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OBSTERICS (GYN APGO) Multiple Questions and Answers with Explanations A+ Graded
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OBSTERICS (GYN APGO) Multiple Questions and Answers with Explanations A+ Graded
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OBSTERICS (GYN APGO) MultipleQuestions and Answers with
Explanations A+ Graded.
A 28-year-old G1P1 woman delivered three days ago and desires to breastfeed
her infant, but is having problems since her milk came in with full tender
breasts. She is uncomfortable and has engorged breasts. Which of the
following strategies may help relieve her discomfort?
A. Discontinue breastfeeding for 24 hours to decrease the milk supply
B. Cover the breast with cool lettuce leaves
C. Increase the interval between breastfeeding sessions to decrease the milk
supply
D. Nurse every 1.5-3 hours around the clock
E. Don't wear a bra until the engorgement subsides
ANSWER -D. Engorgement commonly occurs when milk comes in. Strategies
that may help include frequent nursing, taking a warm shower or warm
compresses to enhance milk flow, massaging the breast and hand expressing
some milk to soften the breast, wearing a good support bra and using an
analgesic 20 minutes before breast feeding.
A 30-year-old G1P1 woman is breastfeeding her baby and feels there is not
enough milk. She is pumping in order to improve the supply of milk. You tell
her that more frequent suckling would be better as it will stimulate which of the
following hormones?
A. Progesterone
B. Insulin
C. Cortisol
,D. Prolactin
E. Oxytocin
ANSWER -E. While prolactin is responsible for milk production, oxytocin is
responsible for milk ejection. Production of oxytocin is stimulated by suckling
which works better than a breast pump for stimulating the secretion of milk.
Cortisol and insulin act in concert with other hormones to stimulate the growth
and development of the milk-secreting apparatus.
A 30-year-old G3P2 woman, whose last normal menstrual period was eight
weeks ago, began spotting three days ago and developed cramping this
morning. She has a history of a chlamydia infection with a previous pregnancy.
She smokes one pack of cigarettes per day and denies alcohol or drug use. On
physical exam: blood pressure 120/70; pulse 82; respirations 20; and
temperature 98.6°F (37.0°C). Abdominal examination is normal. Pelvic
examination reveals old blood in the vaginal vault, closed cervix without
lesions, slightly enlarged uterus and no adnexal tenderness. Pertinent labs:
Quantitative Beta-hCG is 1000 mIU/ml; urinalysis normal; hematocrit = 32%.
Transvaginal ultrasound shows no intrauterine pregnancy, no adnexal masses,
no free fluid in pelvis. Which of the following is the most appropriate next step
in the management of this patient?
A. Treat with methotrexate
B. Exploratory surgery
C. Repeat Beta-hCG in 48
ANSWER -C. The patient first needs to have an accurate diagnosis before a
treatment plan is entertained. She has risk factors for ectopic pregnancy.
Repeating the Beta-hCG is the next step in this patient's management.
Inappropriately rising Beta-hCG levels (less than 50% increase in 48 hours) or
levels that either do not fall following diagnostic dilation and curettage would
be consistent with the diagnosis of ectopic pregnancy. Alternatively, a fetal
pole must be visualized outside the uterus on ultrasound. The patient would
need a Beta-hCG level over the discriminatory zone (the level where an
intrauterine pregnancy can be seen on ultrasound) with an empty uterus. The
,level commonly used is 2000 mIU/ml. Treatment with methotrexate may be
appropriate, but only after a definitive diagnosis is made. The patient does not
yet have this level and is stable. She is, therefore, not a candidate for
exploratory surgery. If she had unstable vital signs or an acute abdomen, a
diagnostic laparoscopy/laparotomy would be indicated. Repeating the
ultrasound in one week is not recommended because a delay in diagnosis
could result in a ruptured ectopic pregnancy and increased risk to the patient.
The patient is hemodynamically stable, therefore, she does not need to be
admitted to the hospital.
A 28-year-old G0 woman whose last normal menstrual period was four weeks
ago presents with a two-day history of spotting. She awoke this morning with
left lower quadrant pain of intensity 4/10. She has no urinary complaints, no
nausea or vomiting, and the remainder of the review of systems is negative.
She has no history of sexually transmitted infections. She smokes one pack of
cigarettes per day and denies alcohol or drug use. Her vital signs are: blood
pressure 124/68, pulse 76, respirations 18, and temperature 100.2° F (37.9°C).
On examination, she has mild left lower quadrant tenderness, with no rebound
or guarding. Pelvic exam is normal except for mild tenderness on the left side.
Quantitative Beta-hCG is 400 mIU/ml; progesterone 5 ng/ml; hematocrit 34%.
Ultrasound shows a fluid collection in the uterus, with no adnexal masses and
no free fluid. What is the most likely diagnosis?
A. Ovarian torsion
B. Missed
ANSWER -D. It is difficult to establish a definitive diagnosis at this time. When
the Beta-hCG level is below the discriminatory zone (2000 mIU/ml), an early
intrauterine pregnancy may not be visualized on ultrasound. Missed abortion,
early intrauterine pregnancy and ectopic pregnancy could only be confirmed by
serial Beta-hCG levels (at least every 48 hours until a trend is established,
usually three levels). Ovarian torsion is a possible diagnosis, however, this is
more common with an ovarian mass
, 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
ANSWER -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 G2P1 woman presents with vaginal spotting and uterine
cramping. Her last normal menstrual period was six weeks ago and she began
spotting three days ago. She has no history of sexually transmitted infections.
Her vital signs are: blood pressure 120/70; pulse 78; respirations 20; and
temperature 98.6 °F (37.0°C). On pelvic examination, she has no cervical motion
tenderness, her uterus is normal size and nontender; no adnexal masses are
palpable. Quantitative Beta-hCG 48 hours ago was 1500 mIU/ml; current beta-
hCG is 3100 mIU/ml; progesterone 26 ng/ml; hematocrit 38%; and urinalysis is
normal. What is the most likely finding on transvaginal ultrasound?
A. Debris in uterus
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