ANSWER KEY NI TERE (EXAM MCN HIRAP)

1. The correct answer is C. Hypertension during pregnancyis very common, occurring in 12 to 22% of all pregnancies.It is also a very important condition in that hypertensionduring pregnancy causes a significant amount ofmaternal and fetal morbidity and mortality. Over theyears, there has been much confusion regarding terminologyfor hypertensive disease during pregnancy. In the year2000, the report of the National High Blood PressureEducation Program Working Group on High BloodPressure in Pregnancy was published. The document recommendsthat the term gestational hypertensionshould be used to describe women who develop elevatedblood pressure without proteinuria after 20 weeks gestationand whose blood pressure returns to normal postpartum.Hypertension is defined as a systolic blood pressureof greater than or equal to 140 mm Hg or a diastolicblood pressure greater than or equal to 90 mm Hg thatoccurs after 20 weeks gestation in a woman with previouslynormal blood pressure. This patient meets these criteria,and the most appropriate diagnosis for her is gestationalhypertension.Pregnant women with chronic hypertension (choice A)will have a history of hypertension, an elevated bookingblood pressure, the development of hypertensionbefore 20 weeks gestation, or the persistence of elevatedblood pressures postpartum. This patient has noneof these, and therefore has gestational hypertension.Eclampsia (choice B) describes the occurrence ofseizures in a patient with preeclampsia. This patient didnot have preeclampsia and she did not have a seizure;therefore, she does not have eclampsia.Malignant hypertension (choice D) is a term typicallyused to describe very elevated blood pressures (e.g.,>220 mm Hg systolic or >120 mm Hg diastolic) withevidence of end organ damage. The organ systems thatare typically affected are the central nervous system, thecardiovascular system, and the kidneys. This patientdoes not have very elevated blood pressure, and she hasno evidence of end organ damage.Preeclampsia (choice E) is a syndrome defined byhypertension and proteinuria. It may also be associatedwith many other signs and symptoms, includingheadache, visual changes, epigastric pain, nausea andvomiting, elevated transaminases, elevated creatinine,and low platelets, among other things. This patient didhave hypertension but no proteinuria or other findings,and therefore she does not have preeclampsia.

2. The correct answer is E. In pregnant patients with nodemonstrated immunity to the varicella zoster virus, itis important to avoid exposure. The virus is spreadthrough respiratory droplets or close contact. There isan incubation period after exposure, averaging 14 days.Affected individuals are contagious from 48 hoursbefore the onset of the rash until all of the vesicularlesions crust over. Fetal infection can occur only ifmaternal infection does, and the transmission rates arevery low. However, severe congenital malformations,such as cardiac anomalies, limb anomalies, and microcephaly,can occur.Ultrasound is used to look for cases of fetal infection. Itis used in patients with maternal infection. This patienthas no signs of infection or even exposure, and an ultrasound(choice A) is not needed at this time.Varicella vaccination can be used in patients withoutdocumented immunity. However, it is a live virus andshould not be administered to pregnant patients(choice B). Ideally, this patient should have received thevaccine as part of preconception counseling.Varicella zoster immunoglobulin is used in patientswithout documented immunity who have a recentexposure, to try to prevent infection or serious complicationsof infection. There is no such history in thiscase, and administration of immunoglobulin (choiceC) is not indicated.Oral acyclovir can be used in pregnant patients thatdevelop varicella. If started within 2 hours of developingthe rash, it can decrease the severity of symptoms. Ithas not been shown to decrease the rate of fetal infection(choice D).

3. The correct answer is E. There is much confusionregarding whether or not women who have had a totalhysterectomy (i.e., a hysterectomy in which both theuterus and cervix are removed) continue to requireroutine Pap testing (i.e., cervical cytology screening).The Pap test is a very effective tool for detecting premalignantcervical abnormalities that can then be treatedin order to prevent the progression to invasive disease.However, the question often arises as to whether or notPap testing is needed once the cervix has been removed.To answer this question, it is important to realize thatPap testing in women who have had the cervix removedis performed in order to detect primary vaginal cancer.Primary vaginal cancer is very rare and represents onlya very small fraction of all gynecologic malignancies.Studies have shown that women who have had a hysterectomyand have no history of Pap smear abnormalityare at an exceedingly low rate of developing vaginalcancer. Therefore, according to the American College ofObstetricians and Gynecologists, women who have hada total hysterectomy and have no prior history of highgradecervical intraepithelial neoplasia may discontinuescreening. This patient should be told that given herhistory of a total hysterectomy and a lifetime of normalPap tests, she does not need to continue to have Paptesting performed.To counsel this patient that she should have a Pap testevery year (choice A), every 2 years (choice B), every 3years (choice C), or every 5 years (choice D) would beincorrect. As discussed earlier, this patient is not at riskfor cervical cancerher cervix has been removed. Sheis also at very low risk of a primary vaginal cancerdeveloping because she has a lifetime history of normalPap tests. This patient, therefore, does not require routinePap testing.

4. The correct answer is C. Decreased fetal movement is acommon complaint in pregnancy, but its usually afalse-positive. It can be a sign of fetal acidemia and mayprecede fetal death. Monitoring the fetal heart rate forperiodic changes from baseline is an accepted methodof fetal surveillance in such situations. A reactive nonstresstest (NST) is defined as two or more fetal heartrate accelerations in a 20-minute period. Accelerationsare defined as elevations in the fetal heart rate that peakat least 15 beats per minute above the baseline and lastat least 15 seconds. The NST is based on the premisethat fetal movement will result in elevations of the fetalheart rate. It is used as an indicator of fetal well-beingand good autonomic function.Betamethasone is administered to patients at risk ofpreterm delivery to promote fetal lung maturity. If evaluationsof this patient are not reassuring, she may havea preterm delivery. However, administration ofbetamethasone at this time (choice A) is not warranted.Induction with oxytocin (choice B), even in pretermgestations, is sometimes warranted. An example of thiswould be severe preeclampsia.However, there is no currentindication for expedited delivery in this case.Evaluation of fetal well-being should be undertakenbefore a decision to induce is made.Abruption may be a cause of decreased fetal movementand fetal death. Abruption is usually a sudden, catastrophicevent, and a cessation of fetal movement is morelikely to be seen than a decrease. Symptoms of abruptioninclude painful uterine contractions, uterine tendernesseven without contractions, and vaginal bleeding. Riskfactors for abruption include trauma, drug use, and elevatedmaternal blood pressure. None of this is present inthis case, and evaluation by ultrasound (choice D) forabruption would not be warranted.A cesarean section for fetal distress (choice E) is occasionallythe end result of evaluations for decreased fetalmovement but should not be done as the initial intervention.

5. The correct answer is C. This patient has signs andsymptoms most consistent with bacterial vaginosis.Patients typically complain of a fishy smelling, thin,grayish-white vaginal discharge with a pH greater than5.0. Epithelial cells with clumps of coccobacillary bacteriaare seen on saline wet mount. Irritation of thevaginal epithelium is not usually seen.Branching hyphae and spores (choice A) are associatedwith an infection with Candida albicans, which is characterizedby intense pruritus and a thick, white (cottagecheese)discharge with a pH less than 4.5. This patientsdischarge is not consistent with a Candida infection.Giant multinucleated cells with intranuclear inclusions(choice B) are associated with an infection with herpessimplex virus, which is characterized by vesicular lesionsand ulcers, paraesthesia, and dysuria. The vaginal pH istypically normal (less than 4.5). The diagnosis is confirmedwith viral cultures and scrapings. Giant multinucleatedcells with eosinophilic intranuclear inclusionsare seen when stained with Wright stain. A saline wetmount smear preparation is not used to diagnose herpesinfections. Also, this patients discharge is not consistentwith a herpes infection.Trichomonas vaginalis infection is diagnosed by findingmotile, flagellated organisms (choice D) on a saline wetmount smear preparation. Patients with T. vaginalis typicallyexperience vulvar itching and burning, a frothymalodorous discharge, dysuria, dyspareunia, and frequencyand urgency of urination. Vaginal and cervicalpetechiae (strawberry cervix) may be present. Thevaginal pH is generally greater than 5.0. This patientspresentation is more consistent with bacterial vaginosisthan with a Trichomonas infection.Squamous cells with perinuclear halos, known as koilocytes(choice E), are associated with an infection with thehuman papilloma virus (HPV), which is characterized bysoft, fleshy lesions on the genital region (condylomaacuminata). The vaginal pH is typically normal (less than4.5). The diagnosis is established with a biopsy of thelesions. A Pap smear may show koilocytes, which are cytologicchanges associated with HPV. A saline wet mountsmear preparation is not used to diagnose HPV. Thispatients signs and symptoms are inconsistent with HPV.

6. The correct answer is B. Even though this is not anemergent procedure, the best obstetric anesthesia forthis patient is general anesthesia with intubation.Conduction anesthesia, or any anesthesia that requiresa needle, is considered unsafe for this patient becauseshe has low platelets.An epidural block (choice A) is not the best option insomeone with thrombocytopenia.Neither a paracervical block (choice C) nor a pudendalblock (choice D) makes sense for this patient. A cesareansection requires pain reception blockage in theabdominal wall and uterus, not in the cervical or perinealareas.A spinal block (choice E) is not the best option in someonewith thrombocytopenia due to the possibility of alarge hematoma.

7. The correct answer is A. Infection with the influenzavirus can cause significant morbidity and mortality forpregnant women. Influenza A is the most common typethat causes epidemic infections and these epidemics tendto occur during the winter. In most healthy adults, theinfection is mild; however, if pneumonia develops theresults can be fatal. Because of this, starting in 1998, theCenters for Disease Control and Prevention (CDC) hasrecommended vaccination for all pregnant women afterthe first trimester. The American College of Obstetriciansand Gynecologists (ACOG) recommends that allwomen who are pregnant in the second and thirdtrimester during the flu season (October through March)should be vaccinated. It also recommends that women athigh risk for pulmonary complications be vaccinated aswell, regardless of trimester. There is no evidence that theinfluenza vaccine results in teratogenicity.Measles (choice B) and rubella (choice C) vaccines arenot recommended for pregnant women. These vaccinesare typically combined as the measles-mumps-rubellavaccine, which is a live attenuated virus vaccine. Theselive attenuated virus vaccines are contraindicated inpregnancy.Varicella (choice D) is also a live attenuated virus vaccineand is, therefore, contraindicated in pregnancy.However, it has been given during pregnancy and noadverse outcomes have been reported.Stating that no immunizations should be offered duringpregnancy (choice E) is incorrect. As explained earlier,the influenza virus is recommended to all pregnantwomen in the second and third trimester during the fluseason (October through March).

8. The correct answer is E. This patient has the classicpresentation of a molar pregnancy: heavy and painlessbleeding in the first half of pregnancy, a large-for-datesuterus, and preeclampsia before 20 weeks gestation. Infact, some physicians argue that preeclampsia before20 weeks gestation is pathognomonic of hydatidiformmole. In addition, you would expect this patient tohave an abnormally elevated (higher than expected)beta-hCG for dates. These patients also can show agrape-like cluster (abnormal placental tissue) protrudingfrom the cervical os. Treatment involves dilationand curettage with appropriate followup: chest x-ray(to rule out metastatic disease) and serial beta-hCGmeasurements. Ultrasound in these patients shows aclassic vesicular pattern that is referred to as having asnowstorm appearance for hypervascular, cystic,molar placental and chorionic villus tissue.An extrauterine, or ectopic, pregnancy (choice A), ifassociated with rupture, is painful and life threatening.There is associated hypotension and tachycardia.Fluid and tissue in the cul-de-sac (choice B) is usuallyindicative of endometriosis, which presents as cyclicabdominal pain without evidence of bleeding. It subsidesduring pregnancy.A ruptured adnexal cyst (choice C) would not beexpected to cause hemorrhage. It is usually painless, butmay be associated with crampy pain. One would notexpect the uterus to be enlarged either.A tuboovarian abscess (choice D) is a serious complicationof pelvic inflammatory disease (PID). It does notcause vaginal bleeding or an enlarged uterus. Patientsgenerally have fever and severe abdominal pain, inaddition to other signs of infection.

9. The correct answer is D. Seven to ten percent of patientshave an abnormal Pap smear and require furtherworkup. Low-grade intraepithelial lesions are ofteninsignificant and either resolve spontaneously or areassociated with only mild abnormalities on further evaluation.A significant subset has more advanced disease,however, such as advanced dysplasia or invasive cervicalcancer. Colposcopy involves the direct visualization ofthe cervix,with the application of acetic acid allowing thevisualization and biopsy of areas of atypical epithelialcells, thus allowing a more definitive evaluation of theunderlying pathology. Some physicians believe that thePap smear can be repeated within 6 months, and then ifabnormal, the patient should be sent for colposcopy.Either way, the question asks for an appropriate managementstrategy, and therefore sending the patient for acolposcopy is the best answer choice given.Cold-knife conization (choice A) and loop electrosurgicalexcision (choice B) are procedures used to removecervical dysplasia or malignancy while leaving as muchof the cervix intact as possible.Neither is indicated untilfurther workup with colposcopy indicates what abnormality,if any, is present.Although occasionally LSIL is an insignificant findingthat resolves on its own, it cannot be ignored (choice C).In one series, 15% of patients with LSIL on Pap smearwere found to have significant dysplasia or invasive cancer,whereas another 15% were found to have moderatedysplasia. Not following up on an abnormal Pap smearcan have disastrous consequences.A repeat Pap smear in 1 to 2 years (choice E) is usuallyan appropriate strategy for Pap smear reports that indicatean inadequate sample was obtained and there is noclinical suspicion of disease. It is not an appropriateapproach to cellular dysplasia, though some physiciansmay repeat a Pap smear within a few months. Giventhat up to 30% of patients in some series have beenfound to have significant disease, delaying treatment fora year could prove disastrous.

10. The correct answer is D. Preeclampsia is a syndromecharacterized by hypertension and proteinuria. Edemaonce was considered part of the diagnostic triad of theillness but is no longer considered part of the diagnosticcriteria. Together with hypertension and proteinuria,preeclampsia can manifest in a myriad of otherways. For example, preeclampsia can lead to hepaticinjury, causing epigastric pain, nausea and vomiting,and elevated transaminase levels. Preeclampsia also canlead to renal injury with oliguria and an elevated creatinine.One of the most feared complications ofpreeclampsia is its effects on the nervous system. Severepreeclampsia sometimes is characterized by headacheand visual changes. Even worse, preeclampsia can leadto eclampsia, which is the occurrence of seizures in apatient with preeclampsia. These seizures can lead tosignificant morbidity and mortality for the mother andfetus. To prevent seizures in preeclamptic patients,magnesium sulfate is given. For years there had beenmuch controversy over the choice of agent to use inpregnant women to prevent seizures.Now, however, thepreponderance of evidence favors the use of magnesiumsulfate to prevent seizures in patients withpreeclampsia and to prevent further seizures in patientswith eclampsia.Magnesium sulfate can cause a lowering of blood pressurein some patients, but it is not given to patients withpreeclampsia to control hypertension (choice A).Hypertension in a preeclamptic patient does not needto be treated unless pressures remain persistently in the160s/110s mm Hg range. In patients in whom thosepressures do exist, intravenous hydralazine or labetalolcan be used.Proteinuria is one of the findings in patients withpreeclampsia. Magnesium sulfate, however, is given forseizure prophylaxis and not to control proteinuria(choice B).Magnesium sulfate is not given to patients withpreeclampsia to prevent hemorrhage (choice C). Thereis some evidence that magnesium sulfate actually canprolong bleeding times to some degree.Magnesium sulfate is not given to patients withpreeclampsia to protect the neonate (choice E). Therehas been some evidence to suggest that magnesium sulfategiven to the mother may protect prematureneonates from neurologic injury. This fetus is not premature,however, and the magnesium is used in thiscase to prevent a maternal seizure.

11. The correct answer is C. Chronic hypertension is one ofthe most common medical conditions that complicatepregnancy. Estimates are that approximately 5% of pregnantwomen have chronic hypertension. It can cause significantmaternal and fetal morbidity and mortality. Theadverse effects of chronic hypertension during pregnancyinclude intrauterine growth restriction (IUGR), prematurebirth, fetal demise, placental abruption, and cesareandelivery.How much harm the chronic hypertension causesduring the pregnancy depends on how many years thewoman has had hypertension and how well controlled orpoorly controlled the condition has been. Patients withsevere, chronic hypertension are at significant risk forhaving a fetus with IUGR. These patients should be monitoredcarefully during the pregnancy and, in particular,have regular ultrasounds to monitor fetal growth.Down syndrome (choice A) is a chromosomal disorderthat is not known to be caused by chronic hypertension.Increasing maternal age, however, is a risk factorfor chronic hypertension and Down syndrome.Intrahepatic cholestasis of pregnancy (choice B) is adisorder that occurs during pregnancy in whichpatients suffer from intrahepatic cholestasis with severepruritus. These patients often can show evidence ofliver dysfunction with abnormal liver function tests.This condition does not seem to be related to chronichypertension.Placenta previa (choice D) is defined as implantation ofthe placenta over or near the internal os.Major risk factorsfor placenta previa are advancing maternal age,multiparity, prior cesarean delivery, and smoking.The major risk factors for shoulder dystocia (choice E)are fetal macrosomia, maternal obesity, maternal diabetes,multiparity, and postdates. Patients with chronichypertension do not seem to be at increased risk forshoulder dystocia.

12. The correct answer is B. Pelvic inflammatory disease(PID) is the term used to describe a variety of inflammatorydisorders of the female upper genital tract. Thesedisorders include endometritis, salpingitis, oophoritis,and tubo-ovarian abscess. N. gonorrhoeae and C. trachomatisare the organisms that are most commonlyimplicated in pelvic inflammatory disease, but, in actuality,the infection is typically polymicrobial and caninvolve organisms found in the normal vaginal flora.Patients with PID can be treated as inpatients or outpatientsdepending on their disease severity, other medicalproblems, and their reliability. This patient was admittedand rapidly improved. Current recommendations for thetreatment of PID are that an admitted patient may bedischarged on oral medication within 24 hours of clinicalimprovement. Doxycycline continues to be the mainstayfor completion of antibiotic therapy in patients withPID, and it should be given to complete a 14-day courseof treatment (i.e., 12 more days in this case.)To discharge this patient home off all medications(choice A) would not be correct. PID can have devastatinglong-term consequences for patients, includinginfertility and chronic pelvic pain. It is essential that acomplete course of therapy be given to patients. ForPID, the complete course is completion of 14 days oftherapy.To give this patient continued intravenous antibioticsfor 5 more days (choice C) would not be necessary.Current recommendations are for a transition to oralantibiotics after 24 hours of clinical improvement.To give this patient continued intravenous antibioticsfor 12 more days (choice D) certainly would not be necessary.As explained above, once clinical improvementis sufficiently established, discharge home on oralantibiotics is recommended.Laparoscopy (choice E) would not be necessary in apatient with a sufficiently certain clinical diagnosis whoimproves on antibiotics, as this patient did.

13. The correct answer is C. This patient most likely haspolycystic ovary syndrome, which typically presentswith obesity, irregular menstrual bleeding, hirsutism,and infertility. Instead of showing the characteristic hormonefluctuation of the normal menstrual cycle, thegonadotropins and sex steroids are in a steady state,resulting in anovulation and infertility. Increased LHlevels cause increased ovarian follicular theca cell productionsof androgens. The increased levels ofandrostenedione and testosterone (choice A) suppresshepatic production of sex hormone binding globulin(choice B). The combined effect of increased totaltestosterone and decreased sex hormone binding globulinleads to mildly elevated levels of free testosterone.This results in hirsutism. The LH to FSH ratio is elevated,often to 3:1 (normal is 1.5:1 in ovulatory women).A mid-cycle temperature elevation (choice D) wouldnot typically be seen in anovulatory states.Ultrasonography of the ovaries of patients with polycysticovary syndrome typically shows multiple subcapsularcysts (string of pearls appearance) (choice E).

14. The correct answer is C. This patients hemoglobin isbelow the nonpregnant reference range. Her MCV isbetween 80 fl and 100 fl and thus normocytic. The redcell distribution width (RDW) is also 100 fl).Iron deficiency anemia (choice B) is microcytic (MCV15.Even though this patient is ofMediterranean descent, shedoes not automatically have thalassemia (choice E) orsickle-cell trait (choice D). In order to diagnose theseconditions, you should perform serum electrophoresis.However, this patient most likely has physiologic anemia.15. The correct answer is B. The classification of diabetesduring pregnancy was created by Priscilla White and colleaguesin the mid twentieth century. This classificationallowed one to estimate the likelihood of stillbirth for agiven patient with diabetes during pregnancy. Patientswho are class A1 have gestational diabetes with a fastingplasma glucose