OB/GYN: ACOG OBSTETRICS QUESTIONS WITH
COMPLETE SOLUTIONS
A 17-year-old G0 high school student is brought in by her
mother for her first gynecologic examination. She began her
menses at age 12 and has had regular periods for the past three
years. Her last menstrual period was one week ago. For privacy,
you ask to examine the patient without her mother. Further
history is obtained in the examination room. She admits that she
has been sexually active with her boyfriend for the past three
years. She uses condoms occasionally and is fearful about
possible pregnancy. She requests that her mother not be
informed about her sexual activity. On physical examination,
she is anxious, but normally developed. Her pelvic examination
reveals no vulvar lesions, minimal non-malodorous discharge,
and a nulliparous appearing cervix. The bimanual examination
reveals a normal size uterus, and her adnexa are non-tender and
not enlarged. Urine pregnancy test is negative. In addition to
discussing Correct Answers D
A 17-year-old G1 woman at 24 weeks gestation presents with
vaginal bleeding. She denies any pain, cramping or dysuria. She
reports last having intercourse three weeks ago. Prenatal care
and labs have been unremarkable. Her vital signs are normal and
she is afebrile. Pelvic ultrasound reveals a fundal placenta and
viable fetus. Abdominal examination is unremarkable. Vaginal
examination reveals a uniformly friable cervix with a small
amount of blood in the vault. Digital examination reveals a firm,
closed cervix. What is the most likely diagnosis that explains the
bleeding?
A. Trauma
, B. Cervical cancer
C. Cervicitis
D. Bloody show
E. Threatened abortion Correct Answers C. Cervicitis caused
by chlamydia, gonorrhea, trichomonas or other infections can
present with vaginal bleeding. The cervix is much more vascular
during pregnancy and inflammation can lead to bleeding.
Evaluation for other causes of bleeding must be completed and
then treatment for the infection should be initiated. The patient
does not give any history of trauma and cancer is unlikely
because of her age. She is not in labor, and a bloody show
associated with cervical dilatation is not consistent with the
history provided. Threatened abortion occurs during the first
trimester.
A 17-year-old G1P0 female at 39 weeks gestation presents with
increased swelling in her face and hands over the last two days.
Her blood pressure is 155/99. She has 2 plus pitting edema of
the lower extremities. A 24-hour urine collection shows 440 mg
of protein. What is the next best step in the management of this
patient?
A. Fluid restriction
B. Magnesium sulfate
C. Furosemide
D. Hydralazine
E. Delivery Correct Answers E. Regardless of disease
severity, the only definitive therapy for preeclampsia is delivery
of the fetus and placenta. This solution can occasionally be
delayed in the setting of stable disease (mild or severe) when it
occurs at an extremely early gestational age. Fluid management
must be monitored closely in this person. Magnesium sulfate is
,the mainstay of therapy during labor and for 24 hours
postpartum to lower the seizure threshold. Low-dose aspirin
may have some benefit in decreasing the risk of preeclampsia in
a subset of high-risk patients. Hydralazine is often the
antihypertensive agent of choice for controlling elevated blood
pressures in the acute setting.
A 17-year-old G2P0 female has severe right lower quadrant
pain. Her last normal menstrual period seven weeks ago. She
notes that last night she began having suprapubic pain that
radiated to her right lower quadrant. This morning, the pain
awoke her from sleep. She has had no vaginal bleeding, no
nausea or vomiting. The patient's history is notable for two first
trimester elective abortions and a history of Chlamydia treated
twice. Vital signs are: blood pressure 90/60; pulse 99;
respirations 22; and temperature 98.6°F (37°C). On physical
exam, the patient is noted to be curled on a stretcher in a fetal
position and says she hurts too much to move. She has rebound
and voluntary guarding on abdominal examination. She has
profound cervical motion tenderness and rectal tenderness. Her
Beta-hCG level is 2500 mIU/ml; hematocrit 24%; and urinalysis
negative. Ultrasound shows no intrauterine pregnancy, a right
adnexal mass t Correct Answers B. This patient has a ruptured
ectopic pregnancy until proven otherwise. Her vital signs,
examination and anemia are consistent with an intra-abdominal
bleed. Exploratory laparoscopy/laparotomy is indicated at this
point. Conservative management with observation, serial
examinations or repeat Beta-hCG testing could be dangerous in
a patient suspected of having a ruptured ectopic pregnancy.
Medical management (methotrexate) is not used in a patient
with an acute surgical abdomen. Dilation and curettage would
, not be the next step in management and might only be
considered in this scenario after the patient's abdomen was
explored.
A 19-year-old G1 woman at 40 weeks gestation has an
uncomplicated vaginal delivery followed by a brisk hemorrhage.
Her past medical history is significant for steroid-dependent
asthma. Her blood pressure is 110/70; pulse 84; and she is
afebrile. Which of the following uterotonic agents should not be
used in this patient?
A. Intramuscular oxytocin
B. Intravenous oxytocin
C. Prostaglandin F2-alpha
D. Prostaglandin E1 (Misoprostol)
E. Methylergonovine Correct Answers C. Methergine,
prostaglandins and oxytocin are all uterotonics and used to
increase uterine contractions and decrease uterine bleeding.
Prostaglandin F2-alpha (Hemabate) is a potent smooth muscle
constrictor, which also has a bronchio-constrictive effect. As
such, it should be used with caution in any patient with a
reported history of asthma. It is absolutely contraindicated in
patients with poorly controlled or severe asthma. Misoprostol,
non-FDA approved for this purpose, is often used for cervical
ripening and labor induction.
A 19-year-old G2P1 African American woman at 30 weeks
gestation presents with preterm rupture of membranes six hours
ago. Her prenatal course has been complicated by two episodes
of bacterial vaginosis for which she was treated. She takes
prenatal vitamins and iron. She denies substance abuse or
alcohol use, but admits to smoking five cigarettes each day. Her
COMPLETE SOLUTIONS
A 17-year-old G0 high school student is brought in by her
mother for her first gynecologic examination. She began her
menses at age 12 and has had regular periods for the past three
years. Her last menstrual period was one week ago. For privacy,
you ask to examine the patient without her mother. Further
history is obtained in the examination room. She admits that she
has been sexually active with her boyfriend for the past three
years. She uses condoms occasionally and is fearful about
possible pregnancy. She requests that her mother not be
informed about her sexual activity. On physical examination,
she is anxious, but normally developed. Her pelvic examination
reveals no vulvar lesions, minimal non-malodorous discharge,
and a nulliparous appearing cervix. The bimanual examination
reveals a normal size uterus, and her adnexa are non-tender and
not enlarged. Urine pregnancy test is negative. In addition to
discussing Correct Answers D
A 17-year-old G1 woman at 24 weeks gestation presents with
vaginal bleeding. She denies any pain, cramping or dysuria. She
reports last having intercourse three weeks ago. Prenatal care
and labs have been unremarkable. Her vital signs are normal and
she is afebrile. Pelvic ultrasound reveals a fundal placenta and
viable fetus. Abdominal examination is unremarkable. Vaginal
examination reveals a uniformly friable cervix with a small
amount of blood in the vault. Digital examination reveals a firm,
closed cervix. What is the most likely diagnosis that explains the
bleeding?
A. Trauma
, B. Cervical cancer
C. Cervicitis
D. Bloody show
E. Threatened abortion Correct Answers C. Cervicitis caused
by chlamydia, gonorrhea, trichomonas or other infections can
present with vaginal bleeding. The cervix is much more vascular
during pregnancy and inflammation can lead to bleeding.
Evaluation for other causes of bleeding must be completed and
then treatment for the infection should be initiated. The patient
does not give any history of trauma and cancer is unlikely
because of her age. She is not in labor, and a bloody show
associated with cervical dilatation is not consistent with the
history provided. Threatened abortion occurs during the first
trimester.
A 17-year-old G1P0 female at 39 weeks gestation presents with
increased swelling in her face and hands over the last two days.
Her blood pressure is 155/99. She has 2 plus pitting edema of
the lower extremities. A 24-hour urine collection shows 440 mg
of protein. What is the next best step in the management of this
patient?
A. Fluid restriction
B. Magnesium sulfate
C. Furosemide
D. Hydralazine
E. Delivery Correct Answers E. Regardless of disease
severity, the only definitive therapy for preeclampsia is delivery
of the fetus and placenta. This solution can occasionally be
delayed in the setting of stable disease (mild or severe) when it
occurs at an extremely early gestational age. Fluid management
must be monitored closely in this person. Magnesium sulfate is
,the mainstay of therapy during labor and for 24 hours
postpartum to lower the seizure threshold. Low-dose aspirin
may have some benefit in decreasing the risk of preeclampsia in
a subset of high-risk patients. Hydralazine is often the
antihypertensive agent of choice for controlling elevated blood
pressures in the acute setting.
A 17-year-old G2P0 female has severe right lower quadrant
pain. Her last normal menstrual period seven weeks ago. She
notes that last night she began having suprapubic pain that
radiated to her right lower quadrant. This morning, the pain
awoke her from sleep. She has had no vaginal bleeding, no
nausea or vomiting. The patient's history is notable for two first
trimester elective abortions and a history of Chlamydia treated
twice. Vital signs are: blood pressure 90/60; pulse 99;
respirations 22; and temperature 98.6°F (37°C). On physical
exam, the patient is noted to be curled on a stretcher in a fetal
position and says she hurts too much to move. She has rebound
and voluntary guarding on abdominal examination. She has
profound cervical motion tenderness and rectal tenderness. Her
Beta-hCG level is 2500 mIU/ml; hematocrit 24%; and urinalysis
negative. Ultrasound shows no intrauterine pregnancy, a right
adnexal mass t Correct Answers B. This patient has a ruptured
ectopic pregnancy until proven otherwise. Her vital signs,
examination and anemia are consistent with an intra-abdominal
bleed. Exploratory laparoscopy/laparotomy is indicated at this
point. Conservative management with observation, serial
examinations or repeat Beta-hCG testing could be dangerous in
a patient suspected of having a ruptured ectopic pregnancy.
Medical management (methotrexate) is not used in a patient
with an acute surgical abdomen. Dilation and curettage would
, not be the next step in management and might only be
considered in this scenario after the patient's abdomen was
explored.
A 19-year-old G1 woman at 40 weeks gestation has an
uncomplicated vaginal delivery followed by a brisk hemorrhage.
Her past medical history is significant for steroid-dependent
asthma. Her blood pressure is 110/70; pulse 84; and she is
afebrile. Which of the following uterotonic agents should not be
used in this patient?
A. Intramuscular oxytocin
B. Intravenous oxytocin
C. Prostaglandin F2-alpha
D. Prostaglandin E1 (Misoprostol)
E. Methylergonovine Correct Answers C. Methergine,
prostaglandins and oxytocin are all uterotonics and used to
increase uterine contractions and decrease uterine bleeding.
Prostaglandin F2-alpha (Hemabate) is a potent smooth muscle
constrictor, which also has a bronchio-constrictive effect. As
such, it should be used with caution in any patient with a
reported history of asthma. It is absolutely contraindicated in
patients with poorly controlled or severe asthma. Misoprostol,
non-FDA approved for this purpose, is often used for cervical
ripening and labor induction.
A 19-year-old G2P1 African American woman at 30 weeks
gestation presents with preterm rupture of membranes six hours
ago. Her prenatal course has been complicated by two episodes
of bacterial vaginosis for which she was treated. She takes
prenatal vitamins and iron. She denies substance abuse or
alcohol use, but admits to smoking five cigarettes each day. Her
