The answer is A. Primary dysmenorrhea is associated with cramping pain in the lower abdomen occurring just before and/or during menstruation, in the absence of other conditions such as endometriosis. The initial presentation of primary dysmenorrhea typically occurs in adolescence. The condition is associated with increased production of endometrial prostaglandin, resulting in increased uterine tone and stronger, more frequent uterine contractions. A diagnostic evaluation is unnecessary in women with typical symptoms and in the absence of risk factors for secondary causes. Nonsteroidal anti-inflammatory drugs are the most effective treatment, with the addition of oral contraceptive pills (OCPs) when necessary. About 10% of affected women do not respond to these measures. In these cases, it is important to consider secondary causes of dysmenorrhea in affected women. Acupuncture is also used as an alternative treatment.

Additional Reading: Dysmenorrhea. Am Fam Physician. 2012; 85(4):386-387.

Category: Reproductive system

The answer is E. Asymptomatic bacteriuria, defined as more than 100,000 colonies of a single bacterial species per milliliter of urine, cultured from midstream sample, is present in 2% to 7% of pregnant women. The most commonly associated bacteria is Escherichia coli. Pregnancy does not increase the incidence of asymptomatic bacteriuria; however, pyelonephritis develops in a significant number of pregnant women with untreated asymptomatic bacteriuria. Asymptomatic bacteriuria in women is associated with a higher preterm delivery rate than women without bacteriuria. Treatment of group B Streptococcus (GBS) bacteriuria has also been shown to decrease the rate of preterm delivery. Additionally, GBS bacteriuria has been associated with heavy GBS genitourinary colonization. The Centers for Disease Control and Prevention (CDC) recommends that pregnant women with GBS bacteriuria be treated at the time of diagnosis and during labor. Intrapartum antibiotic prophylaxis is used to prevent early GBS infection in newborns. In most cases, women who do not have asymptomatic bacteriuria at the initial prenatal visit will not develop bacteriuria later in the pregnancy. Accordingly, routine screening for asymptomatic bacteriuria should be performed at the initial prenatal visit. Treatment options include a 3- to 7-day course of (1) oral amoxicillin, (2) nitrofurantoin (Macrobid), or (3) cephalexin (Keflex). After therapy is completed, a urine culture should be repeated to ensure eradication of infection. This repeat culture also identifies patients with persistent or recurrent bacteriuria. For patients who have persistent or recurrent bacteriuria, consideration should be given to administering suppressive doses of antibiotics.

Additional Reading: Urinary tract infections and asymptomatic bacteriuria in pregnancy. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Nephrologic system

The answer is D. According to the American College of Obstetricians and Gynecologists (ACOG), preterm labor is defined as regular contractions associated with cervical change before 37 weeks’ gestation.

Additional Reading: American College of Obstetricians and Gynecologists. Assessment of risk factors for preterm birth. ACOG Practice Bulletin no. 31. From: http://www.acog.org/Resources_And_Publications/Committee_Opinions_List

Category: Reproductive system

The answer is E. Several bacterial infections have been associated with preterm labor, including Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, and Peptostreptococcus and Bacteroides species. These organisms are usually of low virulence, and it is unclear whether they are etiologic or associated with an acute inflammatory response of another etiology.

Additional Reading: American College of Obstetricians and Gynecologists. Assessment of risk factors for preterm birth. ACOG Practice Bulletin no. 31. From: http://www.acog.org/Resources_And_Publications/Committee_Opinions_List

Category: Reproductive system

The answer is E. A positive fetal fibronectin testing combined with a shortened cervical length in women presenting with symptoms of preterm labor can be a useful predictor of preterm birth. These screening tests have been shown to have a high sensitivity and high positive predictive value, as well as a high negative predictive value so they are useful in guiding decisions regarding steroid and tocolytic administration in women who have positive results and allow avoidance of these therapies in women with negative results.

Additional Reading: Improving the screening accuracy for preterm labor: is the combination of fetal fibronectin and cervical length in symptomatic patients a useful predictor of preterm birth? A systematic review. Am J Obstet Gynecol. 2013;208(3):233; and Preterm labor. Am Family Physician. 2010;81(4):477-484.

Category: Reproductive system

The answer is D. Concerns have been raised about the safety of some forms of exercise during pregnancy. Because of the body changes associated with pregnancy as well as the hemodynamic response to exercise, some precautions should be observed. Pregnant women should avoid exercise that involves the risk of abdominal trauma, falls, or excessive joint stress, as in contact sports, gymnastics, horseback riding, and skiing. In the absence of any obstetric or medical complications, ACOG recommends at least 30 minutes of exercise most or all days of the week during pregnancy. Studies have shown that exercise may contribute to prevention of gestational diabetes in obese women and that exercise can help women with gestational diabetes achieve euglycemia when diet alone is insufficient.

Additional Reading: Exercise during pregnancy. ACOG Committee Opinion no. 267. From: http://www.acog.org/Resources_And_ Publications/Committee_Opinions_List

Category: Reproductive system

The answer is B. An increase of 300 calories per day is required in pregnancy. Caloric demands with exercise are even higher, although no studies have focused on exact requirements. If a mother is exercising while pregnant, she may need to further increase her caloric intake to assure adequate maternal weight gain. Competitive athletes and women with a history of prior growth-restricted infants should be followed especially closely for adequate fetal growth.

Additional Reading: Prenatal care: nutrition. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is C. Although supportive data are limited, there appears to be no reason why women who are in good health should not be permitted to engage in exercise while pregnant. However, women with medical or obstetric complications should be encouraged to avoid vigorous physical activity. Contraindications to exercise during pregnancy include hemodynamically significant cardiac disease, restrictive lung disease, gestational hypertension, pre-eclampsia, preterm rupture of membranes, preterm labor during the current pregnancy, incompetent cervix or cerclage placement, multiple gestation at risk of preterm labor, persistent second- or third-trimester bleeding, and placenta previa at >26 weeks gestational age.

Additional Reading: Prenatal care: common concerns. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is D. Some data suggest a teratogenic potential when maternal temperatures rise above 38.9°C (102°F), especially in the first trimester.

Additional Reading: Tergenic causes of malformations. Ann Clin Lab Sci. 2010;40(2):99-114.

Category: Reproductive system

The answer is E. High-dose aspirin has been theoretically associated with increased perinatal mortality, neonatal hemorrhage, decreased birth weight, prolonged gestation and labor, and possible birth defects and in general should be avoided in pregnancy. Low-dose aspirin in combination with heparin has been used successfully in the treatment of antiphospholipid syndrome in pregnancy. The other medications on the list are considered safe in pregnancy, though patients are encouraged to avoid all nonessential medication use in the first trimester and use the lowest possible doses of necessary medications for the limited periods of time for relief of symptoms throughout the remainder of pregnancy.

Additional Reading: Over-the-counter medications in pregnancy. Am Fam Physician. 2003;67(12):2517-2524.

Category: Reproductive system

The answer is A. Repetitive late decelerations of the fetal heart rate (FHR) may signal uteroplacental insufficiency.

Additional Reading: Electronic fetal monitoring. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is A. Repetitive variable decelerations suggest umbilical cord compression, especially in the presence of oligohydramnios or amniotomy.

Additional Reading: Electronic fetal monitoring. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is B. The recommended sequence for reducing shoulder dystocia begins with calling for help and asking the mother to stop her pushing efforts. The first step is the McRoberts’ maneuver, in
which assistants hyperflex the mother’s hips against her abdomen, thereby rotating the symphysis pubis anteriorly and decreasing the forces needed to deliver the fetal shoulders. A retrospective study found this maneuver to be the safest and most successful technique for relieving shoulder dystocia. An assistant can add gentle posterolateral suprapubic pressure while the physician continues moderate posterior traction on the fetal head. Fundal pressure should be avoided, because it tends to increase the impaction. Rotational maneuvers may be tried next, beginning with the Rubin II maneuver which is done by inserting the fingers of one hand vaginally behind the posterior aspect of the anterior shoulder of the fetus and rotating the shoulder toward the fetal chest. This will adduct the fetal shoulder girdle, reducing its diameter. If the Rubin II maneuver is unsuccessful, the Woods corkscrew maneuver may be attempted. Two fingers are placed on the anterior aspect of the fetal posterior shoulder, applying gentle upward pressure around the circumference of the arc in the same direction as with the Rubin II maneuver. The Rubin II and Woods corkscrew maneuvers may be combined to increase forces by using two fingers behind the fetal anterior shoulder and two fingers in front of the fetal posterior shoulder.

Additional Reading: Shoulder dystocia. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010; and Shoulder dystocia. Am Fam Physician. 2004;69(7):1707-1714.

Category: Reproductive system

The answer is E. In the United States, magnesium sulfate is considered the drug of choice for controlling eclamptic seizures. Fewer intubations are required in the neonates of eclamptic women who are treated with magnesium sulfate. In addition, fewer newborns require placement in neonatal intensive care units. In the treatment of eclampsia and preeclampsia, magnesium sulfate is often given according to established protocols. If serum magnesium levels exceed 10 mEq/L (5 mmol/L), respiratory depression can occur. This problem may be counteracted by the rapid intravenous infusion of 10% calcium gluconate. Magnesium sulfate should be used with caution in patients with impaired renal or cardiac status. It should not be used in patients with myasthenia gravis.

Additional Reading: Eclampsia. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is A. The classic preeclamptic triad include elevated blood pressure, proteinuria, and edema. More recently, edema has been removed as part of the criteria. Seizures are the distinguishing component of eclampsia.

Additional Reading: Pregnancy hypertension. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is C. Hemorrhage after placental delivery should prompt vigorous fundal massage while the patient is rapidly given oxytocin in their intravenous fluid. If the fundus does not become firm, uterine atony is the presumed (and most common) diagnosis. While fundal massage continues, the patient may be given methylergonovine (Methergine) intramuscularly, with the dose repeated at 2- to 4-hour intervals if necessary. Methylergonovine may cause cramping, headache, and dizziness. The use of this drug is contraindicated in patients with hypertension. Carboprost (Hemabate), 15-methyl prostaglandin F_2a, may be administered intramuscularly or intramyometrially every 15 to 90 minutes, up to a maximum dosage. As many as 68% of patients respond to a single carboprost injection, with 86% responding by the second dose. Another prostaglandin that is increasingly used in the treatment of postpartum hemorrhage is misoprostol which is most commonly administered rectally in a 800-to-1,000-mcg dose, though it can also be administered buccally or vaginally.

Additional Reading: Obstetrical hemorrhage. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010; and Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007;75(6):875-882.

Category: Reproductive system

The answer is C. The patient in labor who develops abdominal pain between uterine contractions or a tender uterus must be presumed to have abruptio placentae. Ultrasound examination has a high false-negative rate in diagnosing abruption and as a result this complication is diagnosed clinically. In one prospective study, 78% of patients with abruptio placentae presented with vaginal bleeding, 66% with uterine or back pain, 60% with fetal distress, and only 17% with uterine contractions or hypertonus. The management of abruptio placentae is primarily supportive and entails both aggressive hydration and monitoring of maternal and fetal well-being. Coagulation studies should be performed, and fibrinogen and D-dimers or fibrin-degradation products should be measured to screen for disseminated intravascular coagulation (DIC). Packed red blood cells should be typed and held. If the fetus appears viable but compromised, urgent cesarean delivery should be considered.

Additional Reading: Placental abruption. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is D. Pregnancy is the first consideration in women of childbearing age who present with abnormal uterine bleeding.

Additional Reading: Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012;85(1):35-43.

Category: Reproductive system

The answer is A. According to ACOG, all patients undergoing cesarean delivery should receive prophylaxis with narrow-spectrum antibiotics such as a first-generation cephalosporin within the hour prior to surgical skin incision. Infection is the most common complication of cesarean delivery and can occur in 10% to 40% of women who have a cesarean compared with 1% to 3% of women who deliver vaginally. Although antibiotics have been given to women having cesareans to reduce their risk of postoperative infections, they have generally been given after the baby was born and the umbilical cord was clamped. This was based on concern that the antibiotics that made it into the baby’s bloodstream from the mother would interfere with newborn lab tests or could lead to antibiotic-resistant infections. Newer studies have shown that prophylactic antibiotics given before initiation of cesarean section significantly reduces maternal infection and does not cause harm to newborns.

Additional Reading: Antimicrobial prophylaxis for cesarean delivery: timing of administration. ACOG Committee Opinion no. 465. From: http://www.acog.org/Resources_And_Publications/Committee_Opinions_List

Category: Reproductive system

The answer is C. Epidural analgesia during labor is an effective pain reliever for labor that has become much more commonly used. Despite wide acceptance of this use, the timing of epidural placement remains controversial, with conflicting reports on the risk for subsequent cesarean deliveries and the length of the latent phase of labor. There are data from several studies suggesting that epidural anesthesia does lengthen the duration of the second stage of labor and may increase the rate of instrumented vaginal deliveries. Previously, ACOG recommended using other forms of analgesia in nulliparous women until they reach dilatation of 4 to 5 cm. However, some institutions did not follow these guidelines for all women in labor, so ACOG released a follow-up report recommending that maternal request is a sufficient indication for epidural analgesia during labor and that it should not be denied on the basis of cervical dilatation.

Additional Reading: Hawkins JL. Epidural anesthesia for labor and delivery. NEJM. 2010;362:1503-1510.

Category: Reproductive system

The answer is E. Use of vacuum should be halted when there are three disengagements of the vacuum (or “pop-offs”), more than 20 minutes have elapsed, or three consecutive pulls result in no progress or delivery.

Additional Reading: Vacuum-assisted vaginal delivery. Am Fam Physician. 2008;78(8):953-960.

Category: Reproductive system

The answer is D. When the vacuum extractor is placed on the fetal scalp, the center of the cup should be over the sagittal suture and about 3 cm (1.2 in.) in front of the posterior fontanel. As a general guide, the cup is generally placed as far posteriorly as possible. This cup placement maintains flexion of the fetal head and avoids traction over the anterior fontanel. In positioning the cup, the physician should be careful to avoid trapping maternal soft tissue (e.g., labia) between the cup and the fetal head.

Additional Reading: Vacuum extraction. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is C. Several important changes were made in the July 2012 update of the U.S. Department of Health and Human Services’ Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States (see summary and link below), particularly pertaining to zidovudine and efavirenz.

Zidovudine (AZT) no longer must be a part of a pregnant patient’s antiretroviral therapy regimen (ART), nor is it necessary to administer intravenous AZT during delivery if she is on effective ART with an HIV RNA <400 copies/mL near delivery (BII). Because the risk of neural tube defects is restricted to the first 5 to 6 weeks of gestation when pregnancy is rarely diagnosed, and unnecessary antiretroviral drug changes during pregnancy may be associated with loss of viral control and increased risk of perinatal transmission, efavirenz (pregnancy category D) can be continued in pregnant women receiving an efavirenz-based regimen who present for antenatal care in the first trimester, provided the regimen produces virologic suppression (CIII). There are several ART medications recognized to be generally safe in pregnancy, and all pregnant women should be offered ART (AI). The decision whether to start the regimen in the first trimester or delay until 12 weeks’ gestation will depend on CD4-cell count, HIV RNA levels, and maternal conditions such as nausea and vomiting (AIII). Earlier initiation of a combination antiretroviral regimen may be more effective in reducing transmission, but benefits must be weighed against potential fetal effects of first-trimester drug exposure.

Additional Reading: Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. From: http://www.aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0

Category: Reproductive system

The answer is A. When the perineal muscles are repaired anatomically, the overlying skin is usually well approximated, and skin sutures are generally not required. Skin sutures have been shown to increase the incidence of perineal pain at 3 months after delivery. If the skin requires suturing, running subcuticular sutures have been shown to be superior to interrupted transcutaneous sutures. Synthetic rapidly absorbable sutures are preferable to catgut, standard absorbable sutures, and these sutures should start at the posterior apex of the skin laceration and should be placed approximately 3 mm from the edge of the skin.

Additional Reading: Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev. 2010;6:CD000006.

Category: Reproductive system

The answer is A. While there is an increased risk of PROM and preterm labor following laser conization or LEEP, there is not an associated increase in overall preterm deliveries. Although PROM leads to preterm deliveries, these were higher in the untreated group after adjustments compared with the treated group. The authors attribute this incongruity to the higher rate of iatrogenic preterm deliveries in the untreated group. The authors of the study suggest careful adherence to CIN (Cervical Intraepithelial Neoplasia) management guidelines, avoidance of unnecessary excisions, and appropriate counseling of previously treated women when they become pregnant.

Additional Reading: Treatment for cervical intraepithelial neoplasia and risk of preterm delivery. JAMA. 2004;291: 2100-2106.

Category: Reproductive system

The answer is D. Taking folic acid supplementation before conception reduces the incidence of neural tube defects, including spina bifida and anencephaly. The average woman receives about 100 mcg of folic acid per day, mostly from fortified breads and grains. Supplementation should begin at least 1 month before conception and continue through the first 3 months of pregnancy; women should take a daily vitamin supplement containing at least 400 mcg of folic acid. Higher dosages are indicated for special-risk groups. A dosage of 1 mg per day is recommended for women with diabetes mellitus or epilepsy. Mothers who have given birth to children with neural tube defects should take 4 mg of folic acid per day for subsequent pregnancies.

Additional Reading: Folic acid for the prevention of neural tube defects. Am Fam Physician. 2010;82(12):1533-1534.

Category: Neurologic

The answer is B. Women who have a personal or family history of venous thromboembolism should be offered testing for coagulopathy before pregnancy. Women with a prior history of DVT have a 7% to 12% risk of recurrence during pregnancy. Heparin (in regular or low-molecular-weight form) is indicated for prophylaxis and should be started as early in pregnancy as possible. Women receiving warfarin as maintenance therapy for DVT should be switched to heparin before conception because warfarin is teratogenic.

Additional Reading: ACOG Practice Bulletin no. 123. Thromboembolism in pregnancy. Obstet Gynecol. 2011;118(3):718-729.

Category: Cardiovascular system

The answer is E. Children of mothers with epilepsy have a 4% to 8% risk of congenital anomalies, which may be caused by anticonvulsant medication or may be related to an increased genetic risk. These children also have an increased risk of developing epilepsy. Preconception counseling should include optimizing seizure control, prescribing folic acid supplements of 1 to 4 mg per day, and offering referral to a genetic counselor. Tonic-clonic seizures in pregnancy can lead to hypoxia in the fetus, and pregnant women with any type of seizure are also at risk for trauma (e.g., falls), which can also adversely impact the fetus. The therapeutic goal for women with seizure disorders who are pregnant is to prevent seizures while minimizing teratogenic damage to the fetus. When possible, use of multiple anticonvulsants (polytherapy) should be discouraged. It is advisable to aim to use the best single agent for the seizure type at the lowest protective level. A committee assembled by the American Academy of Neurology reassessed the evidence related to the care of women with epilepsy during pregnancy, including antiepileptic drug (AED) teratogenicity. Some of the conclusions published by this committee related to specific medication concerns are as follows:

Additional Reading: Management issues for women with epilepsy-focus on pregnancy (an evidence-based review): II. Teratogenesis and perinatal outcomes: report of the Quality Standards Subcommittee and Therapeutics and Technology Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Epilepsia. 2009;50(5):1237-1246.

Category: Neurologic

The answer is A. Smoking increases the risk of miscarriage, low birth weight, perinatal mortality, and attention-deficit disorder in the child. If the mother smokes less than 1 pack of cigarettes per day, the risk of a low-birth-weight infant increases by 50%; with more than 1 pack per day, the risk increases by 130%. If the mother quits smoking by 16 weeks of pregnancy, the risk to the fetus is similar to that of a nonsmoker. Behavioral techniques, support groups, and family assistance may be beneficial. Nicotine patches or gum may be helpful before conception, but most authorities recommend avoiding them during pregnancy. Bupropion may be used during pregnancy after a discussion of risks and benefits. If the patient cannot stop smoking, the physician should help her establish a goal to decrease her number of cigarettes to fewer than 7 to 10 per day because many of the adverse effects are dose related.

Additional Reading: Smoking cessation in pregnancy (2013). ACOG committee opinion paper no. 471, 2013. From: http://www. acog.org/Resources_And_Publications/Committee_Opinions_List

Category: Patient/population-based care

The answer is B. Maternal use of benzodiazepines during pregnancy has been associated with anomalies such as cleft lip and palate, as well as a withdrawal syndrome in the newborn.

Additional Reading: ACOG guidelines on psychiatric medication use during pregnancy and lactation. Am Fam Physician. 2008;78(6):772-778.

Category: Reproductive system

The answer is A. Obesity and being underweight increase pregnancy risks. Obesity increases the risks of maternal hypertension, preeclampsia, diabetes, and delivering a macrosomic infant. Women who are obese should diet before conception and then alter their consumption to a maintenance diet of 1,800 calories per day while trying to conceive.

Additional Reading: Obesity in Pregnancy. ACOG Committee Opinion no. 549, 2013. From: http://www.acog.org/Resources_And_Publications/Committee_Opinions_List

Category: Endocrine system

The answer is C. Pruritic urticarial papules and plaques of pregnancy, also known as polymorphic eruption of pregnancy, is the most common dermatologic complaint of pregnancy, occurring in up to 1 in 160 pregnancies, with an increased incidence in multiple gestations. It usually occurs in primigravidas in the third trimester and recurrence in subsequent pregnancies is unusual. The rash may first appear postpartum. Pruritic urticarial papules and plaques of pregnancy typically have a marked pruritic component, the onset of which coincides with the skin lesions. The rash typically begins over the abdomen, commonly involving the striae gravidarum, and may spread to the breasts, upper thighs, and arms. The face, palms, soles, and mucosal surfaces are usually spared. The lesions typically consist of polymorphous, erythematous, nonfollicular papules, plaques, and sometimes vesicles. The lesions can be painful. The rash usually resolves near term or in the early postpartum period. Topical moisturizers and moderately potent steroids in combination with oral antihistamines can provide symptomatic relief.

Additional Reading: The skin disorders of pregnancy: a family physician’s guide. J Fam Pract. 2010;59(2):89-96.

Category: Integumentary

The answer is C. Because of high interobserver variability in the interpretation of FHR tracings, the ACOG, the Society for Maternal-Fetal Medicine (SMFM), and the United States National Institute of Child Health and Human Development (NICHD) convened a workshop in 2008 to standardize definitions and interpretation for electronic fetal monitoring (EFM), propose management guidelines, and develop research questions. Major outputs from this workshop were a clear standard for FHR interpretation and a three-tier system (Categories I, II, and III) for the categorization of intrapartum electronic fetal monitoring.

A category III tracing is defined by either of the following criteria:

Category III tracings are abnormal and associated with an increased risk of fetal hypoxic acidemia. Patients with category III tracings should be prepared for delivery while initiating resuscitative measures. If there is no improvement in the tracing after resuscitative measures (such as IV fluid bolus, oxygen administration, left-sided positioning, discontinuation of uterotonics, consideration of tocolytics, and request for anesthesia to administer alpha adrenergic agonist if patient has recently received an epidural) and scalp stimulation does not result in FHR acceleration, delivery should be accomplished expeditiously, ideally within 30 minutes of the beginning of the Category III tracing.

Additional Reading: American College of Obstetricians and Gynecologists. ACOG Practice Bulletin no. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol. 2009;114:192.

Category: Reproductive system

The answer is D. After 20 weeks of gestation, the enlarged uterus may compress the great vessels when a pregnant woman is in a supine position. This compression can cause a decrease of up to
30 mm Hg in maternal systolic blood pressure, a 30% decrease in stroke volume, and a consequent decrease in uterine blood flow. Manual deflection of the uterus laterally or placement of the patient in the lateral decubitus position avoids uterine compression. Because of suspected neck trauma in this patient, placing her supine on a backboard with her right hip elevated 4 to 6 in. with towels is the safest treatment.

Additional Reading: Blunt trauma in pregnancy. Am Fam Physician. 2004;70:1303-1310, 1313.

Category: Reproductive system

The answer is C. Infertility affects as many as 10% to 15% of couples in the United States and appears to be increasing in incidence. The definition of infertility is the lack of conception after 1 year of unprotected intercourse. As many as 40% of infertility cases are the result of the male factor (i.e., inadequate sperm production, abnormal sperm motility, or abnormally formed sperm). Other factors involve the female factor and include previous pelvic infections with fallopian tube damage, anovulation, low progesterone levels, hypothyroidism, hyperprolactinemia, or the presence of antisperm antibodies. In the evaluation of infertility, the man is usually evaluated first with a sperm analysis, because the female evaluation may be more extensive. If the sperm is found to be adequate, the woman can be evaluated with a postcoital test, hormone level determination, endometrial sampling, and hysterosalpingogram, which determine patency of the fallopian tubes. Measurement of basal body temperature may show a 0.5°F to 1.0°F increase in temperature-supporting ovulation. Further evaluation may require endocrine testing or computed tomography (CT) scanning of the head to rule out pituitary tumors or testing to rule out polycystic ovary disease.

Additional Reading: Infertility. Am Fam Physician. 2007;75(6): 849-856.

Category: Reproductive system

The answer is C. Sheehan’s syndrome is a complication of childbirth that results from shock and excessive peripartum bleeding. During pregnancy the pituitary gland usually enlarges and is vulnerable to infarction if excessive bleeding compromises blood flow. Necrosis of the pituitary can occur with varying loss of pituitary function. Symptoms of Sheehan’s syndrome include lack of postpartum milk production as a result of low prolactin levels, breast atrophy, loss of pubic or axillary hair, amenorrhea, depressed mental status, low blood pressure, loss of libido, and lack of sweating. Laboratory findings include evidence of hypothyroidism, adrenal insufficiency, and decreased gonadotropin hormone secretion. Treatment involves the replacement of inadequate hormones, including thyroxine, glucocorticoids, and sex hormones. Asherman’s syndrome is the development of adhesions, also known as “uterine synechiae,” within the endometrial cavity, most commonly as a result of instrumentation such as D + C postpartum or from intrauterine infection. Stein-Leventhal is an older term for polycystic ovary syndrome (PCOS) characterized by anovulation, oligo or amenorrhea, excess androgens, obesity, insulin resistance, and infertility. Cushing’s disease is a condition that is caused by excess corticosteroids, especially cortisol, usually from adrenal or pituitary hyperfunction and is characterized by obesity, hypertension, muscular weakness, and easy bruising. Nelson’s syndrome refers to a spectrum of symptoms and signs arising from an adrenocorticotropin (ACTH)-secreting pituitary macroadenoma after a therapeutic bilateral adrenalectomy.

Additional Reading: Sheehan syndrome. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Endocrine system

The answer is C. The major risk factors for early-onset neonatal sepsis are preterm birth, maternal colonization with GBS rupture of membranes >18 hours, and maternal signs or symptoms of intra-amniotic infection. Other variables include ethnicity (i.e., black women are at higher risk of being colonized with GBS), low socioeconomic status, male sex, and low Apgar scores. Preterm birth/low birth weight is the risk factor most closely associated with early-onset sepsis. Infant birth weight is inversely related to risk of early-onset sepsis, so large-for-gestational age infants would be less likely to get early-onset sepsis. In the United States, the most common pathogens responsible for early-onset neonatal sepsis are GBS and Escherichia coli. A combination of ampicillin and an aminoglycoside (usually gentamicin) is generally used as initial therapy, and this combination of antimicrobial agents also has synergistic activity against GBS and Listeria monocytogenes. Third-generation cephalosporins (e.g., cefotaxime) represent a reasonable alternative to an aminoglycoside. However, several studies have reported rapid development of resistance when cefotaxime has been used routinely for the treatment of early-onset neonatal sepsis, and extensive/prolonged use of third-generation cephalosporins is a risk factor for invasive candidiasis. Because of its excellent cerebrospinal fluid (CSF) penetration, empirical or therapeutic use of cefotaxime should be restricted for use in infants with meningitis attributable to gram-negative organisms. Ceftriaxone is contraindicated in neonates because it is highly protein bound and may displace bilirubin, leading to a risk of kernicterus.

Additional Reading: Management of neonates with suspected or proven early-onset bacterial sepsis. Pediatrics. 2012;129(5):1006-1015.

Category: Reproductive system

The answer is D. Proper seat belt use is the most significant preventive measure in decreasing maternal and fetal injury and mortality after motor vehicle crashes. Seat belt-restrained women who are in motor vehicle crashes have the identical fetal mortality rate as women who are not in motor vehicle crashes, but unrestrained women who are in crashes are more than twice as likely to lose their fetuses. Prenatal care should include three-point seat belt instruction. The lap belt should be placed under the gravid abdomen, snugly over the thighs, with the shoulder harness off to the side of the uterus, between the breasts and over the midline of the clavicle. Seat belts placed directly over the uterus can cause fetal injury. Airbags should not be disabled during pregnancy.

Additional Reading: Blunt trauma in pregnancy. Am Fam Physician. 2004;70:1303-1310, 1313.

Category: Patient/population-based care

The answer is A. American College of Obstetrics and Gynecology recommends that all pregnant women are offered aneuploidy screening before 20 weeks. Currently available screening includes the ultrasound measurement of fetal nuchal translucency in the late first trimester which, when enlarged, is associated with a variety of trisomies, most notable trisomy-21, as well as fetal congenital anomalies such as cardiac defects. Combining the nuchal translucency with 1st trimester biochemical markers allows identification of a population of pregnant women at high risk for aneuploidy early in their pregnancies, and these women should receive genetic counseling and be offered first-trimester chorionic villus sampling (CVS) or second-trimester amniocentesis. If no increased risk is identified with first-trimester screening, this information can be combined later in pregnancy with second-trimester maternal serum screening to increase the sensitivity of testing for aneuploidy and decrease the false positive rate of either of these forms of testing done separately. If either a fetal anatomical survey done by second-trimester U/S (Ultra Sound) sug-gests a major congenital anomaly and/or if a high risk for aneuploidy is detected on combined first- and second-trimester aneuploidy screening, the patient should receive genetic counseling and offered diagnostic fetal chromosomal testing via amniocentesis. A relatively new option for women is to be offered noninvasive prenatal testing (NIPT) as an alternative to amniocentesis. NIPT allows the isolation of cell-free fetal DNA from the plasma of pregnant women as another detection tool for fetal aneuploidy. Counseling regarding the limitations of NIPT should include a discussion that the screening test provides information regarding only trisomy 21 and trisomy 18 and, in some laboratories, trisomy 13. It does not replace the precision obtained with diagnostic tests, such as chorionic villus sampling or amniocentesis, and currently does not offer other genetic information.

Additional Reading: Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin no. 77, 2007; and Noninvasive prenatal testing for fetal aneuploidy. ACOG Practice Bulletin no. 545, and 2012. From: http://www.acog.org/Resources_And_Publications/Committee_Opinions_List

Category: Reproductive system

The answer is C. Toxoplasmosis is a granulomatous disease caused by the protozoan Toxoplasmosis gondii, which affects the central nervous system (CNS). The disease is extremely common, and affected patients are usually asymptomatic. Symptoms, when present, mimic mononucleosis and include malaise, fever, myalgias, rashes, and cervical and axillary lymphadenopathy. Laboratory and physical findings include mild anemia, leukopenia, lymphocytosis, elevated liver function tests, and hypotension. A more severe form may occur in patients with acquired immunodeficiency syndrome (AIDS) or other patients who are immunocompromised; complications include hepatitis, pneumonitis, meningoencephalitis, and myocarditis. Chronic toxoplasmosis can lead to retinochoroiditis, persistent diarrhea, muscular weakness, and headache. Congenital toxoplasmosis can lead to spontaneous abortion or stillbirths. A multitude of congenital defects may occur, including blindness and severe mental retardation. Diagnosis is usually made by serologic tests with fluorescent antibody techniques. CT examination of the brain may show enhancing lesions, and biopsies can be taken to look for the organisms microscopically. Treatment is reserved for more severe cases and consists of the combined use of pyrimethamine, sulfadiazine, and folinic acid (leucovorin). Immunocompromised patients require maintenance treatment for life. Because the protozoan is found in cat feces, pregnant women should avoid handling cat litter.

Additional Reading: Pet-related infections. Am Fam Physician. 2007;76(9):1314-1322.

Category: Nonspecific system

The answer is B. Prenatal screening for HIV should be offered to all pregnant women. Approximately 25% of newborns born to HIV-positive mothers will be infected with HIV, and another approximately 10% to 15% will become infected if breast-fed. Hence, breastfeeding is discouraged if there is access to clean water and formula. In the United States, Cesarean section is recommended if the maternal viral load exceeds 1,000 copies/mL, but this is controversial and some centers do this at any detectable viral load close to delivery. After delivery, the infant should be screened repeatedly using HIV DNA or RNA polymerase chain reaction (PCR) assays. Maternal HIV antibody crosses the placenta and will be detectable in all HIV-exposed infants up to age 18 months; therefore, standard antibody tests should not be used for HIV diagnosis in newborns until that time. HIV RNA or DNA PCR should be performed within the first 14 to 21 days of life, at 1 to 2 months, and at 4 to 6 months of age. Some experts also perform a virologic test at birth, especially in women who have not had good virologic control during pregnancy or if adequate follow-up of the infant may not be assured. A positive HIV virologic test should be confirmed as soon as possible with a second HIV virologic test on a different specimen. Two positive HIV tests constitute a diagnosis of HIV infection. All HIV-exposed infants should receive 6 weeks of zidovudine, and some centers add either a single or repeated doses of nevirapine if the mother was not fully virally suppressed before delivery.

Additional Reading: U.S. Department of Health and Human Services’ Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. From: http://www.aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0

Category: Reproductive system

The answer is C. The risk of disseminated intravascular coagulation is increased if a dead fetus has been retained in utero for more than 4 weeks. Therefore, it is practical to provide expectant management for patients with in utero fetal demise for up to 1 to 3 weeks. However, because many mothers experience significant psychological stress from carrying a dead fetus, patients who have experienced a fetal demise should be offered hospital admission and induction of labor. Induction is most effective if vaginal prostaglandins such as misoprosol are given first to provide cervical ripening followed by intravenous pitocin. Doses of misoprostol for cervical ripening in the third trimester of pregnancy are typically 25 to 50 mcg through vagina every 4 hours, while higher doses (200 to 400 mcg every 4 hours) can be used to achieve uterine evacuation for second-trimester intrauterine fetal demise.

Additional Reading: Diagnosis and management of stillbirth. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Reproductive system

The answer is A. Rh immune globulin (RhIg) must be administered to an Rh-negative mother immediately after abortion or delivery (live or stillborn) unless the infant is Rho (D) and Du negative, the mother’s serum already contains anti-Rho (D), or the mother refuses. The standard dose of intramuscular RhIg (300 µg) prevents sensitization from fetomaternal hemorrhage of up to 30 mL whole blood. It is necessary to identify women with fetomaternal hemorrhage to calculate the doses needed to prevent sensitization via a screening rosette test, which, if positive, is followed by a quantitative test (e.g., Kleihauer-Betke).

Additional Reading: Evidence-based prenatal care: Part II. Third-trimester care and prevention of infectious diseases. Am Fam Physician. 2005;71:1555-1562.

Category: Hematologic system

The answer is C. If varicella testing is performed in the preconception period, women can be offered two doses of varicella vaccine at least 1 month apart. Pregnancy should be delayed 1 month after vaccination. Varicella vaccine is contraindicated in pregnant women. Women found to be nonimmune during pregnancy should be counseled to avoid exposure to chickenpox and to report exposure immediately. Susceptible pregnant women who are exposed to varicella are candidates for varicella zoster immune globulin. Nonimmune women should be offered postpartum varicella vaccination. The vaccine is considered safe in breast-feeding women.

Additional Reading: Evidence-based prenatal care: Part II. Third-trimester care and prevention of infectious diseases. Am Fam Physician. 2005;71:1555-1562.

Category: Patient/population-based care

The answer is D. If the antibody test is negative, Rh-negative mothers should be given an immune globulin preparation at 28 weeks’ gestation to prevent erythroblastosis fetalis. If the father is also Rh negative, the administration is unnecessary; however, extramarital pregnancies should be considered. A dose of RhoGAM should also be given at the time of delivery, depending on the blood type of the infant. If the infant is Rh negative, the mother’s dose can be determined by the Kleihauer-Betke (FetalDex) test, which measures the amount of fetal erythrocytes in the maternal blood. If the newborn is Rh negative, there is no need for immune globulin administration. The immune globulin should also be given to Rh-negative women after elective or spontaneous abortion, placental abruption, ectopic pregnancy, or amniocentesis. Typically, the standard dose is 300 µg, which protects up to 10 mL of Rh-positive fetal red cells.

Additional Reading: Evidence-based prenatal care: Part II. Third-trimester care and prevention of infectious diseases. Am Fam Physician. 2005;71:1555-1562.

Category: Hematologic system

The answer is C. Approximately 25% of pregnant women experience vaginal spotting or heavier bleeding during the first trimester of pregnancy, and 25% to 50% of these pregnant women experience spontaneous abortion. Genetic anomalies are the most common cause of spontaneous abortion in the first trimester. Qualitative hCG determination only gives a diagnosis of the positive presence of hCG, usually at a level of >25 mIU/mL, but does not give any information regarding the viability or location of an actual pregnancy. When first-trimester bleeding is present, potential viability of the pregnancy can be determined with a quantitative β-hCG determination, which is repeated 3 to 5 days later. The β-hCG level should double every 48 hours when a normal pregnancy is present, but does not definitively diagnose an intrauterine viable pregnancy until confirmed by ultrasound. A fetus should be seen with vaginal ultrasound by the 33rd to 35th day after the last menstrual period, or when the β-hCG level has reached 1,500 to 2,000 mIU/mL. If the β-hCG level exceeds 1,500 to 2,000 mIU/mL and no intrauterine pregnancy is found with vaginal ultrasound, an ectopic pregnancy should be suspected, especially if an adnexal mass is palpated on physical examination or the expecting mother experiences lower abdominal pain. Progesterone levels of <5 ng/dL usually indicate a nonviable pregnancy but progesterone measurements are not generally used for diagnosis of viability.

Additional Reading: First trimester bleeding. Am Fam Physician. 2009;79(11):985-992.

Category: Reproductive system

The answer is D. PCOS is the most common endocrine abnormality in women of reproductive age. The syndrome is associated with chronic anovulation, oligomenorrhea, and infertility. Macrovascular diseases such as type 2 diabetes mellitus, hypertension, and atherosclerotic heart disease are more likely in women with PCOS. In addition, chronic anovulation predisposes women to endometrial hyperplasia and carcinoma. Symptoms that prompt women to seek attention include irregular menses, hirsutism, or infertility. The earliest manifestations of PCOS are noted around the time of puberty. Adolescent girls affected with PCOS often have early puberty and show hyperandrogenism and insulin resistance. In the early reproductive period, chronic anovulation results in difficulty with fertility. If pregnancy is achieved, it frequently terminates in spontaneous, first-trimester loss or is associated with gestational diabetes. More than 50% of those affected are obese. Abnormal androgen production declines as menopause approaches (as it does in women without PCOS), and menstrual patterns may normalize. However, perimenopausal and postmenopausal women with a history of PCOS have increased rates of type 2 diabetes, hypertension, and coronary artery disease compared with control patients. PCOS appears to follow a familial distribution. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels are often elevated in PCOS, with the LH:FSH ratio greater than 3:1. Individualized therapy should incorporate steroid hormones, antiandrogens, and insulin-sensitizing agents such as metformin. Metformin increases ovulation rates in some women with PCOS and also may reduce fasting insulin concentrations, lower blood pressure, and reduce low-density lipoprotein cholesterol. Weight loss by way of reduced carbohydrate intake and exercise is the most important intervention; this step alone can restore menstrual regularity and fertility and provide long-term prevention against diabetes and heart disease.

Additional Reading: Clinical manifestations of polycystic ovary syndrome in adults. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Endocrine system

The answer is B. HSV is a sexually transmitted infection (STI) that is not curable and has a varying rate of recurrence in all individuals. In pregnancy, the highest risk for neonatal transmission (30% to 50%) is among infants of women with their first outbreak of genital HSV close to the time of delivery. The risk of neonatal transmission is low (<1%) for pregnant women who have recurrences near term; however, because recurrent genital HSV is much more common than initial HSV infection in pregnancy, the proportion of neonatal HSV infections acquired from mothers with recurrent herpes is still significant. Prevention of neonatal HSV infection is best accomplished by preventing the acquisition of new genital HSV infection during late pregnancy, decreasing the recurrence rate of HSV infections near term for pregnant women with a history of prior genital HSV infection, and avoiding exposure of the infant to herpetic lesions during delivery. Suppressive antiviral treatment late in pregnancy reduces the frequency of cesarean sections among women who have recurrent genital herpes by diminishing the frequency of recurrences at term. Women with recurrent HSV infection should be counseled about the use of antiviral therapy such as acyclover close to term to decrease the rate of cesarean delivery. They should also be informed about the role of cesarean delivery in decreasing vertical transmission, which is typically only offered in the presence of active HSV genital lesions at the time of labor. For women with active lesions after delivery, care should be taken to avoid postpartum transmission to the infant through direct contact.

Additional Reading: Diseases characterized by genital, anal or perianal ulcers. CDC Sexually Transmitted Disease Treatment Guidelines; 2010.

Category: Reproductive system

The answer is A. GBS infection is responsible for a significant amount of neonatal morbidity and mortality. Up to 30% of women are colonized by GBS. Risk factors for neonatal infection include less than 37 weeks’ gestation, prolonged rupture of membranes (>18 hours), and maternal fever. Multiple organizations recommend that all women be offered GBS screening by vaginorectal culture at 35 to 37 weeks’ gestation and that colonized women be treated with appropriate intravenous antibiotics at the time of labor or rupture of membranes. GBS bacteriuria indicates heavy maternal colonization. Women with GBS bacteriuria in their current pregnancy or a previous infant with GBS infection should be offered intrapartum antibiotics routinely and therefore do not require vaginorectal culture.

Additional Reading: Prevention of perinatal group B streptococcal disease: updated CDC guideline. Am Fam Physician. 2012;86(1):59-65.

Category: Reproductive system

The answer is D. Immunologic infertility can occur in women as a result of the development of local and circulating antisperm antibodies. In men, there may also be circulating antibodies that prevent conception. Men with previous vasectomies have an increased risk of antisperm antibodies. Immunologic tests are now available for the detection of these antibodies. In some cases, spontaneous remission of antibodies has occurred. In cases in which they persist, steroids may be useful in lowering the levels of antibodies, thus allowing pregnancy.

Additional Reading: Evaluation of male infertility. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Reproductive system

The answer is C. An IUD is a contraceptive method that involves placing a foreign body through the cervical os and into the uterus. Interest in the IUD started in the 1960s, and its use in this country increased over the next decade. A 1974 study, however, linked the Dalkon Shield to maternal death and found it to have a disproportionately higher rate of infection than any other IUD. The cause of infection was the multifilament string (or tail), which was a modification of the monofilament tails used by other IUDs. This multifilament tail provided a pathway for bacteria, enabling them to bypass the immunologic barrier provided by the endocervix. This design flaw caused a fivefold increase in PID and an increase in septic abortion. After the Dalkon Shield was removed from the market, the use of IUDs declined in the United States. Currently, there are two IUDs on the market in the United State, both of which have an improved
design and research has shown them to be a safe and efficacious form of birth control. The availability of these types of IUDs and their improved safety record has led to increased use of IUDs in the United States over the past 10 to 20 years. The “ParaGard” copper T308A is a type of IUD that is marketed for use for 10 years. A common side effect of the copper IUD is menorrhagia, which necessitates its removal in some women. The “Mirena” levonorgestrel-secreting IUD is effective for at least 5 years, and some sources suggest that it may effectively prevent pregnancy for up to 7 years. The levonorgestrel exerts a direct effect on the uterus, which diminishes menstrual bleeding. Combined failure rates of both types of IUDs are <1% to 1.9% over 10 years, which is comparable to female sterilization. Contraindications for the use of IUDs include current cervical or uterine infections and pregnancy. Multiple studies conclude that the IUD poses little or no increased risk of PID or infertility when used by appropriately selected patients. Multiple studies have shown no increased risk for cervical or uterine malignancies in IUD users.

Additional Reading: Long-acting reversible contraception: implants and intrauterine devices. ACOG Practice Bulletin no. 1, 2011. From: http://www.acog.org/Resources_ And_Publications/Committee_Opinions_List

Category: Reproductive system

The answer is A. Melasma occurs in some women taking oral contraceptives. The condition is characterized by areas of darkened pigmentation that may affect the face. The condition is also seen in pregnancy. The condition is more common in African Americans and Latinas. Sun exposure can worsen the condition. Usually, the areas fade when pregnancy is complete or oral contraceptives are discontinued. Lupus pernio is a chronic, raised, indurated lesion of the skin, often purplish in color and associated with underlying sarcoidosis. Melanoma lesions are typically dark black and are not associated with oral contraceptive use. Sebaceous hyperplasia is a disorder of the sebaceous glands in which they become enlarged, sometimes in response to the hormones of pregnancy, producing yellow shiny bumps on the face, but do not alter the pigmentation of the skin. Oral contraceptives can both predispose patients to acne or improve it; however, acne lesions do typically appear as dark areas, except in cases of postacne scar formation.

Additional Reading: Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):211-218.

Category: Integumentary

The answer is C. Intravenous penicillin G is the preferred antibiotic for the prevention of group B β-streptococcal infection in newborns, with ampicillin as an alternative. Penicillin G should be administered at least 4 hours before delivery for maximum effectiveness. Cefazolin is recommended in women allergic to penicillin who are at low risk of anaphylaxis. Clindamycin and erythromycin are options for women at high risk for anaphylaxis if testing shows that their GBS isolates are sensitive to these agents. Vancomycin should be used in women allergic to penicillin and whose cultures indicate resistance to clindamycin and erythromycin or when susceptibility is unknown.

Additional Reading: Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC 2010. MMWR Recomm Rep. 2010;59(RR-10):1-32.

Category: Reproductive system

The answer is D. Ectopic pregnancy occurs in 1.5% to 2% of pregnancies and is potentially life threatening. Although there has been decreased mortality associated with this condition due to early detection and treatment before rupture, ectopic pregnancy still accounts for 0.5 deaths per 1,000 pregnancies, which represents 6% of all maternal deaths. Risk factors for ectopic pregnancy include prior PID, tubal surgery, and previous ectopic pregnancy. If a pregnancy occurs in the presence of an IUD, there is a higher risk that it will be ectopic. When diagnosed early, ectopic pregnancy may be treated medically rather than surgically. Therefore, ectopic pregnancy should be considered and quickly ruled out in all women of reproductive age who present with abdominal pain or vaginal bleeding. Transvaginal ultrasonography used in conjunction with quantitative hCG levels is the best method for diagnosis of ectopic pregnancy.

Additional Reading: Ectopic pregnancy NEJM. 2009;361: 379-387.

Category: Reproductive system

The answer is C. A molar pregnancy (hydatidiform mole) occurs when the placenta undergoes trophoblastic transformation and results in a neoplasm of the placenta. The abnormal placenta is usually swollen, edematous, and vesicular, resembling a cluster of grapes. The condition usually affects women younger than 20 and older than 40 years of age, and those with a prior history of hydatidiform mole
are at increased risk. Hydatidiform moles are usually associated with hyperemesis gravidarum and preeclampsia that occurs before the third trimester. Other associated conditions include vaginal bleeding; signs and symptoms of hyperthyroidism; trophoblastic embolization that may cause cough, tachypnea, and cyanosis; enlarged uterus associated with gestation; and theca lutein cysts resulting in ovarian enlargement. In 80% of patients, the molar pregnancy resolves after dilation and curettage without complications; however, in 20%, there is a malignant transformation of the tissue. Therefore, serum hCG determination (which is usually significantly elevated at time of diagnosis) should be monitored every 2 weeks after evacuation of the uterus until the value drops to nonpregnant values and then every 1 to 2 months for 1 year. Repeated pelvic examinations should be performed on a monthly basis after a molar pregnancy for the first year. In addition, a chest x-ray should be performed at the time of evacuation and 4 to 8 weeks after evacuation to check for metastasis. The lungs are the most common sites for metastasis. Patients should avoid pregnancy for at least 1 year after the development of a molar pregnancy. Those who have had prior molar pregnancies have an increased risk for recurrent molar pregnancies, and those who have recurrent molar pregnancies are at an increased risk for malignant transformation. Malignant transformation is usually treated with methotrexate.

Additional Reading: Gestational trophoblastic neoplasia. Williams Obstetrics, 23rd ed. New York, NY: McGraw-Hill; 2010.

Category: Reproductive system

The answer is A. Women who are reproductively mature, are older than 40, and experience irregular vaginal bleeding should be evaluated with endometrial biopsy to rule out endometrial hyperplasia or carcinoma. In addition, other tests to rule out thyroid dysfunction and bleeding disorders should be considered. Adolescents with abnormal vaginal bleeding can be regulated with oral contraceptive medications once pregnancy and infection have been ruled out. Vaginal bleeding before the age of 9 and after the age of 52 in the absence of hormone replacement is a cause for concern and requires investigation.

Additional Reading: Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012;85(1):35-43.

Category: Reproductive system

The answer is D. The following medication classifications are used to determine the risk of their use during pregnancy:

Additional Reading: Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

Category: Reproductive system

The answer is B. In recent years, intramuscular methotrexate has been advocated as an alternative to salpingostomy for management of ectopic pregnancy. In addition, there is also interest in using serum hCG or progesterone levels to monitor resolution of ectopic pregnancy after intervention. On the basis of study results, a single dose of intramuscular methotrexate is comparable to laparoscopic salpingostomy for the treatment of a small, unruptured ectopic pregnancy. The fact that serum progesterone levels resolved faster than serum hCG levels suggests that serum progesterone may be a better marker for monitoring resolution of ectopic pregnancy. Guidelines have been developed to choose appropriate candidates for medical treatment of ectopic versus surgical. The good candidate for methotrexate must be hemodynamically stable, with no evidence of pending or current rupture of the ectopic, preferably with hCG level < 5000 K, ectopic mass size <3 to 4 cm, and able to comply with follow-up. Patients with abnormal renal or hepatic function at baseline or certain gastric or hematologic disorders are not generally candidates for this therapy.

Additional Reading: Medical management of ectopic pregnancy. ACOG Practice Bulletin no. 94, 2008. From: http://www.acog.org/Resources_And_Publications/Committee_Opinions_List

Category: Reproductive system