A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?
Q2
A 60-year-old post-menopausal female presents to her gynecologist with vaginal bleeding. Her last period was over 10 years ago. Dilation and curettage reveals endometrial carcinoma so she is scheduled to undergo a total abdominal hysterectomy and bilateral salpingo-oophorectomy. During surgery, the gynecologist visualizes paired fibrous structures arising from the cervix and attaching to the lateral pelvic walls at the level of the ischial spines. Which of the following vessels is found within each of the paired visualized structure?
Q3
A 31-year-old female presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to the three months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are currently trying to have children. What is the next best step?
Q4
A 55-year-old woman is being managed on the surgical floor after having a total abdominal hysterectomy as a definitive treatment for endometriosis. On day 1 after the operation, the patient complains of fevers. She has no other complaints other than aches and pains from lying in bed as she has not moved since the procedure. She is currently receiving ondansetron, acetaminophen, and morphine. Her temperature is 101°F (38.3°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 94% on room air. Her abdominal exam is within normal limits and cardiopulmonary exam is only notable for mild crackles. Which of the following is the most likely etiology of this patient’s fever?
Q5
A 42-year-old woman, gravida 3, para 3 comes to the physician because of a 14-month history of prolonged and heavy menstrual bleeding. Menses occur at regular 28-day intervals and last 7 days with heavy flow. She also feels fatigued. She is sexually active with her husband and does not use contraception. Vital signs are within normal limits. Pelvic examination shows a firm, irregularly-shaped uterus consistent in size with a 16-week gestation. Her hemoglobin concentration is 9 g/dL, hematocrit is 30%, and mean corpuscular volume is 92 μm3. Pelvic ultrasound shows multiple intramural masses in an irregularly enlarged uterus. The ovaries appear normal bilaterally. The patient has completed childbearing and would like definitive treatment for her symptoms. Operative treatment is scheduled. Which of the following is the most appropriate next step in management?
Q6
A 48-year-old Caucasian woman presents to her physician for an initial visit. She has no chronic diseases. The past medical history is significant for myomectomy performed 10 years ago for a large uterine fibroid. She had 2 uncomplicated pregnancies and 2 spontaneous vaginal deliveries. Currently, she only takes oral contraceptives. She is a former smoker with a 3-pack-year history. Her last Pap test performed 2 years ago was negative. She had a normal blood glucose measurement 3 years ago. The family history is remarkable for systolic hypertension in her mother and older brother. The blood pressure is 110/80 mm Hg, heart rate is 76/min, respirations are 16/min, and oxygen saturation is 99% on room air. The patient is afebrile. The BMI is 32 kg/m2. Her physical examination is unremarkable. Which of the following preventative tests is indicated for this patient at this time?
Q7
Thirty minutes after normal vaginal delivery of twins, a 35-year-old woman, gravida 5, para 4, has heavy vaginal bleeding with clots. Physical examination shows a soft, enlarged, and boggy uterus. Despite bimanual uterine massage, administration of uterotonic drugs, and placement of an intrauterine balloon for tamponade, the bleeding continues. A hysterectomy is performed. Vessels running through which of the following structures must be ligated during the surgery to achieve hemostasis?
Q8
A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min.
Which of the following is the best next step in management?
Q9
A 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She said she initially had dull, generalized stomach pain about 6 hours prior, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of any serious illnesses. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most appropriate definitive treatment in the management of this patient?
Q10
A 67-year-old woman with endometrial cancer undergoes robotic-assisted staging surgery. Final pathology reveals grade 2 endometrioid adenocarcinoma with 60% myometrial invasion, positive pelvic lymph nodes (2/15), negative para-aortic nodes (0/8), and lymphovascular space invasion. No cervical or adnexal involvement. The tumor care team debates adjuvant treatment. Evaluate which combination of pathologic features most significantly impacts treatment recommendations?
Myomectomy procedures US Medical PG Practice Questions and MCQs
Question 1: A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?
A. Bladder trigone
B. Uterine artery
C. Kidney
D. Ureter (Correct Answer)
Explanation: ***Ureter***
- The **infundibulopelvic ligament** (also known as the suspensory ligament of the ovary) contains the **ovarian artery and vein** and is in close proximity to the ureter as it crosses the pelvic brim.
- During dissection or clamping of this ligament, especially in an emergency setting or when anatomy is distorted (e.g., by an enlarged ovary or edema), the **ureter** is highly susceptible to injury.
*Bladder trigone*
- The **bladder trigone** is the smooth triangular region at the base of the bladder, formed by the openings of the ureters and the internal urethral orifice.
- It is not directly adjacent to the infundibulopelvic ligament and is therefore at a comparably lower risk of injury during dissection of this ligament.
*Uterine artery*
- The **uterine artery** travels within the cardinal ligament and supplies the uterus; it is located more medially and inferiorly within the broad ligament.
- While important in pelvic surgery, it is not in the immediate vicinity of the infundibulopelvic ligament dissection itself.
*Kidney*
- The **kidneys** are retroperitoneal organs located much higher in the abdominal cavity, far superior to the pelvis.
- They are not at risk of direct injury during pelvic surgery involving the infundibulopelvic ligament.
Question 2: A 60-year-old post-menopausal female presents to her gynecologist with vaginal bleeding. Her last period was over 10 years ago. Dilation and curettage reveals endometrial carcinoma so she is scheduled to undergo a total abdominal hysterectomy and bilateral salpingo-oophorectomy. During surgery, the gynecologist visualizes paired fibrous structures arising from the cervix and attaching to the lateral pelvic walls at the level of the ischial spines. Which of the following vessels is found within each of the paired visualized structure?
A. Vaginal artery
B. Superior vesical artery
C. Uterine artery (Correct Answer)
D. Artery of Sampson
E. Ovarian artery
Explanation: ***Uterine artery***
- The paired fibrous structures described are the **cardinal ligaments (transverse cervical ligaments)**, which contain the **uterine arteries** as they course towards the uterus.
- The uterine artery, a branch of the **internal iliac artery**, crosses over the **ureter** within the cardinal ligament—a critical anatomical relationship during gynecological surgery ("water under the bridge").
- This is the primary vessel within the cardinal ligament and the key vascular structure at risk during hysterectomy.
*Vaginal artery*
- The vaginal artery typically branches from the **uterine artery** or directly from the **internal iliac artery**, but it is not the main vessel found within the cardinal ligament.
- It primarily supplies the **vagina**, not contained within the cardinal ligament support structure.
*Superior vesical artery*
- The superior vesical artery supplies the **upper part of the bladder** and originates from the **umbilical artery** (a branch of the internal iliac artery).
- It is not anatomically associated with the cardinal ligament or uterine support structures.
*Artery of Sampson*
- The Artery of Sampson is a branch of the **uterine artery** that anastomoses with the **ovarian artery** within the **broad ligament**, not the cardinal ligament.
- It is a minor vessel involved in the dual blood supply to the ovaries and uterus, not a primary structure within the cardinal ligament.
*Ovarian artery*
- The ovarian artery originates directly from the **abdominal aorta** and travels within the **suspensory ligament of the ovary (infundibulopelvic ligament)**, not the cardinal ligament.
- It supplies the **ovaries and fallopian tubes**, with a trajectory that is anatomically distinct from structures within the cardinal ligament.
Question 3: A 31-year-old female presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to the three months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are currently trying to have children. What is the next best step?
A. Start progestin-only therapy (Correct Answer)
B. Partial, cervix-sparing hysterectomy
C. Observation with annual endometrial biopsies
D. Start combination estrogen and progestin therapy
E. Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Explanation: ***Start progestin-only therapy***
- This patient has **endometrial hyperplasia with atypia**, which carries a high risk of progression to **endometrial cancer**, especially when associated with **tamoxifen use**.
- Given her desire for **fertility preservation**, **high-dose progestin therapy** (e.g., megestrol acetate, medroxyprogesterone acetate) is the **first-line treatment** to reverse the hyperplasia while allowing for potential conception.
*Partial, cervix-sparing hysterectomy*
- This procedure treats the uterus but would still preclude future pregnancies and is typically reserved for cases where definitive surgical management is required but the patient wishes to preserve vaginal function.
- It would be too aggressive for a patient desiring fertility who has not failed medical therapy, and it does not remove the at-risk endometrium effectively.
*Observation with annual endometrial biopsies*
- **Endometrial hyperplasia with atypia** has a significant risk of progressing to **endometrial carcinoma**, estimated at 29% over 20 years.
- Simply observing without intervention is **inappropriate** given this high risk, even with regular monitoring.
*Start combination estrogen and progestin therapy*
- The patient's endometrial hyperplasia is likely due to the **unopposed estrogenic effect of tamoxifen** on the endometrium, which acts as a selective estrogen receptor modulator (SERM).
- Adding **estrogen** would exacerbate the problem and increase the risk of endometrial cancer, making this an unsafe and inappropriate treatment.
*Total abdominal hysterectomy with bilateral salpingo-oophorectomy*
- This is a definitive surgical treatment for endometrial hyperplasia with atypia and endometrial cancer, and would effectively remove the affected tissue.
- However, this option would render the patient **infertile**, which contradicts her expressed desire to have children. It would be considered if progestin therapy fails or if fertility is not a concern.
Question 4: A 55-year-old woman is being managed on the surgical floor after having a total abdominal hysterectomy as a definitive treatment for endometriosis. On day 1 after the operation, the patient complains of fevers. She has no other complaints other than aches and pains from lying in bed as she has not moved since the procedure. She is currently receiving ondansetron, acetaminophen, and morphine. Her temperature is 101°F (38.3°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 94% on room air. Her abdominal exam is within normal limits and cardiopulmonary exam is only notable for mild crackles. Which of the following is the most likely etiology of this patient’s fever?
A. Deep vein thrombosis
B. Abscess formation
C. Inflammatory stimulus of surgery (Correct Answer)
D. Urinary tract infection
E. Wound infection
Explanation: ***Inflammatory stimulus of surgery***
- Postoperative fever occurring within the first 24-48 hours after surgery, especially a major abdominal procedure, is most commonly due to the **systemic inflammatory response** to tissue trauma and stress from the surgery itself.
- The temperature of 101°F (38.3°C) is a common reactive fever. In this timeframe, **atelectasis** (part of the inflammatory response to surgery) is the classic cause, supported by the patient's **immobility since surgery** and **mild crackles** on exam.
- The patient has no other specific signs of infection, making this the most likely cause.
*Deep vein thrombosis*
- While DVT is a concern post-surgery, it typically presents with **leg pain, swelling, and tenderness**, not primarily as fever alone on day 1.
- A fever from DVT would usually indicate a more advanced complication like pulmonary embolism, which is inconsistent with the mild crackles and stable oxygen saturation.
*Abscess formation*
- Abscesses usually take several days to form and present with significant fevers, localized pain, and possibly purulent drainage, not typically within the first **24 hours post-op**.
- The abdominal exam is noted as within normal limits, making an abscess unlikely at this early stage.
*Urinary tract infection*
- UTIs are common post-op, especially with catheterization, but typically present with **dysuria, frequency, urgency**, and sometimes suprapubic pain, which are absent here.
- While fever can be a symptom, the lack of urinary complaints makes it a less likely primary diagnosis on day 1.
*Wound infection*
- Wound infections rarely develop within the first **24-48 hours** post-surgery, as bacteria require time to proliferate and cause inflammatory signs.
- Typical signs include **erythema, warmth, tenderness, and purulent drainage** at the incision site, which are not mentioned.
Question 5: A 42-year-old woman, gravida 3, para 3 comes to the physician because of a 14-month history of prolonged and heavy menstrual bleeding. Menses occur at regular 28-day intervals and last 7 days with heavy flow. She also feels fatigued. She is sexually active with her husband and does not use contraception. Vital signs are within normal limits. Pelvic examination shows a firm, irregularly-shaped uterus consistent in size with a 16-week gestation. Her hemoglobin concentration is 9 g/dL, hematocrit is 30%, and mean corpuscular volume is 92 μm3. Pelvic ultrasound shows multiple intramural masses in an irregularly enlarged uterus. The ovaries appear normal bilaterally. The patient has completed childbearing and would like definitive treatment for her symptoms. Operative treatment is scheduled. Which of the following is the most appropriate next step in management?
A. Leuprolide (Correct Answer)
B. Progestin-only contraceptive pills
C. Tranexamic acid
D. Levonorgestrel-releasing intrauterine device
E. Estrogen-progestin contraceptive pills
Explanation: ***Leuprolide***
- **Leuprolide** is a **GnRH agonist** that creates a hypoestrogenic state, effectively reducing the size of **fibroids** and decreasing blood flow.
- Using leuprolide pre-operatively in this patient with **anemia** can improve her **hemoglobin levels**, reduce intraoperative blood loss, and potentially make surgery easier.
*Progestin-only contraceptive pills*
- While progestins can help with abnormal uterine bleeding, they are generally **less effective** in significantly reducing the size of large **fibroids** like those described.
- They may not effectively address the **anemia** or the need for definitive surgical management.
*Tranexamic acid*
- **Tranexamic acid** is an **antifibrinolytic** that can reduce menstrual blood flow but does not affect the size of **fibroids** or address the underlying cause of heavy bleeding.
- It would provide symptomatic relief during menstruation but would not prepare the patient for definitive operative treatment or correct chronic **anemia**.
*Levonorgestrel-releasing intrauterine device*
- A **levonorgestrel-releasing IUD** is effective at reducing menstrual bleeding by causing endometrial atrophy.
- However, it may be difficult to insert or less effective in a significantly enlarged and irregularly-shaped uterus due to multiple large **fibroids**, and it does not reduce fibroid size.
*Estrogen-progestin contraceptive pills*
- **Estrogen-progestin pills** can regulate menstrual cycles and reduce bleeding but are not typically used to shrink large **fibroids**.
- They may not be sufficient for severe bleeding or to prepare for surgery in a patient with significant **anemia** and large fibroids.
Question 6: A 48-year-old Caucasian woman presents to her physician for an initial visit. She has no chronic diseases. The past medical history is significant for myomectomy performed 10 years ago for a large uterine fibroid. She had 2 uncomplicated pregnancies and 2 spontaneous vaginal deliveries. Currently, she only takes oral contraceptives. She is a former smoker with a 3-pack-year history. Her last Pap test performed 2 years ago was negative. She had a normal blood glucose measurement 3 years ago. The family history is remarkable for systolic hypertension in her mother and older brother. The blood pressure is 110/80 mm Hg, heart rate is 76/min, respirations are 16/min, and oxygen saturation is 99% on room air. The patient is afebrile. The BMI is 32 kg/m2. Her physical examination is unremarkable. Which of the following preventative tests is indicated for this patient at this time?
A. Abdominal ultrasound
B. Colonoscopy
C. Pap smear
D. Chest CT
E. Fasting blood glucose (Correct Answer)
Explanation: ***Fasting blood glucose***
- This patient has a **BMI of 32 kg/m² (obesity)** and is 48 years old, which are significant risk factors for **type 2 diabetes mellitus**.
- The American Diabetes Association (ADA) recommends screening for type 2 diabetes with a **fasting plasma glucose**, 2-hour 75-g oral glucose tolerance test, or HbA1c in asymptomatic adults who are overweight or obese (BMI ≥25 kg/m² or ≥23 kg/m² in Asian Americans) and have one or more additional risk factors, or starting at age 35 for all individuals.
- Her **last glucose measurement was 3 years ago**, making rescreening appropriate at this visit.
- Given her obesity and the time interval, **diabetes screening is the highest priority preventative test** at this time.
*Abdominal ultrasound*
- An abdominal ultrasound is generally not indicated as a routine screening test in an asymptomatic 48-year-old woman without specific risk factors for abdominal pathology.
- While it's used to diagnose conditions like **gallstones** or **hepatic steatosis**, it is not a recommended preventative screening measure in this context.
*Colonoscopy*
- Routine screening colonoscopy is recommended starting at **age 45** for individuals of average risk.
- While this patient is 48 and colonoscopy screening would be appropriate if not previously done, the question provides no information about prior colonoscopy screening.
- More importantly, given her **obesity and 3-year interval since last glucose check**, diabetes screening takes priority as the most indicated test "at this time."
*Pap smear*
- The patient had a normal Pap test 2 years ago, and recommended screening intervals are typically every **3 years for cytology alone** or every 5 years for co-testing (cytology plus HPV) in women aged 30-65.
- Thus, a Pap smear is not indicated for another year based on current guidelines.
*Chest CT*
- Chest CT for lung cancer screening is indicated only for individuals with a significant **smoking history (≥20 pack-years)** and who are current smokers or have quit within the last 15 years, aged 50-80.
- This patient has a 3-pack-year history and is a former smoker, placing her well below the threshold for lung cancer screening with chest CT.
Question 7: Thirty minutes after normal vaginal delivery of twins, a 35-year-old woman, gravida 5, para 4, has heavy vaginal bleeding with clots. Physical examination shows a soft, enlarged, and boggy uterus. Despite bimanual uterine massage, administration of uterotonic drugs, and placement of an intrauterine balloon for tamponade, the bleeding continues. A hysterectomy is performed. Vessels running through which of the following structures must be ligated during the surgery to achieve hemostasis?
A. Suspensory ligament
B. Round ligament
C. Ovarian ligament
D. Uterosacral ligament
E. Cardinal ligament (Correct Answer)
Explanation: ***Cardinal ligament***
- The **uterine artery** and **uterine vein**, which supply the uterus, run through the **cardinal ligament** (also known as the transverse cervical ligament).
- Ligation of these vessels is crucial during a hysterectomy to control bleeding from the uterus.
*Suspensory ligament*
- The **suspensory ligament of the ovary** contains the **ovarian artery** and vein, which primarily supply the ovaries and fallopian tubes.
- While these may be ligated during a hysterectomy if the ovaries are removed, they are not the primary vessels causing uterine bleeding in postpartum hemorrhage.
*Round ligament*
- The **round ligament of the uterus** extends from the uterus to the labia majora and contains relatively small vessels, primarily contributing to uterine support.
- Ligation of this ligament alone would not effectively control heavy uterine bleeding.
*Ovarian ligament*
- The **ovarian ligament** connects the ovary to the uterus and contains small vessels that mainly supply the ovary.
- It does not house the major blood supply to the uterus itself.
*Uterosacral ligament*
- The **uterosacral ligaments** primarily provide support to the uterus by connecting it to the sacrum and contain small nerves and vessels.
- Ligation of these ligaments would not control the main arterial supply to the uterus.
Question 8: A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min.
Which of the following is the best next step in management?
A. Diagnostic peritoneal lavage
B. Emergency laparotomy (Correct Answer)
C. Upper gastrointestinal endoscopy
D. Close observation
E. Diagnostic laparoscopy
Explanation: ***Emergency laparotomy***
- The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch).
- This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding.
*Diagnostic peritoneal lavage*
- **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans.
- While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST.
*Upper gastrointestinal endoscopy*
- This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities.
- It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma.
*Close observation*
- Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings.
- This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step.
*Diagnostic laparoscopy*
- **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity.
- While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.
Question 9: A 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She said she initially had dull, generalized stomach pain about 6 hours prior, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of any serious illnesses. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most appropriate definitive treatment in the management of this patient?
A. Laparoscopic removal of ovarian cysts
B. Cefoxitin and azithromycin
C. Appendectomy
D. Cholecystectomy (Correct Answer)
E. Intramuscular ceftriaxone followed by cephalexin
Explanation: ***Cholecystectomy***
- The patient's presentation (fever, RUQ pain, leukocytosis, vomiting) is classic for **acute cholecystitis** in pregnancy, which requires **cholecystectomy** as the definitive treatment.
- **Laparoscopic cholecystectomy** is safe during pregnancy and is the **preferred definitive treatment** for acute cholecystitis, ideally performed in the second trimester but can be done in the third trimester when indicated.
- While conservative management with antibiotics and supportive care can be attempted initially, cholecystectomy remains the definitive treatment and is increasingly performed during pregnancy to avoid recurrent symptoms and complications.
- The mild pyuria is likely secondary to adjacent inflammation rather than a primary UTI.
*Laparoscopic removal of ovarian cysts*
- Ovarian cysts typically present with **pelvic or lower abdominal pain**, not RUQ tenderness.
- The clinical picture with fever, leukocytosis, and RUQ pain strongly suggests biliary pathology, not ovarian pathology.
*Cefoxitin and azithromycin*
- This regimen is used for **pelvic inflammatory disease (PID)**, which presents with lower abdominal/pelvic pain, cervical motion tenderness, and vaginal discharge.
- The patient's RUQ localization and fever pattern do not support PID as the primary diagnosis.
*Intramuscular ceftriaxone followed by cephalexin*
- This regimen treats **gonorrhea/chlamydia** or uncomplicated UTIs.
- While mild pyuria is present, the dominant clinical features (fever, RUQ pain, leukocytosis) point to cholecystitis, not a primary genitourinary infection.
- Antibiotics alone would not provide definitive treatment for acute cholecystitis.
*Appendectomy*
- **Appendicitis** in pregnancy typically causes **RLQ pain** (though it can migrate superiorly in the third trimester due to uterine displacement).
- The distinct **RUQ localization** with the classic triad of fever, RUQ pain, and leukocytosis makes cholecystitis far more likely than appendicitis.
Question 10: A 67-year-old woman with endometrial cancer undergoes robotic-assisted staging surgery. Final pathology reveals grade 2 endometrioid adenocarcinoma with 60% myometrial invasion, positive pelvic lymph nodes (2/15), negative para-aortic nodes (0/8), and lymphovascular space invasion. No cervical or adnexal involvement. The tumor care team debates adjuvant treatment. Evaluate which combination of pathologic features most significantly impacts treatment recommendations?
A. Grade 2 histology and depth of myometrial invasion
B. Number of positive nodes and total nodes removed
C. Lymphovascular space invasion and myometrial invasion depth
D. Positive pelvic nodes and negative para-aortic nodes (Correct Answer)
E. Absence of cervical involvement and patient age
Explanation: ***Positive pelvic nodes and negative para-aortic nodes***
- The presence of positive pelvic lymph nodes classifies this as **FIGO Stage IIIC1** disease, which is the primary driver for recommending **systemic chemotherapy**.
- The negative para-aortic nodes help delineate the **radiation field**, focusing treatment on the pelvis rather than extended-field radiation, thus making this combination critical for the management plan.
*Grade 2 histology and depth of myometrial invasion*
- While these factors contribute to the **GOG-99** or **PORTEC** risk criteria for early-stage disease, they are superseded by the presence of **nodal metastasis** (Stage IIIC).
- Myometrial invasion (>50%) and Grade 2 are baseline risk factors, but they do not dictate the switch from local to **systemic therapy** once nodes are positive.
*Number of positive nodes and total nodes removed*
- The **lymph node count** (2/15) confirms the stage but does not change the treatment algorithm as much as the **anatomical location** (pelvic vs. para-aortic) of those nodes.
- While a low total node count might suggest staging inadequacy, Stage IIIC status is already established here, making the **distribution** more clinically significant for therapy planning.
*Lymphovascular space invasion and myometrial invasion depth*
- **Lymphovascular space invasion (LVSI)** is a strong prognostic indicator for recurrence, but it is often a precursor to the nodal involvement already identified in this patient.
- These features are used to justify **adjuvant therapy** in early-stage (Stage I) patients, but nodal status is a more powerful determinant in Stage III disease.
*Absence of cervical involvement and patient age*
- The lack of **cervical stromal invasion** means the patient is not Stage II, but this is less impactful than the upgrade to **Stage IIIC** due to positive nodes.
- **Patient age** is a clinical factor used in risk-stratification models like **GOG-99**, but it does not outweigh the pathological finding of **metastasized disease** in treatment selection.
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