ACOG PRACTICE BULLETINS QUESTIONS WITH CORRECT SOLUTIONS
When is endometrial evaluation indicated in women 13-18 years of age with AUB-O? - Correct
AnswersEndometrial cancer is rare in <20 yo women; if it occurs, it usually presents with 2-3
years of abnormal bleeding and obesity. Evaluation is needed when medical treatment has failed
after thorough investigation
When is endometrial evaluation indicated in women 19-39 years of age with AUB-O? - Correct
Answersrisk of endometrial cancer in 20-34 is 1.6%
risk in 35-44 is 6.2%
assessment is needed in women who do not respond to medical therapy or have prolonged
periods of unopposed estrogen
if biopsy is non-diagnostic, hysteroscopy or saline sonohysterscope may be warranted
what are the risk factors for endometrial cancer in women <40 years old? - Correct
Answersnulliparity
hypertension
BMI >30
irregular menstruation
family history
When is endometrial evaluation indicated in women 40+ years of age with AUB-O? - Correct
Answersbetween 40-50, incidence is 13-24/100,000
between 70-74, incidence is 87/100,000
Better prognosis in women less than 45 yo
therefore women 45+ with suspected anovulatory uterine bleeding should received endometrial
biopsy
in women with AUB-O, what is the treatment approach to guide therapy? - Correct
AnswersExogenous steroids
1. progestin only - levonogestrel IUD, medroxyprogesterone acetate, megestrol acetate,
norethindrone acetate, depot medroxyprogesterone acetate
2. combined hormonal contraception
both will help thin endometrium and protect from hyperplastic transition; combined also induce
regular withdrawal bleeding when taken cyclically
What are examples of progestin only medications? - Correct Answersprogestin only -
levonogestrel IUD, medroxyprogesterone acetate, megestrol acetate, norethindrone acetate, depot
medroxyprogesterone acetate
what medical therapies are most appropriate for AUB-O in 13-18 yo age range? - Correct
Answers1. exogenous steroids
2. if clinically symptomatic or hemodynamically unstable --> ADMIT
,3. can also prolong the interval of menstruation by skipping the placebo week, allowing anemia
to resolve
4. combined hormonal contraceptives also have the added benefit of increased factor VIII and
VWD levels, therefore combating coagulopathy
what medical therapies are most appropriate for AUB-O in 19-40 yo age range? - Correct
Answers1. low dose combined hormonal contraceptives or
2. progestin only
3. weight loss and exercise for obese, anovulatory women
what medical therapies are most appropriate for AUB-O in 40+ yo age range?` - Correct
Answersin Late perimenopausal women, cyclic progestin therapy, low dose oral contraceptives,
levonorgestrel IUD or cyclic hormone therapy
It was found that perimenopausal symptoms were better managed with cyclic hormone therapy
whats are the added benefit for younger patients who have a coagulopathy and AUB-O who take
combined oral contraceptives? - Correct Answerscombined hormonal contraceptives also have
the added benefit of increased factor VIII and VWD levels, therefore combating coagulopathy
whats are the added benefit for younger patients who have PCOS and AUB-O who take
combined oral contraceptives? - Correct Answerscombined oral contraceptives suppress ovarian
and adrenal androgen production and increase hormone binding globulin, therefore decreasing
androgens which in turn improve symptoms of hirsuitism and acne in PCOS
In patients with AUB-O who have completed childbearing, what are the potential concerns of
endometrial ablation treatment? - Correct Answers- risk for endometrial cancer
- impeded future evaluation
- postablation asherman, cervical stenosis, endometrial distortion, strictures, synechiae
what is the suggested further investigation of women with AUB-O who have failed medical
management? - Correct Answers1. hysteroscopy
2. TVUS (in pre-menopausal women, should be conducted when endometrium is thinnest at days
4-6)
3. saline infusion sonohysterography (high sensitivity and high NPV)
what method of contraception has been show to effectively treat AUB? - Correct
Answerslevonorgestrel IUD
which women are candidates for hysterecomy without cervical preservation secondary to AUB? -
Correct Answerswomen who have completed child bearing
women have failed medical therapy
women with contraindications
What are the goal ranges of insulin therapy for women with pre-gestational diabetes mellitus (i.e.
at fasting, pre-meal, 1 hour postprandial, and 2 hour) - Correct Answersfasting = <95 mg/dL
, pre meal = <100
1 hour = <140
2 hour = <120
when are the various insulins utilized during management of patient glucose levels? - Correct
Answersshort/rapid acting = before meals
intermediate acting = before breakfast and before dinner (with short/rapid acting)
longer acting = utilized to restrain hepatic glucose production during fasting states
what are the uses for magnesium sulfate during pregnancy? - Correct Answers- tocolysis during
pre-term labor to provide time for steroid administration
- neuroprotection
What are the indications for treatment with magnesium sulfate for neuroprotection? - Correct
Answers-PPROM
-PTL with intact membranes
-indicated Pre term delivery
- limited to pregnancies less than 32 weeks GA
What dose of magnesium sulfate is given for neuroprotection? - Correct Answersloading dose 4
grams followed by 1 gram/hr for maintenance; discontinue after 24 hours if delivery has not
occurred
what are the side effects of magnesium sulfate? - Correct Answersdiaphoresis
flushing
nausea
headache
magnesium toxicity (cardiac arrest, respiratory depression)
What are the contraindications for magnesium sulfate for neuroprotection? - Correct
Answersmyasthenia gravis
cardiac defects
renal impairment
What are the monitoring protocols for patients on magnesium sulfate? - Correct Answersurine
output
deep tendon reflexes
maintenance may continue if:
1. patellar reflex is still present
2. respiration exceeds 12/min
3. urine output >100 mL/4 hours
if a tocolytic is needed for a woman on MgSO4 for neuro protection, what is the most effective
agent? - Correct AnswersIndomethacin
CCB
When is endometrial evaluation indicated in women 13-18 years of age with AUB-O? - Correct
AnswersEndometrial cancer is rare in <20 yo women; if it occurs, it usually presents with 2-3
years of abnormal bleeding and obesity. Evaluation is needed when medical treatment has failed
after thorough investigation
When is endometrial evaluation indicated in women 19-39 years of age with AUB-O? - Correct
Answersrisk of endometrial cancer in 20-34 is 1.6%
risk in 35-44 is 6.2%
assessment is needed in women who do not respond to medical therapy or have prolonged
periods of unopposed estrogen
if biopsy is non-diagnostic, hysteroscopy or saline sonohysterscope may be warranted
what are the risk factors for endometrial cancer in women <40 years old? - Correct
Answersnulliparity
hypertension
BMI >30
irregular menstruation
family history
When is endometrial evaluation indicated in women 40+ years of age with AUB-O? - Correct
Answersbetween 40-50, incidence is 13-24/100,000
between 70-74, incidence is 87/100,000
Better prognosis in women less than 45 yo
therefore women 45+ with suspected anovulatory uterine bleeding should received endometrial
biopsy
in women with AUB-O, what is the treatment approach to guide therapy? - Correct
AnswersExogenous steroids
1. progestin only - levonogestrel IUD, medroxyprogesterone acetate, megestrol acetate,
norethindrone acetate, depot medroxyprogesterone acetate
2. combined hormonal contraception
both will help thin endometrium and protect from hyperplastic transition; combined also induce
regular withdrawal bleeding when taken cyclically
What are examples of progestin only medications? - Correct Answersprogestin only -
levonogestrel IUD, medroxyprogesterone acetate, megestrol acetate, norethindrone acetate, depot
medroxyprogesterone acetate
what medical therapies are most appropriate for AUB-O in 13-18 yo age range? - Correct
Answers1. exogenous steroids
2. if clinically symptomatic or hemodynamically unstable --> ADMIT
,3. can also prolong the interval of menstruation by skipping the placebo week, allowing anemia
to resolve
4. combined hormonal contraceptives also have the added benefit of increased factor VIII and
VWD levels, therefore combating coagulopathy
what medical therapies are most appropriate for AUB-O in 19-40 yo age range? - Correct
Answers1. low dose combined hormonal contraceptives or
2. progestin only
3. weight loss and exercise for obese, anovulatory women
what medical therapies are most appropriate for AUB-O in 40+ yo age range?` - Correct
Answersin Late perimenopausal women, cyclic progestin therapy, low dose oral contraceptives,
levonorgestrel IUD or cyclic hormone therapy
It was found that perimenopausal symptoms were better managed with cyclic hormone therapy
whats are the added benefit for younger patients who have a coagulopathy and AUB-O who take
combined oral contraceptives? - Correct Answerscombined hormonal contraceptives also have
the added benefit of increased factor VIII and VWD levels, therefore combating coagulopathy
whats are the added benefit for younger patients who have PCOS and AUB-O who take
combined oral contraceptives? - Correct Answerscombined oral contraceptives suppress ovarian
and adrenal androgen production and increase hormone binding globulin, therefore decreasing
androgens which in turn improve symptoms of hirsuitism and acne in PCOS
In patients with AUB-O who have completed childbearing, what are the potential concerns of
endometrial ablation treatment? - Correct Answers- risk for endometrial cancer
- impeded future evaluation
- postablation asherman, cervical stenosis, endometrial distortion, strictures, synechiae
what is the suggested further investigation of women with AUB-O who have failed medical
management? - Correct Answers1. hysteroscopy
2. TVUS (in pre-menopausal women, should be conducted when endometrium is thinnest at days
4-6)
3. saline infusion sonohysterography (high sensitivity and high NPV)
what method of contraception has been show to effectively treat AUB? - Correct
Answerslevonorgestrel IUD
which women are candidates for hysterecomy without cervical preservation secondary to AUB? -
Correct Answerswomen who have completed child bearing
women have failed medical therapy
women with contraindications
What are the goal ranges of insulin therapy for women with pre-gestational diabetes mellitus (i.e.
at fasting, pre-meal, 1 hour postprandial, and 2 hour) - Correct Answersfasting = <95 mg/dL
, pre meal = <100
1 hour = <140
2 hour = <120
when are the various insulins utilized during management of patient glucose levels? - Correct
Answersshort/rapid acting = before meals
intermediate acting = before breakfast and before dinner (with short/rapid acting)
longer acting = utilized to restrain hepatic glucose production during fasting states
what are the uses for magnesium sulfate during pregnancy? - Correct Answers- tocolysis during
pre-term labor to provide time for steroid administration
- neuroprotection
What are the indications for treatment with magnesium sulfate for neuroprotection? - Correct
Answers-PPROM
-PTL with intact membranes
-indicated Pre term delivery
- limited to pregnancies less than 32 weeks GA
What dose of magnesium sulfate is given for neuroprotection? - Correct Answersloading dose 4
grams followed by 1 gram/hr for maintenance; discontinue after 24 hours if delivery has not
occurred
what are the side effects of magnesium sulfate? - Correct Answersdiaphoresis
flushing
nausea
headache
magnesium toxicity (cardiac arrest, respiratory depression)
What are the contraindications for magnesium sulfate for neuroprotection? - Correct
Answersmyasthenia gravis
cardiac defects
renal impairment
What are the monitoring protocols for patients on magnesium sulfate? - Correct Answersurine
output
deep tendon reflexes
maintenance may continue if:
1. patellar reflex is still present
2. respiration exceeds 12/min
3. urine output >100 mL/4 hours
if a tocolytic is needed for a woman on MgSO4 for neuro protection, what is the most effective
agent? - Correct AnswersIndomethacin
CCB
