NINTH EDITION LANGE Q&A™ OBSTETRICS & GYNECOLOGY Vern L Katz, MD Clinical Professor Department of Obstetrics and Gynecology Oregon Health Science University Medical Director, Perinatal Services Sacred Heart Medical Center Eugene, Oregon Sharon Phelan, MD Professor of Obstetrics & Gynecology School of Medicine Department of Obstetrics and Gynecology University of New Mexico Albuquerque, New Mexico Vicki Mendiratta, MD Associate Professor Department of Obstetrics and Gynecology University of Washington School of Medicine Seattle, Washington Roger P Smith, MD The Robert A Munsick Professor of Clinical Obstetrics & Gynecology Director, Medical Student Education Director, Division of General Obstetrics & Gynecology Department of Obstetrics and Gynecology Indiana University School of Medicine Indianapolis, Indiana Copyright © 2011 by The McGraw-Hill Companies, Inc All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be 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PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise Contents Student Reviewers Preface Abbreviations USMLE Step CK Laboratory Values Anatomy Questions Answers and Explanations Histology and Pathology Questions Answers and Explanations Embryology Questions Answers and Explanations Genetics and Teratology Questions Answers and Explanations Physiology of Reproduction Questions Answers and Explanations Maternal Physiology During Pregnancy Questions Answers and Explanations Placental, Fetal, and Newborn Physiology Questions Answers and Explanations Prenatal Care Questions Answers and Explanations Diseases Complicating Pregnancy Questions Answers and Explanations 10 Normal Labor and Delivery Questions Answers and Explanations 11 Abnormal Labor and Delivery Questions Answers and Explanations 12 Operative Obstetrics Questions Answers and Explanations 13 Puerperium Questions Answers and Explanations 14 Newborn Assessment and Care Questions Answers and Explanations 15 Infertility Questions Answers and Explanations 16 Clinical Endocrinology Questions Answers and Explanations 17 Contraception Questions Answers and Explanations 18 Gynecology: Common Lesions of the Vulva, Vagina, Cervix, and Uterus; Gynecologic Pain Syndromes; Imaging in Obstetrics and Gynecology Questions Answers and Explanations 19 Pelvic Floor Dysfunction: Genital Prolapse and Urogynecology Questions Answers and Explanations 20 The Pelvic Mass Questions Answers and Explanations 21 Gynecologic Oncology: Premalignant and Malignant Diseases of the Lower Genital Tract— Vulva, Vagina, and Cervix Questions Answers and Explanations 22 Gynecologic Oncology: Upper Genital Tract Benign and Malignant Conditions Questions Answers and Explanations 23 Breast Cancer Questions Answers and Explanations 24 Infectious Diseases in Obstetrics and Gynecology Questions Answers and Explanations 25 Special Topics in Gynecology: Pediatric and Adolescent Gynecology, Sexual Abuse, Medical Ethics, and Medical–Legal Considerations Questions Answers and Explanations 26 Primary Health Care for Women Questions Answers and Explanations 27 Practice Test Questions Answers and Explanations References Index Student Reviewers Adam Darnobid, MD Resident Physician UMass Memorial Medical Center Worcester, Massachusetts Class of 2009 Barrett Little Temple University School of Medicine Philadelphia, Pennsylvania Class of 2010 Radhika Lu Sundararajan New York University School of Medicine New York, New York Class of 2010 Preface Education is the kindling of a flame, not the filling of a vessel —Socrates The ninth edition of Lange Q&A: Obstetrics and Gynecology book has been written, as were the prior editions, to be a study aid for self-examination and review in the field of obstetrics and gynecology Each chapter has been updated with new questions written to cover new information These encompass new areas in the field, updates in other areas, and some of the new clinical guidelines from national organizations The questions are designed to review many topics commonly covered in tests such as the clerkship examination and United States Medical Licensing Examination (USMLE) Step CK The style and presentation of the questions have been fully revised to conform with the USMLE This will enable readers to familiarize themselves with the types of questions to be expected and practice answering questions in each board format used in the actual examination The majority of questions are multiplechoice one best answer-single-item questions For these questions, you will choose the one best response to the question Some questions are matching sets consisting of a group of questions preceded by a list of lettered options For these questions you will select one lettered option that is most closely associated with the question In some cases, a group of two or three questions may be related to one patient situation These questions—often called second- or third-order questions—will require you to think through the entire set of questions to reach the correct answers in the patient scenario Since the USMLE seems to prefer questions requiring judgment and critical thinking, we have attempted to emphasize these questions In addition, some questions have images that require understanding and interpretation to reach the correct answer Each chapter of this book presents questions covering important topics in the obstetrics and gynecology specialty The question sections are followed by a section containing the answers and explanations These answer sections provide background information on the subject matter and discuss the various issues raised by the question and its answer After answering a question, we encourage you to review the explanations further—even if you have answered the question correctly—to enhance your study and understanding These explanations will often discuss not only why one answer is correct, but also why the other choices are incorrect This reinforces your knowledge and provides feedback to guide further study At the end of the book we have included a practice test that contains randomly ordered questions of all styles covering all the topics This test is designed to more closely approximate the form of the USMLE Step CK examination An answer and comment section follows the practice test and relates to the questions contained in it We hope that using this review will help you consolidate your knowledge, evaluate your capabilities, and motivate you to continually expand your horizons to levels far beyond this study aid Ovarian epithelial cancers Ovarian epithelial carcinoma Ovarian epithelium Ovarian fibroma Ovarian follicles Ovarian neoplasia pelvic examination Ovarian neoplasms Ovarian steroidogenesis Ovarian tumors Ovary Ovary, removal of Overflow incontinence Ovulation Ovulation induction Oxygen dissociation curve saturation Oxytocin Oxytocin infusion Oxytocin IV P Packed red blood cells (PRBCs) Paclitaxel Pad test Paget’s carcinoma Paget’s disease Painless genital bleeding Palmar erythema Palpable ovary PAMBA See Para-aminomethylbenzoic acid (PAMBA) Pap smear Papanicolaou smear Para-aminomethylbenzoic acid (PAMBA) Paracentric Parakeratosis Paralysis facial Paramesonephric ducts development of Paramesonephros Parametritis Paramyxovirus Paraovarian cysts Parathyroid hormone (PTH) Paroxetine Partial breech extraction Parvovirus PCOS See Polycystic ovarian syndrome (PCOS) PCT See Postcoital test (PCT) Pediatric ovarian malignancies Pediculosis pubis Pelvic abscess Pelvic axis Pelvic cellulitis Pelvic diaphragm Pelvic examination Pelvic floor dysfunction innervation of Pelvic inflammatory disease (PID) Pelvic kidney Pelvic ligaments Pelvic mass Pelvic tuberculosis Pelvic ultrasound Pelvimetry Pelvis fascial support of human Penicillin Penis Peptostreptococcus Percreta Perinatal deaths Perineal laceration Perineum arteries and nerves of Peripartum hysterectomy Peritoneal cavity Peritonei pseudomyxoma Peritoneum Permanent contraception See Surgical sterilization Permethrin (Nix) Petechial rash Peutz-Jeghers syndrome PG synthetase inhibitors PGs See Prostaglandins (PGs) Phenylketonuria (PKU) Phosphatidylglycerol (PG) Phospholipase A PID See Pelvic inflammatory disease (PID) Pigmented lesions, on vulva Pin worms Piriformis muscle Pituitary adenoma Pituitary cells Pituitary infarction Pituitary necrosis Pituitary somatomammotropin levels Pityriasis rosea PKU See Phenylketonuria (PKU) Placenta battledore bipartite circumvallate cotyledons human implantation of multiple-pregnancy separation Placenta accreta Placenta increta Placenta previa Placental anastomosis Placental fragments Placental lactogen Plasma bicarbonate Plasma chorionic somatomammotropin Plasma fibrinogen Plasma volume Platinum chemotherapy PMS See Premenstrual syndrome (PMS) Pneumococcus vaccine Pneumonia Podophyllin resin Polio vaccine Polycystic ovarian syndrome (PCOS) Polygenic/multifactorial inheritance Polyglandular autoimmune syndrome Polyhydramnios Polyploidy Ponstel Portal sinus Positive pregnancy tests Post-tubal ligation syndrome Postcoital contraception Postcoital test (PCT) Postembolization syndrome Posterior iliac nerve Posterior vaginal fornix Postmaturity Postpartum bleed Postpartum blues Postpartum hemorrhage Postpill amenorrhea Postterm labor Postural diuresis Posturethral value Potter’s syndrome Precocious puberty Preeclampsia Pregnancy diseases complicating epulis of fundal height in HIV testing in immunization during lung volumes in Pregnanediol drops Pregnenolone Premalignant and malignant diseases, of lower genital tract Premature labor Premature thelarche Prematurity Premenstrual dysphoric disorder, diagnostic criteria for Premenstrual syndrome (PMS) Prescription medications, sale of Preterm birth Preterm infants Primary amenorrhea Primary dysmenorrhea Primary health care, for women Primordial germ cells Prior clotting and liquefaction PRL See Prolactin (PRL) Procidentia Prodromal labor Professional liability insurance Progesterone effect of production receptors Progestin therapy Progestins Prolactin (PRL) Prolactinomas Prolonged labor Pronephros function of Prophylactic antibiotics Propylthiouracil (PTU) therapy Prostaglandin F2 alpha Prostaglandins (PGs) Proteus species Pruritus Pseudohermaphroditism Pseudomyxoma peritonei Pseudoprecocious puberty PTH See Parathyroid hormone (PTH) Ptyalism Pubertal changes in female Puberty onset of precocious Pubic hair growth Pubic symphysis Pubic tubercle Pubourethral ligaments Pubovaginal slings Pudendal anesthetic blockade Pudendal canal Pudendal nerve Puerperium Pulmonary angiography Pulmonary edema Pulmonary emboli Pulmonary embolism Pulmonary system of fetus Punch biopsy Purpura Pyelonephritis Pyloric stenosis Pyosalpinx Q Q-tip test QUAD screen R Radiation enteritis Radiation exposure Radiation therapy Radical hysterectomy Radical vulvectomy Radioactive iodine scans Radiogram Radiopaque dye Radiotherapy Rape, emotional sequella of Rapid plasma reagin (RPR) RBCs See Red blood cells (RBCs) RDS See Respiratory distress syndrome (RDS) Reassurance and pelvic rest Receptor action Rectal incontinence Rectocele Rectus muscles Red blood cells (RBCs) Regional enteritis Reiter syndrome Remnants of the hymen Renal agenesis Renal atresia Renal function Renal lithiasis Reproductive-age bleeding Reproductive-age couples Resectable disease Residual urine, measurement of Respiratory distress Respiratory distress syndrome (RDS) Retention reason for Retention cysts Retinal hemorrhage Retraction rings Retroflexion of uterus Rhabdomyosarcomas embryonal Rheumatoid arthritis RhoGAM Rhythm method Right inguinal mass Ring chromosome Ritgen maneuver Ritodrine RNA virus Rokitansky’s protuberances Routine episiotomy RPR test See Rapid plasma reagin (RPR) test RPR See Rapid plasma reagin (RPR) RU-486 Rubella Rubella exposure, fetal infection after Rubella immunization, for nonimmune patients Rubella nonimmune Rubeola (measles) Ruptured corpus luteum cyst, of ovary Ruptured uterus S Sacral promontory Sacrospinous ligament Sacrotuberous ligament Saliva Salivation during pregnancy Salmonella Salpingo-oophorectomy Sarcoma botryoides Sarcomas Sarcomatous degeneration, in uterine leiomyoma Scabies Scalp defects Sciatic foramen lesser Sciatic nerve Sciatica Sclerosis Lichen Second-degree tear Second twin Secondary dysmenorrhea causes of Secondary dysmenorrheal Secondary syphilis Sella turcica Semen analysis Semicircularis linea Sensory innervation of perineum Sensory urgency Sentinel node mapping Septic abortion Septic shock Serial sectioning Serotonin Serous cystadenocarcinoma Serous cystadenomas Serous ovarian tumors Serous tumors Sertili-Leydig cell type Sertoli-Leydic cell tumor Sertraline Serum beta-globulins Serum CA-125 measurements Serum creatinine Serum early follicular phase, FSH and estradiol levels Serum hCG determination Serum testosterone Severe headache Severe ovarian hyperstimulation syndrome Sex assignment Sex chromatin Sex steroid Sex steroid levels, postpartum decline in Sex-determining region of Y chromosome (SRY) Sexual assault victim, alleged Sexually abused children Sexually transmitted disease (STD) Sheehan’s syndrome Short maternal stature Shoulder dystocia Sickle cell anemia Sickle cell disease Sigmoidocele Sigmoidoscopy “Silent killer” Simms-Huhner test Simple hyperplasia Sims-Huhner test Skin drying nipple retraction tests SLE See Systemic lupus erythematosus (SLE) Sliding hernia Smoking Soft/boggy uterus Sonography abdominal transvaginal Spermatogenesis Spermicidal creams Spermicides Spider angiomata Spigelian Spigelian hernia Spina bifida Spinal cord Spinnbarkeit Spiral computed tomography scan Spirochetes Spongy zones Spontaneous abortion Spontaneous miscarriage Squamocolumnar junction Squamous Squamous cell Squamous epithelium Squamous metaplasia SRY See Sex-determining region of Y chromosome (SRY) Staphylococcus Staphylococcus aureus Staphylococcus saprophyticus STD See Sexually transmitted disease (STD) Stem cell theory Stenosis pyloric Sterilization Steroids Stimulation by testosterone Stomach physical elevation of Stool guaiac examination Strangulated hernia Stratified squamous epithelium Streptococci Streptococcus Streptomycin Stress Stress incontinence Stroma Stromal hyperthecosis Struma ovarii Subdural hematomas Subgaleal hemorrhage Suboccipitobregmatic diameter Succenturiate lobe Suction Sulfa drugs Sulfa ointment Sulfas Sulfonamides “Sundowning” Superficial drainage Superficial inguinal ring Superficial squamous cells Superficial transverse perineal muscle Supine hypotension symptoms of Supine hypotensive syndrome Surfactant Surfactant therapy Surgery Surgical sterilization Swan-Ganz catheter Symphysis pubic Synarthroses Syphilis Systemic circulation of fetus Systemic lupus erythematosus (SLE) T T cells Tachycardia Tachysystole Tamoxifen Tampon ulcers Tamponade effect TB See Tuberculosis (TB) TBG See Thyroxine-binding globulin (TBG) Telogen effluvium Teratogen Teratogenicity Testicular feminization Testosterone Tetany Tetracycline Tetralogy of Fallot Tetraploidy Thalassemia Thalidomide Theca Theca interna Theca lutein cyst Thecal cells Thecoma Thermogenic effect Third-degree lacerations Threatened abortion high doses of progesterone for therapy for Thrombocytopenia Thrombophilia Thrombophlebitis Thyroid cancer Thyroid stimulators long-acting Thyroid-stimulating hormone (TSH) Thyrotropin-releasing hormone (TRH) Thyroxine-binding globulin (TBG) Tissue trauma TMP-SMZ See Trimethoprim-sulfamethoxazole (TMP-SMZ) TNM See Tumor, Node, Metastasis (TNM) Tococystic agents Topical anesthetics Topical application of ice Topical estrogen therapy Torsion Total thyroxine (T4) Total triiodothyronine (T3) Toxic shock syndrome (TSS) Toxoplasmosis Toxoplasmosis infection during pregnancy Tracing Tranexamic acid (AMCA) Transformation zone Translocation Transvaginal sonography Transvaginal ultrasonography Transverse cervical ligaments Traumatic alopec Traveler’s diarrhea TRH See Thyrotropin-releasing hormone (TRH) Trial of forceps Trichomonas Trimethoprim-sulfa Trimethoprim-sulfamethoxazole (TMP-SMZ) Triploidy Trisomy autosomal Trophoblast True pelvis characteristics of TSH See Thyroid-stimulating hormone (TSH) TSS See Toxic shock syndrome (TSS) Tubal abortion Tubal tumors Tuberculosis (TB) Tumor grade Tumor, Node, Metastasis (TNM) Turcica sella Turner’s syndrome U Ulceration Ulcerative colitis Ultrasonographic evaluation Ultrasonography transvaginal Ultrasound with ductography examination for placental localization Ultrasound directed biopsy Umbilical hernia Umbilical stump Umbilical vein Uncomplicated anogenital gonorrhea Unconjugated bilirubin Undifferentiated cells Unexplained Infertility Unilateral renal agenesis Universal blood donors Upper airway obstruction Upper genital tract benign and malignant conditions Ureaplasma urealyticum Ureteral lithiasis Ureterovaginal fistula Urethra erosion of Urethral caruncle Urethral diverticulum Urethral pressure profile study Urethral syndrome Urethrocele Urethrogram Urethroscopy Uric acid Uridine diphosphoglucose dehydrogenase Urinalysis Urinary incontinence Urinary luteinizing hormone (LH) kit testing Urinary retention Urinary system, defects in Urinary tract disease Urinary tract infection (UTI) Urinary urge incontinence Urinary urgency and bloating Urine culture Urine cytology Urodynamic stress incontinence Urogenital diaphragm Urogenital sinus Urologic consequence, of aging U.S Food and Drug Administration U.S Preventive Services Task Force (USPSTF) Uterine anomaly Uterine atony Uterine bleeding excessive Uterine cavity Uterine contractions Uterine corpus Uterine curettage Uterine didelphys Uterine incision Uterine inversion Uterine leiomyomas Uterine leiomyomata Uterine muscle cells Uterine myomas Uterine packing Uterine rupture Uterine sarcom Uterine sarcomas Uteroplacental apoplexy Uterosacral and cardinal ligaments Uterovaginal prolapse Uterus evacuation after adrninistering antibiotics irregular size of retroflexion of UTI See Urinary tract infection (UTI) V Vacuum extraction (VE) Vacuum extractor Vagina absence of lacerations of lesions in venous drainage of Vaginal adenosis Vaginal agenesis Vaginal birth after cesarean section (VBAC) Vaginal bleeding Vaginal cancer Vaginal cuff, opening Vaginal delivery Vaginal epithelium Vaginal estrogen cream Vaginal examination Vaginal hysterectomy Vaginal packing Vaginal repair, of fistula Vaginal rupture Vaginal septum Vaginitis Vaginoscopy Valproic acid (Depakote) Valvular heart disease diagnosis of signs of Varicella Varicella zoster immune globulin (VZIG) Vasa previa Vascular smooth muscle cells Vasectomy See Male sterilization VATER syndrome VBAC See Vaginal birth after cesarean section (VBAC) VDRL test See Venereal Disease Research Laboratory (VDRL) test VE See Vacuum extraction (VE) Venereal Disease Research Laboratory (VDRL) test Venous drainage of vagina Venous thromboembolism, perioperative risk of Ventilation, by mask Ventricular hemorrhages Ventricular septal defect (VSD) Vertex premature births Vesicovaginal fistula Vestibule VIN III See Vulvar intraepithelial neoplasia (VIN III) Virilization Vital signs Vitamin A Vitamin K Vitamin K deficiency von Recklinghausen disease VSD See Ventricular septal defect (VSD) Vulva lymphatic drainage of painless raised lesion on pigmented lesions on tumor of Vulvar biopsy Vulvar cancer anterior Vulvar diseases Vulvar intraepithelial neoplasia (VIN III) Vulvar intraepithelial neoplasia Vulvar ulcer Vulvitis atrophic Vulvovaginitis VZIG See varicella zoster immune globulin (VZIG) W Walking WHI See Women’s Health Initiative (WHI) Wolffian duct Women’s Health Initiative (WHI) World Health Organization X X chromosome, short arm of Z Zonabasalis Zygote ...NINTH EDITION LANGE Q&A OBSTETRICS & GYNECOLOGY Vern L Katz, MD Clinical Professor Department of Obstetrics and Gynecology Oregon Health Science University Medical... edition of Lange Q&A: Obstetrics and Gynecology book has been written, as were the prior editions, to be a study aid for self-examination and review in the field of obstetrics and gynecology. .. of Obstetrics & Gynecology School of Medicine Department of Obstetrics and Gynecology University of New Mexico Albuquerque, New Mexico Vicki Mendiratta, MD Associate Professor Department of Obstetrics