A 24-year-old nullipara is being evaluated for infertility. On pelvic examination, she has a single cervix. A diagnostic laparoscopy shows a double uterine fundus. Which of the following is the most likely diagnosis of her uterine anomaly?
Answer(s): C
Asingle cavity uterus forms from fusion of paired Müllerian ducts followed by dissolution of the fused medial walls. Uterine anomalies can be divided into five distinct categories: A. failure of formation of one or both Müllerian ducts (unicornuate uterus or absent uterus, respectively); B. failure of fusion of the Müllerian ducts (didelphic uterus, with two cervixes and two vaginal canals separated by a longitudinal septum); C.partial fusion of the Müllerian ducts (bicornuate uterus); D. failure of dissolution of the fused medial walls of the Müllerian ducts (septate uterus); and E. DES exposed uterus. Afetus exposed to DES (or any estrogen) in the first trimester will often develop a T-shaped uterine cavity. The pathophysiology of this abnormality is unknown. In this patient, a single cervix and a double uterine fundus indicate a bicornuate uterus.
A 58-year-old G6P4Ab2 diabetic woman who weighs 122.6 kg (270 lb) has her first episode of vaginal bleeding in 5 years. Her physician performs an outpatient operative hysteroscopy and dilatation and curettage (D&C). Which of the following is an indication for the procedure and the most likely diagnosis?
Answer(s): B
Obesity, advanced age, and hepatic disease are associated with an increased risk of endometrial adenocarcinoma. While postmenopausal bleeding is most commonly caused by atrophic changes in the genital tract, cancer must be considered. Cervical cytology and examination of endometrial histology are absolutely indicated. The risk of endometrial cancer is increased approximately threefold in diabetic women, and obese women have a three- to fourfold increased risk. High parity is a risk factor for cervical cancer; low parity is a risk factor for ovarian and endometrial cancer. Postmenopausal bleeding is a sign of ovarian cancer only if the malignancy secretes estrogen to stimulate the endometrium. An office endometrial biopsy has a sensitivity of about90%. If postmenopausal bleeding persists, a D&C with hysteroscopy should be done. AD&C alone samples about 50% of the endometrium. For this reason, many gynecologists are performing a hysteroscopy and directed endometrial biopsy in addition to a D&C.
A pregnant woman is being followed by a nephrologist for chronic glomerulonephritis. Which of the following findings is normal at 28 weeks' gestation?
Answer(s): D
Blood pressure tends to drop slightly in normal pregnancy. This woman's blood pressure of 132/86 mmHg is definitely higher than would be expected and suggests the possibility of chronic hypertension. Because the GFR in pregnancy increases normally by as much as 50% to a peak of approximately 160 mL/min, serum creatinine and BUN should be less than 0.9 and 13 mg/100 mL, respectively. The observed values in this patient are elevated or pregnancy. The renal threshold for glucose normally decreases in pregnancy.Therefore, glycosuria does not always mean diabetes in pregnancy. Several plasma glucose measurements should be obtained in pregnant women with glycosuria to correlate urinary and plasma glucose levels.
A 25-year-old woman has a positive cervical culture for Neisseria gonorrhoeae. She has had at least two positive cultures for gonorrhea treated in the past. She is afebrile and has no symptoms. The incidence of penicillin-resistant gonorrhea in some areas of the United States is currently as great as 10%. Because of this, the recommended treatment for gonorrhea includes which of the following?
Answer(s): A
The current treatment guideline from the Centers for Disease Control and Prevention for uncomplicated gonococcal infections is ceftriaxone 125 mg IM one time. Cefixime 400 mg orally is an alternative. Each is given as a single dose. Importantly, the quinolone class, for example, ciprofloxacin is no longer considered appropriate treatment for gonococcal infections due to drug resistance. To the chosen drug is added azithromycin, 1 g orally, or doxycycline, 100 mg orally twice daily for 7 days. The second drug is added to treat C. trachomatis, which is present in almost 50% of women with gonorrhea. Sexual partners should be treated at the same time
A 37-year-old pregnant woman with type 2 diabetes mellitus and chronic hypertension is 35 weeks' pregnant. Which of the following is the best test to screen for fetal well-being?
Answer(s): E
Of the choices listed, a biophysical profile is the best assessment of fetal well-being. This assesses multiple fetal variables: breathing movement, body or limb movements, tone and posture, fetal heart rate pattern, and amniotic fluid volume. A NST, oxytocin challenge test, and fetal movement counts assess only one determinant of fetal well-being. An amniocentesis has no value in assessing fetal well- being, but may be appropriate to determine fetal lung maturity if induction of labor before 40 gestational weeks is indicated because of her chronic illnesses. Fetal Doppler studies to assess systolic:diastolic (SD) ratio may be a better test of fetal well-being and a significant decrease or reversal of the ratio is an indication for delivery.
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