You are seeing a 38-year-old woman for her annual gynecologic examination. She asks you for some information regarding the HPV vaccine and whether you think it would be appropriate for her 17-year- old daughter. Which of the following statements regarding the quadrivalent human papillomavirus vaccine and HPV is true?
Answer(s): A
The quadrivalent human papillomavirus (under the name Gardasil) was licensed for use in June 2006. It is currently recommended for routine vaccination of young women ages 1112 with "catch-up" vaccination for women 1326. It can be given as young as age 9. The vaccine is three separate 0.5-mL doses, given at 0, 2 and 6 months apart. If one dose is delayed, there is no need to restart the schedule. Rather, the doses should be given as soon as possible. The vaccine is targeted against the L1 proteins of HPV types 6, 11, 16, and 18. HPV 6 and 11 are "low-risk" strains causing genital condylomata, and HPV 16 and 18 are "high-risk" oncogenic strains responsible for 70% of all cervical cancer. Guidelines for screening for cervical cancer have not changed--patients should still be advised to have routine Pap smear screening and HPV screening as indicated. Women with a prior history of abnormal Pap smears are still candidates for the vaccine, as it is unlikely that they have been exposed to all four strains.
A19-year-old primigravid woman at 39 weeks' gestation is in active labor, and her cervix is 4 cm dilated, 90% effaced. Her amniotic membranes have been ruptured for 4 hours. Contractions are strong at 2- to 3- minute intervals and of 60- to 70-second duration. For the past 30 minutes, repetitive variable decelerations of the fetal heart rate have occurred. They have lasted 6090 seconds, and the fetal heart rate has dropped as low as 60 beats per minute (BPM). You explain that there is a risk that the baby will become hypoxic and recommend a cesarean section. She refuses. Which of the following is the most appropriate course of action?
Answer(s): D
In many states, a pregnant woman under the age of 21 years is considered an emancipated minor and is the only person who may make legal decisions pertaining to the pregnancy. Although an immediate cesarean section is indicated because of the severe fetal heart rate decelerations, to perform it without her permission violates the ethical principle of autonomy. This is a principle that states that human beings should have their wishes respected as autonomous persons if they are capable of self- determination.Obtaining a court order may fulfill the ethical principle of beneficence, a physician acting to do no harm and to help the patient. In this situation, the ethical (moral) decision is complicated by a conflict between beneficence and autonomy. However, proceeding with a cesarean section exposes the obstetrician to a legal charge of battery. Assigning her care to another physician is a standard and accepted solution when there is a moral conflict between patient and physician. However, this is not an acceptable option in an emergency situation. The obstetrician is at risk for abandonment. Although not a satisfying choice, the choice most ethically sound is to counsel her carefully, but eventually accede to her wishes. Placing her in the lateral position, giving her oxygen by mask, and providing adequate intravenous hydration should be instituted to minimize the risk of fetal hypoxia.
A 35-year-old primigravid woman with a history of cyclic menses at 28- to 30-day intervals began her last menses on August 18. A home pregnancy test was positive on September 20. At her first prenatal visit, she asks you what the duration of pregnancy is and what her due date is. You tell her that the average number of days from the onset of menses to delivery is which of the following?
The mean duration of human pregnancy is 266 days from conception. To this is added 14 days for the interval between the onset of the last menses and the conception date. Thus, it is important to ascertain the range of days for each woman's menstrual cycles. The more variable a woman's menstrual cycles are, the less certain is the estimated due date calculated from the LMP. The standard deviation of pregnancy duration is ±17 days. Thus, 95% of human pregnancies will deliver between 263 and 297 days after the onset of the LMP.
A 44-year-old woman had a normal Pap smear 3 years ago. Her menstrual periods occur monthly and last 5 days. She has had intermenstrual and postcoital spotting intermittently for the past 6 months. The pelvic examination is normal.Which of the following is the most appropriate test to perform?
Postcoital spotting and intermenstrual spotting in a woman with cyclic menses is suggestive of a cervical abnormality, rather than an endometrial hormonal abnormality. In the absence of a visible lesion, a Pap smear that includes cells from both the ectocervix and endocervix is the preferred method of evaluation, especially when the woman has no history of cervical pathology or a normal Pap smear in the recent past.Endometrial biopsy and hysteroscopy assess the endometrium, not the cervix. A conization of the cervix should be reserved for women with documented cervical neoplasia when determination of the extent ofthe lesion is necessary. An endocervical curettage is usually reserved for women with unsatisfactory Pap smears and persistent abnormal bleeding.
A 44-year-old woman had a normal Pap smear 3 years ago. Her menstrual periods occur monthly and last 5 days. She has had intermenstrual and postcoital spotting intermittently for the past 6 months. The pelvic examination is normal. All tests performed on the woman were normal. She returns 1 year later for her annual gynecologic examination. On speculum examination, she has a visible 7-mm lesion on her cervix that bleeds on contact. Which of the following is the most appropriate procedure to perform?
Answer(s): B
Pap smear and colposcopy are screening tests appropriate when there is no visible cervical pathology. In the presence of a lesion, pathologic evaluation is necessary to make a diagnosis. An office cervical biopsy is the procedure of choice to establish the diagnosis. If the diagnosis from the biopsy is cancer, a conization of the cervix is indicated to determine the extent of the disease surface spread as well as depth of stromal invasion. As a general principle, cytology is a screening tool, not a diagnostic test, and any visible lesion (vulvar, vaginal, or cervical) should be biopsied for a definitive diagnosis
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