A 24-year-old woman lost her previous two pregnancies at approximately 20 weeks' gestation, without having noted any contractions. She is currently at 15 weeks' gestation and denies having uterine contractions. Her cervix is undilated and uneffaced. Which of the following is the most appropriate management of this patient?
Answer(s): E
The patient described in the question has a classic history of an incompetent cervix: expulsion of a fetus without labor. It is believed to be caused by previous cervical trauma, DES exposure, or, most commonly, a congenital defect in cervical stroma. In the absence of preterm labor, there is no indication for terbutaline or other tocolytic agents. DES is contraindicated in pregnancy, but was used in the past to treat repeated pregnancy loss. Hydroxyprogesterone is a progestational compound that is being used by some hospitals for patients in premature labor, but its use is controversial. Bed rest is occasionally encouraged by some practitioners for patients with a history of premature deliveries. The probability of a successful pregnancy after a cervical cerclage increases from 20% to approximately 80%. It is crucial to eliminate the possibility of preterm labor before placing a cerclage.
A 69-year-old woman with diabetes mellitus complains of urinary incontinence. Her diabetesis well controlled with oral hypoglycemic agents. She has no complaints other than the wetness. Which of the following tests is most likely to demonstrate the cause?
The combination of aging and diabetes suggests the likelihood of a neurologic defect in the bladder, resulting in overflow incontinence. This occurs when the detrusor muscle becomes hypotonic or atonic.Such women complain of voiding small amounts but still having the feeling of a full bladder. In addition, these women are incontinent of small amounts of urine and are unable to stop the flow. This helps to distinguish those with overflow incontinence from those with GSI; the latter are able to voluntarily increase urethral pressure enough to stop urine flow. Cystitis commonly causes urgency and increased urinary frequency, but not incontinence. Urinalysis and urine culture are not likely to be revealing in this patient, but should be done routinely in all incontinent women. Instillation of methylene blue into the bladder after placement of a vaginal tampon should be done when a vesicovaginal fistula is suspected. This occurs most often following gynecologic surgery and should be suspected in women complaining of constant urine leakage. The Q- tip test is useful to demonstrate posterior urethral rotation found in women with GSI.
A48-year-old G5P5 woman has genuine stress incontinence (GSI). Kegel exercises have not helped, and her incontinence is gradually worsening. Her urethrovesical junction (UVJ) is prolapsed into the vagina, and her urethral closure pressure is normal. Which of the following procedures will most likely cure her incontinence?
Answer(s): A
In a patient with GSI, a retropubic approach offers the best long-term cure of the incontinence. The Burch procedure and the Marshall- Marchetti-Krantz procedure are the most common retropubic procedures.With an anterior colporrhaphy, plication sutures are placed at the UVJ in an effort to support and elevate it.Long-term results are not as good as a retropubic urethropexy or a suburethral sling. Asuburethral sling procedure is used when urethral closing pressure is low, less than 20 cmH2O. A needle suspension procedure is most often done when there is associated genital prolapse with potential incontinence.Collagen injections at the UVJ have been attempted to obstruct the urethra partially. Incontinent patients who may benefit the most from collagen injections are those with intrinsic sphincter deficiency and a fixed bladder neck.
On a routine annual examination, a 43-yearold woman is found to have a 2-cm mass in the lateral aspect of her right breast. Which of the following is the most appropriate next step in management?
Answer(s): C
The presence of a dominant mass requires immediate evaluation. While all women with a dominant mass should have a mammogram, this is a screening test. Afine-needle aspiration is a diagnostic tool that will resolve whether the mass is cystic or solid. Any fluid or tissue obtained should be sent for cytologic evaluation to further aid in the diagnosis. If clear or cloudy fluid is aspirated, and the mass disappears, the woman should have a repeat breast examination in 1 month. If the mass remains after aspiration, if the fluid is bloody, or if there is a residual mass on a follow-up visit in 1 month, an open biopsy should be done.A segmental resection is a therapeutic option for a circumscribed carcinoma, but is not an appropriate diagnostic tool.
A 37-year-old pregnant woman has a genetic amniocentesis at 16 weeks' gestation. Aconcurrent ultrasound shows normal fetal anatomy. Her prenatal course has been unremarkable. Her prenatal laboratory tests include a B-negative blood type, a negative rubella antibody titer, a negative hepatitis B surface antigen, and a hematocrit of 31%. Which of the following is the most appropriate management for this woman?
Answer(s): D
Rh immune globulin should always be administered to an Rh-negative pregnant woman who sustains any trauma or has any type of invasive procedure, such as an amniocentesis. Detectable fetomaternal hemorrhage occurs in 6% of women having an amniocentesis and 1% of Rh-negative women will develop Rh isoimmunization after amniocentesis (without Rh immune globulin). The immune globulin reduces the risk of subsequent Rh sensitization during the pregnancy, which could result in severe erythroblastosis fetalis. Although chorionic villus biopsy might be an alternative to amniocentesis, it is done earlier in pregnancy, and occasionally must be followed by an amniocentesis after 14 weeks' gestation because of the possibility that maternal decidua was analyzed. Rubella immunization should be given after delivery to avoid the theoretical risk of a congenital rubella syndrome from the administration of the live vaccine. The presence of hepatitis B surface antibody suggests immunity to hepatitis B but is unrelated to amniocentesis. Intra-amniotic bleeding is a complication of amniocentesis but occurs at thetime of the procedure. The amniotic fluid will appear bloody
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