1. A healthy 5 ft 6 in. tall, adult female is most likely to have a pelvic inlet that would be classified as which of the following Caldwell-Moloy types?
(D) Pelvises in most U.S. women are gynecoid, but they may be of a mixed type (for instance, having a gynecoid forepelvis and an anthropoid posterior pelvis). The obstetrician has to judge the capacity of the pelvis on the basis of its total configuration, including midplane and outlet capacities, and always in relation to the size and position of the fetus.
2. The inguinal canal in an adult female was opened surgically. Which of the following structures would normally be found?
(D) The superficial inguinal ring is just cepha-lad to the pubic tubercle and just lateral to it, the deep inguinal ring passes through the transver-salis fascia. The connection of these rings forms the inguinal canal. The round ligament, the ilioinguinal nerve, and the processus vaginalis pass out of the abdomen through this canal (as does the spermatic cord in the male). Gartner’s ducts are found in the lateral walls of the vagina. One would not normally find a cyst of the processus vaginalis (cyst of the canal of Nuck).
3. Hernias occur more commonly in men than in women beneath the thickened lower margin of a fascial aponeurosis extending from the pubic tubercle to the anterior superior iliac spine. This thickened fascia is called which of the following?
(A) From the pubic tubercle to the anterior superior iliac spine, the thickened lower margin of the fascial aponeurosis forms the inguinal ligament. This aponeurosis of the external oblique muscle fuses with its counterpart from the opposite side and with the underlying internal oblique fascia. Cooper’s ligament is a thickening of fascia along the pubic bone. The linea alba is in the midline and the round ligament attaches to the uterus.
4. The part of the pelvis lying above the linea terminalis has little effect on a woman’s ability to deliver a baby vaginally. What is the name of this portion of the pelvis?
(D) The false pelvis or pelvis major lies above the linea terminalis. It seldom affects obstetric management, and measurements of the iliac crest flare do not usually aid in determining the size of the true pelvis. An important measurable indicator of the size of the true pelvis is the inter-spinous diameter.
5. The plane from the sacral promontory to the inner posterior surface of the pubic symphysis is an important dimension of the pelvis for normal delivery. What is the name of this plane?
(B) The obstetric conjugate is the shortest line from the inside of the symphysis to the most prominent point on the front two segments of the sacrum. It defines what is often the smallest diameter of the pelvic inlet. It should be estimated during clinical examination (pelvimetry) and considered whenever evaluating a pelvis for possible cephalopelvic disproportion, especially during abnormalities of labor. It differs from the true conjugate, which is measured from the top of the symphysis, and also from the diagonal conjugate, which is measured clinically from the bottom of the symphysis to the sacral promontory. The biischial diameter is on the pelvic outlet.
6. You are counseling a 32-year-old nulligravida with breast cancer about preserving fertility. You explain that the maximal number of oogonia is found at what age?
(B) An oogonium becomes an oocyte when it enters the first stage of meiosis. This occurs prior to birth. After birth there is a slow decrease in the number of oocytes. By menopause none can be found. By 5 months’ gestation there is a maximum number of oocytes, of about 4 to 7 million! At birth, the number of oocytes has decreased to 1 or 2 million. There continues to be attrition of oocytes during childhood so that by the onset of puberty fewer than 500,000 oocytes remain.
7. The paramesonephric ducts will form which of the following?
(C) The genital ducts (mesonephric or Wolffian and paramesonephric or Müllerian) are present in both sexes. The mesonephric ducts will become the male ducts and seminal vesicles. The female paramesonephros will form the oviducts, uterus, and upper two-thirds of the vagina. The lining of these ducts becomes the epithelial lining of the adult structures. Muscle and connective tissue originate from the adjoining mesenchyme. The prostatic utricle and the appendix testis in the male may indeed be remnants of paramesonephric duct but are not really formed by the ducts
8. A 24-year-old G2P1, living children 0, came to see you at 12 weeks’ gestation. Her previous child died at 1 day of age with hypoplastic left heart. In this pregnancy you should advise which of the following?
(D) The risk of recurrence is approximately 6% to 10% if there is a previous child or first-degree relative with left-sided disease. The recurrence though falls into a spectrum from hypoplastic left heart to bicuspid aortic valve. Structural evaluation with ultrasound, and in particular fetal cardiac echo, is the modality of choice for screening.
9. A 26-year-old woman is trying to quit smoking. She was using the nicotine patch (28 mg/d) with nicotine gum for breakthrough when she found out she was pregnant. She immediately stopped the patch and is back to smoking 1 to 1.5 packs a day. She is 11 weeks’ pregnant. What should you advise your patient?
(E) In this patient’s case we should work with her to quit smoking. However, she is not at increased risk for fetal birth defects. However, if she continues to smoke she is at increased risk of pregnancy complications.
10. During pregnancy, what is the safest analgesic with the least fetal affect?
(B) Acetaminophen is the analgesic of choice. Short courses of nonsteroidal anti-inflammatory drugs (NSAIDs) are safe prior to 32 weeks. However, the pregnancy should be monitored. Gabapentin is probably safe, but we have little information.
11. A woman was being treated for polycystic ovary disease with metformin (Glucophage). During her first visit at 10 weeks’ gestation, you should do which of the following?
(D) Current studies have shown that women using metformin do better if they stay on the medication through 20 weeks. It is not associated with specific fetal anomalies
12. A patient presents with amenorrhea and galactorrhea. Her PRL levels are elevated. She is not and has never been pregnant. In addition to evaluating her for a prolactinoma, one also needs to evaluate for other causes that would increase PRL such as elevated level of which of the following?
(E) PRL secretion is dominated by the inhibitory action of hypothalamic dopamine. Other mechanisms of PRL inhibition are GABA and histamine type II receptor activation. TRH is a potent stimulator of PRL and may induce galactorrhea under conditions of primary hypothyroidism, which should be checked for by measuring TSH.
13. In the 1950s to 1960s physicians commonly used various compounds in an attempt to hormonally support a pregnancy and avoid a miscarriage. A popular preparation was found to cause vaginal adenosis in female offspring often 20 to 30 years later. Which of the following compounds that were used to prevent miscarriages had this unfortunate complication?
(B) Although DES is the only one of these compounds without a steroid configuration, it is strongly estrogenic. Before its ban as an antiabortifacient in 1971, the use of DES for miscarriage prevention was associated with Müllerian tract abnormalities and clear cell adenocarcinoma of the vagina in offspring exposed in utero. The most frequent Müllerian tract abnormality was a T-shaped uterus, with a small uterine cavity, accompanied by structural abnormalities of the cervix.
14. A patient with polycystic ovarian syndrome will often have an increase in insulin resistance (commonly known as metabolic X syndrome). The subsequent menstrual irregularities are a result of an increase in which of the following?
(C) The metabolic clearance rate (MCR) is defined as the volume of blood that is cleared of a substance per unit time. The circulating level of a substance is determined by its blood production rate (PR) divided by its MCR. With increased insulin resistance, insulin levels rise and inhibit hepatic production of SHBG. As most circulating testosterone is bound to SHBG, a decrease in SHBG will increase the amount of free testosterone and decrease the amount of free estrogen. The free testosterone and levels of estrone from peripheral conversion of androstenedione will keep FSH levels low. The underlying insulin resistance augments the stimulatory action of LH on the growth and androgen secretion of ovarian theca cells.
15. Given that prostaglandins (PGs) appear to be involved in preterm labor, which of the following medications might provide some help through interference with PG synthesis or release in stopping preterm labor?
(B) Indomethacin is an inhibitor of PG synthesis and is used as a tocolytic agent. Inhibitors of PG synthesis may be prescribed for pain relief during menstruation (dysmenorrhea), since PGs also play a role in dysmenorrhea. Although progesterone may be a tocolytic agent it does not appear to be mediated primarily through the PG cascade.
16. A mother brings her 2-month-old daughter to the pediatrician because she feels a lump in her abdomen. On pelvic ultrasound the infant has an ovarian mass. When counseling the mother, you inform her that the most common ovarian lesion associated with the transient elevated gonadotropins in a female newborn during the first 6 to 12 months of life is which of the following?
(D) With removal of the placenta at birth, the decline in circulating sex steroid levels causes loss of sex steroid negative feedback to the neonatal hypothalamus. A transient elevation in circulating gonadotropin levels temporarily stimulates gonadal steroidogenesis and disappears by 6 months of age in males and 1 to 2 years in females. During this time, circulating gonadotropins in infants may transiently induce formation of ovarian cysts, which results in estrogen stimulation of breast tissue.
17. A 50-year-old woman presents to her health care provider complaining of hot flushes. Hot flushes are often the symptom in a perimenopausal woman that causes her to seek medical assistance. Hot flushes entail which of the following?
(B) The physiological changes accompanying the hot flush include peripheral vasodilation, sweating, elevated heart rate, and increased oxygen consumption. These events promote heat loss via redistribution of blood flow to the periphery and reflect a change in the set point of the hypothalamic thermoregulatory center. Peripheral blood flow increases approximately 1.5 minutes before and continues for several minutes beyond the subjective symptoms of the hot flush. Perspiration begins 2 to 3 minutes later and is followed by an increase in peripheral temperature, occurring several minutes after the initial rise in peripheral blood flow. At this time, core body temperature drops to 0.2°C and chills begin. The duration is typically a few minutes (1–5). Although in some women an increase in LH is associated with flushing, there is no causal relationship.
18. Because the fetus is growing rapidly, its need for nutrients and energy exceeds the mother’s on a gramfor-gram basis. Often, the placental transport will achieve a fetal concentration greater than maternal, but occasionally the converse occurs. Which of the following has a lower concentration in the fetus than in the mother?
(C) Although much of placental transport is passive, a large number of necessary metabolic products are actively transported against a concentration gradient. This accounts for many instances of nutritional sparing of the fetus even though maternal nutrition is poor. Fetal PO2, however, is significantly less than maternal. This is why Hb F is needed to facilitate transport of the decreased oxygen to the fetal tissue. The average oxygen saturation of intervillous blood is estimated to be 65% to 75% with a partial pressure (PO2) of 30 to 35 mm Hg. The oxygen saturation of umbilical vein blood is similar but with a lower oxygen partial pressure.
19. A chronic hypertensive patient presents with complaints of decreased fetal movement. Her prenatal care has been sporadic but it appears that she is at 37 weeks’ gestation with an estimated fetal weight of 2,200 g. Concerns are raised regarding placental reserves for oxygenating the fetus. This can be most directly assessed by which of the following?
(A) This is a series of assessments utilizing ultrasound evaluation and a nonstress test. It is the only immediate and direct measure of placental respiratory function and fetal activity listed. Es-triol changes can be delayed as can a fall-off in fetal growth. L/S ratio is a test for lung maturity of the fetus, not the placental reserve. Maternal serum alpha-fetoprotein (MSAFP) is a prenatal screen for neural tube defects. Although asymmetric intrauterine growth retardation can result from a decreased reserve and be detected by ultrasound, this is not an immediate assessment of status.
20. The fetal head is usually the largest part of the infant. Depending on the positioning of the head as it enters the pelvis, labor will progress normally or experience a dystocia due to cephalopelvic disproportion. The smallest circumference of the normal fetal head corresponds to the plane of which diameter?
(E) A vertex presentation offers the smallest circumference of the fetal head to the pelvic passage. The circumference at this point is about 32 cm. At the greatest point of the circumference (the occipitofrontal diameter), it is about 34 cm. In addition to the circumference, the ability of the fetus to negotiate the pelvic curve is very much dependent on the position of the presenting vertex, with a wellflexed head in the occiput anterior (OA) position being optimal.
21. Worldwide, which of the following is the most common problem during pregnancy?
(E) The National Institutes of Health estimates that 50% of all pregnant women worldwide are iron deficient. In the United States, the average woman has iron stores of less than 1 g. This amount is needed for the increased maternal blood volume and fetal growth during pregnancy. Poorly nourished women have an even greater deficiency. The National Academy of Sciences recommends 27-mg iron supplementation—the amount found in most prenatal vitamins. All women should be routinely screened for iron-deficiency anemia during early pregnancy and be given additional supplementation as needed. Preeclampsia, diabetes, UTIs, and heart disease do complicate pregnancies but to a lesser extent overall, as compared with iron-deficiency anemia.
22. Using your knowledge of normal maternal physiology, which of the following would you employ if a patient at 38 weeks became faint while lying supine on your examination table?
(B) In the third trimester, the supine position facilitates the large pregnant uterus to compress the venous system that returns blood from the lower half of the body. This results in potentially decreased cardiac filling and cardiac output. In about 10% of women, this causes significant arterial hypotension, sometimes referred to as the supine hypotensive syndrome. Altering material position is usually sufficient to remedy this compression and alleviate the hypotension. Administration of fluids or pressors is rarely necessary.
23. A pregnant woman at 4 weeks’ gestation had an upper gastrointestinal (GI) series and is worried about possible fetal effects from radiation. You inform her that the risk for mental retardation to the fetus is greatest during which phase of pregnancy?
(C) Data derived from the survivors of the atomic bomb place the greatest risk for mental retardation from radiation when the fetus is exposed at 8 to 15 weeks’ gestation and virtually no risk with small (i.e., <5 rads) doses before 8 or after 25 weeks’ gestation. If a woman is exposed in the preimplantation time period, 0 to 9 days, an “all or none” phenomenon occurs with either the loss of the pregnancy or a fetus that is unaffected. An Upper GI series exposes the uterus/embryo to 0.56 mrad. Single exposures much higher than this would be necessary to affect the fetus.
24. The most worrisome sign or symptom of potentially serious pathology in late pregnancy is which of the following?
(C) Cerebral visual disturbances such as sco-tomata can occur in preeclamptic patients, and such women require further evaluation. The other listed choices are common nuisances related to the physiologic changes of pregnancy.
25. During late pregnancy, which of the following implies urinary tract disease?
(E) Because of increased glomerular filtration rate (GFR), serum creatinine is usually low during pregnancy and creatinine clearance is increased. Decreased creatinine clearance may be seen in a variety of conditions such as preeclampsia and renal insufficiency. The increased GFR is also responsible for glucosuria in gravidas with normal glucose levels. The kidneys often excrete excess extracellular fluid after a period of recumbency, so the urine may not be concentrated after decreased oral intake of fluid, and urine is often the least concentrated in the morning. There is usually normal dilation of the collecting system on IVP during pregnancy.
26. Because treatment of HIV during pregnancy and labor can significantly decrease fetal transmission as well as maternal morbidity, which of the following is the standard of care regarding HIV testing in pregnancy?
(E) Universal HIV testing with patient notification was recommended by the Institute of Medicine in an effort to reduce the rate of perinatal HIV transmission in the United States. By 2008, the American Academy of Pediatrics, United States Preventive Services Task Force, the Centers for Disease Control and Prevention, and the ACOG supported recommendation for universal screening using an opt-out approach. The use of patient notification allows the woman to decline to be tested. No signed consent is required.
27. An abnormal biophysical profile (BPP) predicts which of the following?
(A) The BPP measures amniotic fluid volume (requiring a fluid pocket of 2 cm), the results of the NST, an episode of fetal breathing that lasts at least 30 seconds, three discrete limb movements of the fetus, and at least one episode of extension with return to flexion by a fetal limb or trunk. Each of these factors is given two points. A normal score is 8 or 10, indicating fetal well-being. Progressive perinatal mortality rate correlates with decreasing BPP score. A normal BPP has a false-negative rate, as defined by antepartum death, of 1 per 1,000. The other conditions are not predicted by the antepartum assessment of fetal well-being.
28. A patient is measuring size larger than dates at her initial obstetric visit at 24 weeks’ EGA. She is worried about twins since they “run” in the family. The best method to safely and reliably diagnose twins is by which of the following?
(A) Leopold’s maneuvers are used to assess fetal lie, presentation, and engagement by palpation of the gravid abdomen. They are not intended as a means to diagnose twins. Auscultation of two fetal heartbeats may help in diagnosing twins, but the diagnosis may be uncertain and is generally confirmed by ultrasound. The three radiologic methods listed can all diagnose twins, but the use of ultrasound can reliably make the diagnosis early and safely in pregnancy.
29. Of the following evaluations done during routine prenatal care in a normal pregnancy, which of the following is most important in the initial clinic visit?
(B) The early determination of the gestational age allows informed decision making if any pregnancy complication demands treatment that depends on knowledge of the gestational age. Although it is true that all of the evaluations listed are important, the accurate assessment and recording of gestational age is generally deemed most important in otherwise clinically normal pregnancies.
30. Which of the following is the most prominent cause of pregnancy loss?
(E) Contraception that prevents pregnancy is not pregnancy wastage. Abortion, which is the loss of pregnancy before 500 g or approximately 20 weeks, exceeds all other causes of loss of pregnancy. Ten to twenty percent of known pregnancies will end in spontaneous abortion. In addition, over 1 million voluntary abortions are performed yearly in the United States. Stillbirth and intrauterine fetal demise are basically the same and have a rate of 6–7 per 10,000. Neonatal deaths have a rate of 5–6 per 10,000.