Abnormal Uterine Bleeding
ACOG recommends that all adolescents with heavy menstrual bleeding since menarche who present with acute AUB should be evaluated for this bleeding disorder.
What is Von Willebrand Disease?
According to ACOG, the most common presenting symptom of uterine leiomyomas is this.
What is heavy menstrual bleeding?
ACOG recommends this type of hormonal therapy as first-line for adolescents with endometriosis.
What is continuous combined hormonal contraceptives or progestin-only agents?
ACOG defines active phase arrest as no cervical change at or beyond 6 cm dilation with ruptured membranes after this duration of adequate uterine activity.
What is 4 hours?
According to ACOG, the most common maternal complication of prelabor rupture of membranes is this
What is infection?
According ACOG, this endometrial thickness threshold on transvaginal ultrasonography has a greater than 99% negative predictive value for endometrial cancer in women with postmenopausal bleeding.
What is 4 mm or less?
A premenopausal woman presents with a simple, unilocular ovarian cyst measuring 4 cm. According ACOG, this is the recommended management.
What is observation?
An adolescent with dysmenorrhea does not improve after 3 months of NSAIDs and hormonal therapy. According to ACOG, this is the next step in evaluation.
What is evaluation for secondary causes, including endometriosis, with pelvic examination and ultrasonography?
For nulliparous individuals, ACOG defines prolonged second stage of labor as more than this duration of pushing.
What is 3 hours?
ACOG recommends daily vaginal progesterone to reduce the risk of spontaneous preterm birth for patients with a singleton pregnancy with this cervical length at this gestational age.
What is less than 25 mm between 16 and 24 weeks?
A 38-year-old nulligravid woman presents with heavy regular menses despite high-dose cyclic oral contraceptive therapy. Her medical and surgical histories are normal. She does not take other medications. The results of recent serum laboratory testing were normal, including thyroid function tests. Pelvic ultrasonography shows a normal-sized uterus with a 1.2-cm endometrial echocomplex and normal-appearing ovaries. This is the best next step in management?
A) Discontinue OCPs and repeat labs
B) Insert a levonorgestrel IUD
C) Prescribe TXA therapy during menses
D) Perform an endometrial biopsy
E) Perform a dilation & curretage
What is D) Perform an endometrial biopsy?
In a woman older than 45 with abnormal uterine bleeding, an endometrial biopsy is recommended. Biopsy is also indicated for women under 45 if other risk factors exist, such as obesity, PCOS, persistent abnormal uterine bleeding, or lack of improvement with medical management. Thyroid function test results are not affected by oral contraceptive use. A levonorgestrel IUD and tranexamic acid may be offered if the endometrial biopsy result is normal. Dilation and curettage is inappropriate without a preoperative endometrial biopsy.
ACOG states that these two ovarian pathologies are most commonly associated with adnexal torsion in adolescents.
What are benign functional ovarian cysts and benign teratomas?
A patient with suspected endometriosis has persistent pain despite medical therapy. According to ACOG, this diagnostic procedure should be considered.
What is diagnostic laparoscopy?
As the duration of pushing increases, the odds of postpartum hemorrhage, cesarean delivery, and third- or fourth-degree lacerations increase, but the absolute difference in neonatal risks is approximately this percentage or less.
What is 1% or less?
For patients with a history of dilation and curettage, ACOG notes an increased risk of preterm birth by approximately this percentage for a single procedure.
What is 30%?
A 56-year-old postmenopausal women reports 2 episodes of light vaginal bleeding over the past month. Her physical examination findings are unremarkable and do not suggest a possible source of her bleeding. Pelvic ultrasonographic evaluation shows a regular-appearing endometrial stripe with a thickness of 3 mm. This is the most likely cause of her bleeding.
A) Endometrial atrophy
B) Endometrial cancer
C) Endometrial hyperplasia
D) Endometrial polyp
What is A) endometrial atrophy?
In postmenopausal women with vaginal bleeding, an endometrial stripe thickness of 4 mm or less confers a 99% negative predictive value for endometrial cancer. Given no other abnormalities on ultrasonography, the most likely diagnosis for this patient is endometrial atrophy. Should further bleeding occur, additional evaluation may be indicated.
A 59-year-old white postmenopausal woman presents with bilateral adnexal masses. On ultrasonographic evaluation, the masses are found to have both cystic and solid components. Her serum CA 125 concentration is 150 U/mL. This factor in her presentation is associated with the greatest increased risk for ovarian malignancy.
A) Age
B) Race/ethnicity
C) Bilaterality of masses
D) Solid components
E) Serum Ca 125 concentration
What is A) Age?
Patient characteristics, physical examination findings, imaging studies, and laboratory testing can all help to better characterize an adnexal mass as likely benign versus likely malignant. A serum CA 125 concentration above 35 U/mL in a postmenopausal woman is abnormal and should prompt referral to a gynecologic oncologist. Additionally, ultrasonographic findings including a cyst size greater than 10 cm in diameter, papillary or solid components, irregularity of shape, and the presence of ascites are also suggestive of malignancy. However, age is the single most important independent risk factor for ovarian cancer in the general population, with a sharp increase in incidence in the postmenopausal period and a median age at diagnosis of 63 years.
ACOG recommends this second-line class of medications for patients with persistent pain despite first-line hormonal therapy.
What are gonadotropin-releasing hormone (GnRH) agonists or antagonists?
A 33F G2P0010, at 39 2/7 is undergoing IOL. The EFW is 3,200 g, the fetal tracing is cat I, and the cervical examination is 1/25/−3. The patient receives a Foley balloon and three doses of miso. The balloon is expelled after 12 hours, and oxytocin is started. The fetal tracing remains reassuring, with regular contractions. The cervical examination is now 4/75/−3. This is the next step in labor management to decrease the time to a vaginal delivery without increasing cesarean delivery or maternal or neonatal complications.
A) Monitoring contraction strength with an IUPC
B) Administering high-dose oxytocin
C) Maternal use of a peanut ball
D) Performance of early AROM at time of oxytocin initiation
What is
D) Performance of early AROM at time of oxytocin initiation?
A 32F G2P0101, presents at 30 weeks of gestation with contractions that are 2–5 minutes apart. They deny bleeding, leakage of fluid, and endorse fetal movement. Past medical history is notable for aortic insufficiency and GDMA2 that is poorly controlled. Vital signs are within normal limits and a non-stress test is reactive with contractions every 3 minutes. The cervix is 3 cm dilated and 50% effaced. The patient accepted corticosteroids and magnesium sulfate and 1 hour later continues to contract every 3 minutes. This tocolytic agent is most appropriate for providing short-term prolongation of this pregnancy.
What is indomethicin?
Tocolytic therapy may provide short-term prolongation of pregnancy. Indomethacin is the most appropriate choice for this patient who is at less than 32 weeks of gestation. Short courses are not associated with premature construction of the ductus arteriosus and oligohydramnios at this gestational age. Calcium channel blockers are contraindicated in preload-dependent cardiac lesions. Terbutaline is contraindicated in patients with poorly controlled diabetes. Transdermal nitroglycerin is associated with significant maternal side effects. Atosiban is the only tocolytic that has demonstrated superiority as maintenance therapy but is not available in the United States.
A 38-year-old woman, gravida 2, para 2, presents with intermenstrual spotting. Physical examination results do not indicate a likely etiology of her bleeding. Transvaginal ultrasonography findings suggest a possible endometrial polyp, but the results are not diagnostic. This is the best next step in evaluation.
A) Transabdominal ultrasound
B) Saline-infusion sonohysterography
C) Computed tomography
D) Magnetic resonance imaging
What is B) Saline-infusion sonohysterography
Saline-infusion sonohysterography is the next step if transvaginal ultrasonography is inadequate for diagnosis or further assessment of intracavitary uterine lesions is needed. Routine use of MRI or CT is not recommended for the evaluation of abnormal uterine bleeding.
The following ultrasonographic finding is NOT suggestive of ovarian torsion.
A) Disruption of normal adnexal blood flow
B) Tubular-shaped sonolucent cysts
C) Twisted pedicle with a bullseye or whirlpool appearance
D) Unilateral enhanced ovarian echogenicity
E) Unilateral ovarian displacement
What is B) Tubular-shaped sonolucent cysts?
Ultrasonographically, a hydrosalpinx is represented by a tubular-shaped sonolucent cyst. All of the other findings could suggest ovarian torsion.
A 35-year-old patient with endometriosis undergoes a hysterectomy with bilateral salpingo-oophorectomy. This is the most common site of recurrence of endometriotic lesions after surgery.
A) Bladder
B) Large bowel
C) Pelvic peritoneum
D) Umbilicus
E) Ureter
What is B) large bowel?
The most common site of involvement of endometriosis is the ovary. After definitive surgical therapy with hysterectomy and removal of the ovaries, the most common site of involvement is the large and small bowel.
A 26F G2P1001 at 38 5/7 is admitted in labor. The EFW is 4,200 g. Cervical examination on admission is 6/90/0 with ruptured membranes. The patient receives an epidural and is started on low-dose oxytocin. The cervical examination is unchanged after 2 hours, and an IUPC is placed. The fetal tracing is cat I, and the tocometer shows 150 MVUs. Oxytocin continues to be titrated per protocol. Four hours later, the cervical examination remains unchanged, and the IUPC shows 180 MVUs. This is the best next step in the management of this patient.
A) Continue oxytocin until adequate contractions are achieved
B) Replace the IUPC and monitor for an additional 4 hours
C) Administer IV fluids
D) Recommend C-section
What is
D) Recommend C-section?
A 26F G1P0, presented at 28 weeks of gestation with contractions that were 2–5 minutes apart. They were admitted for management of preterm labor and have completed a course of corticosteroids, magnesium sulfate, and indomethacin. In patients presenting with preterm labor, this tocolytic agent is most effective for prolongation of pregnancy past the 48-hour window.
A) Indomethicin
B) Nifedipine
C) Terbutaline
D) Transdermal nitroglycerin
E) None of the above
What is E) None of the above?
Maintenance therapy with tocolytics is ineffective for preventing preterm birth and improving neonatal outcomes and is not recommended for this purpose. Tocolytic therapy may provide short-term prolongation of pregnancy, enabling the administration of antenatal corticosteroids and magnesium sulfate for neuroprotection, as well as transport, if indicated, to a tertiary facility. However, no evidence exists that tocolytic therapy has any direct favorable effect on neonatal outcomes or that any prolongation of pregnancy afforded by tocolytics translates into a statistically significant neonatal benefit.