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Answers (Grade A+)
You are caring for a 29-year-old G3P2 at 39 weeks gestation, who has been laboring for 6 hours. She is a diet-controlled diabetic. Her last child was 9 pounds 8 ounces. She has been completely dilated for 2 hours, and the fetal head is at a plus 2 station, which is unchanged. What is the next most appropriate course of action? A Begin oxytocin B Vacuum extraction C High forcep extraction D High forcep rotation E Cesarean section - correct answer ✅Cesarian Section The patient is a diabetic with a history of a macrosomic infant; the likelihood of macrosomia in this infant is significant. Instrument delivery is not recommended if macrosomia is suspected. By definition, she has had an arrest of descent of the fetal head and one should be highly suspicious for macrosomia, in which case a c-section is the preferred method of delivery.
Answers (Grade A+)
A 75-year-old woman presents to your office complaining of intense pruritis of the vulva and occasional bleeding. She is unsure if the bleeding is caused by her scratching in attempts to alleviate the itching. She has tried some OTC preparations to alleviate the itching and has not had any relief from them. She denies any vaginal discharge or dysuria. On physical examination you notice excoriations and some scattered lesions that look like eczema on the vulva and they do not scrape off. Also noted was inguinal lymphadenopathy. You decide to do a punch biopsy. The pathology report reveals large eosinophilic cells. Question What is the most likely diagnosis? Answer Choices 1 Lichen sclerosis 2 Vulvar carcinoma 3 Paget's disease 4 Melanoma
Answers (Grade A+)
The pregnant mother of a 2-year-old patient is concerned about exposure to environmental neurotoxins affecting her developing fetus. She asks you questions about whether the placenta would block any transfer of toxins to a growing fetus. Which environmental neurotoxin transfer to the fetal system is actually enhanced by the placenta? Answer Choices 1 Mercury 2 Cadmium 3 Polychlorinated biphenyls 4 Insecticides 5 Environmental tobacco smoke - correct answer ✅mercury Explanation Methyl mercury is absorbed almost completely and crosses the placenta easily and then becomes stored in the fetus. Fetal blood concentrations exceed maternal concentrations by 50- 100%. High doses can result in mental retardation, spastic paralysis, and death. Low doses are linked to deficits in neuromotor performance, cognition, memory, and language.
Answers (Grade A+)
The placenta effectively blocks the transfer of cadmium. Studies have shown cadmium concentrations in umbilical cord blood to be significantly lower than that in maternal blood and placental cadmium concentration to be highest. Polychlorinated biphenyls (PCP) have contaminated sport fish, particularly bottom-feeding species from water contaminated with PCPs. Also during the 1940s and 1950s the inside of concrete silos on many farms in the Midwest were coated with sealants containing PCPs that over time have peeled off and become mixed with silage to feed beef and dairy cattle. Incinerators and other PCP-disposal facilities or hazardous waste sites are other sources of PCP exposure. PCPs are synthetic hydrocarbons that are lipophilic, have a long half-life, and can cross the placenta easily. Fetuses and neonates are more sensitive to PCPs because the hepatic microsomal enzyme system that facilitates metabolism and excretion are not fully functional. Insecticides or pesticides appear to cross the placenta relatively easily being lipophilic and having a low molecular weight. Residue levels of DDT and its
Answers (Grade A+)
Explanation Terbutaline relaxes smooth muscle in the bronchial system and the uterus by stimulating β2-receptors. It is a tocolytic drug, and most commonly used in patients with bronchospasms caused by reversible obstructive airway disease. Headache, tachycardia, and nausea are common side effects of beta-mimetic drugs, which relax the uterine muscle. Other side effects are shown in the following table. Central nervous system Drowsiness, dizziness, headache, tremor, nervousness Gastrointestinal Nausea, vomiting Cardiovascular Palpitations, tachycardia, arrhythmia Respiratory Paradox bronchospasm Metabolic Hypokalemia Skin Diaphoresis Other Dry mouth and throat Constipation and dry mouth are side effects of skeletal muscle relaxants, like cyclobenzaprine, which is used as short-term treatment of muscle spasms.
Answers (Grade A+)
Sedation, urinary retention, and dry mouth are side effects of antihistamine drugs, which effect the peripheral H1-receptors. Urinary retention and sedation however are side effects of the "older" drugs like brompheniramine, chlorpheniramine, clemastine, promethazine, and triprolidine and not the "newer" ones like fexofenadine, loratadine, and cetirizine. Anxiety, headache, and mydriasis are signs of atropine overdosage. Atropin is an anticholinergic that inhibits acetylcholine at the parasympathica neuroeffector junction. It blocks vagal effects on the sinuatrial and atrioventricular nodes thereby enhancing conduction through the AV node and increasing the heart rate. It is used to treat bradycardia and to dilate the pupils. Cold extremities, bronchospasm, and insomnia are side effects of beta-blockers. Beta-blockers (or symppatholytics) decrease myocardial contractility, heart rate, blood pressure, and cardiac output (less blood getting to the periphery, which explains cold e A 32-year-old woman is 2-hours status post cesarean delivery of a twin gestation at 36 weeks. Her
Answers (Grade A+)
The most likely cause of bleeding in this patient is uterine atony. Uterine atony occurs when the uterine myometrium fails to contract following delivery. Contractions of the uterine muscles after delivery normally tamponade bleeding from uterine arterioles. Absence of this response causes continued bleeding, which usually becomes evident early after delivery. Bimanual uterine palpation revealing a soft, 'boggy' uterus confirms the diagnosis. Initial treatment involves bimanual uterine massage, which helps promote uterine contractions. In addition, uterotonic agents are administered. The first-line of therapy is intravenous oxytocin. Second-line therapies including ergot alkaloid derivates and prostaglandins (e.g., Hemabate) are used when oxytocin therapy is unsuccessful. When these measures are unsuccessful, surgical interventions are required, the most common of which is bilateral uterine artery ligation. Uterine atony can also occur as a result of retained products of conception; these products inhibit uterine contraction. In this case, manual or surgical extraction is necessary.
Answers (Grade A+)
Intravenous magnesium is a uterine relaxant used to inhibit uterine contractions in settings of premature labor. It has the opposite effect than that desired to treat uterine atony. Transfusion with fresh frozen plasma may be indicated as a temporizing measure in the setting of disseminated intravascular coagulation accompanied by severe bleeding or massive uncontrolled hemorrhage from uterine rupture, neither of which is suspected in this clinical scenario. Transvaginal ultrasound is rarely needed to diagnose postpartum hemorrhage, and it is not the most appropriate next step in light of the patient's condition. our patient, a 48-year-old woman, presents with vaginal bleeding and states that she is "alarmed" because she is quite sure she is 2 months pregnant. History includes unremarkable live birth of a male child 7 years ago and a molar pregnancy a year ago. Examination reveals a uterus that is inappropriately large for gestational length and hCG levels are higher than expected. Fetal parts and heart sounds are not
Answers (Grade A+)
Serous cystadenocarcinoma occurs in the ovary and is a cystic or semi-cystic neoplasm. It usually occurs bilaterally An ovarian dysgerminoma is a malignant ovarian neoplasm, hypothesized to be derived from primordial germ cells of the sexually undifferentiated embryonic gonad. Endometrioid carcinoma resembles the typical carcinoma of the endometrium, as its name suggests, but is an ovarian carcinoma. This neoplasm may be seen with endometrial carcinoma. Ovarian teratoma is composed of tissues that are derived from three germinal layers, the endoderm, mesoderm, and ectoderm. Many teratomas will contain hair or teeth. These true neoplasms will usually present with lower quadrant pain. A sexually active, 17-year-old patient presents alone to your office and requests contraceptive counseling. Because she is under the age of consent, what is an
Answers (Grade A+)
ethical concern of which you must be aware in seeing her? Answer Choices 1 You are obligated to refuse to see her. 2 You may only see her with parental consent. 3 You do not need parental consent if she is accompanied by an adult. 4 She can give consent for contraceptive counseling and evaluation of STDs. 5 You must counsel abstinence as contraception at her age. - correct answer ✅She can give consent for contraceptive counseling and evaluation of STDs. Explanation This case highlights several ethical issues. Autonomy indicates that an individual may make his/her own health care decisions based on their own values. It is usually limited by a determination of whether the individual is competent and, in pediatrics, at least in part determined by the age of the individual. Competence is an individual's ability to understand the possible consequences of his/her decision and the available alternatives. Patients are generally
Answers (Grade A+)
pregnant. She denies any chronic medical problems, although she states that her previous physician has advised her to lose weight because she has borderline diabetes. She is 5 feet 5 inches tall and weighs 240 lbs. Her gynecologic examination is unremarkable. Question What is the most likely explanation for her abnormal uterine bleeding? Answer Choices 1 A testosterone-secreting tumor of the ovary or adrenal 2 Increased exogenous estrogen 3 Increased exogenous progesterone 4 Loss of pulsatile GnRH due to thyroid dysfunction 5 Polycystic ovary syndrome (PCOS) - correct answer ✅Polycystic ovary syndrome (PCOS) Explanation
Answers (Grade A+)
This patient has polycystic ovary syndrome. PCOS, also known by the name Stein-Leventhal syndrome, is an endocrine condition present in 5% to 10% of women of reproductive age. It is the most common cause of infertility in women. It is referred to as polycystic because most women with the condition have a number of small cysts in the ovaries; however, it is the characteristic constellation of signs, symptoms, and biochemical aberrations, rather than the presence of the cysts themselves, that is important in establishing the diagnosis, including dysfunctional uterine bleeding (DUB) due to estrogen breakthrough bleeding, hyperandrogenism, insulin resistance, and often obesity. Each plays a role in the evolution of an oligo-ovulatory state. It most commonly affects women ages 15 - 20 and is characterized by high estrogen and androgen levels, resulting in virilization (hair growth and acne), chronic menstrual irregularities, and infertility. Although the exact mechanism is yet to be determined, it is thought to involve a disorder of the hypothalamic- pituitary axis, in which access luteinizing hormone (LH) and androgen production causes virilization and anovulation with cyst formation in the ovary.
Answers (Grade A+)
You refer the patient to a tertiary care center for further evaluation and explain that you suspect that the fetus may have what condition? Answer Choices 1 Tiisomy 13 2 Trisomy 18 3 Trisomy 21 4 Skeletal dysplasia 5 45, X - correct answer ✅skeletal dysplasia Explanation In this case, there are signs of a skeletal dysplasia where bony growth of the long bones of the skeleton is not normal. Increased head circumference size can also be observed in the skeletal dysplasias. While achondroplasia is the most common recognized skeletal dysplasia, over 100 disorders have been reported and additional ultrasound imaging and possibly genetic testing will be needed to make a specific diagnosis.
Answers (Grade A+)
Trisomy 13 is often fatal in utero or in the first few days or weeks of life. Global growth retardation (not just long bone shortening), renal anomalies, cleft lip/palate, and severe central nervous system malformations may be noted on ultrasound. Trisomy 18 is often fatal in utero or in the first few days or weeks of life. Growth retardation may be present, along with renal anomalies, severe cardiac malformations, and omphaloceles. Skeletally, there may be shortening of the sternum and prominent calcanei on the feet. Trisomy 21 sometimes leads to shortening of the long bones in utero. although head circumference is often decreased. Ultrasound markers would include the presence of congenital heart disease (1/3 of all live born cases), duodenal atresia, and increased nuchal translucency. 45 X, or Turner syndrome, has few major structural problems in fetal development in spite of the fact that many 45 X fetuses will spontaneously miscarry. Ultrasound imaging may identify a short neck, increased nuchal translucency (or even a cystic
