QUESTION: 121

The mother of a 3-year-old girl brings her daughter to see you because the girl developed breasts 6 months ago. The girl has had no vaginal bleeding, and there is no pubic hair. She takes no medication

Which of the following is the most appropriate management of this girl?

pituitary suppression with a gonadotropin-releasing hormone (GnRH) agonist
laparoscopy
assurance that the condition is benign and self-limiting
corticosteroid suppression of adrenal function
breast biopsy

Answer(s): C

Explanation:

Premature thelarche is a benign, self-limited disorder that does not progress. Breast development may actually regress, though the regression may not be complete. The girl and her parents should be assured that the events of puberty will be normal at a normal age. Examination of the girl should be repeated at 3- to 6-month intervals for about 1 year to be certain that additional pubertal events do not occur (such as growth of pubic hair, accelerated linear growth, and vaginal bleeding). Because pituitary and adrenal functions are normal for a prepubertal girl, therapy with a GnRH agonist (Lupron, Synarel, and so forth) or a corticosteroid is ineffective and inappropriate. Although breast cancer is a rare possibility in prepubertal girls, the presence of bilateral breast buds effectively excludes this diagnosis. A breast biopsy may destroy breast analge, and these girls will not have breast development at puberty.

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QUESTION: 122

After an appropriate diagnostic evaluation, a 59-year-old woman with postmenopausal bleeding had a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). The pathologic diagnosis is adenocarcinoma of the endometrium. An endometrial adenocarcinoma that is confined to the uterus and extends more than 50% through the myometrium is at which stage?

IC
IIA
IIB
IIIA
IVA

Answer(s): A

Explanation:

In general, gynecologic cancers confined to the organ of origin are stage I. Thus, this patient has a stage I cancer. In 1988, FIGO revised the staging of endometrial cancer from a clinical staging to surgical staging.
Cancer limited to the endometrium is stage IA. Myometrial invasion less than 50% is stage IB, and myometrial invasion more than 50%, but not involving the serosa, is stage IC.

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QUESTION: 123

A 39-year-old woman at 16 weeks' gestation complains of headaches, blurred vision, and epigastric pain. Her blood pressure is now 56/104 mmHg. Her uterine fundus is palpable 2 cm above her symphysis pubis. Fetal heart tones could not be heard with a handheld Doppler. She has 3+ proteinuria.
Which of the following is the most likely diagnosis?

anencephaly
twin gestation
maternal renal disease
hydatidiform mole
gestational diabetes mellitus

Answer(s): D

Explanation:

The onset of preeclampsia before the 20th week of pregnancy is clinically seen only with a hydatidiform mole. Advanced maternal age, uterine size greater than gestational weeks, and the absence of a fetal heartbeat are added features to suggest gestational trophoblastic disease. Hydramnios, which can be associated with anencephaly and other fetal developmental abnormalities, also predisposes to preeclampsia, but its onset does not occur before 24 weeks. Renal disease, diabetes mellitus, and chronic hypertension also increase the likelihood of preeclampsia, but not before 24 weeks of pregnancy. The incidence of preeclampsia is increased in twin gestation, but again, its onset is not before 24 weeks

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QUESTION: 124

A23-year-old woman develops painful vulvar vesicles that contain intranuclear inclusions on cytologic examination. She is 22 weeks' pregnant. Which of the following statements about genital herpes is correct?

Acyclovir should be prescribed from 36 gestational weeks until after delivery in women with primary herpes anytime during pregnancy.
Herpes cultures from the cervix should be obtained weekly beginning at 36 weeks' gestation.
An active genital herpetic lesion any time after 20 weeks' gestation requires a cesarean section.
Intrauterine infection with herpes is common after 20 weeks in women with primary herpes.
Pitocin induction of labor should be started within 4 hours after ruptured amniotic membranes in a woman at term with active genital herpes.

Answer(s): A

Explanation:

Acyclovir prescribed from 36 gestational weeks until after delivery reduces the probability of a cesarean section, although in one study of a small number of patients there were no cases of neonatal herpes in either the treatment or control group. Nonetheless, acyclovir (a class C drug) and newer antiviral drugs (valacyclovir, famciclovir, both class B) should be given to women with either a primary outbreak or a recurrence during pregnancy. Weekly cultures are unreliable to exclude active herpes lesions in pregnancy and are not recommended for basing a decision to perform a cesarean section. A cesarean section should be performed if a woman develops an active cervical or vaginal lesion at term. However, genital herpetic lesions before 36 weeks do not necessitate a cesarean section, because there is no evidence that vertical transmission to the fetus is increased until the pregnancy is within 24 weeks of delivery. Intrauterine infections via transplacental or transmembrane transmission of the herpesvirus are rare. Most infections of the infant occur after passage through an infected birth canal. A cesarean section should be performed at term if the amniotic membranes rupture in a woman with an active herpetic lesion in the genital area, regardless of the duration of membrane rupture.

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QUESTION: 121

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QUESTION: 123

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QUESTION: 124

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