AMIRICAN BOARD-1-1-Consider three 45-year-old patients, all in good health, who are candidates for these elective or planned procedures:

Patient A: Abdominal hysterectomyPatient B: MyomectomyPatient C: Open oophorectomy with salpingectomy

Based solely on the indicated procedure, which patient(s) should receive perioperative antibiotic prophylaxis in accordance with current ACOG guidelines?Patient A onlyPatient B onlyPatients A and BPatients A and CAnswer:Patient A only. ACOG guidelines recommend antibiotic prophylaxis for hysterectomy, urogynecologic procedures, hysterosalpingogram, and induced abortion. These guidelines do not recommend antibiotic prophylaxis for lower-risk clean procedures, including operative and diagnostic laparoscopy, tubal sterilization, hysteroscopy, and laparotomy.2-Your 63-year-old patient presents with advanced-stage, high-grade epithelial ovarian cancer (EOC). A work-up confirms serous tumor histology. This tumor most likely harbors a genetic mutation in:TP53PTENKRASBRAFAnswer:TP53. Recent evidence suggests that almost all serous EOC harbors TP53 mutations and are classified as type 2 EOC. In contrast, type 1 tumors usually present at earlier stages, have a more indolent course, and more commonly carry other genetic mutations, such as PTEN, KRAS, and BRAF.3- All of the following structures of the female genital tract are derived from the Mllerian ducts, EXCEPT:OvariesFallopian tubesUterusCervixAnswer:Ovaries. The ovary is derived from multiple embryonic structures, including the coelomic epithelium, the subcoelomic mesoderm, and the primordial germ cells from the yolk sac endoderm. The rest of the female genital tract, including the fallopian tubes, uterus, cervix, and upper vagina, are derived from the Mllerian ducts.4- Consider 2 similar patients who previously underwent procedures for pelvic organ prolapse:

Patient A: Anterior colporrhaphy alonePatient B: Anterior colporrhaphy with concomitant hysterectomy

Assuming all surgical procedures were performed transvaginally and other factors are constant, which patient is at the most risk for recurrence of prolapse within 10 years of surgery?-2-Patient APatient BRates of recurrent prolapse are equalNot enough informationAnswer:Patient A. A study evaluating outcomes of vaginal prolapse surgery among female Medicare beneficiaries showed that 10 years after surgery, the reoperation rate was significantly reduced when a concomitant apical suspension procedure was performed, particularly among women who underwent anterior repair (20.2% vs 11.6%, respectively).5-Your 30-year-old patient is at 35 weeks' 2 days gestation with a twin pregnancy. The first twin is in the cephalic presentation. Both fetuses are alive, are of similar size (estimated weight of 2.2 kg), and are dichorionic and diamniotic. Your patient has no history of cesarean section. You and your patient decide on a planned vaginal delivery at 38 weeks' 0 days gestation. Compared with a similar woman scheduled to undergo a planned cesarean section, you might expect your patient to have:Increased risk of fetal or neonatal mortalityDecreased risk of fetal or neonatal mortalityIncreased risk of birth traumaNo difference in risk of fetal or neonatal death or birth traumaAnswer:No difference in risk of fetal or neonatal death or birth trauma. A randomized trial, which included >2,800 women, showed that between 32 weeks' 0 days and 38 weeks' 6 days gestation, planned cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery.6- Your 28-year-old patient is presenting with a pregnancy of unknown location. Ultrasonography shows no intrauterine fluid collection and normal adnexa. A single hCG measurement is 3,000 mIU/mL. Based solely on this information, what is the most likely diagnosis?

Ectopic pregnancyViable intrauterine pregnancyNonviable intrauterine pregnancyViable or nonviable intrauterine pregnancyAnswer:Nonviable intrauterine pregnancy. In a woman with a pregnancy of unknown location, no intrauterine fluid collection, normal (or near-normal) adnexa on ultrasonography, and a single hCG measurement 3,000 mIU/mL indicate that a viable intrauterine pregnancy is possible but unlikely. The most likely diagnosis is a nonviable intrauterine pregnancy.7- Based on the information in the previous question, what is the most appropriate next step for this patient?Pharmacologic treatment for ectopic pregnancySurgical treatment for ectopic pregnancyFollow-up hCG measurementFollow-up hCG measurement and ultrasonogramAnswer:Follow-up hCG measurement and ultrasonogram. Because guidelines indicate that the most likely diagnosis is a nonviable intrauterine pregnancy, it is generally appropriate to obtain at least 1 follow-up hCG measurement and ultrasonogram before initiating treatment for ectopic pregnancy.-3-8- Your patient, a 25-year-old Hispanic, has a 5-year history of intravenous opioid use. At 20 weeks' gestation with her first pregnancy, she decides to enter an inpatient opioid detoxification program. Which of these factors most strongly influences your patients likelihood of successful detoxification (defined as no illicit drug use at delivery)?Maternal age, ethnicity, or nulliparityYears of maternal substance useIntravenous vs intranasal/oral opioidsNo maternal factors influence successAnswer:No maternal factors influence success. A retrospective cohort study of 95 women found no maternal demographics or drug histories associated with success, thus supporting continued opiate detoxification being offered to all women expressing intent.9- Assume your patient was unsuccessful in the detoxification program and was engaging in illicit substance use at the time of delivery. Compared with a similar woman who had success in the program, your patient is more likely to be seropositive for:Hepatitis C virusHIVSyphilisHepatitis B virusAnswer:Hepatitis C virus. Compared with women who were drug free at the time of delivery, women with illicit substance use were more likely to test positive for hepatitis C antibody. HIV, syphilis, and hepatitis B seropositivity did not differ.10-Consider 3 therapies for the treatment of recurrentClostridium difficileinfection:

Therapy 1: An initial vancomycin regimen (500 mg orally 4 times per day for 4 days), followed by bowel lavage and subsequent infusion of a solution of donor feces through a nasoduodenal tubeTherapy 2: A standard vancomycin regimen (500 mg orally 4 times per day for 14 days)Therapy 3: A standard vancomycin regimen (500 mg orally 4 times per day for 14 days) with bowel lavage

Which therapy has been shown to be most effective in adult patients with a life expectancy of >3 months and a relapse ofC. difficileinfection after >1 course of adequate antibiotic therapy?Therapy 1Therapy 2Therapy 2 and 3 are equally effectiveTherapy 1 and 3 are equally effectiveAnswer:Therapy 1. In a randomized study, the infusion of donor feces was significantly more effective for the treatment of recurrentC. difficileinfection than the use of vancomycin.11-Your 55-year-old patient has urinary stress incontinence, but is ambulatory. To date, she has been using absorbent products to manage her incontinence, but now desires treatment. Which management strategy do ACOG guidelines advocate as first-line treatment for this patient?-4-Physiotherapy (eg, pelvic muscle training)Surgery (eg, midurethral sling)Pharmacotherapy (eg, oxybutynin, tolterodine)Mechanical devices (eg, pessaries)Answer:Physiotherapy (eg, pelvic muscle training). ACOG Practice Bulletin No. 63 states that pelvic floor training, with or without behavioral modifications, appears to be an effective treatment for adult women with stress and mixed incontinence and can be recommended as a noninvasive treatment for many women. Pharmacologic agents may be effective in cases of detrusor overactivity, and surgery is indicated when conservative treatments have failed to satisfactorily relieve symptoms. Evidence regarding the effectiveness of mechanical devices is lacking.12- Assuming your patients treatment goal is cure, consider 3 initial treatment scenarios:Treatment A: Physiotherapy aloneTreatment B: Midurethral-sling surgery aloneTreatment C: Physiotherapy followed by midurethral-sling surgery

According to a recent randomized trial, which first-line treatment is most likely to achieve your patients goal by 1 year?Treatment ATreatment BTreatment CTreatment B or CAnswer:Treatment B or C. For women with urinary stress incontinence, initial midurethral-sling surgery, as compared with initial physiotherapy, resulted in higher rates of subjective improvement and subjective and objective cure at 1 year. Women who crossed over from the physiotherapy group to the surgery group had outcomes similar to those of women initially assigned to surgery, and both these groups had outcomes superior to those women who received physiotherapy alone.13- A 30-year-old, African-American patient seeks your advice on reversible contraception. She is a high-school graduate, earns 90% overall success rate, with relatively fewer adverse events, relatively low drug cost, and no return office visit necessary for administration?

Regimen A: Mifepristone 600 mg orally, followed by misoprostol 400 mcg orally 48 hours laterRegimen B: Mifepristone 200 mg orally, followed by misoprostol 800 mcg vaginally, buccally, or sublingually 2448 hours laterRegimen C: Methotrexate 50 mg vaginally, followed by misoprostol 800 mcg vaginally 37 days laterRegimen D: Misoprostol only, 800 mcg vaginally or sublingually every 3 hours for 3 dosesRegimens A or CRegimen B onlyRegimens B or CRegimens B or DAnswer:Regimens B or C. These two common medical abortion regimens are collectively associated with a 92%99% overall success rate, fewer adverse effects than the FDA-approved or misoprostol-only regimens, relatively low drug cost, and no need to return to the office or clinic for misoprostol administration. According to the ACOG Practice Bulletin, women can safely and effectively self-administer misoprostol at home as part of a medical abortion regimen.65- How would your answer to the previous question change if the patient was scheduled to undergo medical abortion at 56 days' gestation?

Regimen A: Mifepristone 600 mg orally, followed by misoprostol 400 mcg orally 48 hours laterRegimen B: Mifepristone 200 mg orally, followed by misoprostol 800 mcg vaginally, buccally, or sublingually 2448 hours laterRegimen C: Methotrexate 50 mg vaginally, followed by misoprostol 800 mcg vaginally 37 days laterRegimen D: Misoprostol only, 800 mcg vaginally or sublingually every 3 hours for 3 doses-19-Regimens A or CRegimen B onlyRegimens B or CRegimens B or DAnswer:Regimen B only. Methotrexate in combination with misoprostol has shown efficacy up to 49 days' gestation, whereas mifepristone plus misoprostol administered by a nonoral route has high complete abortion rates up to 63 days' gestation. Vaginal, buccal, and sublingual routes of misoprostol administration increase the gestational age range for use as compared with the FDA-approved regimen.66- You are considering the initiation of androgen therapyoff-label transdermal testosteronefor the treatment of hypoactive sexual desire disorder in your postmenopausal patient. Based on available evidence, what is the maximum recommended duration of transdermal testosterone use in this setting?2 months6 months1 year2 yearsAnswer:6 months. Transdermal testosterone has been shown to be effective for the short-term treatment of hypoactive sexual desire disorder in women, with little evidence to support long-term use (>6 months).67- Which class of medications is most commonly linked to female sexual dysfunction, including orgasmic dysfunction, decreased sexual desire, and decreased arousal?Selective serotonin reuptake inhibitors (SSRIs)Oral contraceptivesCorticosteroidsAntihypertensivesAnswer:Selective serotonin reuptake inhibitors (SSRIs). The most frequently reported problems are hypoactive sexual desire disorder, sexual arousal disorder, and orgasmic dysfunction.68-To reduce the incidence of breast cancer mortality, at what age should women start getting mammograms and how often should this be offered?40; annually40; biennially50; annually50; bienniallyAnswer:40; annually. ACOG, the American Cancer Society, and the National Comprehensive Cancer Network all recommend annual mammography screening beginning at age 40 years. The US Preventive Services Task Force recently changed its guidelines to recommend biennial mammography in women aged 5074 years and suggested that screening be conducted on a case-by-case basis in women