying infection leads to systemic inflammatory responses that cause fever, but higher baseline body temperature does not directly contribute to the development of the condition. *Decreased urine volume* - **Decreased urine volume** (e.g., dehydration) would lead to more concentrated urine, which can sometimes be associated with a higher risk of infection due to less frequent flushing of bacteria from the urinary tract. - However, in pregnancy, women typically have **increased GFR** and often **increased urine volume**, and the primary predisposing factor for pyelonephritis is urinary stasis due to ureteral changes, not reduced volume. *Increased urinary pH* - An **increased urinary pH** can favor the growth of certain bacteria (e.g., *Proteus mirabilis*), which can produce urease and create an alkaline environment. - However, in pregnancy, the hormonal and anatomical changes leading to **urinary stasis** are the more significant and direct contributors to the development of ascending UTIs like pyelonephritis. *Decreased urine glucose concentration* - A **decreased urine glucose concentration** is not a known risk factor for urinary tract infections or pyelonephritis. - Women with **gestational diabetes** or uncontrolled diabetes (leading to increased urine glucose) are at higher risk for UTIs due to glucose providing a substrate for bacterial growth, so a *decreased* concentration would theoretically be protective or irrelevant.

Question 70: A 27-year-old woman, gravida 2, para 1, at 36 weeks' gestation comes to the physician for a prenatal visit. She feels well. Fetal movements are adequate. This is her 7th prenatal visit. She had an ultrasound scan performed 1 month ago that showed a live intrauterine pregnancy consistent with a 32-week gestation with no anomalies. She had a Pap smear performed 1 year ago, which was normal. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Her blood group and type is A negative. Which of the following is the most appropriate next step in management?

A. Transabdominal doppler ultrasonography
B. Rh antibody testing
C. Swab for GBS culture (Correct Answer)
D. Serum PAPP-A and HCG levels
E. Complete blood count

Explanation: ***Swab for GBS culture*** - All pregnant women should be screened for **Group B Streptococcus (GBS)** between **36 weeks 0 days and 37 weeks 6 days** of gestation. - A positive GBS culture requires **intrapartum antibiotic prophylaxis** to prevent early-onset neonatal GBS disease. *Transabdominal doppler ultrasonography* - **Doppler ultrasonography** is primarily used to assess **fetal well-being** in cases of **fetal growth restriction**, preeclampsia, or other high-risk conditions. - This patient has a **normal-sized uterus** and **adequate fetal movements**, indicating no immediate need for fetal Doppler assessment. *Rh antibody testing* - **Rh antibody testing** (indirect Coombs test) is performed early in pregnancy for Rh-negative women and typically repeated at **28 weeks' gestation** before anti-D immune globulin administration. - Repeating this test at 36 weeks is not the most appropriate *next* step as the routine schedule for Rh immune globulin would typically be managed prior to this point. *Serum PAPP-A and HCG levels* - **Serum PAPP-A and HCG levels** are components of **first-trimester screening** for chromosomal abnormalities, performed between 11 and 14 weeks of gestation. - At 36 weeks' gestation, these markers are not relevant for current fetal assessment. *Complete blood count* - A **complete blood count (CBC)** is routinely performed in the first trimester and often repeated in the **late second or early third trimester** (around 28 weeks) to check for anemia. - While a CBC might be done as part of general prenatal care, it is not the most urgent or specifically indicated test at 36 weeks in the absence of symptoms.

Question 71: A 38-year-old woman, gravida 2, para 1, at 24 weeks' gestation comes to the physician for a routine prenatal evaluation. She has no history of major medical illness and takes no medications. Fetal ultrasonography shows a cardiac defect resulting from abnormal development of the endocardial cushions. This defect is most likely to result in which of the following?

A. Transposition of the great vessels
B. Atrioventricular septal defect (Correct Answer)
C. Dextrocardia
D. Patent foramen ovale
E. Sinus venosus defect

Explanation: ***Atrioventricular septal defect*** - **Endocardial cushion defects** are a hallmark of atrioventricular septal defects, leading to a common atrioventricular valve and an interatrial and/or interventricular communication. - This defect commonly presents in individuals with **Down syndrome (Trisomy 21)**, though it can occur in isolation. *Transposition of the great vessels* - This defect results from abnormal **spiraling of the conotruncal septum**, not from endocardial cushion malformation. - It leads to the **aorta arising from the right ventricle** and the **pulmonary artery from the left ventricle**, a circulation incompatible with life without a shunt. *Dextrocardia* - **Dextrocardia** is a condition where the heart is located on the right side of the chest, usually due to abnormal embryonic folding, and is not directly caused by endocardial cushion defects. - It can occur as an isolated finding or as part of a more complex syndrome like **Kartagener syndrome**. *Patent foramen ovale* - A **patent foramen ovale** is a common remnant of fetal circulation, occurring when the foramen ovale fails to close after birth. - It is a defect of the **atrial septum secondary to incomplete fusion between the septum primum and septum secundum**, not an endocardial cushion defect. *Sinus venosus defect* - A **sinus venosus defect** is a type of atrial septal defect occurring near the entrance of the superior or inferior vena cava. - It is caused by **abnormal development of the sinus venosus** and is not directly related to endocardial cushion malformation.

Question 72: A 28-year-old woman comes to the physician because she had a positive pregnancy test at home. She reports feeling nauseated and has vomited several times over the past week. During this period, she has also had increased urinary frequency. She is sexually active with her boyfriend and they use condoms inconsistently. Her last menstrual period was 5 weeks ago. Physical examination shows no abnormalities. A urine pregnancy test is positive. A pap smear is positive for a high-grade squamous intraepithelial lesion. Colposcopy shows cervical intraepithelial neoplasia grade II and III. Which of the following is the most appropriate next step in the management of this patient?

A. Perform loop electrosurgical excision
B. Diagnostic excisional procedure
C. Colposcopy and cytology at 6-month intervals for 12 months
D. Reevaluation with cytology and colposcopy 6 weeks after birth (Correct Answer)
E. Endocervical curettage

Explanation: ***Reevaluation with cytology and colposcopy 6 weeks after birth*** - Pregnancy is a state of relative **immunosuppression**, allowing high-grade lesions (CIN II/III) to potentially regress postpartum. - **Invasive procedures** should be delayed until after delivery to avoid obstetric complications unless invasion is suspected. *Perform loop electrosurgical excision* - This procedure, while effective for CIN II/III, is generally **avoided during pregnancy** due to increased risks of hemorrhage, infection, and preterm labor. - **Observation** is preferred in pregnant patients with CIN II/III, given the possibility of lesion regression postpartum. *Diagnostic excisional procedure* - Like LEEP, diagnostic excisional procedures (e.g., **cone biopsy**) carry significant risks during pregnancy, including **miscarriage** and **cervical incompetence**. - It is usually reserved for cases where **invasive cancer** cannot be excluded by colposcopy and directed biopsies alone. *Colposcopy and cytology at 6-month intervals for 12 months* - While follow-up is appropriate, waiting 6 months for the initial follow-up is **too long** given the patient's pregnant status. - The standard approach is to reevaluate postpartum, as pregnancy-related changes can affect lesion appearance and natural history. *Endocervical curettage* - **Endocervical curettage (ECC)** is **contraindicated in pregnancy** as it can disrupt the pregnancy and lead to complications. - It is performed in non-pregnant patients to evaluate for disease extending into the endocervical canal.

Question 73: A 28-year-old woman presents with an abnormal vaginal discharge for the past week. She maintains a monogamous relationship but denies the use of barrier protection with her partner. She is 5 weeks late for her menstrual cycle. Subsequent testing demonstrates a positive pregnancy test. A wet mount demonstrates motile, pear-shaped organisms. Which of the following is the most appropriate treatment for this patient?

A. Metronidazole (Correct Answer)
B. Ceftriaxone
C. Tinidazole
D. Azithromycin
E. Fluconazole

Explanation: ***Metronidazole*** - The presence of **motile, pear-shaped organisms** on a wet mount is characteristic of **Trichomonas vaginalis infection**, which is treated effectively with metronidazole. - While metronidazole is generally avoided early in pregnancy, the benefits often outweigh the risks for symptomatic trichomoniasis, especially since the patient is already 5 weeks late for her period and a positive pregnancy test has been confirmed. *Ceftriaxone* - This antibiotic is primarily used to treat **gonorrhea**, a sexually transmitted infection that presents with purulent discharge but does not typically show motile, pear-shaped organisms on wet mount. - It is not effective against *Trichomonas vaginalis*. *Tinidazole* - Tinidazole is another effective drug against *Trichomonas vaginalis*, similar to metronidazole. However, **metronidazole is generally preferred as the first-line treatment**, especially in pregnancy, due to more extensive safety data and established guidelines. - Although it could be used for trichomoniasis, metronidazole is typically the more immediate and widely recommended choice. *Azithromycin* - Azithromycin is the treatment of choice for **Chlamydia trachomatis infection**, which causes a different type of vaginal discharge and does not involve motile, pear-shaped organisms. - It has no activity against *Trichomonas vaginalis*. *Fluconazole* - This antifungal medication is used to treat **vulvovaginal candidiasis (yeast infection)**, which presents with a thick, white, "cottage cheese-like" discharge and spores/hyphae on microscopy, not motile protozoa. - It is ineffective against *Trichomonas vaginalis*.

Question 74: A 23-year-old woman gravida 2, para 1 at 12 weeks' gestation comes to the physician for her initial prenatal visit. She feels well. She was treated for genital herpes one year ago and gonorrhea 3 months ago. Medications include folic acid and a multivitamin. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 12-week gestation. Urine dipstick is positive for leukocyte esterase and nitrite. Urine culture shows E. coli (> 100,000 colony forming units/mL). Which of the following is the most appropriate next step in management?

A. Perform cystoscopy
B. Administer gentamicin
C. Administer trimethoprim/sulfamethoxazole (TMP/SMX)
D. Administer amoxicillin/clavulanate (Correct Answer)
E. Perform renal ultrasound

Explanation: ***Administer amoxicillin/clavulanate*** - The patient has **asymptomatic bacteriuria** based on a positive urine dipstick for leukocyte esterase and nitrite and a urine culture showing *E. coli* (> 100,000 CFU/mL) in a pregnant patient. - **Amoxicillin/clavulanate** is a safe and effective first-line antibiotic for treating asymptomatic bacteriuria in pregnancy due to its broad spectrum and safety profile for the fetus. *Perform cystoscopy* - **Cystoscopy** is an invasive procedure typically reserved for evaluating persistent hematuria, recurrent UTIs despite appropriate therapy, or suspected bladder pathology. - It is not indicated for initial management of asymptomatic bacteriuria, especially in pregnancy, as it carries risks and offers no immediate therapeutic benefit for this condition. *Administer gentamicin* - **Gentamicin** is an aminoglycoside antibiotic that is generally **contraindicated in pregnancy** due to potential **fetal ototoxicity** and nephrotoxicity. - While effective against *E. coli*, its risks outweigh the benefits for asymptomatic bacteriuria, especially when safer alternatives are available. *Administer trimethoprim/sulfamethoxazole (TMP/SMX)* - **Trimethoprim/sulfamethoxazole (TMP/SMX)** is generally **avoided in the first trimester** of pregnancy due to concerns about **folate antagonism** (trimethoprim) and potential teratogenic effects, such as neural tube defects, particularly between 6-12 weeks' gestation. - The patient is at 12 weeks' gestation, making TMP/SMX a less safe choice compared to other antibiotics. *Perform renal ultrasound* - A **renal ultrasound** is typically performed if there are complications such as **pyelonephritis**, recurrent urinary tract infections, or suspicion of **structural abnormalities** in the urinary tract. - For asymptomatic bacteriuria, an ultrasound is not part of the initial management unless there are specific indications or if the infection does not resolve with appropriate antibiotic therapy.

Question 75: A 29-year-old woman presents to a medical office complaining of fatigue, nausea, and vomiting for 1 week. Recently, the smell of certain foods makes her nauseous. Her symptoms are more pronounced in the mornings. The emesis is clear-to-yellow without blood. She has had no recent travel out of the country. The medical history is significant for peptic ulcer, for which she takes pantoprazole. The blood pressure is 100/60 mm Hg, the pulse is 70/min, and the respiratory rate is 12/min. The physical examination reveals pale mucosa and conjunctiva, and bilateral breast tenderness. The LMP was 9 weeks ago. What is the most appropriate next step in the management of this patient?

A. Beta-HCG levels and a transvaginal ultrasound (Correct Answer)
B. Beta-HCG levels and a transabdominal ultrasound
C. Beta-HCG levels and a pelvic CT
D. Abdominal x-ray
E. Abdominal CT with contrast

Explanation: ***Beta-HCG levels and a transvaginal ultrasound*** - The patient's symptoms (fatigue, nausea, vomiting, morning sickness, breast tenderness, and **amenorrhea** for 9 weeks) strongly suggest **early pregnancy**. - **Urine or serum beta-HCG** confirms pregnancy, and a **transvaginal ultrasound** is crucial for confirming an **intrauterine pregnancy**, estimating gestational age, and ruling out complications like ectopic pregnancy, especially at this early stage when transabdominal ultrasound might not provide clear images. *Beta-HCG levels and a transabdominal ultrasound* - While beta-HCG levels are appropriate, a **transabdominal ultrasound** may not be sufficient to visualize an early intrauterine pregnancy at 9 weeks due to limited resolution compared to transvaginal ultrasound. - A definitive confirmation of **intrauterine pregnancy** is critical to rule out an **ectopic pregnancy**, which is better achieved with transvaginal imaging in early gestation. *Beta-HCG levels and a pelvic CT* - **CT scans** expose the patient to significant **ionizing radiation**, which is **contraindicated in pregnancy** unless absolutely necessary for life-threatening conditions. - While it could identify some pelvic pathologies, it is **not the primary imaging modality** for confirming or evaluating early pregnancy due to radiation risks and inferior soft tissue resolution for early gestational sacs compared to ultrasound. *Abdominal x-ray* - An **abdominal X-ray** involves **ionizing radiation** and offers very limited diagnostic value for early pregnancy, as it cannot visualize the gestational sac, fetus, or fetal heart activity. - It is **contraindicated** in suspected pregnancy due to the risk of fetal harm. *Abdominal CT with contrast* - **Abdominal CT with contrast** involves both **ionizing radiation** and **contrast agents**, both of which pose significant risks to a developing fetus. - It is an **inappropriate initial step** for suspected pregnancy and offers no specific diagnostic benefits for confirming or characterizing early gestation.

Question 76: A 16-year-old girl comes to the physician with her mother because of intermittent abdominal cramps, fatigue, and increased urination over the past 3 months. She has no history of serious illness. She reports that she has not yet had her first menstrual period. Her mother states that she receives mostly A and B grades in school and is very active in school athletics. Her mother has type 2 diabetes mellitus and her maternal aunt has polycystic ovary syndrome. Her only medication is a daily multivitamin. The patient is 150 cm (4 ft 11 in) tall and weighs 50 kg (110 lb); BMI is 22.2 kg/m2. Vital signs are within normal limits. A grade 2/6 early systolic murmur is heard best over the pulmonic area and increases with inspiration. The abdomen is diffusely tender to palpation and a firm mass is felt in the lower abdomen. Breast and pubic hair development are at Tanner stage 5. Which of the following is the most appropriate next step in management?

A. Pelvic ultrasound (Correct Answer)
B. Karyotyping
C. Serum β-hCG
D. Fasting glucose and lipid panel
E. Serum fT4

Explanation: ***Pelvic ultrasound*** - A **firm mass** in the **lower abdomen** of a 16-year-old with primary amenorrhea and a family history concerning for genetic predispositions (type 2 diabetes, PCOS) warrants imaging to evaluate for structural abnormalities. - A pelvic ultrasound is the **first-line imaging modality** to assess the uterus, ovaries, and other pelvic organs, and to further characterize the palpable mass. *Karyotyping* - While **primary amenorrhea** can be caused by chromosomal abnormalities (e.g., Turner syndrome), a palpable abdominal mass points toward an **anatomical issue** over a genetic one. - Karyotyping would be more appropriate if initial imaging was normal or if there were other features suggestive of a specific genetic syndrome, such as short stature or webbed neck. *Serum β-hCG* - Although abdominal cramps and a mass can occur in pregnancy, the patient reports **primary amenorrhea** (never had a period), making pregnancy less likely, especially with no stated sexual activity although it could exist. - While a **beta-hCG** is often part of a workup for abdominal pain in reproductive-age females, the primary amenorrhea and a firm, palpable mass in this context make structural evaluation more urgent. *Fasting glucose and lipid panel* - The family history of type 2 diabetes and PCOS might suggest metabolic screening, but these investigations are not directly related to evaluating the **acute complaint of a palpable abdominal mass** and primary amenorrhea. - These tests would be more appropriate for ongoing management or if polycystic ovary syndrome (PCOS) was being specifically investigated after excluding structural causes of amenorrhea. *Serum fT4* - **Thyroid hormone imbalances** can cause menstrual irregularities, but typically present as secondary amenorrhea (cessation of periods), not primary amenorrhea with a distinct abdominal mass. - **Hypothyroidism** can lead to delayed puberty and menstrual irregularities, but it would not explain a palpable abdominal mass.

Question 77: A 29-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the physician for a prenatal visit. Over the past two weeks, she has felt nauseous in the morning and has had vulvar pruritus and dysuria that started 5 days ago. Her first child was delivered by lower segment transverse cesarean section because of macrosomia from gestational diabetes. Her gestational diabetes resolved after the child was born. She appears well. Ultrasound confirms fetal heart tones and an intrauterine pregnancy. Speculum exam shows a whitish chunky discharge. Her vaginal pH is 4.2. A wet mount is performed and microscopic examination is shown. Which of the following is the most appropriate treatment?

A. Topical nystatin
B. Oral fluconazole
C. Intravaginal clotrimazole (Correct Answer)
D. Oral metronidazole
E. Intravaginal treatment with lactobacillus

Explanation: ***Intravaginal clotrimazole*** - The patient's symptoms of **vulvar pruritus**, **dysuria**, **whitish chunky discharge**, a **vaginal pH of 4.2**, and microscopy consistent with **yeast buds and hyphae** are highly suggestive of **vulvovaginal candidiasis (VVC)**. - **Intravaginal azole antifungals** like clotrimazole are the **first-line treatment for VVC in pregnancy** due to their local action and minimal systemic absorption, making them safe for the fetus. *Topical nystatin* - While **nystatin** is an antifungal used for candidiasis, its **efficacy for vulvovaginal candidiasis is lower** compared to azoles. - **Topical nystatin** is generally **not the preferred first-line treatment** for VVC, especially when more effective alternatives like azoles are available. *Oral fluconazole* - **Oral fluconazole** is generally **avoided in the first trimester of pregnancy** due to potential risks of **teratogenicity**, including an increased risk of miscarriage and congenital malformations at higher doses, though lower single doses are considered by some to be low risk. - Given the patient is at **10 weeks' gestation**, topical treatment is preferred over oral options to minimize systemic exposure. *Oral metronidazole* - **Metronidazole** is an **antibiotic and antiprotozoal** medication primarily used to treat **bacterial vaginosis** or **trichomoniasis**, conditions that do not match the patient's presentation. - The patient's **vaginal pH of 4.2** and **chunky discharge** differentiate VVC from bacterial vaginosis (which typically has a pH >4.5 and thin, malodorous discharge) or trichomoniasis (often frothy discharge and high pH). *Intravaginal treatment with lactobacillus* - **Lactobacillus** is used to help restore the normal vaginal flora, often as an **adjunctive treatment** or for prophylaxis, particularly in cases of **recurrent bacterial vaginosis** or after antibiotic therapy. - It is **not a primary treatment for active fungal infections** like vulvovaginal candidiasis, as it does not directly eradicate the yeast.

Question 78: A 34-year-old woman, gravida 3, para 2, at 16 weeks' gestation comes to the physician because of nausea and recurrent burning epigastric discomfort for 1 month. Her symptoms are worse after heavy meals. She does not smoke or drink alcohol. Examination shows a uterus consistent in size with a 16-week gestation. Palpation of the abdomen elicits mild epigastric tenderness. The physician prescribes her medication to alleviate her symptoms. Treatment with which of the following drugs should be avoided in this patient?

A. Magnesium hydroxide
B. Sucralfate
C. Pantoprazole
D. Cimetidine
E. Misoprostol (Correct Answer)

Explanation: ***Misoprostol*** - **Misoprostol** is a prostaglandin E1 analog that stimulates uterine contractions, which can lead to **miscarriage** or **preterm labor**. - Its **abortifacient properties** contraindicate its use in pregnancy, particularly for symptoms like heartburn. *Magnesium hydroxide* - **Magnesium hydroxide** is a common **antacid** that is generally considered safe for occasional use during pregnancy to relieve heartburn. - While excessive doses can lead to **diarrhea**, it is not contraindicated and does not pose a direct threat to fetal development or pregnancy maintenance. *Sucralfate* - **Sucralfate** forms a protective barrier over ulcers and erosions in the GI tract and is minimally absorbed systemically, making it a safe option in pregnancy. - It works locally and has no known teratogenic effects, often used for **gastric protection** during gestation. *Pantoprazole* - **Pantoprazole** is a **proton pump inhibitor (PPI)** that reduces stomach acid production and is generally considered safe for use in pregnancy when indicated for GERD or severe heartburn. - It is classified as pregnancy category B or C, but extensive observational data have not shown an increased risk of malformations. *Cimetidine* - **Cimetidine** is an **H2 receptor antagonist** that decreases gastric acid secretion and is generally considered safe for use in pregnancy to treat heartburn or GERD. - It is classified as pregnancy category B, and its use is well-established with no significant adverse fetal outcomes reported.

Question 79: A 27-year-old female in her 20th week of pregnancy presents for a routine fetal ultrasound screening. An abnormality of the right fetal kidney is detected. It is determined that the right ureteropelvic junction has failed to recanalize. Which of the following findings is most likely to be seen on fetal ultrasound:

A. Renal cysts
B. Duplicated ureter
C. Bilateral renal agenesis
D. Pelvic kidney
E. Unilateral hydronephrosis (Correct Answer)

Explanation: ***Unilateral hydronephrosis*** - Failure of the **ureteropelvic junction (UPJ)** to recanalize leads to an obstruction of urine flow from the **renal pelvis** into the ureter. - This obstruction causes a buildup of urine in the renal pelvis and calyces, a condition known as **hydronephrosis**, which will be unilateral as only the right kidney is affected. *Renal cysts* - **Renal cysts** are typically associated with conditions like polycystic kidney disease or multicystic dysplastic kidney, which involve abnormal development of renal parenchyma, not specifically a UPJ obstruction. - While hydronephrosis can sometimes lead to cystic changes if severe and prolonged, in the initial stages of a UPJ obstruction detected on fetal ultrasound, **hydronephrosis** itself is the primary and most likely finding. *Duplicated ureter* - A **duplicated ureter** is a distinct congenital anomaly involving the formation of two ureters draining a single kidney or separate renal moieties. - It does not directly result from the failure of **ureteropelvic junction recanalization**. *Bilateral renal agenesis* - **Bilateral renal agenesis** means both kidneys failed to develop, which would lead to severe oligohydramnios and is incompatible with sustained fetal life. - The question describes an abnormality only in the **right kidney**, making bilateral agenesis incorrect. *Pelvic kidney* - A **pelvic kidney** (renal ectopia) occurs when the kidney fails to ascend from the pelvis to its normal lumbar position. - This is a positional anomaly and is not directly caused by a failure of **ureteropelvic junction recanalization**.

Question 80: A 23-year-old nulligravida presents for evaluation 5 weeks after her last menstrual period. Her previous menstruation cycle was regular, and her medical history is benign. She is sexually active with one partner and does not use contraception. A urine dipstick pregnancy test is negative. The vital signs are as follows: blood pressure 120/80 mm Hg, heart rate 71/min, respiratory rate 13/min, and temperature 36.8°C (98.2°F). The physical examination is notable for breast engorgement, increased pigmentation of the nipples, and linea nigra. The gynecologic examination demonstrates cervical and vaginal cyanosis. Measurement of which of the following substances is most appropriate in this case?

A. Blood estriol
B. Blood human chorionic gonadotropin (Correct Answer)
C. Urinary estrogen metabolites
D. Urinary human chorionic gonadotropin
E. Blood progesterone

Explanation: ***Blood human chorionic gonadotropin*** - The patient exhibits classic signs of early pregnancy, including **breast engorgement**, **nipple hyperpigmentation**, **linea nigra**, and **cervical and vaginal cyanosis** (Chadwick's sign). These signs, combined with a missed menstrual period and unprotected intercourse, strongly indicate pregnancy despite the negative urine dipstick. - A **blood human chorionic gonadotropin (hCG)** test is more sensitive than a urine test, detecting lower levels of hCG earlier in pregnancy, and is therefore the most appropriate next step to confirm pregnancy. *Blood estriol* - **Estriol** levels are used to assess fetal well-being in the late second and third trimesters, typically as part of the **triple or quadruple screen**, not for early pregnancy detection. - Its levels become significantly elevated much later in pregnancy, making it unsuitable for confirming a pregnancy at 5 weeks. *Urinary estrogen metabolites* - **Urinary estrogen metabolites** are primarily used to assess ovarian function and fertility, or to monitor hormone replacement therapy. - They are not a reliable or standard method for the early detection or confirmation of pregnancy. *Urinary human chorionic gonadotropin* - While **urinary hCG** is used for pregnancy detection (e.g., home pregnancy tests), a negative result at 5 weeks, especially in the presence of strong clinical signs of pregnancy, suggests that the levels might be below the detection threshold of the urine test. - A **quantitative blood hCG** test is superior in sensitivity and can detect very low levels of hCG, confirming or ruling out early pregnancy more definitively. *Blood progesterone* - **Progesterone** levels are necessary to maintain a pregnancy, but they do not confirm a pregnancy itself. High progesterone can indicate ovulation and potential luteal phase support. - While useful for assessing the viability of a confirmed early pregnancy or diagnosing conditions like ectopic pregnancy, it's not the primary test to confirm the presence of pregnancy.

Question 81: A 24-year-old woman comes to the clinic because her period is 4 weeks late, and she is experiencing fatigue and morning nausea. She had her last period almost 8 weeks ago. She is gravida 0 para 0 with previously regular menses and an unremarkable medical history. She had her menarche at the age of 13 years. She has a single sexual partner and does not use contraception. At presentation, her vital signs are within normal limits. Gynecological examination reveals breast and uterine enlargement. There is also cyanosis and softening in the cervical and vaginal regions. Which of the following statements is correct?

A. Hyperestrogenemia is the most probable cause of this patient’s menstrual delay
B. Estrone has the largest blood concentration among the estrogens in this patient
C. In the patient’s condition, blood estrogen level falls dramatically
D. As the patient's condition progresses, her estriol levels may rise up to 100-300 fold
E. The venous congestion in the patient’s reproductive organs is due to the influence of estrogens (Correct Answer)

Explanation: ***The venous congestion in the patient’s reproductive organs is due to the influence of estrogens*** - The patient's symptoms (late period, fatigue, morning nausea, breast and uterine enlargement, cyanosis, and softening of the cervix and vagina) are highly suggestive of **early pregnancy**. - During pregnancy, **estrogen levels dramatically increase**, causing increased blood flow and venous congestion in the reproductive organs, leading to signs like **Chadwick's sign** (cyanosis of the cervix and vagina). *Hyperestrogenemia is the most probable cause of this patient’s menstrual delay* - While estrogen levels are high in pregnancy, it is the **presence of human chorionic gonadotropin (hCG)** maintaining the corpus luteum and subsequently the placenta that prevents menstruation, not simply hyperestrogenemia alone. - The primary cause of menstrual delay in early pregnancy is the **absence of luteolysis** due to hCG, leading to continued progesterone production by the corpus luteum. *Estrone has the largest blood concentration among the estrogens in this patient* - **Estradiol** is the predominant estrogen produced by the ovaries in non-pregnant women and during early pregnancy. - In later pregnancy, **estriol** becomes the most abundant estrogen due to production by the fetal adrenal glands and placenta. *In the patient’s condition, blood estrogen level falls dramatically* - In early pregnancy, **estrogen levels actually rise** significantly to support the uterine environment and fetal development. - A dramatic fall in estrogen levels would typically indicate a **missed abortion or luteal phase defect**, which is contrary to the clinical presentation. *As the patient's condition progresses, her estriol levels may rise up to 100-300 fold* - While estriol levels do rise significantly during pregnancy, the primary early estrogen of pregnancy is **estradiol**. - **Estriol** levels increase dramatically later in pregnancy, reflecting fetal-placental unit function, but it is not the initial dominant estrogen and the rise is typically more pronounced than 100-300 fold relative to non-pregnant levels.

Question 82: A 34-year-old gravida 2 para 1 woman at 16 weeks gestation presents for prenatal care. Her prenatal course has been uncomplicated. She takes no medications besides her prenatal vitamin which she takes every day, and she has been compliant with routine prenatal care. She has a 7-year-old daughter who is healthy. The results of her recent quadruple screen are listed below: AFP: Low hCG: Low Estriol: Low Inhibin-A: Normal Which of the following is the most appropriate next step to confirm the diagnosis?

A. Chorionic villus sampling
B. Amniocentesis (Correct Answer)
C. Ultrasound for nuchal translucency
D. Folic acid supplementation
E. Return to clinic in 4 weeks

Explanation: ***Amniocentesis*** - The presented quad screen results (low AFP, low hCG, low estriol, normal Inhibin-A) are highly suggestive of **trisomy 18 (Edwards syndrome)**. Amniocentesis is a **definitive diagnostic test** that can confirm aneuploidy by providing a fetal karyotype. - While typically performed between **15 and 20 weeks gestation**, it can differentiate between trisomy 18 and trisomy 21 (Down syndrome), which usually presents with high hCG and high Inhibin-A. *Chorionic villus sampling (CVS)* - **CVS** is typically performed earlier in pregnancy, between **10 and 13 weeks gestation**, meaning it is too late to perform at 16 weeks gestation. - While it can provide a fetal karyotype for genetic diagnosis, the gestational age presented in the vignette makes this option currently inappropriate. *Ultrasound for nuchal translucency* - **Nuchal translucency (NT)** is part of the first-trimester screening, usually measured between **11 and 14 weeks gestation**. - At 16 weeks gestation, measuring NT would be **outside the appropriate timeframe**, and the second-trimester quad screen has already been completed, making further screening rather than diagnosis less useful. *Folic acid supplementation* - **Folic acid supplementation** is crucial before and during early pregnancy to prevent neural tube defects, which would be associated with high AFP. - The patient is already taking prenatal vitamins (which contain folic acid), and her quad screen results are not indicative of a neural tube defect but rather a chromosomal abnormality. *Return to clinic in 4 weeks* - The abnormal quad screen results indicate a **high risk for aneuploidy**, specifically trisomy 18, which requires immediate follow-up and definitive diagnosis. - Delaying further assessment for 4 weeks would be clinically inappropriate and could increase patient anxiety and potentially reduce options for further management.

Question 83: A 40-year-old pregnant woman, G4 P3, visits your office at week 30 of gestation. She is very excited about her pregnancy and wants to be the healthiest she can be in preparation for labor and for her baby. What vaccination should she receive at this visit?

A. Measles, mumps, and rubella (MMR)
B. Varicella vaccine
C. Herpes zoster vaccine
D. Live attenuated influenza vaccine
E. Tetanus, diphtheria, and acellular pertussis (Tdap) (Correct Answer)

Explanation: ***Tetanus, diphtheria, and acellular pertussis (Tdap)*** - The Tdap vaccine is recommended during each pregnancy, preferably between **27 and 36 weeks of gestation**, to maximize maternal antibody response and passive antibody transfer to the fetus. - This provides critical protection against **pertussis (whooping cough)** for the newborn, who is too young to be vaccinated. *Measles, mumps, and rubella (MMR)* - The **MMR vaccine is a live vaccine** and is **contraindicated during pregnancy** due to the theoretical risk of congenital rubella syndrome, although no cases have been reported. - It should be administered **postpartum** if the mother is not immune to rubella. *Varicella vaccine* - The **varicella vaccine is a live vaccine** and is **contraindicated during pregnancy** due to the theoretical risk of congenital varicella syndrome. - Like MMR, it should be offered in the **postpartum period** if the woman is not immune. *Herpes zoster vaccine* - The herpes zoster vaccine is typically recommended for **older adults** (50 years and older) for shingles prevention. - It is **not routinely recommended during pregnancy**, and its safety and efficacy in this population have not been sufficiently established. *Live attenuated influenza vaccine* - The **live attenuated influenza vaccine (LAIV)** is **contraindicated during pregnancy** due to its live virus content. - Pregnant women should receive the **inactivated influenza vaccine (IIV)**, which is safe and recommended during any trimester.

Question 84: A 24-year-old primigravida at 28 weeks gestation presents to the office stating that she “can’t feel her baby kicking anymore.” She also noticed mild-to-moderate vaginal bleeding. A prenatal visit a few days ago confirmed the fetal cardiac activity by Doppler. The medical history is significant for GERD, hypertension, and SLE. The temperature is 36.78°C (98.2°F), the blood pressure is 125/80 mm Hg, the pulse is 70/min, and the respiratory rate is 14/min. Which of the following is the next best step in evaluation?

A. Confirmation of cardiac activity by Doppler (Correct Answer)
B. Order platelet count, fibrinogen, PT and PTT levels
C. Abdominal delivery
D. Speculum examination
E. Misoprostol

Explanation: ***Confirmation of cardiac activity by Doppler*** - The patient presents with **decreased fetal movement** and **vaginal bleeding** at 28 weeks, which are concerning signs for complications like **placental abruption** or **fetal demise**. - The immediate priority is to assess **fetal viability** by confirming the presence of a **fetal heartbeat**, with **Doppler ultrasonography** being the quickest and most accessible method. *Order platelet count, fibrinogen, PT and PTT levels* - While **coagulation studies** are important in cases of significant vaginal bleeding, especially if **placental abruption** is suspected, they are not the *next best step*. - Assessing **fetal well-being** takes precedence, as the presence or absence of a **fetal heart rate** will guide subsequent emergency management. *Abdominal delivery* - **Abdominal delivery (C-section)** is a definitive intervention and should only be considered *after* an immediate assessment of **fetal status** and maternal stability. - Delivery at 28 weeks gestation would be considered **preterm**, and careful evaluation is needed before making such a critical decision. *Speculum examination* - A **speculum examination** is used to investigate the source of vaginal bleeding, assess the cervix, and rule out causes such as **cervical lesions** or **cervical dilation**. - However, given the *decreased fetal movement* and the potential for severe obstetrical emergencies, **fetal viability** must be confirmed first. *Misoprostol* - **Misoprostol** is a **prostaglandin analog** used to induce cervical ripening and uterine contractions, primarily for **labor induction** or **abortion**. - It is not indicated as an initial diagnostic or therapeutic step in a patient with *decreased fetal movement* and *vaginal bleeding* without a clear diagnosis or indication for delivery.

Question 85: A 53-year-old woman comes to the physician for evaluation of a 5-month history of painful sexual intercourse. She also reports vaginal dryness and occasional spotting. She has no pain with urination. She has hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Her last menstrual period was 8 months ago. She is sexually active with her husband and has two children. Current medications include ramipril, metformin, atorvastatin, and aspirin. Her temperature is 37°C (98.6°F), pulse is 85/min, and blood pressure is 140/82 mm Hg. Pelvic examination shows decreasing labial fat pad, receding pubic hair, and clear vaginal discharge. Which of the following is the most appropriate pharmacotherapy?

A. Topical estrogen cream (Correct Answer)
B. Oral fluconazole
C. Oral metronidazole
D. Topical nystatin
E. Topical corticosteroids

Explanation: ***Topical estrogen cream*** - The patient's symptoms (painful sexual intercourse, vaginal dryness, occasional spotting, last menstrual period 8 months ago) and examination findings (decreasing **labial fat pad**, receding **pubic hair**) are highly suggestive of **genitourinary syndrome of menopause (GSM)**, previously known as vulvovaginal atrophy. - **Topical estrogen therapy** directly addresses the underlying **estrogen deficiency**, restoring vaginal moisture, elasticity, and reducing dyspareunia. *Oral fluconazole* - This is an **antifungal medication** used to treat **yeast infections**, which typically present with itching, burning, and a cottage cheese-like discharge. - The patient's symptoms are not consistent with a fungal infection, and her discharge is described as clear, not characteristic of candidiasis. *Oral metronidazole* - This is an **antibiotic** primarily used to treat **bacterial vaginosis** (characterized by a foul-smelling, thin, gray discharge) or **trichomoniasis** (vaginal discharge that is green/yellow, frothy, and malodorous). - The patient's clinical picture does not align with either of these infections. *Topical nystatin* - Nystatin is another **antifungal agent**, primarily used for topical treatment of **cutaneous candidiasis** or in oral suspension for oral thrush. - It would not be effective for the symptoms of vaginal atrophy and is not a first-line treatment for vaginal candidiasis (fluconazole is preferred). *Topical corticosteroids* - Corticosteroids are **anti-inflammatory agents** used to treat conditions like dermatological inflammation, allergic reactions, or certain autoimmune skin diseases. - They would not address the **estrogen deficiency** underlying the patient's symptoms and are not indicated for genitourinary syndrome of menopause.

Question 86: A 15-year-old girl comes to the physician for a routine health maintenance examination. She recently became sexually active with her boyfriend and requests a prescription for an oral contraception. She lives with her parents. She has smoked half a pack of cigarettes daily for the past 2 years. Physical examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate response?

A. I would recommend performing a Pap smear, since you have become sexually active.
B. I would need your parent's permission before I can provide information about contraceptive therapy.
C. I would like to discuss the various contraceptive options that are available. (Correct Answer)
D. I cannot prescribe oral contraceptives if you are currently a smoker.
E. I would recommend a multiphasic combination of ethinyl estradiol and norgestimate.

Explanation: ***I would like to discuss the various contraceptive options that are available.*** - This response is appropriate because it respects the patient's autonomy and initiates an open discussion about her needs while ensuring she receives comprehensive information. - A thorough discussion of **contraceptive options** allows the physician to assess the patient's individual risk factors, lifestyle, and preferences before prescribing, which is crucial given her age and smoking history. *I would recommend performing a Pap smear, since you have become sexually active.* - While a Pap smear is important for sexually active individuals, it is generally recommended from **age 21** regardless of sexual activity, or **3 years after sexual debut** for immunocompromised individuals or those with a history of cervical dysplasia, not immediately for a 15-year-old. - Focusing solely on a Pap smear at this juncture **defers the patient's primary concern** of contraception and may unnecessarily cause anxiety. *I would need your parent's permission before I can provide information about contraceptive therapy.* - In many jurisdictions, including numerous US states, minors have the right to **confidential access to contraception** without parental consent. - Requiring parental permission would be a barrier to care and may violate the patient's **confidentiality** and **autonomy** regarding reproductive health. *I cannot prescribe oral contraceptives if you are currently a smoker.* - While smoking is a **contraindication for combined oral contraceptives (COCs)** in women over 35, and a relative contraindication for younger smokers, it is not an absolute contraindication for all forms of hormonal contraception. - This statement prematurely closes the discussion on **all contraceptive options**, including progestin-only pills or long-acting reversible contraceptives (LARCs), which would be safer choices for a young smoker. *I would recommend a multiphasic combination of ethinyl estradiol and norgestimate.* - Prescribing a specific combined oral contraceptive immediately without a full discussion of risks, benefits, and alternatives is **premature and potentially unsafe** given her smoking history. - **Combined oral contraceptives** containing estrogen generally carry an increased risk of **thromboembolism** in smokers, especially those over 35, making a thorough assessment and alternative consideration essential for this 15-year-old.

Question 87: A 21-year-old woman comes to the physician because she had a positive pregnancy test at home. For the past 3 weeks, she has had nausea and increased urinary frequency. She also had three episodes of non-bloody vomiting. She attends college and is on the varsity soccer team. She runs 45 minutes daily and lifts weights for strength training for 1 hour three times per week. She also reports that she wants to renew her ski pass for the upcoming winter season. Her vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate recommendation?

A. Stop playing soccer, stop strength training, and do not buy a ski pass
B. Continue playing soccer, stop strength training, and do not buy a ski pass
C. Stop playing soccer, continue strength training, and buy a ski pass
D. Stop playing soccer, continue strength training, and do not buy a ski pass (Correct Answer)
E. Continue playing soccer, continue strength training, and do not buy a ski pass

Explanation: ***Stop playing soccer, continue strength training, and do not buy a ski pass*** - This recommendation balances a **healthy lifestyle** with the **safety concerns** associated with pregnancy, reducing exposure to high-impact activities while encouraging beneficial exercises. - **Soccer** and **skiing** pose risks of falls and abdominal trauma, which are best avoided during pregnancy, while **strength training** can be safely modified. *Stop playing soccer, stop strength training, and do not buy a ski pass* - While stopping soccer and skiing is appropriate, completely stopping **strength training** may be overly restrictive, as moderate exercise is generally encouraged in pregnancy. - Maintaining some level of physical activity, such as **modified strength training**, can help manage weight, improve mood, and prepare the body for labor. *Continue playing soccer, stop strength training, and do not buy a ski pass* - **Continuing soccer** is not recommended due to the **high risk of falls** and **abdominal trauma**, which could harm the fetus. - While stopping skiing is appropriate, discouraging all forms of strength training might remove **beneficial exercise** from her routine. *Stop playing soccer, continue strength training, and buy a ski pass* - **Buying a ski pass** and potentially skiing is **contraindicated** due to the high risk of falls and injury, which could endanger the pregnancy. - Although stopping soccer and continuing strength training are appropriate, the inclusion of skiing makes this an **unsafe recommendation**. *Continue playing soccer, continue strength training, and do not buy a ski pass* - **Continuing soccer** is unsafe during pregnancy due to the significant risk of falls, collisions, and **abdominal injury**. - While strength training can be safely continued with modifications, the inclusion of soccer makes this recommendation **inappropriate**.

Question 88: A 24-year-old woman visits her physician to seek preconception advice. She is recently married and plans to have a child soon. Menses occur at regular 28-day intervals and last 5 days. She has sexual intercourse only with her husband and, at this time, they consistently use condoms for birth control. The patient consumes a well-balanced diet with moderate intake of meat and dairy products. She has no history of serious illness and takes no medications currently. She does not smoke or drink alcohol. The patient’s history reveals no birth defects or severe genetic abnormalities in the family. Physical examination shows no abnormalities. Pelvic examination indicates a normal vagina, cervix, uterus, and adnexa. To decrease the likelihood of fetal neural-tube defects in her future pregnancy, which of the following is the most appropriate recommendation for initiation of folic acid supplementation?

A. As soon as her pregnancy is confirmed
B. No folic acid supplement is required as nutritional sources are adequate
C. As soon as possible (Correct Answer)
D. When off contraception
E. In the second half of pregnancy

Explanation: ***As soon as possible*** - Folic acid supplementation is crucial for preventing **neural tube defects (NTDs)**, which occur very early in pregnancy, often before a woman even knows she is pregnant. - To be effective, supplementation should begin at least **one month prior to conception** and continue through the first trimester. *As soon as her pregnancy is confirmed* - This timing is too late because **neurulation** (the formation of the neural tube) is completed by the **28th day post-conception**, often before a pregnancy is confirmed. - Delaying supplementation until confirmation significantly reduces its preventative effect against neural tube defects. *No folic acid supplement is required as nutritional sources are adequate* - While a balanced diet contains some folic acid, it is generally **insufficient** to reach the protective levels needed to prevent NTDs. - The Centers for Disease Control and Prevention (CDC) and other health organizations recommend universal folic acid supplementation for all women of childbearing age, regardless of diet. *When off contraception* - Although discontinuing contraception indicates an intent to conceive, starting folic acid *only* at this point might still be too late. - It's recommended to start supplementation at least **1 month before attempting conception** to ensure adequate folate levels at the critical time of neural tube closure. *In the second half of pregnancy* - Supplementing in the second half of pregnancy is **too late** to prevent neural tube defects. - By this stage, the neural tube has already fully developed or failed to close, and supplementation will not reverse any existing defects.

Question 89: An otherwise healthy 15-year-old girl is brought to the physician for evaluation of severe acne that involves her face, chest, and back. It has not improved with her current combination therapy of oral cephalexin and topical benzoyl peroxide. She is sexually active with one male partner, and they use condoms consistently. Facial scarring and numerous comedones are present, with sebaceous skin lesions on her face, chest, and back. Which of the following is indicated prior to initiating the appropriate treatment in this patient?

A. Evaluate color vision
B. Measure serum DHEA-S and testosterone levels
C. Switch cephalexin to doxycycline
D. Administer oral contraceptives
E. Perform quantitative beta-hCG assay (Correct Answer)

Explanation: ***Perform quantitative beta-hCG assay*** - The patient needs a **quantitative beta-hCG assay** to rule out pregnancy before initiating **isotretinoin**, which is highly teratogenic and the likely next step for severe, refractory acne not responding to initial treatments. - Due to the high risk of severe birth defects (e.g., **craniofacial, cardiac, CNS abnormalities**), female patients of child-bearing potential must commit to two forms of contraception and have regular pregnancy tests before and during isotretinoin therapy as part of the **iPLEDGE program**. *Evaluate color vision* - **Color vision testing** is not typically indicated before initiating treatment for severe acne; it is sometimes performed if **ethambutol** (an antitubercular drug) is used, which can cause optic neuritis. - This evaluation is irrelevant for the management of acne with agents like isotretinoin. *Measure serum DHEA-S and testosterone levels* - Measuring **serum DHEA-S and testosterone levels** is usually done to investigate underlying hyperandrogenism in cases of **hormonal acne** that is resistant to typical treatments, or if there are other signs of virilization (e.g., hirsutism, irregular menses). - While hormonal factors contribute to acne, the immediate priority in this case of severe, refractory acne in a sexually active female, prior to initiating isotretinoin, is to exclude pregnancy. *Switch cephalexin to doxycycline* - Switching from **cephalexin** to **doxycycline** might be considered in cases of treatment failure with one antibiotic, as doxycycline is a very common and effective oral antibiotic for moderate to severe acne due to its anti-inflammatory properties. - However, for "severe" acne with "facial scarring" that has already failed initial combination therapy, including an oral antibiotic, the next step is often **isotretinoin**, and doxycycline carries its own risks (e.g., photosensitivity, GI upset) and may not be sufficient for such severe cases. *Administer oral contraceptives* - **Oral contraceptives** can be effective for managing acne, especially hormonal acne, but they are typically used as a treatment option and not a prerequisite test before initiating the "appropriate treatment" (likely isotretinoin in this severe case). - While they can be part of the therapeutic regimen, especially for their contraceptive benefits when isotretinoin is used, they are not a diagnostic step or a required prior intervention for this specific clinical scenario.

Question 90: A 33-year-old pregnant woman in the 28th week of gestation presents to the emergency department for evaluation of bilateral edema of her legs. It seems to worsen at the end of the day and has lasted for the past 3 weeks. History reveals that this is her 3rd pregnancy. Vital signs include: blood pressure 120/80 mm Hg, heart rate 74/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F). Body mass index is 36 kg/m2. Physical examination reveals bilateral leg edema with engorged surface veins. A photograph of the patient’s legs is shown. Which of the following is the best initial management of the patient?

A. Enoxaparin
B. Endovenous laser treatment
C. Warfarin
D. Compression stockings (Correct Answer)
E. Foam sclerotherapy

Explanation: ***Compression stockings*** - This patient presents with typical symptoms of **varicose veins and edema** associated with pregnancy, namely bilateral leg edema that worsens with activity. Compression stockings are the **first-line non-pharmacological treatment** for reducing symptoms and preventing progression. - The increased **uterine pressure**, coupled with **hormonal changes** during pregnancy, leads to venous stasis, which is effectively managed by **graduated compression** provided by the stockings. *Enoxaparin* - **Enoxaparin** is an anticoagulant used for treating or preventing **deep vein thrombosis (DVT)** or pulmonary embolism. The patient's presentation of bilateral edema and engorged veins is more consistent with **venous insufficiency or varicose veins** rather than an acute thrombotic event. - There are **no signs suggestive of DVT** such as unilateral swelling, pain, or redness, and current evidence points towards benign rather than thrombotic compression. *Endovenous laser treatment* - **Endovenous laser treatment (EVLT)** is a minimally invasive procedure used to close off incompetent veins, typically for **symptomatic varicose veins** that are not responsive to conservative management. - While effective, EVLT is generally **not recommended during pregnancy** given the risk of potential complications and is reserved for post-partum treatment if symptoms persist. *Warfarin* - **Warfarin** is an oral anticoagulant primarily used for long-term anticoagulation in conditions like atrial fibrillation or prosthetic heart valves. It is **contraindicated in pregnancy** due to its known **teratogenic effects**, particularly during the first trimester, and risk of fetal hemorrhage in later stages. - This patient's symptoms are not indicative of a condition requiring systemic anticoagulation, and certainly not with warfarin given her pregnancy status. *Foam sclerotherapy* - **Foam sclerotherapy** is a procedure where a foamed sclerosant is injected into varicose veins to cause their closure. It is generally used for **symptomatic varicose veins** or cosmetic concerns. - Similar to EVLT, sclerotherapy is typically **avoided during pregnancy** due to potential risks to the fetus and increased risk of complications at time of pregnancy, with treatment deferred to the postpartum period.

Question 91: A 22-year-old G1P1 woman comes to the clinic asking about “the morning after pill.” She reports that she had sexual intercourse with her boyfriend last night and she thinks the condom broke. She is not using any other form of contraception. She reports her last menstrual period was 10 days ago, and they are normally regular. The patient’s medical history is significant for obesity, asthma and allergic rhinitis. Her medications include albuterol and occasional intranasal corticosteroids. She has no history of sexually transmitted diseases and is sexually active with only her current boyfriend of 5 years. The patient denies genitourinary symptoms. Her temperature is 98°F (36.7°C), blood pressure is 112/74 mmHg, pulse is 63/min, and respirations are 12/min with an oxygen saturation of 99% O2 on room air. Physical examination, including a pelvic exam, shows no abnormalities. The patient is worried because she is back in graduate school and cannot afford another child. Which of the following is the most effective emergency contraception?

A. Copper intrauterine device (Correct Answer)
B. Ulipristal pill
C. High-dose oral contraceptive therapy
D. Levonorgestrel-releasing intrauterine device
E. Levonorgestrel pill

Explanation: ***Copper intrauterine device*** - The **copper IUD** is the **most effective** form of emergency contraception, with a failure rate of less than 0.1%. It can be inserted up to 5 days after unprotected intercourse. - It works by creating a **spermicidal inflammatory reaction** in the uterus, preventing fertilization and implantation. It also offers long-term contraception. *Ulipristal pill* - The **ulipristal pill** is an effective oral emergency contraceptive, but it is **less effective** than the copper IUD, with a failure rate of 1.3-1.6%. - It is a **selective progesterone receptor modulator** that delays or inhibits ovulation and can be taken up to 5 days after unprotected intercourse. *High-dose oral contraceptive therapy* - This method (the **Yuzpe regimen**) involves taking multiple doses of combined estrogen-progestin pills. It is **less effective** than ulipristal or levonorgestrel pills, with a failure rate higher than 2%. - It works by disrupting the **ovulatory cycle**. Its use has declined due to higher rates of side effects like nausea and vomiting. *Levonorgestrel-releasing intrauterine device* - The **levonorgestrel-releasing IUD** is **not approved or recommended** for emergency contraception. Its primary use is for long-term contraception. - While it can prevent pregnancy, there is **insufficient evidence** to support its efficacy as an emergency contraceptive compared to the copper IUD. *Levonorgestrel pill* - The **levonorgestrel pill** (e.g., Plan B One-Step) is an oral emergency contraceptive that is **less effective** than the copper IUD or ulipristal. Its efficacy decreases beyond 72 hours and for individuals with a higher BMI. - It acts primarily by **inhibiting or delaying ovulation**. It is ineffective if ovulation has already occurred.

Question 92: A 37-year-old woman, gravida 3, para 3, comes to the physician for a follow-up examination. She gave birth to her third child 8 months ago and now wishes to start a contraception method. Prior to her most recent pregnancy, she used a combined estrogen-progestin pill. Which of the following aspects of her history would be a contraindication for restarting an oral contraceptive pill?

A. She has recurrent migraine headaches without aura
B. Her hemoglobin A1c is 8.6%
C. She smokes 1 pack of cigarettes daily (Correct Answer)
D. Her infant is still breastfeeding
E. She has a history of cervical dysplasia

Explanation: ***She smokes 1 pack of cigarettes daily*** - **Smoking**, especially in women over 35, significantly increases the risk of **cardiovascular events** such as myocardial infarction and stroke, which is further exacerbated by the use of combined oral contraceptives (COCs). - The **estrogen component** of COCs can promote a hypercoagulable state, making the combination with smoking particularly dangerous. *She has recurrent migraine headaches without aura* - **Migraine with aura** is a contraindication to combined oral contraceptives because it increases the risk of **ischemic stroke**. - **Migraine without aura** is generally not a contraindication and is categorized as a U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) category 2, meaning the advantages generally outweigh the theoretical or proven risks. *Her hemoglobin A1c is 8.6%* - A **high HbA1c** indicates uncontrolled diabetes, which is a condition that, if accompanied by vascular disease or of >20 years' duration, would be a contraindication to COCs. - However, in the absence of **vascular complications**, diabetes itself (even uncontrolled) is not an absolute contraindication to COCs, but rather a US MEC category 3 (risks generally outweigh advantages). *Her infant is still breastfeeding* - While combined oral contraceptives can **reduce milk supply** and alter milk composition, particularly if initiated before 6 weeks postpartum, they are not an absolute contraindication, especially after 6 months. - **Progestin-only pills** are generally preferred for breastfeeding mothers due to their minimal impact on lactation. *She has a history of cervical dysplasia* - There is no evidence suggesting that oral contraceptive use is contraindicated in women with a history of **cervical dysplasia**. - Current guidelines do not list cervical dysplasia as a condition that would preclude the use of combined oral contraceptives.

Question 93: A 22-year-old woman comes to the physician because of a 1-week history of nausea and vomiting. She has not had fever, abdominal pain, diarrhea, or vaginal bleeding. She does not remember the date of her last menstrual period. She uses oral contraceptive pills but occasionally forgot to take them. She had pelvic inflammatory disease 2 years ago and was treated with antibiotics. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 16/min, and blood pressure is 118/75 mm Hg. Physical examination shows no abnormalities. Pelvic examination shows a normal appearing vagina, cervix, uterus, and adnexa. A urine pregnancy test is positive. Her serum β-human chorionic gonadotropin concentration is 805 mIU/mL. Which of the following is the most appropriate next step in diagnosis?

A. Administer methotrexate now
B. Schedule dilation and evacuation
C. Transvaginal ultrasound in 4 days (Correct Answer)
D. Diagnostic laparoscopy now
E. Administer misoprostol now

Explanation: ***Transvaginal ultrasound in 4 days*** - A serum β-hCG level of 805 mIU/mL is below the **discriminatory zone** (1500-2000 mIU/mL) where an intrauterine pregnancy should be visible on transvaginal ultrasound. Repeating the ultrasound in a few days will allow the β-hCG level to rise, potentially past the discriminatory zone, and confirm the location of the pregnancy. - The patient has risk factors for **ectopic pregnancy** (history of PID, occasional missed OCPs indicating potential conception despite contraception), making it crucial to determine pregnancy location. However, immediate intervention is not indicated given her stable vitals and low β-hCG. *Administer methotrexate now* - Methotrexate is used for ectopic pregnancies but only after **confirmation of an ectopic pregnancy** and consideration of gestational sac size and β-hCG levels, none of which are definitively known yet. - Giving methotrexate prior to confirming diagnosis and stable vs. unstable presentation can be premature and potentially harmful if the pregnancy is intrauterine. *Schedule dilation and evacuation* - **Dilation and evacuation (D&E)** is a procedure for terminating an intrauterine pregnancy or removing retained products of conception. - It is inappropriate without first determining the **location of the pregnancy** (intrauterine vs. ectopic) and confirming viability or non-viability. *Diagnostic laparoscopy now* - **Diagnostic laparoscopy** is an invasive surgical procedure used to diagnose and treat ectopic pregnancies, especially in unstable patients or when ultrasound is inconclusive. - It is not indicated as a first step here because the patient is **hemodynamically stable**, and a less invasive diagnostic step (ultrasound) has not yet been optimally utilized. *Administer misoprostol now* - **Misoprostol** is used for medical abortion of intrauterine pregnancies or for cervical ripening. - It is not appropriate at this stage as the **location and viability of the pregnancy are yet unknown**, and misoprostol would be ineffective or harmful in an undiagnosed ectopic pregnancy.

Question 94: A healthy 31-year-old woman comes to the physician because she is trying to conceive. She is currently timing the frequency of intercourse with at-home ovulation test kits. An increase in the levels of which of the following is the best indicator that ovulation has occurred?

A. Luteinizing hormone
B. Follicle stimulating hormone
C. Progesterone (Correct Answer)
D. Estrogen
E. Gonadotropin-releasing hormone

Explanation: ***Progesterone*** - A sustained post-ovulatory rise in **progesterone** levels is the most reliable indicator that ovulation has occurred, as it is produced by the **corpus luteum** after the egg is released. - Ovulation test kits detect the **LH surge** preceding ovulation, but a rise in progesterone confirms that ovulation actually took place. *Luteinizing hormone* - The **LH surge** is a key trigger for ovulation, but it indicates that ovulation is *about to occur*, not that it has already taken place. - LH levels return to baseline shortly after the surge, making a sustained increase an unreliable indicator of *past* ovulation. *Follicle stimulating hormone* - **FSH** is primarily involved in the development of ovarian follicles and is high during the early follicular phase, declining before ovulation. - While essential for follicle maturation, changes in FSH levels are not used to confirm that ovulation has occurred. *Estrogen* - **Estrogen** levels, particularly **estradiol**, peak just before the LH surge, indicating impending ovulation. - After ovulation, estrogen levels initially decrease before a secondary rise during the luteal phase, making peak estrogen a sign before ovulation rather than confirmation of it. *Gonadotropin-releasing hormone* - **GnRH** is released in a pulsatile manner from the hypothalamus, stimulating the anterior pituitary to release FSH and LH. - **GnRH** levels are difficult to measure directly and do not serve as a practical or direct indicator of ovulation itself.

Question 95: A 17-year-old girl comes to your outpatient clinic. She is sexually active with multiple partners and requests a prescription for oral contraceptive pills. A urine pregnancy test in your office is negative. Which of the following is the most appropriate next step?

A. Recommend sexually-transmitted infection screening and provide the requested prescription (Correct Answer)
B. Perform urine drug screen
C. Refer the patient for counseling and recommend sexually-transmitted infection screening
D. Contact the patient's parents to obtain consent
E. Advise against oral contraceptive medications and recommend condom use instead

Explanation: ***Recommend sexually-transmitted infection screening and provide the requested prescription*** - As a sexually active adolescent with multiple partners, **STI screening** is crucial for preventing negative health outcomes. - Providing **oral contraceptive pills** empowers the patient to make informed decisions about her reproductive health, especially after a negative pregnancy test. *Perform urine drug screen* - There is **no clinical indication** presented in the scenario to suggest drug use, making a drug screen inappropriate. - Performing a drug screen without cause could **damage trust** and is **not relevant** to her request for contraception. *Refer the patient for counseling and recommend sexually-transmitted infection screening* - While STI screening is appropriate, **referring for counseling without specific indication** may be perceived as judgmental and is not the most immediate next step. - The physician can provide initial counseling regarding **safe sexual practices** in the same visit. *Contact the patient's parents to obtain consent* - In many jurisdictions, adolescents have the right to **confidential access to reproductive healthcare**, including contraception, without parental consent. - Contacting parents could **violate confidentiality** and deter the patient from seeking necessary care in the future. *Advise against oral contraceptive medications and recommend condom use instead* - While condom use is important for STI prevention and can be used for contraception, **oral contraceptive pills offer a highly effective method** of pregnancy prevention. - **Both methods can be discussed**, but advising against oral contraceptives outright disrespects the patient's request and limits her choices for birth control.

Question 96: A 28-year-old woman, gravida 1, para 0, at 10 weeks' gestation comes to the physician for her initial prenatal visit. She has no history of serious illness, but reports that she is allergic to penicillin. Vital signs are within normal limits. The lungs are clear to auscultation, and cardiac examination shows no abnormalities. Transvaginal ultrasonography shows an intrauterine pregnancy with no abnormalities. The fetal heart rate is 174/min. Routine prenatal laboratory tests are drawn. Rapid plasma reagin (RPR) test is 1:128 and fluorescent treponemal antibody absorption test (FTA-ABS) is positive. Which of the following is the most appropriate next step in management?

A. Perform oral penicillin challenge test
B. Administer therapeutic dose of intramuscular penicillin G
C. Administer intravenous ceftriaxone
D. Administer oral azithromycin
E. Administer penicillin desensitization dose (Correct Answer)

Explanation: ***Administer penicillin desensitization dose*** - This patient has **syphilis** confirmed by positive RPR and FTA-ABS, and is pregnant with a reported penicillin allergy. **Penicillin** is the **only effective treatment** for **syphilis during pregnancy** that prevents congenital syphilis. - Due to the critical need for penicillin and the reported allergy, **penicillin desensitization** is the most appropriate next step to allow for safe administration of the necessary treatment. *Perform oral penicillin challenge test* - An oral penicillin challenge test is used to **confirm or rule out a penicillin allergy** in non-urgent situations. - This patient has confirmed syphilis in pregnancy, which requires **immediate treatment** with penicillin, making a challenge test too time-consuming and risky. *Administer therapeutic dose of intramuscular penicillin G* - Administering a full therapeutic dose of penicillin G directly without prior allergy evaluation or desensitization would be **dangerous** given her reported penicillin allergy. - This could lead to a **severe allergic reaction**, such as anaphylaxis, which would be harmful to both the mother and the fetus. *Administer intravenous ceftriaxone* - Ceftriaxone is a **cephalosporin** and is effective against syphilis in non-pregnant patients. However, it is **not recommended for syphilis in pregnancy** due to its inability to adequately cross the placenta to treat fetal infection effectively. - Additionally, there is a risk of **cross-reactivity** in patients with penicillin allergy, though usually lower than with other penicillins. *Administer oral azithromycin* - Azithromycin is an **alternative treatment for early syphilis** in non-pregnant individuals who are allergic to penicillin. - However, **macrolides like azithromycin are not recommended in pregnancy** for syphilis treatment due to high rates of treatment failure and its inability to effectively prevent congenital syphilis.

Question 97: A 24-year-old G1P0000 presents for her first obstetric visit and is found to be at approximately 8 weeks gestation. She has no complaints aside from increased fatigue and occasional nausea. The patient is a recent immigrant from Africa and is currently working as a babysitter for several neighborhood children. One of them recently had the flu, and another is home sick with chickenpox. The patient has no immunization records and does not recall if she has had any vaccinations. She is sexually active with only her husband, has never had a sexually transmitted disease, and denies intravenous drug use. Her husband has no past medical history. Exam at this visit is unremarkable. Her temperature is 98.7°F (37.1°C), blood pressure is 122/76 mmHg, pulse is 66/min, and respirations are 12/min. Which of the following immunizations should this patient receive at this time?

A. Hepatitis B vaccine
B. Varicella vaccine
C. Intranasal flu vaccine
D. Tetanus/Diphtheria/Pertussis vaccine
E. Intramuscular flu vaccine (Correct Answer)

Explanation: ***Intramuscular flu vaccine*** - The **inactivated influenza vaccine** (intramuscular flu vaccine) is safe and recommended for all pregnant women, regardless of gestational age, during flu season. - Given the patient's exposure to children, one of whom recently had the flu, vaccination is crucial for both maternal and fetal protection. *Hepatitis B vaccine* - While generally safe in pregnancy and recommended for at-risk individuals, there is no indication of high-risk behavior or exposure in this patient to warrant immediate vaccination during her first visit. - Screening for **Hepatitis B surface antigen (HBsAg)** is a routine prenatal test, and vaccination decisions can be made based on those results or ongoing risk assessment. *Varicella vaccine* - The **varicella vaccine is a live attenuated vaccine** and is **contraindicated during pregnancy** due to the theoretical risk of congenital varicella syndrome. - If indicated, it should be given postpartum. *Intranasal flu vaccine* - The **intranasal flu vaccine is a live attenuated vaccine** and is **contraindicated during pregnancy** due to the theoretical risk of transmitting a weakened live virus to the fetus. - Only the inactivated injectable form of the flu vaccine is recommended for pregnant women. *Tetanus/Diphtheria/Pertussis vaccine* - The **Tdap vaccine** is recommended for all pregnant women, but it is typically administered between **27 and 36 weeks of gestation** to maximize antibody transfer to the fetus. - Giving it at 8 weeks is premature for optimal passive immunity for the neonate.

Question 98: A 27-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the physician for a prenatal visit. She feels that her baby's movements have decreased recently. She says that she used to feel 10–12 movements/hour earlier, but that it has recently decreased to about 7–8/hour. Pregnancy and delivery of her first child were uncomplicated. Medications include folic acid 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 32-week gestation. The fetus is in a transverse lie presentation. The fetal heart rate is 134/min. A 14-minute recording of the nonstress test is shown. Which of the following is the most appropriate next step in managing this patient?

A. Perform vibroacoustic stimulation
B. Administer intravenous oxytocin
C. Repeat the nonstress test weekly
D. Extend the nonstress test by 20 minutes
E. Provide reassurance to the mother (Correct Answer)

Explanation: **Provide reassurance to the mother** - The nonstress test (NST) shows a **reassuring fetal heart rate baseline (134 bpm)**, good variability, and **two accelerations of 15 bpm for 15 seconds** within 14 minutes, indicating a reactive NST. - A **reactive NST**, even with perceived decreased fetal movements, suggests fetal well-being, lessening the need for further immediate interventions. *Perform vibroacoustic stimulation* - **Vibroacoustic stimulation** is typically used to elicit accelerations if the initial NST is non-reactive or inconclusive after a certain period of fetal monitoring. - Since the NST is already reactive and reassuring, there is no immediate indication for **vibroacoustic stimulation**. *Administer intravenous oxytocin* - The administration of **intravenous oxytocin** is used for cervical ripening or induction of labor, or in a contraction stress test to assess uteroplacental function. - It is not indicated as a primary response to decreased fetal movements with a **reassuring reactive NST**. *Repeat the nonstress test weekly* - While regular fetal monitoring is important in high-risk pregnancies, performing an NST weekly is typically a management strategy for **ongoing high-risk conditions** or non-reassuring findings. - Given the current **reactive NST** and no other immediate risk factors besides subjective decreased movement, weekly NSTs are not immediately warranted as a next step. *Extend the nonstress test by 20 minutes* - Extending the NST is common practice if the initial tracing is **non-reactive or equivocal**, to allow more time for fetal activity and accelerations to occur. - In this case, the NST is already **reactive within 14 minutes** (showing two accelerations), so extending it is unnecessary.

Question 99: A 36-year-old woman presents with a whitish vaginal discharge over the last week. She also complains of itching and discomfort around her genitals. She says her symptoms are getting progressively worse. She has been changing her undergarments frequently and changed the brand of detergent she uses to wash her clothes, but it did not resolve her problem. Additionally, she admits to having painful urination and increased urinary frequency for the past one month, which she was told are expected side effects of her medication. The patient denies any recent history of fever or malaise. She has 2 children, both delivered via cesarean section in her late twenties. Past medical history is significant for hypertension and diabetes mellitus type 2. Current medications are atorvastatin, captopril, metformin, and empagliflozin. Her medications were changed one month ago to improve her glycemic control, as her HbA1c at that time was 7.5%. Her vital signs are a blood pressure of 126/84 mm Hg and a pulse of 78/min. Her fingerstick glucose is 108 mg/dL. Pelvic examination reveals erythema and mild edema of the vulva. A thick, white, clumpy vaginal discharge is seen. The vaginal pH is 4.0. Microscopic examination of a KOH-treated sample of the discharge demonstrates lysis of normal cellular elements with branching pseudohyphae. Which of the following is the next best step in the management of this patient?

A. Start metronidazole.
B. Advise her to drink lots of cranberry juice.
C. Switch her from oral antidiabetic medication to insulin.
D. Start fluconazole. (Correct Answer)
E. Stop empagliflozin.

Explanation: **Start fluconazole.** - The patient's symptoms (whitish, thick, clumpy vaginal discharge, itching, discomfort, vulvar erythema and edema, vaginal pH 4.0) combined with the microscopic finding of **branching pseudohyphae** (after KOH treatment) are classic for **vulvovaginal candidiasis (yeast infection).** - **Fluconazole** is an antifungal medication commonly used to treat fungal infections, including candidiasis. Her use of empagliflozin, a SGLT2 inhibitor, which increases glucose excretion in urine, is a predisposing factor for both recurrent UTIs and yeast infections. *Start metronidazole.* - Metronidazole is an antibiotic used to treat bacterial vaginosis and trichomoniasis. - The microscopic finding of **pseudohyphae** rules out bacterial vaginosis and trichomoniasis, making metronidazole an inappropriate choice here. *Advise her to drink lots of cranberry juice.* - Cranberry juice is often suggested for the prevention and symptomatic relief of urinary tract infections (UTIs). - While the patient has some urinary symptoms (dysuria, frequency), the primary issue is symptomatic vaginal discharge with clear evidence of a fungal infection, for which cranberry juice is not a treatment. *Switch her from oral antidiabetic medication to insulin.* - The patient's current blood glucose (108 mg/dL) is well-controlled, and her HbA1c improved with the current medication regimen. - While optimizing glycemic control is important, there is no immediate indication to switch to insulin, especially as her current regimen seems effective. *Stop empagliflozin.* - Empagliflozin, an SGLT2 inhibitor, increases glucosuria, which can predispose to genitourinary infections (UTIs and yeast infections). - However, stopping the medication immediately might disrupt her glycemic control, which has recently improved. The best approach is to treat the infection first while continuing to manage her diabetes.

Question 100: A 23-year-old woman presented to the clinic for her first prenatal appointment with fatigue and pain in the perineum for the past 8 days. The past medical history is benign and she claimed to have only had unprotected intercourse with her husband. She had a documented allergic reaction to amoxicillin 2 years ago. The vaginal speculum exam revealed a clean, ulcerated genital lesion, which was tender and non-exudative. No lymphadenopathy was detected. A rapid plasma reagin (RPR) test revealed a titer of 1:64 and the fluorescent treponemal antibody absorption (FTA- abs) test was positive. What is the next best step in the management of this patient?

A. Doxycycline, 100 mg twice daily x 14 days
B. Parenteral ceftriaxone, 1 g x 10 days
C. Delay treatment until delivery
D. Penicillin desensitization, then intramuscular benzathine penicillin, G 2.4 million units (Correct Answer)
E. Oral tetracycline, 500 mg 4 times daily x 1 week

Explanation: ***Penicillin desensitization, then intramuscular benzathine penicillin, G 2.4 million units*** - This patient presents with primary syphilis (chancre, positive RPR 1:64, positive FTA-abs) and a **penicillin allergy**. **Benzathine penicillin G** is the only proven treatment for syphilis in pregnancy to prevent congenital syphilis. - In pregnant patients with syphilis and a penicillin allergy, **desensitization to penicillin** is the recommended next step to allow for the administration of the appropriate treatment. *Doxycycline, 100 mg twice daily x 14 days* - **Doxycycline** is an effective treatment for primary syphilis in non-pregnant individuals. - However, **tetracyclines are contraindicated in pregnancy** due to adverse effects on fetal bone and tooth development. *Parenteral ceftriaxone, 1 g x 10 days* - **Ceftriaxone** can be used as an alternative treatment for syphilis in non-pregnant individuals with penicillin allergy. - However, its efficacy in **preventing congenital syphilis** is not fully established, making penicillin the preferred agent in pregnancy after desensitization. *Delay treatment until delivery* - Delaying treatment is **not appropriate** as it significantly increases the risk of **congenital syphilis**, leading to severe fetal morbidity and mortality. - Treating syphilis during pregnancy is crucial for **preventing vertical transmission**. *Oral tetracycline, 500 mg 4 times daily x 1 week* - **Tetracycline** is an effective treatment for primary syphilis but is **contraindicated in pregnancy**. - It poses a risk of **fetal tooth discoloration** and inhibition of bone growth.

Question 101: A 34-year-old primigravid woman comes to the physician for a prenatal visit at 37-weeks' gestation because of worsening back pain for 3 weeks. The pain is worse with extended periods of walking, standing, and sitting. She has not had any changes in bowel movements or urination. Her mother has rheumatoid arthritis. Examination of the back shows bilateral pain along the sacroiliac joint area as a posterior force is applied through the femurs while the knees are flexed. She has difficulty actively raising either leg while the knee is extended. Motor and sensory function are normal bilaterally. Deep tendon reflexes are 2+. Babinski sign is absent. Pelvic examination shows a uterus consistent in size with a 37-weeks' gestation. There is no tenderness during abdominal palpation. Which of the following is the most likely explanation for this patient's symptoms?

A. Spinal cord compression
B. Relaxation of the pelvic girdle ligaments (Correct Answer)
C. Vertebral bone compression fracture
D. Placental abruption
E. Rheumatoid arthritis

Explanation: ***Relaxation of the pelvic girdle ligaments*** - During pregnancy, **hormonal changes** (especially relaxin) lead to the relaxation of **ligaments** in the **pelvic girdle**, including those around the sacroiliac joint. This can cause instability and pain, particularly with prolonged activity and in the third trimester. - The exam findings of **bilateral pain along the sacroiliac joint** with posterior force and **difficulty raising extended legs** (suggesting weakness related to pelvic instability) are consistent with increased ligamentous laxity. *Spinal cord compression* - This would typically present with **neurological deficits** such as significant motor weakness, sensory changes, or bowel/bladder dysfunction, which are absent in this patient. - The patient's **normal motor and sensory function** and **intact deep tendon reflexes** do not support spinal cord compression. *Vertebral bone compression fracture* - A compression fracture would likely result in **acute, severe, localized pain** often exacerbated by movement, and it is uncommon in healthy pregnant women without significant trauma or underlying bone pathology. - The patient's symptoms are chronic (3 weeks), bilateral, and related to activity, which is not characteristic of an acute compression fracture. *Placental abruption* - This is characterized by **acute, severe abdominal pain**, **vaginal bleeding**, and signs of **fetal distress**, none of which are present in this patient. - The pain is described as back pain, and the abdominal examination is normal, ruling out placental abruption. *Rheumatoid arthritis* - Although the patient's mother has rheumatoid arthritis, this condition primarily affects **small, peripheral joints** symmetrically and would not typically present with isolated sacroiliac pain in late pregnancy. - Rheumatoid arthritis usually involves morning stiffness that improves with activity and is associated with systemic inflammatory symptoms, which are not described.

Question 102: A 26-year-old gravida 2 para 1 presents to her physician at 12 weeks gestation. She has no complaints. Her previous pregnancy 5 years ago had an uncomplicated course with vaginal delivery of a healthy boy at 39 + 1 weeks gestation. Her weight is 75 kg (165 lb) and the height is 168 cm (5 ft 6 in). On presentation, the blood pressure is 110/70 mm Hg, the heart rate is 83/min, the respiratory rate is 14/min, and the temperature is 36.6℃ (97.9℉). The physical examination is within normal limits. The gynecologic examination demonstrates a fetal heart rate of 180/min. The uterus cannot be palpated and the ultrasound exam is benign. Blood testing showed the following: RBC count 3.9 million/mm3 Leukocyte count 11,100/mm3 Hb 11.6 g/dL Hct 32% MCV 87 fl Reticulocyte count 0.4% The patient’s blood type is A neg. Which testing is indicated in this patient?

A. White blood cell differential
B. Measurement of serum vitamin B12
C. Measurement of serum iron
D. Indirect Coombs test (Correct Answer)
E. Direct Coombs test

Explanation: ***Indirect Coombs test*** - This patient is **Rh-negative** (blood type A neg), and an indirect Coombs test is crucial to assess for the presence of **Rh antibodies** which could put her fetus at risk for **hemolytic disease of the newborn** if the fetus is Rh-positive. - Identification of these antibodies during pregnancy guides the need for **RhoGAM administration** to prevent alloimmunization. *White blood cell differential* - While a leukocyte count of 11,100/mm3 is slightly elevated, it is within the normal physiological range for pregnancy, particularly in the **first trimester**. - Without any signs of infection or other specific concerns, a **differential count** is not the most immediate or crucial test indicated. *Measurement of serum vitamin B12* - The patient's **MCV of 87 fl** is within the normal range, indicating a **normocytic anemia**, not a macrocytic anemia typically associated with vitamin B12 deficiency. - A low reticulocyte count (0.4%) suggests hypoproliferative anemia, but without macrocytosis, B12 deficiency is less likely to be the primary cause. *Measurement of serum iron* - The patient's **Hb (11.6 g/dL)** and **Hct (32%)** suggest a mild anemia, but the **MCV of 87 fl** is not microcytic, which would be expected in iron deficiency anemia. - While iron deficiency is common in pregnancy, further investigation for iron studies would typically be prompted by an MCV below 80 fl or other clinical signs. *Direct Coombs test* - A direct Coombs test detects antibodies **already bound to the surface of red blood cells**, typically used to diagnose **autoimmune hemolytic anemia** in the patient or hemolytic disease in a newborn. - It would not be used to screen an Rh-negative mother for circulating antibodies against fetal red blood cells; that is the role of the indirect Coombs test.

Question 103: A 24-year-old woman with a missed menstrual cycle has a positive pregnancy test. The estimated gestational age is 4 weeks. The patient questions the pregnancy test results and mentions that a urinary pregnancy test she took 3 weeks ago was negative. What is the explanation for the patient’s first negative pregnancy test result?

A. Pregnancy test becomes positive during organogenesis so should be expected positive no earlier than at week 4.
B. The syncytiotrophoblast had not yet developed to produce human chorionic gonadotropin at that term. (Correct Answer)
C. Human chorionic gonadotropin can only be found in the urine after its placental production is started.
D. Human chorionic gonadotropin starts to be produced by the uterus only after the embryonic implantation which has not yet occurred.
E. The embryonic liver has not yet developed to produce human chorionic gonadotropin at that term.

Explanation: ***The syncytiotrophoblast had not yet developed to produce human chorionic gonadotropin at that term.*** - Urinary pregnancy tests detect **human chorionic gonadotropin (hCG)**, a hormone produced by the **syncytiotrophoblast** layer of the early embryo. - At an estimated gestational age of 4 weeks, the pregnancy test is positive, indicating that the syncytiotrophoblast has developed sufficiently to produce detectable levels of hCG; 3 weeks prior, it was likely not yet formed or producing enough hCG for detection. *Pregnancy test becomes positive during organogenesis so should be expected positive no earlier than at week 4.* - Pregnancy tests can become positive as early as 1 week after conception, often before the 4-week mark, as soon as the **syncytiotrophoblast** begins to produce detectable hCG. - **Organogenesis** primarily occurs from week 3 to week 8 of gestation, and while hCG levels are rising during this period, its detectability is not solely tied to the start of organogenesis but rather to implantation and trophoblast development. *Human chorionic gonadotropin can only be found in the urine after its placental production is started.* - While hCG is produced by the early placenta (specifically the **syncytiotrophoblast**), it appears in the urine shortly after implantation, well before the placenta is fully formed and established as an organ. - Urine tests are commonly used due to this early detection and convenience, not waiting for complete placental maturity. *Human chorionic gonadotropin starts to be produced by the uterus only after the embryonic implantation which has not yet occurred.* - **hCG is produced by the syncytiotrophoblast** of the developing embryo, not the uterus itself, starting shortly after implantation. - The uterus is the site of implantation, but it does not produce hCG. *The embryonic liver has not yet developed to produce human chorionic gonadotropin at that term.* - The **embryonic liver is not the source of human chorionic gonadotropin (hCG)**; hCG is produced by the **syncytiotrophoblast** of the developing embryo. - The liver has distinct functions, primarily metabolic and detoxification, and begins to develop later in embryonic life.

Question 104: Hormone balance is essential for maintaining a normal pregnancy. Early on, elevated progesterone levels are needed to maintain pregnancy and progesterone is produced in excess by the corpus luteum. In the normal menstrual cycle the corpus luteum involutes, but this process is impeded during pregnancy because of the presence of which hormone?

A. Human chorionic gonadotropin (Correct Answer)
B. Cortisol
C. Progesterone
D. Inhibin A
E. Estrogen

Explanation: **Human chorionic gonadotropin** - **Human chorionic gonadotropin (hCG)** is produced by **trophoblast cells** after implantation and acts to maintain the corpus luteum. - hCG has a similar structure to **luteinizing hormone (LH)** and binds to LH receptors on the corpus luteum, preventing its degradation and ensuring continued progesterone production. *Cortisol* - **Cortisol** is a **glucocorticoid** primarily involved in stress response, metabolism, and immune regulation. - While crucial for fetal development and parturition at later stages, it does not directly prevent the **involution of the corpus luteum** early in pregnancy. *Progesterone* - **Progesterone** is the hormone produced by the **corpus luteum** that maintains the uterine lining and prevents contractions. - It is the hormone whose production is sustained, not the hormone that prevents the corpus luteum's involution. *Inhibin A* - **Inhibin A** is produced by the **granulosa cells** and **corpus luteum**, and its primary role is to inhibit the secretion of **follicle-stimulating hormone (FSH)**. - It is involved in feedback regulation of the hypothalamic-pituitary-gonadal axis but does not prevent the **involution of the corpus luteum**. *Estrogen* - **Estrogen** levels rise significantly during pregnancy, supporting uterine growth and fetal development, but it does not directly maintain the corpus luteum. - **Estradiol**, the primary estrogen during pregnancy, is largely produced by the **placenta** after the first trimester, and its role in early pregnancy is more complex than directly preventing corpus luteum involution.

Question 105: A 25-year-old G1P0000 presents to her obstetrician’s office for a routine prenatal visit at 32 weeks gestation. At this visit, she feels well and has no complaints. Her pregnancy has been uncomplicated, aside from her Rh negative status, for which she received Rhogam at 28 weeks gestation. The patient has a past medical history of mild intermittent asthma and migraine headaches. She currently uses her albuterol inhaler once a week and takes a prenatal vitamin. Her temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 117/68 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and abdominal exam reveals a gravid uterus with fundal height at 30 centimeters. Bedside ultrasound reveals that the fetus is in transverse lie. The patient states that she prefers to have a vaginal delivery. Which of the following is the best next step in management?

A. Expectant management (Correct Answer)
B. Caesarean section at 38 weeks
C. Weekly ultrasound
D. Immediate external cephalic version
E. External cephalic version

Explanation: ***Expectant management*** - Many fetuses in **transverse lie** at **32 weeks gestation** will spontaneously convert to a **cephalic presentation** by term. - Interventions like external cephalic version are generally postponed until closer to term (e.g., 36-37 weeks) to allow for spontaneous version and optimize success rates. *Caesarean section at 38 weeks* - This is a definitive intervention for an uncorrected transverse lie, but it is **premature** considering the possibility of spontaneous version. - A C-section should only be scheduled if the transverse lie persists closer to term and external cephalic version is unsuccessful or contraindicated. *Weekly ultrasound* - While monitoring fetal position is important, **weekly ultrasounds** are not typically necessary at this stage for an uncomplicated transverse lie. - Less frequent monitoring is usually sufficient, as spontaneous version is common. *Immediate external cephalic version* - Performing an **external cephalic version (ECV)** at **32 weeks is generally discouraged** because of the high likelihood of spontaneous version and a lower success rate compared to performing it closer to term. - ECV carries risks, and delaying it minimizes interventions when they may not be needed. *External cephalic version* - While ECV is a viable option for **transverse lie**, it is typically considered around **36-37 weeks gestation**, not at 32 weeks. - The rationale for delaying is to maximize the chances of **spontaneous resolution** and improve the success rate of the procedure when performed.

Question 106: A 29-year-old G1P0 woman, at 12 weeks estimated gestational age, presents for her first prenatal visit. Past medical history reveals the patient has type O+ blood and that her husband has type A+ blood. The patient is worried about the risk of her baby having hemolytic disease. Which of the following is correct regarding fetomaternal incompatibility in this patient?

A. It generally causes more severe disease than Rh incompatibility
B. It is the most common cause of hemolytic disease of the newborn
C. It cannot occur in first pregnancies due to lack of prior sensitization
D. The direct Coombs test is typically strongly positive
E. It typically presents with severe fetal anemia requiring intrauterine transfusion (Correct Answer)

Explanation: ***It typically presents with severe fetal anemia requiring intrauterine transfusion*** - While ABO incompatibility can cause hemolytic disease, it rarely leads to severe fetal anemia requiring interventions like **intrauterine transfusion**, as the **antibodies are usually IgM** and do not cross the placenta efficiently. - The disease is generally **milder than Rh incompatibility** and often requires only phototherapy postnatally. *It generally causes more severe disease than Rh incompatibility* - **Rh incompatibility** typically causes more severe hemolytic disease, often leading to **hydrops fetalis** and severe anemia due to IgG antibodies crossing the placenta. - In comparison, **ABO incompatibility** usually results in a milder, postnatal presentation of jaundice. *It is the most common cause of hemolytic disease of the newborn* - **ABO incompatibility** is the most common cause of *mild* hemolytic disease of the newborn, but Rh incompatibility is historically known for causing more severe forms of the disease prior to the advent of Rhogam. - The scenario in the question describes a Type O mother and a Type A father, which is the most common scenario for **ABO incompatibility**. *It cannot occur in first pregnancies due to lack of prior sensitization* - **ABO incompatibility** can occur in the *first pregnancy* because mothers can be naturally sensitized to A or B antigens through exposure to environmental antigens (e.g., bacteria, food) that are structurally similar to blood group antigens. - This is a key difference from **Rh incompatibility**, which generally requires prior exposure to Rh-positive blood for sensitization to occur. *The direct Coombs test is typically strongly positive* - In **ABO incompatibility**, the direct Coombs test on the infant's red blood cells is often **weakly positive or negative**, even when hemolytic disease is present. - This is because fewer antibodies are usually bound to the red blood cells, and the antibodies involved are often IgM, which are less efficient at sensitizing red blood cells for Coombs testing.

Question 107: A 19-year-old woman, gravida 1, para 0, at 21 weeks’ gestation comes to the physician for a follow-up prenatal visit. At her previous appointment, her serum α-fetoprotein concentration was elevated. She had smoked 1 pack of cigarettes daily for 3 years but quit at 6 weeks' gestation. Examination shows a uterus consistent in size with a 21-week gestation. Ultrasonography shows fetal viscera suspended freely into the amniotic cavity. Which of the following is the most likely diagnosis?

A. Omphalocele
B. Vesicourachal diverticulum
C. Umbilical hernia
D. Gastroschisis (Correct Answer)
E. Diaphragmatic hernia

Explanation: ***Gastroschisis*** - This condition is characterized by **fetal viscera suspended freely into the amniotic cavity**, indicating an abdominal wall defect where organs are exposed directly. - **Elevated maternal serum α-fetoprotein (MSAFP)** is a classic finding in gastroschisis due to the direct exposure of fetal blood to the amniotic fluid. *Omphalocele* - In an omphalocele, the abdominal organs are covered by a **peritoneal sac**, which would not result in viscera "freely suspended" in the amniotic cavity. - Omphaloceles are often associated with **chromosomal abnormalities** and other congenital anomalies, which are not suggested here. *Vesicourachal diverticulum* - This is a rare anomaly of the **urachus**, an embryonic remnant connecting the bladder to the umbilicus. - It involves a diverticulum of the bladder and would **not cause exposed abdominal organs** or elevated MSAFP. *Umbilical hernia* - An umbilical hernia involves a protrusion of abdominal contents through the umbilical ring but is typically **covered by skin** and does not involve free exposure of viscera. - It usually presents as a **reducible bulge** and is not associated with elevated MSAFP in utero. *Diaphragmatic hernia* - This involves a defect in the diaphragm leading to abdominal organs migrating into the **thoracic cavity**, affecting lung development. - While it can cause some elevation of MSAFP, the ultrasound finding of **viscera freely suspended in the amniotic cavity** is not consistent with a diaphragmatic hernia.

Question 108: Three weeks after delivering a healthy boy, a 28-year-old woman, gravida 1, para 1, comes to the physician for a postpartum check-up. Labor and delivery were uncomplicated. Two days after delivery she was diagnosed with postpartum endometritis and received intravenous clindamycin plus gentamicin for 2 days. She had painful swelling of the breasts at the beginning of lactation, but frequent breastfeeding and warm compresses prior to breastfeeding improved her symptoms. Physical examination shows no abnormalities. The patient asks about a reliable contraceptive method. Which of the following is the most appropriate recommendation?

A. No contraception needed while lactating
B. Combined oral contraceptives
C. Spermicide
D. Basal body temperature method
E. Progestin-only contraceptive pills (Correct Answer)

Explanation: ***Progestin-only contraceptive pills*** - **Progestin-only pills** are safe and effective for breastfeeding mothers as they do not affect **milk production or composition**. - They provide reliable contraception by thickening cervical mucus, inhibiting ovulation, and thinning the endometrial lining. *No contraception needed while lactating* - While **lactational amenorrhea method (LAM)** can provide contraception, it's highly dependent on **exclusive breastfeeding** at specific intervals and absence of menses. - Its effectiveness decreases over time as breastfeeding patterns change, making it unreliable for long-term or highly effective contraception. *Combined oral contraceptives* - **Combined oral contraceptives (COCs)** contain **estrogen**, which can decrease **milk supply** and alter milk composition. - They are generally contraindicated in the immediate postpartum period, especially for breastfeeding mothers, due to the risk of **thrombosis**. *Spermicide* - **Spermicides** are a less effective form of contraception when used alone, with typical failure rates ranging from 15-28%. - They can cause **vaginal irritation** or allergic reactions, which may deter consistent use and effectiveness. *Basal body temperature method* - The **basal body temperature (BBT) method** requires daily tracking of body temperature variations to identify ovulation. - This method is often **unreliable postpartum** due to fluctuating hormones and disturbed sleep patterns, making accurate temperature tracking difficult.

Question 109: A 28-year-old woman, gravida 1, para 0, at 10 weeks gestation comes to the physician for her first prenatal visit. Today, she feels well. She has no history of serious illness. Her pulse is 75/min and blood pressure is 110/74 mm Hg. Examination shows no abnormalities. Ultrasonography shows a pregnancy consistent in size with a 10-week gestation. Serum studies in this patient are most likely to show which of the following sets of laboratory values? $$$ Thyroid-binding globulin %%% Free Triiodothyronine (T3) %%% Free Thyroxine (T4) %%% Total T3+T4 $$$

A. Normal ↑ ↑ ↑
B. ↑ normal normal ↑ (Correct Answer)
C. Normal normal normal normal
D. ↓ normal normal ↓
E. ↓ ↓ normal ↓

Explanation: ***↑ normal normal ↑*** - This option correctly reflects the typical changes in thyroid economy during pregnancy: **increased thyroid-binding globulin (TBG)** due to estrogen, leading to **increased total T3 and T4**, while **free T3 and free T4 remain normal** as the thyroid gland compensates. - The elevated TBG binds more thyroid hormones, initially decreasing free hormone levels slightly, but the thyroid gland responds by producing more T3 and T4 to maintain **euthyroid** state with normal free hormone levels. *Normal ↑ ↑ ↑* - This option incorrectly suggests that **free T3 and free T4 would be elevated** along with total T3 and T4, which is not typical in a healthy pregnant woman. - While total T3 and T4 increase, the body maintains **euthyroidism** by keeping free thyroid hormone levels within the normal range. *Normal normal normal normal* - This option incorrectly suggests that all thyroid parameters remain normal, which is not true for **TBG, total T3, and total T4** in pregnancy. - The significant physiological changes during pregnancy, particularly the increase in **estrogen**, directly impact TBG levels and subsequently total thyroid hormone levels. *↓ normal normal ↓* - This option is incorrect as **TBG and total T3+T4 generally increase** during pregnancy, not decrease. - A decrease in these values, especially with normal free hormones, is not consistent with the typical **euthyroid state** of a healthy pregnant woman. *↓ ↓ normal ↓* - This option incorrectly suggests a decrease in **TBG, free T3, and total T3+T4**, which would indicate a hypothyroid state, inconsistent with the patient's well-being and normal examination findings. - A healthy pregnant woman maintains **euthyroidism** with normal free thyroid hormone levels.

Question 110: A 17-year-old girl presents with significant weight loss over the last few months. There is a positive family history of Hodgkin lymphoma and hyperthyroidism. Her blood pressure is 100/65 mm Hg, pulse rate is 60/min, and respiratory rate is 17/min. Her weight is 41 kg and height is 165 cm. On physical examination, the patient is ill-appearing. Her skin is dry, and there are several patches of thin hair on her arm. No parotid gland enlargement is noted and her knuckles show no signs of trauma. Laboratory findings are significant for the following: Hemoglobin 10.1 g/dL Hematocrit 37.7% Leukocyte count 5,500/mm³ Neutrophils 65% Lymphocytes 30% Monocytes 5% Mean corpuscular volume 65.2 µm³ Platelet count 190,000/mm³ Erythrocyte sedimentation rate 10 mm/h Which of the following findings is associated with this patient’s most likely condition?

A. Abdominal striae
B. Dental caries
C. Parotid gland enlargement
D. Diarrhea
E. Amenorrhea (Correct Answer)

Explanation: **Amenorrhea** - The patient's presentation with significant **weight loss**, low BMI (165 cm, 41 kg), `dry skin`, `thin hair`, `bradycardia`, and `hypotension` strongly suggests **anorexia nervosa**. - **Amenorrhea**, defined as the absence of menstruation, is a classic endocrine complication of anorexia nervosa due to **hypothalamic-pituitary-gonadal axis dysfunction** caused by severe caloric restriction and low body fat. *Abdominal striae* - **Abdominal striae** (stretch marks) are commonly associated with rapid weight gain, obesity, pregnancy, or **Cushing's syndrome** due to excessive cortisol, which is not indicated by this patient's presentation. - While the patient is young, her significant **weight loss** makes these findings unlikely as they are typically associated with skin stretching from weight gain. *Dental caries* - **Dental caries** can occur with poor hygiene or extreme sugar intake and are not specifically linked to anorexia nervosa. - They are also often seen in **bulimia nervosa** due to recurrent vomiting and acid exposure, but the current presentation lacks signs of purging behaviors like eroded tooth enamel or trauma to knuckles. *Parotid gland enlargement* - **Parotid gland enlargement** (sialadenosis) is a common finding in **bulimia nervosa** as a result of recurrent vomiting and salivary gland stimulation, which is explicitly noted as absent in this patient. - The patient's physical examination specifically states that **no parotid gland enlargement is noted**, ruling out this option. *Diarrhea* - While gastrointestinal issues can occur with disordered eating, **constipation** is a more common symptom in anorexia nervosa due to slowed gastrointestinal motility from starvation. - **Diarrhea** is not a typical direct association but can be present due to laxative abuse (if bulimia nervosa) or refeeding syndrome, neither of which is indicated here.

Question 111: A 27-year-old G0P0 female presents to her OB/GYN for a preconception visit to seek advice before becoming pregnant. A detailed history reveals no prior medical or surgical history, and she appears to be in good health currently. Her vaccination history is up-to-date. She denies tobacco or recreational drug use and admits to drinking 2 glasses of wine per week. She states that she is looking to start trying to become pregnant within the next month, hopefully by the end of January. Which of the following is NOT recommended as a next step for this patient's preconception care?

A. Begin 400 mcg folic acid supplementation
B. Administer measles, mumps, rubella (MMR) vaccination (Correct Answer)
C. Obtain rubella titer
D. Obtain varicella zoster titer
E. Recommend inactivated influenza vaccination

Explanation: ***Administer measles, mumps, rubella (MMR) vaccination*** - Live-attenuated vaccines like **MMR** are contraindicated during pregnancy and should ideally be given **at least one month prior to conception**. - If her vaccination history is up-to-date and she plans to conceive within the month, administering MMR is not recommended at this time without confirming immunity first. *Begin 400 mcg folic acid supplementation* - **Folic acid supplementation** at 400 mcg daily is recommended for all women of childbearing age to prevent **neural tube defects**, ideally starting at least one month before conception and continuing through the first trimester. - This is a crucial step in preconception care to ensure adequate levels when the neural tube is forming. *Obtain rubella titer* - Checking a **rubella titer** is standard preconception care to determine immunity, as rubella infection during pregnancy can lead to serious congenital anomalies. - If she is not immune, the MMR vaccine can be offered, but with a **one-month contraception period** before attempting conception. *Obtain varicella zoster titer* - Determining **varicella immunity** is important because congenital varicella syndrome can occur if a non-immune mother contracts chickenpox during pregnancy. - If she is not immune, the **varicella vaccine** can be administered, followed by a **one-month waiting period** before conception. *Recommend inactivated influenza vaccination* - **Inactivated influenza vaccination** is safe and recommended during any stage of pregnancy, including the preconception period, to protect both the mother and newborn from severe influenza outcomes. - It can be given even if she plans to conceive within the month, as it is not a live vaccine.

Question 112: A 35-year-old woman, gravida 4, para 3, at 34 weeks' gestation comes to the physician for a prenatal visit. She feels well. She does not note any contractions or fluid from her vagina. Her third child was delivered spontaneously at 35 weeks' gestation; pregnancy and delivery of her other two children were uncomplicated. Vital signs are normal. The abdomen is nontender and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 34-weeks' gestation. Ultrasonography shows the fetus in a breech presentation. The fetal heart rate is 148/min. Which of the following is the most appropriate next step in management?

A. Internal cephalic version
B. Intravenous penicillin
C. Cesarean section
D. Observation (Correct Answer)
E. External cephalic version

Explanation: ***Observation*** - At 34 weeks' gestation, **spontaneous version** from **breech to cephalic presentation** can still occur, especially in multiparous women. - Waiting until 37 weeks allows time for the fetus to turn naturally before considering interventions. *Internal cephalic version* - This procedure involves a physician inserting a hand into the uterus to manually turn the fetus from inside. - It is typically performed during **labor** to correct a **malpresentation** once the cervix is dilated sufficiently and is not appropriate for an antepartum breech presentation. *Intravenous penicillin* - **Penicillin** is administered to prevent **Group B Streptococcus (GBS) transmission** to the neonate, usually during labor for GBS-positive mothers. - There is no indication for **GBS prophylaxis** in this case, and GBS status is not provided. *Cesarean section* - While breech presentation often necessitates a **cesarean section**, it is generally planned for 39 weeks' gestation or when labor begins if other interventions fail. - It is premature to schedule a **C-section** at 34 weeks, as the fetus might still undergo spontaneous version. *External cephalic version* - This procedure involves manually manipulating the fetus through the maternal abdomen to turn it from breech to cephalic. - It is usually attempted at **37 weeks' gestation** to maximize success rates and minimize risks, as earlier attempts have lower success and higher re-version rates.

Question 113: A 26-year-old nurse at 8 weeks of gestation presents to the physician with low-grade fever and body ache for the past 2 days. She also complains of a fine pink and itchy rash that appeared 2 nights ago. The rash 1st appeared on her face and spread to her neck. Past medical history is noncontributory. She takes prenatal vitamins with folate every day. She has had many sick contacts while working in the hospital. Additionally, her daughter has had several colds over the last few months. On examination, the temperature is 38.3°C (100.9°F), she has a fine macular rash on her face and neck with focal macules on her chest. Palpation of the neck reveals lymphadenopathy in the posterior auricular nodes. What is the most appropriate next step in the management of this patient?

A. Administer rubella vaccine
B. Termination of pregnancy
C. Admit the patient and place her in isolation
D. Administer anti-rubella antibodies
E. Test for rubella antibodies in her blood (Correct Answer)

Explanation: ***Test for rubella antibodies in her blood*** - The patient's symptoms (low-grade fever, body ache, fine maculopapular rash spreading from face to neck, posterior auricular lymphadenopathy) are highly suggestive of **rubella (German measles)**. - Due to the risk of **congenital rubella syndrome** in pregnancy, confirming the diagnosis with **IgM and IgG rubella antibody titers** is the most appropriate initial step to assess recent infection and immunity status. *Administer rubella vaccine* - The rubella vaccine is a **live attenuated vaccine** and is **contraindicated in pregnancy** due to the theoretical risk of fetal infection. - Vaccination should only be performed **postpartum** or when pregnancy is not a concern. *Termination of pregnancy* - **Termination of pregnancy** is a significant decision and is only considered in cases of confirmed severe congenital rubella syndrome, after extensive counseling, and in line with patient wishes. - This step is **premature** and should not be considered until a rubella infection is confirmed and the potential fetal risks are thoroughly evaluated. *Admit the patient and place her in isolation* - While isolation might be necessary if rubella is confirmed due to its **infectious nature**, this is not the **first step** in management. - The priority is to **confirm the diagnosis** to guide further appropriate medical and obstetric decisions. *Administer anti-rubella antibodies* - **Passive immunization with immunoglobulin** might be considered in specific cases of non-immune pregnant women exposed to rubella, but its efficacy in preventing congenital rubella syndrome is **uncertain** and it is not a first-line treatment for an active suspected infection. - The immediate priority is accurate diagnosis through **antibody testing**.

Question 114: A 27-year-old G1P0 at 12 weeks estimated gestational age presents for prenatal care. The patient says she has occasional nausea and vomiting and a few episodes of palpitations and diarrhea this last week. Physical examination is unremarkable, except for a heart rate of 145/min. Basic thyroid function tests are shown in the table below. Which of the following additional laboratory tests would be most useful in assessing this patient's condition? Thyroid-stimulating hormone (TSH) 0.28 mIU/L (0.3–4.5 mIU/L) Total T4 12 µg/dL (5.4–11.5 µg/dL)

A. Thyrotropin receptor antibodies (TRAb)
B. Total triiodothyronine (T3) levels
C. Thyroid peroxidase (TPO) antibodies
D. Free thyroxine (T4) levels (Correct Answer)
E. Thyroxine-binding globulin (TBG) levels

Explanation: ***Free thyroxine (T4) levels*** - In pregnancy, **estrogen increases thyroxine-binding globulin (TBG)**, leading to higher **total T4** levels even if free T4 is normal. - Measuring **free T4 provides a more accurate assessment** of the biologically active thyroid hormone, which is crucial for distinguishing between physiological changes of pregnancy and true hyperthyroidism. *Thyrotropin receptor antibodies (TRAb)* - **TRAb are specific for Graves' disease**, which is a cause of hyperthyroidism, but their presence is a confirmatory test after hyperthyroidism has been established. - The initial step is to confirm the diagnosis of **hyperthyroidism** by evaluating free hormone levels, particularly in pregnancy where total hormone levels are less reliable. *Total triiodothyronine (T3) levels* - Similar to total T4, **total T3 levels are also affected by increased TBG in pregnancy**, making them less reliable for initial diagnosis of thyroid dysfunction. - While T3 is an important thyroid hormone, **free T4 is generally the primary screening test** for hyperthyroidism. *Thyroid peroxidase (TPO) antibodies* - **TPO antibodies are indicative of autoimmune thyroiditis**, such as Hashimoto's thyroiditis, which typically causes hypothyroidism, not hyperthyroidism, as suggested by the patient's symptoms and elevated T4. - Although TPO antibodies can sometimes be positive in Graves' disease, they are **not the primary diagnostic test for active hyperthyroidism**, especially regarding the magnitude of the elevation. *Thyroxine-binding globulin (TBG) levels* - While **TBG levels are elevated in pregnancy**, measuring TBG itself doesn't directly assess thyroid function. - Understanding the physiology of **TBG elevation explains why total T4 is high**, but it doesn't help in determining whether the patient is truly hyperthyroid; for that, free T4 is needed.

Question 115: A 16-year-old girl comes to the physician because of episodic lower abdominal pain for 5 months. The pain starts to occur a few hours before her menses and lasts for 2–3 days. Ibuprofen helped reduce the pain in the first months but has no effect now. She has missed a couple of days at school because of severe pain. Menarche was at the age of 14 years, and menses occur at regular 29-day intervals. She is sexually active with one male partner and uses condoms inconsistently. Her temperature is 37.1°C (98.8°F), pulse is 88/min, and blood pressure is 110/70 mm Hg. Physical and pelvic examination show no abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A. Diagnostic laparoscopy
B. Oral contraceptive pill (Correct Answer)
C. Ceftriaxone and doxycycline therapy
D. Urinalysis
E. Pelvic ultrasonography

Explanation: ***Oral contraceptive pill*** - This patient's symptoms are highly suggestive of **secondary dysmenorrhea**, possibly due to **endometriosis**, given the worsening pain and lack of response to NSAIDs. **Oral contraceptive pills (OCPs)** are a first-line treatment for dysmenorrhea, including that caused by endometriosis, as they suppress ovulation and reduce endometrial growth. - The patient also reports inconsistent condom use and is sexually active, making OCPs a beneficial choice for **contraception**, addressing two concerns simultaneously. *Diagnostic laparoscopy* - **Laparoscopy** is the gold standard for diagnosing endometriosis, but it is an **invasive surgical procedure**. - It is generally reserved for cases where empirical medical therapy has failed or when there is a strong suspicion of severe disease or infertility. *Ceftriaxone and doxycycline therapy* - This antibiotic regimen is used to treat **pelvic inflammatory disease (PID)**. While the patient is sexually active and uses condoms inconsistently, she presents with no signs of active infection (e.g., fever, cervical motion tenderness, purulent discharge), making empiric antibiotics unwarranted at this stage. - Her pain is also clearly cyclical and related to menses, which is more characteristic of dysmenorrhea. *Urinalysis* - A **urinalysis** would be appropriate if there were symptoms suggestive of a **urinary tract infection (UTI)**, such as dysuria, frequency, urgency, or hematuria. - The patient's symptoms are primarily cyclical lower abdominal pain, which is not typical for a UTI. *Pelvic ultrasonography* - **Pelvic ultrasonography** is a non-invasive imaging technique that can help identify structural abnormalities like **ovarian cysts**, **fibroids**, or adenomyosis. - However, it often cannot reliably detect mild endometriosis and a normal ultrasound does not rule out the condition. Given the classic symptoms of dysmenorrhea, empirical treatment often precedes imaging.

Question 116: A 3670-g (8 lb 1 oz) male newborn is delivered to a 26-year-old primigravid woman. She received adequate prenatal care and labor was uncomplicated. She has chronic hepatitis B infection and gastroesophageal reflux disease. Her only medication is ranitidine. She admits to smoking cannabis and one half-pack of cigarettes daily. She drinks two beers on the weekend. The mother is apprehensive about taking care of her baby and requests for some information regarding breastfeeding. Which of the following is a contraindication to breastfeeding?

A. Cannabis use (Correct Answer)
B. Ranitidine use
C. Hepatitis B infection
D. Smoking
E. Seropositive for cytomegalovirus

Explanation: ***Cannabis use*** - **Cannabis** and its active compounds, particularly **tetrahydrocannabinol (THC)**, are secreted into breast milk and can accumulate in breastfed infants' adipose tissue and brain. - Exposure via breast milk can lead to potential neurodevelopmental effects, sedation, and impaired motor development in the infant, making it a contraindication to breastfeeding. *Ranitidine use* - **Ranitidine** (now largely replaced by famotidine) is generally considered safe during breastfeeding because only very small amounts are transferred into breast milk and are unlikely to cause adverse effects in the infant. - The benefits of breastfeeding typically outweigh the minimal risks associated with commonly used medications like ranitidine for maternal conditions. *Hepatitis B infection* - **Maternal hepatitis B infection** is not a contraindication to breastfeeding, especially if the infant receives **hepatitis B vaccine** and **hepatitis B immunoglobulin (HBIG)** at birth. - These interventions effectively protect the infant from acquiring the virus, and the benefits of breastfeeding for nutrition and immunity are significant. *Smoking* - While **smoking** by the mother is harmful and linked to various health issues in the infant, it is generally considered a strong caution rather than an absolute contraindication to breastfeeding. - Mothers are encouraged to quit or reduce smoking, and to smoke away from the infant and breastfeed after a longer interval, but the immunological and nutritional benefits of breast milk still often outweigh the risks in mild to moderate smoking. *Seropositive for cytomegalovirus* - **Cytomegalovirus (CMV)** is excreted in breast milk by seropositive mothers, but for **healthy, term infants**, breastfeeding is generally considered safe and beneficial despite the presence of CMV antibodies. - In contrast, for **premature or immunocompromised infants**, there might be a theoretical risk, and pasteurization of breast milk or temporary cessation might be considered, but it's not an absolute contraindication for a full-term, healthy baby.

Question 117: A 21-year-old gravida 1 presents to her physician's office for an antepartum visit at 11 weeks gestation. She has complaints of malaise, occasional nausea, and changes in food preferences. Her vital signs include: blood pressure 100/70 mm Hg, heart rate 90/min, respiratory rate 14/min, and temperature 36.8℃ (98.2℉). Examination reveals a systolic ejection murmur along the left sternal border. There are no changes in skin color, nails, or hair growth. No neck enlargement is noted. Blood analysis shows the following: Erythrocyte count 3.5 million/mm3 Hb 11.9 g/dL HCT 35% Reticulocyte count 0.2% MCV 85 fL Platelet count 210,000/mm3 Leukocyte count 7800/mm3 Serum iron 17 µmol/L Ferritin 120 µg/L What is the most likely cause of the changes in the patient's blood count?

A. Increase in plasma volume (Correct Answer)
B. Failure of purine and thymidylate synthesis
C. Insufficient iron intake
D. Failure of synthesis of a D-aminolevulinic acid
E. Decreased iron transport across the intestinal wall

Explanation: ***Increase in plasma volume*** - The patient's **hemoglobin (Hb) of 11.9 g/dL**, **hematocrit (HCT) of 35%**, and **erythrocyte count of 3.5 million/mm3** are slightly below normal reference ranges. However, her **MCV (85 fL)** is normal, and **serum iron (17 µmol/L)** and **ferritin (120 µg/L)** are within healthy limits, indicating that iron stores are adequate. - In pregnancy, a physiological **hemodilution** occurs due to a disproportionate increase in plasma volume compared to red blood cell mass. This leads to a relative decrease in Hb and HCT, which is normal and expected, rather than a true anemia. *Failure of purine and thymidylate synthesis* - This typically occurs in **megaloblastic anemias**, such as those caused by **folate or vitamin B12 deficiency**. - Such anemias are characterized by **macrocytic red blood cells (high MCV)**, which is not seen here as the MCV is normal (85 fL). *Insufficient iron intake* - **Iron deficiency anemia** would present with significantly lower **serum iron** and **ferritin** levels, along with **microcytic (low MCV)** and **hypochromic** red blood cells. - The patient's iron studies (serum iron 17 µmol/L, ferritin 120 µg/L) are normal, and her MCV is normal, ruling out iron deficiency. *Failure of synthesis of a D-aminolevulinic acid* - This refers to impaired heme synthesis, often seen in conditions like **sideroblastic anemia** or **lead poisoning**. - These conditions typically cause **microcytic or dimorphic anemia** with **increased iron stores** and often **basophilic stippling**, none of which are indicated here. *Decreased iron transport across the intestinal wall* - This would result in **iron deficiency**, leading to low serum iron and ferritin, and potentially iron-deficiency anemia. - As noted, the patient has **normal iron stores** (ferritin 120 µg/L) and serum iron levels, making impaired absorption unlikely to be the cause of her current blood counts.

Question 118: A 24-year-old woman comes to the physician for preconceptional advice. She has been married for 2 years and would like to conceive within the next year. Menses occur at regular 30-day intervals and last 4 days with normal flow. She does not smoke or drink alcohol and follows a balanced diet. She takes no medications. She is 160 cm (5 ft 3 in) tall and weighs 55 kg (121 lb); BMI is 21.5 kg/m2. Physical examination, including pelvic examination, shows no abnormalities. She has adequate knowledge of the fertile days of her menstrual cycle. Which of the following is most appropriate recommendation for this patient at this time?

A. Begin high-dose vitamin A supplementation
B. Begin vitamin B12 supplementation
C. Begin folate supplementation (Correct Answer)
D. Begin iron supplementation
E. Gain 2 kg prior to conception

Explanation: ***Begin folate supplementation*** - **Folate supplementation** of 400 mcg daily is recommended for all women of childbearing age to reduce the risk of **neural tube defects** (NTDs) in the fetus. This should ideally begin at least one month before conception and continue through the first trimester. - The patient is planning to conceive, making preemptive folate supplementation critical for preventing serious birth defects. *Begin high-dose vitamin A supplementation* - **High-dose vitamin A** (more than 10,000 IU/day) can be **teratogenic** and is therefore contraindicated during preconception and pregnancy. - While vitamin A is essential for fetal development, excessive amounts can lead to fetal abnormalities. *Begin vitamin B12 supplementation* - **Vitamin B12 supplementation** is generally not necessary unless the patient has a diagnosed deficiency, such as in strict vegetarians or those with malabsorption issues. - There is no indication of B12 deficiency in this patient's history or presentation. *Begin iron supplementation* - Routine **iron supplementation** is not recommended preconception unless the patient is diagnosed with **iron deficiency anemia**. - Excessive iron intake without a clear indication can cause gastrointestinal upset and has not been shown to improve pregnancy outcomes in non-anemic women. *Gain 2 kg prior to conception* - The patient has a **healthy BMI of 21.5 kg/m2**, which is within the normal range (18.5-24.9 kg/m2). - There is no medical indication for her to gain weight prior to conception.

Question 119: A 21-year-old female presents to her primary care doctor for prenatal counseling before attempting to become pregnant for the first time. She is an avid runner, and the physician notes her BMI of 17.5. The patient complains of chronic fatigue, which she attributes to her busy lifestyle. The physician orders a complete blood count that reveals a Hgb 10.2 g/dL (normal 12.1 to 15.1 g/dL) with an MCV 102 µm^3 (normal 78 to 98 µm^3). A serum measurement of a catabolic derivative of methionine returns elevated. Which of the following complications is the patient at most risk for if she becomes pregnant?

A. Placenta abruptio (Correct Answer)
B. Placenta previa
C. Placenta accreta
D. Neural tube defects
E. Gestational diabetes

Explanation: **Placenta abruptio** * The patient presents with several risk factors for **placental abruption**, including **low BMI**, **anemia** (Hgb 10.2), and **elevated homocysteine** (indicated by elevated catabolic derivative of methionine, implying **folate or B12 deficiency**, which leads to high homocysteine). * **Anemia** and **folate deficiency** are associated with an increased risk of placental abruption. *Placenta previa* * **Placenta previa** is characterized by the placenta covering the cervical os, typically associated with risk factors like **previous C-section**, **multiparity**, and **advanced maternal age**. * The patient's profile (first pregnancy, young) does not align with the typical risk factors for placenta previa. *Placenta accreta* * **Placenta accreta** involves abnormal placental adherence to the uterine wall, most commonly linked to **prior uterine surgery** (especially C-sections) and **placenta previa**. * The patient has no history of uterine surgery, making placenta accreta an unlikely primary risk. *Neural tube defects* * **Neural tube defects** are associated with **folate deficiency**, which is likely present given the **macrocytic anemia** (MCV 102) and elevated homocysteine. * However, the question asks for the complication the patient is *most* at risk for due to her overall profile including her low BMI and anemia, and while NTDs are a risk, the combination of factors points more strongly to placental abruption. *Gestational diabetes* * **Gestational diabetes** is linked to risk factors like **obesity**, **family history of diabetes**, and **advanced maternal age**. * The patient's **low BMI** (17.5) and young age make gestational diabetes an unlikely significant risk.

Question 120: A 23-year-old woman presents to her physician requesting the chickenpox vaccine. She is also complaining of nausea, malaise, and moderate weight gain. She developed these symptoms gradually over the past 2 weeks. She reports no respiratory or cardiovascular disorders. Her last menstruation was about 6 weeks ago. She has one sexual partner and uses a natural planning method for contraception. Her vital signs include: blood pressure 110/70 mm Hg, heart rate 92/min, respiratory rate 14/min, and temperature 37.2℃ (99℉). The physical examination shows non-painful breast engorgement and nipple hyperpigmentation. There is no neck enlargement and no palpable nodules in the thyroid gland. The urine beta-hCG is positive. What is the proper recommendation regarding chickenpox vaccination in this patient?

A. Confirm pregnancy with serum beta-hCG and if positive delay administration of the vaccine until the third trimester.
B. Perform varicella viral load and schedule the vaccine based on these results.
C. Confirm pregnancy with serum beta-hCG and if positive, postpone administration of the vaccine until after completion of the pregnancy. (Correct Answer)
D. Schedule the vaccination.
E. Confirm pregnancy with serum beta-hCG and if positive, schedule the patient for pregnancy termination.

Explanation: ***Confirm pregnancy with serum beta-hCG and if positive, postpone administration of the vaccine until after completion of the pregnancy.*** - The patient's symptoms (nausea, malaise, weight gain, breast engorgement, nipple hyperpigmentation, missed menses) and a **positive urine beta-hCG** are highly indicative of **pregnancy**. - The **chickenpox vaccine (varicella vaccine)** is a **live attenuated vaccine**, which is **contraindicated in pregnancy** due to the theoretical risk of fetal infection and congenital varicella syndrome. Vaccination should be deferred until after delivery. *Confirm pregnancy with serum beta-hCG and if positive delay administration of the vaccine until the third trimester.* - While confirming pregnancy with **serum beta-hCG** is appropriate, delaying vaccination only until the **third trimester** is still inappropriate for a live attenuated vaccine. - Live attenuated vaccines are generally **contraindicated throughout pregnancy** due to potential fetal risks. *Perform varicella viral load and schedule the vaccine based on these results.* - A **varicella viral load** test is used to detect active viral infections, not to determine immunity or the need for vaccination in an uninfected individual. - The primary concern here is the patient's likely pregnancy, not current varicella infection status. *Schedule the vaccination.* - Given the strong suspicion of **pregnancy** and a **positive urine beta-hCG**, immediately scheduling a live attenuated vaccine like the chickenpox vaccine would be **medically inappropriate and potentially harmful** to the fetus. - Vaccination must be deferred until pregnancy status is confirmed and, if positive, until after delivery. *Confirm pregnancy with serum beta-hCG and if positive, schedule the patient for pregnancy termination.* - A potential need for a chickenpox vaccine, even if the patient is pregnant, is not an indication for **pregnancy termination**. - This option is ethically and medically unsound, as exposure to the varicella vaccine in pregnancy does not warrant termination.

Question 121: A 16-year-old girl comes to the physician because of a 3-week history of nausea, increased urinary frequency, and breast tenderness. She has never had a menstrual period. She is actively involved in her school's track and field team. She is 173 cm (5 ft 8 in) tall and weighs 54 kg (120 lb); BMI is 18 kg/m2. Her breast and pubic hair development are at Tanner stage 5. Which of the following serum assays is the most appropriate next step in the diagnosis of this patient's condition?

A. Thyrotropin
B. Human chorionic gonadotropin (Correct Answer)
C. Estriol
D. Prolactin
E. Luteinizing hormone

Explanation: **Human chorionic gonadotropin** - The patient's symptoms (nausea, increased urinary frequency, breast tenderness) are classic signs of **pregnancy**, especially given her primary amenorrhea. - A **human chorionic gonadotropin (hCG)** assay is the definitive test to confirm or rule out pregnancy. *Thyrotropin* - **Thyroid disorders** can cause menstrual irregularities, but the acute onset of nausea, increased urinary frequency, and breast tenderness points away from primary thyroid dysfunction as the initial primary diagnosis. - While thyroid function may be assessed later if pregnancy is ruled out, it's not the most immediate next step for these specific symptoms. *Estriol* - **Estriol** is primarily useful in assessing **fetal well-being** later in pregnancy and in diagnosing estrogen deficiencies; it is not the initial test for suspected pregnancy. - While part of the estrogen family, measuring estriol directly is not the first-line diagnostic for the patient's presenting symptoms. *Prolactin* - Elevated **prolactin** can cause **amenorrhea** and **galactorrhea** (breast discharge), but it doesn't typically cause nausea or increased urinary frequency. - While hyperprolactinemia could be a cause for primary amenorrhea, the combination of symptoms strongly suggests pregnancy over hyperprolactinemia. *Luteinizing hormone* - **Luteinizing hormone (LH)** levels are used to assess ovulation and other causes of menstrual dysfunction, but they do not directly indicate pregnancy. - While relevant to reproductive health, an LH assay isn't the most appropriate first step given the strong suspicious for pregnancy based on symptoms.

Question 122: A 26-year-old gravida 3 para 1 is admitted to labor and delivery with uterine contractions. She is at 37 weeks gestation with no primary care provider or prenatal care. She gives birth to a boy after an uncomplicated vaginal delivery with APGAR scores of 7 at 1 minute and 8 at 5 minutes. His weight is 2.2 kg (4.4 lb) and the length is 48 cm (1.6 ft). The infant has weak extremities and poor reflexes. The physical examination reveals microcephaly, palpebral fissures, thin lips, and a smooth philtrum. A systolic murmur is heard on auscultation. Identification of which of the following factors early in the pregnancy could prevent this condition?

A. Phenytoin usage
B. Maternal hypothyroidism
C. Alcohol consumption (Correct Answer)
D. Physical abuse
E. Maternal toxoplasmosis

Explanation: ***Alcohol consumption*** - The constellation of **microcephaly**, **palpebral fissures**, **thin lips**, **smooth philtrum**, and **cardiac defects** (systolic murmur) in an infant points to **Fetal Alcohol Syndrome (FAS)**. - **FAS** is entirely preventable if alcohol is avoided during pregnancy, especially early in gestation, as there is no safe amount or time to drink alcohol during pregnancy. *Phenytoin usage* - **Phenytoin** is associated with **fetal hydantoin syndrome**, which can present with microcephaly, distinct facial features (e.g., broad nasal bridge, epicanthal folds), and hypoplastic nails, but typically not the specific facial features of FAS. - While it is a teratogen, preventing its use would not specifically address the described clinical picture, which strongly aligns with alcohol exposure. *Maternal hypothyroidism* - **Untreated maternal hypothyroidism** can lead to **neurodevelopmental delays** and **cognitive impairment** in the child. - It does not, however, cause the characteristic facial dysmorphology or cardiac defects seen in FAS. *Physical abuse* - **Physical abuse** does not cause congenital malformations or a specific syndrome evident at birth like FAS. - While it is a serious concern for maternal and fetal well-being, it is not a direct teratogenic cause of the described neonatal findings. *Maternal toxoplasmosis* - **Congenital toxoplasmosis** can cause hydrocephalus, chorioretinitis, and intracranial calcifications. - It does not cause the specific facial dysmorphology, cardiac defects, or microcephaly seen in this infant.

Question 123: A 25-year-old gravida 1 para 0 woman visits an OB/GYN for her first prenatal visit and to establish care. She is concerned about the costs related to future prenatal visits, medications, procedures, and the delivery. She has no type of health insurance through her work and has previously been denied coverage by public health insurance based on her income. Since then she has been promoted and earns a higher salary. In addressing this patient, which of the following is the most appropriate counseling?

A. She may be eligible for Medigap based on her higher salary
B. She may be eligible for Medigap because she is pregnant
C. She may be eligible for Medicaid because she is pregnant (Correct Answer)
D. She may be eligible for Medicaid based on her higher salary
E. She may be eligible for Medicare based on her higher salary

Explanation: ***She may be eligible for Medicaid because she is pregnant*** - Pregnancy is a **qualifying life event** that often makes women, even those with higher incomes, eligible for expanded **Medicaid coverage** during and shortly after pregnancy. - This program provides comprehensive coverage for prenatal care, delivery, and postpartum care, significantly reducing out-of-pocket costs. *She may be eligible for Medigap based on her higher salary* - **Medigap** policies are designed to supplement Medicare, which is general health insurance for individuals **aged 65 or older**, or those with certain disabilities. - Eligibility for Medigap is tied to Medicare enrollment, not income or pregnancy status. *She may be eligible for Medigap because she is pregnant* - Again, **Medigap** is supplemental insurance for individuals enrolled in **Medicare**, which primarily covers individuals aged 65 and older or those with specific disabilities. - Pregnancy does not make an individual eligible for Medigap or Medicare. *She may be eligible for Medicaid based on her higher salary* - While **Medicaid** eligibility is often income-based, a higher salary typically **decreases** the likelihood of general Medicaid eligibility, as it usually pushes individuals above the income thresholds. - However, pregnant women often qualify under **expanded eligibility criteria** regardless of their income, which supersedes general income requirements. *She may be eligible for Medicare based on her higher salary* - **Medicare** is a federal health insurance program for people **aged 65 or older**, certain younger people with disabilities, and people with End-Stage Renal Disease. - A higher salary does not qualify someone for Medicare; rather, it's based on age, disability, or specific medical conditions.

Question 124: A 16-year-old girl is brought to the physician for evaluation of severe acne on her face, chest, and back for the past 2 years. She has no itching or scaling. She has been treated in the past with a combination of oral cephalexin and topical benzoyl peroxide without clinical improvement. She is sexually active with one male partner, and they use condoms inconsistently. She does not smoke, drink alcohol, or use illicit drugs. There is no personal or family history of serious illness. Her vital signs are within normal limits. Examination shows mild facial scarring and numerous open comedones and sebaceous skin lesions on her face, chest, and back. Before initiating treatment, which of the following is the most appropriate next step?

A. Administer oral contraceptives
B. Switch cephalexin to doxycycline
C. Screen for depression with a questionnaire
D. Measure serum beta-hCG levels (Correct Answer)
E. Measure creatinine kinase levels

Explanation: ***Measure serum beta-hCG levels*** - The patient is a **sexually active** adolescent with **inconsistent condom use**, making her at risk for pregnancy. - Before initiating any systemic **acne treatment**, especially those with teratogenic potential like **isotretinoin** or certain **antibiotics**, pregnancy must be ruled out. *Administer oral contraceptives* - While **oral contraceptives** can be effective for managing **acne**, they should only be prescribed after **pregnancy is ruled out**. - Starting **hormonal therapy** without confirming non-pregnancy poses a risk to a potential fetus. *Switch cephalexin to doxycycline* - Switching to another **antibiotic** like **doxycycline** may be considered for acne, but it's crucial to first **rule out pregnancy** due to potential **teratogenic effects** (e.g., inhibition of bone growth, tooth discoloration) and photosensitivity. - This step does not address the immediate safety concern regarding potential pregnancy. *Screen for depression with a questionnaire* - While **acne** can negatively impact **mental health**, screening for **depression** is not the immediate priority **before initiating medical treatment** that could harm a potential fetus. - This is an important consideration for long-term care but not the immediate next step. *Measure creatinine kinase levels* - **Creatinine kinase (CK)** levels are typically monitored with medications like **statins** or in conditions involving **muscle damage**, which are not indicated for acne treatment. - This test has no relevance to the initial workup for acne in this clinical scenario.

Question 125: A primigravida at 10+5 weeks gestation registers in an obstetric clinic for prenatal care. She has noted a rash that is rough with red-brown spots on her palms. The rapid plasma reagin (RPR) test is positive. The diagnosis is confirmed by darkfield microscopy. What is the fetus at risk for secondary to the mother’s condition?

A. Muscle atrophy
B. Saddle nose (Correct Answer)
C. Seizures
D. Vision loss
E. Chorioretinitis

Explanation: ***Saddle nose*** - The patient's symptoms (rash on palms, positive RPR, confirmed by darkfield microscopy) indicate **syphilis**. **Congenital syphilis** can lead to facial deformities, including a **saddle nose** due to destruction of cartilaginous nasal structures. - This is a classic manifestation of **late congenital syphilis**, which results from undetected or untreated maternal infection. *Muscle atrophy* - While congenital syphilis can cause widespread systemic effects, **muscle atrophy** is not a primary or characteristic complication. - Musculoskeletal abnormalities such as **osteochondritis** and **periostitis** are more typical, not generalized muscle wasting. *Seizures* - **Neurosyphilis** can occur in congenital syphilis, potentially causing central nervous system involvement. However, **seizures** are not among the most common or characteristic features of congenital syphilis in neonates. - Common neurological manifestations might include **sensorineural hearing loss** or **hydrocephalus**, but not typically seizures as a primary sign. *Vision loss* - Congenital syphilis can affect the eyes, leading to conditions like **interstitial keratitis** or **chorioretinitis**. - **Vision loss** can be a consequence of severe ocular involvement but is not a direct or primary and a common presenting symptom like the classic facial deformities. *Chorioretinitis* - **Chorioretinitis** is indeed a manifestation of congenital syphilis, especially affecting the posterior segment of the eye. - However, the question asks for a specific risk, and **saddle nose** is more uniquely characteristic and commonly emphasized as a congenital syphilis sequela than chorioretinitis.

Question 126: An 80-year-old woman seeks evaluation at an outpatient clinic for a firm nodular lump on the left side of her labia. The medical history is notable for hypertension, coronary artery disease status post CABG, and lichen sclerosus of the vagina that was treated with an over-the-counter steroid cream as needed. She first noticed the lump about 5 months ago. On physical examination, the temperature is 37°C (98.6°F), the blood pressure is 135/89 mm Hg, the pulse is 95/min, and the respiratory rate is 17/min. Examination of the genital area reveals a small nodular lump on the left labium majus with visible excoriations, but no white plaque-like lesions. What is the next best step in management?

A. Vulvar punch biopsy (Correct Answer)
B. Estrogen level measurement
C. HPV DNA testing
D. Potassium hydroxide test after scraping of the lesion
E. Pap smear

Explanation: ***Vulvar punch biopsy*** - A **firm, nodular lump** that has been present for 5 months, especially in an area previously affected by **lichen sclerosus**, raises high suspicion for **vulvar squamous cell carcinoma**. - A punch biopsy is the **gold standard** for definitive diagnosis, allowing for histological examination to confirm or rule out malignancy. *Estrogen level measurement* - **Estrogen levels** do not provide diagnostic information for a suspicious vulvar lesion like a nodule, which is more concerning for malignancy rather than a hormonal imbalance. - While low estrogen levels can cause vulvar atrophy and dryness, they are not directly linked to the development of a specific, firm nodule requiring diagnostic workup for cancer. *HPV DNA testing* - **Human Papillomavirus (HPV)** is a risk factor for some vulvar cancers, particularly those associated with vulvar intraepithelial neoplasia (VIN). However, many vulvar cancers, especially those arising in older women with a history of **lichen sclerosus**, are **HPV-independent**. - While knowing HPV status can be part of a comprehensive workup, the immediate concern is ruling out malignancy, which requires a **biopsy**, not just HPV testing. *Potassium hydroxide test after scraping of the lesion* - A **potassium hydroxide (KOH) test** is used to identify fungal elements (e.g., in candidiasis), which typically cause itching, redness, and discharge. - The patient's firm nodular lump is suggestive of a **neoplastic process**, not a fungal infection, making a KOH test inappropriate as the next step. *Pap smear* - A **Pap smear** (Papanicolaou test) is used to screen for **cervical cancer** by detecting abnormal cells from the cervix. - It is not designed to diagnose vulvar lesions and will not provide any information regarding the nature of a **firm nodular lump on the labia**.

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Management of common pregnancy complaints

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Fetal growth assessment

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