Questions
DIRECTIONS (Questions 1 through 25): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.
1. A 23-year-old woman at 29 weeks’ gestation ruptures her amniotic membrane. She is admitted to the hospital, and 3 days later, she is found to have a temperature of 101.1°F, a white blood cell (WBC) count of 15,000, fetal tachycardia, and mild tenderness over her lower abdomen. Which of the following is the most likely diagnosis for this patient?
(A) intra-amniotic infection
(B) lower urinary tract infection (UTI) (C) pyelonephritis
(D) genital herpes
(E) cytomegalovirus (CMV)
2. Three weeks after delivery, a 29-year-old primipara, who is breast-feeding twin girls, presents to the clinic, complaining of a tender right breast mass. On physical examination, you find a 5-cm fluctuant, swollen, reddened mass in her right breast that is exquisitely tender to the touch. Axillary lymph nodes on the ipsilateral side are enlarged and tender. What is the most appropriate next step in the
management of this patient?
(A) excisional biopsy of the mass (B) needle aspiration of the mass
(C) intravenous antibiotic therapy for the mother and infants (D) have the patient continue to breast-feed on the other side
(E) incision and drainage of the mass plus oral antibiotics for the mother
3. Two weeks after the birth of her infant, a new mother brings the child in to see you. The child’s eyes are edematous, with conjunctival erythema and a mucopurulent discharge. Your evaluation and treatment should include which of the following?
(A) a pelvic examination (using a small scope) of the infant (B) culture maternal genital tract for GC and chlamydia (C) anaerobic cultures of the infant’s and mother’s eyes (D) immunoglobulin M (IgM) titers of the infant
(E) penicillin VK for both the mother and the infant
4. Three days after an elective termination of pregnancy, a 29-year-old woman presents to the emergency department with a history of mild abdominal pain and fever, a physical examination showing pelvic tenderness, and a purulent cervical discharge. A Gram’s stain of the cervical discharge shows gram- negative intracellular diplococci. What is the most likely causative agent in this patient’s case?
(A) Neisseria gonorrhoeae (B) Chlamydia trachomatis
(C) Escherichia coli (D) Treponema pallidum (E) Staphylococcus aureus
5. A 31-year-old woman in her first trimester presents for her initial visit. She complains of a painless raised lesion in her vulva. Examination reveals a chancre. Rapid plasma reagin (RPR) test with elevated titer is positive along with fluorescent treponemal antibody absorption (FTA-ABS), confirming the diagnosis of primary syphilis. The patient should be offered which of the following counseling or treatment options?
(A) Offer the woman termination, as the fetus will be infected and develop congenital syphilis.
(B) Immediately treat her with parenteral penicillin G.
(C) The causative agent for syphilis, T. pallidum, does not cross the placenta; therefore, there is no risk for congenital syphilis.
(D) Penicillin-allergic women should be treated with erythromycin.
(E) If a fetus is affected, the anatomic ultrasound will always be abnormal.
6. A woman has a stillborn infant covered with a petechial rash. Which of the following infections would be most likely?
(A) herpes zoster (B) herpes simplex
(C) Listeria monocytogenes (D) human papillomavirus (HPV) (E) chronic active hepatitis
7. Regarding immunization during pregnancy, which of the following vaccines would be the safest to receive during pregnancy?
(A) mumps (B) polio (C) rabies (D) rubella
(E) rubeola (measles)
8. A patient presents to labor and delivery in active labor and has a precipitous delivery within 15
minutes of arrival. Her prenatal care has been erratic. During the repair of a second-degree laceration, you note ulcerations on the labia consistent with herpes simplex virus (HSV). On further questioning of the patient, her history is consistent with a primary outbreak of herpes. You send cultures but
recommend immediate treatment of the newborn for HSV while waiting for the results. When the patient inquiries why, you tell her that HSV infection in pregnancy is associated with a neonatal mortality rate for untreated infected infants. What is this mortality rate?
(A) 10%
(B) 25%
(C) 50%
(D) 75%
(E) 95%
9. An infant, seemingly well when born, demonstrates microcephaly, chorioretinitis, deafness, and delayed development later in life. Which of the following is the most likely cause?
(A) type 2 herpes hominis virus acquired at the time of delivery (B) CMV infection during pregnancy
(C) vitamin K deficiency in the newborn (D) late-onset group B streptococcal infection (E) parvovirus infection
10. A 19-year-old woman who has never had chick-enpox has just been exposed to the disease
(approximately 36 hours ago) at 16 weeks’ gestation. What is the most appropriate next step in the management of this patient?
(A) reassurance only
(B) a measurement of maternal varicella titer 3 weeks after exposure (C) a measurement of maternal varicella titer 6 weeks after exposure (D) the patient should be advised to consider termination
(E) the administration of varicella zoster immune globulin (VZIG)
11. A 27-year-old gravida you have been following throughout her pregnancy presents at 22 weeks’
gestation not feeling well. She complains of fever, cough, a runny nose, conjunctivitis, and on examination has white spots surrounded by a halo of erythema on her buccal mucosa and an erythematous maculopapular rash on her abdomen. What is the most likely cause of this patient’s condition?
(A) varicella zoster (B) rubella
(C) rubeola (measles) (D) syphilis
(E) herpes
12. A 25-year-old G1 is newly pregnant. She is found to be rubella nonimmune. She asks you about the implication of this. You should inform her about which of the following?
(A) A significant percentage of fetuses of women who develop rubella infection during pregnancy will develop congenital rubella syndrome.
(B) Rubella infection increases maternal mortality.
(C) Treatment with antiviral medications is effective.
(D) She should receive rubella immunization during this pregnancy.
(E) If she is infected, she will likely develop significant fever and rash.
13. Of the following individuals, who would theoretically be at highest demographic risk for toxoplasmosis infection during pregnancy?
(A) country western singer (B) medical technologist (C) plumber
(D) cat breeder
(E) kitchen worker in Los Angeles
14. A 25-year-old sexually active woman complains of a “fishy” smelling gray-white vaginal discharge.
You examine this on wet mount and see epithelial cells with clusters of bacteria obscuring their borders. The vaginal pH is 5.5. This infection has been most closely implicated in which of the following complications of pregnancy?
(A) intrauterine growth restriction (B) preterm birth
(C) congenital cataracts
(D) learning disabilities during childhood (E) preeclampsia
15. A 45-year-old Laotian woman is visiting her daughter. She comes to your office complaining of frequent intermenstrual bleeding for years. You examine her and feel that her pelvis is “firmly fixed,”
with little mobility of the organs. You perform an endometrial biopsy. The pathology report returns stating that “frequent giant cells, caseous necrosis, and granuloma formation” are seen. Which of the following is the most likely cause of this woman’s condition?
(A) syphilis
(B) C. trachomatis (C) tuberculosis (D) N. gonorrhoeae (E) L. monocytogenes
16. A 43-year-old woman has had a history of frequency, urgency, and dysuria for the past 8 years. She has had five negative urine cultures and urinalyses in the last year. Cystoscopy 1 month ago showed a normal bladder and reddened urethra. An intravenous pyelogram (IVP) is normal. What is the most likely diagnosis?
(A) surreptitious use of antibiotics by the patient to mask her laboratory results (B) tuberculous urethritis
(C) vulvar vestibulitis syndrome (D) urethral syndrome
(E) urethral gonorrhea
17. A 51-year-old woman presents complaining of dysuria, dyspareunia, frequency of urination, dribbling of urine from the urethra when she stands after voiding, and a painful swelling under her urethra. Which of the following is the most likely diagnosis?
(A) simple cystitis (B) urethral syndrome
(C) infection of the Skene’s glands (D) infected urethral diverticulum (E) urethral carcinoma
Questions 18 and 19 apply to the following patient:
On the evening after a vaginal hysterectomy, a patient develops a temperature of 100.4°C. You are called to evaluate her.
18. Which of the following do you consider most likely prior to examining the patient?
(A) She probably has a UTI.
(B) Ureteral obstruction is likely.
(C) Her fever may be factitious.
(D) She may be having an allergic reaction to her medications.
(E) The temperature elevation is most likely unrelated to a surgical infection.
19. The same patient continues to have fever in the 102°F to 104°F range over the next few days. A pelvic examination is repeated and a midline, tender mass approximately 8 cm in diameter is noted over the vaginal cuff. What is the most appropriate next step in this patient’s management?
(A) obtain an ESR and WBC, and start or change antibiotics (B) get an infectious disease consult
(C) send a vaginal culture to assess the coverage of your antibiotics (D) open the vaginal cuff in the midline
(E) aspirate the vaginal cuff for culture
20. The hospital is reviewing its protocols to decrease the iatrogenic infection rate within the hospital.
For which of the following procedures would prophylactic antibiotics be appropriate?
(A) amniocentesis (B) laparoscopy (C) tubal sterilization (D) vaginal hysterectomy (E) episiotomy repair
21. A 35-year-old woman undergoes a cesarean section after a failed induction for postmaturity. Three days after surgery, she develops a high spiking fever. Ampicillin and gentamicin are administered.
Complete physical examination shows no abnormality except a tender uterus. Blood, urine, and sputum cultures are negative. On the fifth day after surgery, a hectic (spiking) fever is still present. The
antibiotics are changed to ampicillin, gentamicin, and clindamycin in high dosage. Forty-eight hours later, the fever persists, and examination shows a tender uterus. A chest X-ray is normal. Pelvic CT is consistent with parametrial thrombosed vessels but no abscess. Which of the following is the next best step in managing this patient?
(A) reoperate to find the source of the fever (B) anticoagulate the patient with heparin (C) get an infectious disease consult
(D) discontinue all antibiotic medication and reculture the patient (E) change antibiotics again
22. A 34-year-old woman (gravida 2, para 1) is at 13 weeks’ gestation by last menstrual period (LMP) with a desired pregnancy. She presents to the emergency department very anxious with a 10-hour
history of low abdominal cramping and vaginal bleeding. Her temperature is 102.2°F, and her uterus is markedly tender on bimanual examination. Ultrasound shows an intrauterine pregnancy with a crown- rump length consistent with her LMP and fetal cardiac activity present. Her cervix is dilated by 1 cm.
Her WBC count is 26,000. What is the best management for this patient?
(A) place a cervical cerclage immediately after administering antibiotics (B) administer antibiotics and expectantly manage her
(C) evacuate her uterus after administering antibiotics
(D) administer antibiotics, and if she does not spontaneously abort after 24 hours of observation, place a cervical cerclage
(E) place her on bed rest and administer both a tocolytic and antibiotics Questions 23 through 25 apply to the following patient:
An asymptomatic 24-year-old African-American woman with sickle cell trait is found on routine prenatal
screening at 14 weeks’ gestation to have symptomatic bacteriuria (105 colonies/mL).
23. What is her risk of developing pyelonephritis if untreated?
(A) 5–10%
(B) 20–30%
(C) 40–50%
(D) 60–70%
(E) 90–100%
24. What is the most likely organism to be cultured?
(A) group B streptococcus (B) Klebsiella pneumoniae (C) C. trachomatis
(D) Proteus species (E) E. coli
25. What is an appropriate choice of antibiotic therapy for this patient pending culture results?
(A) ampicillin (B) tetracycline (C) ciprofloxacin (D) nitrofurantoin (E) metronidazole
DIRECTIONS (Questions 26 through 43): The following groups of questions are preceded by a list of lettered options. For each question, select the one lettered option that is most closely associated with it. Each lettered option may be used once, multiple times, or not at all.
Questions 26 through 32
(A) candidal vaginal infections (B) Trichomonas
(C) bacterial vaginosis (D) atrophic vaginitis (E) mucopurulent cervicitis (F) foreign body
26. Most common type of vaginitis with a high pH in the sexually active patient.
27. In cases of treatment failure, combined oral and intravenous therapy with metronidazole may be indicated.
28. The patient complains of a white, curdy discharge, and vaginal burning and itching; on examination, the copious discharge is confirmed. The vaginal pH is 3.0.
29. Associated most commonly with chlamydia or gonorrhea.
30. Diagnosis may require vaginoscopy.
31. The treatment should include intravaginal estrogen therapy.
32. The most likely causative organism also has a highly associated incidence of upper genital tract infection.
Questions 33 through 43
(A) uncomplicated anogenital gonorrhea (B) disseminated gonococcal infection (C) syphilis
(D) chancroid
(E) lymphogranuloma venereum (F) donovanosis
(G) pediculosis pubis (H) scabies
(I) molluscum contagiosum (J) genital herpes infection (K) HPV infection
(L) genital mycoplasma
33. Diagnosis can be made from culture on Thayer-Martin or Transgrow media.
34. An asymptomatic disease on the vulvar skin, spread by close contact; it can be found as a disseminated disease in children that is not necessarily spread by sexual contact.
35. The causative organism for genital condyloma, an etiologic agent, cofactor, or enhancer for the development of most intraepithelial neoplasias of the genital tract.
36. A 44-year-old schoolteacher returns from a vacation in Haiti, where she had unprotected intercourse with a native Haitian approximately 3 weeks previously; she now has a painless vulvar ulcer.
37. A 48-year-old Nigerian woman presents with vesicular and pustular lesions with ulceration of the vulvar areas. She also has painful elevated inguinal nodes.
38. One of the most infectious of all sexually transmitted diseases (STDs); characteristic lesions are found at the base of hair follicles.
39. One week after her first intercourse, an 18-year-old college student presents to your office with intense, constant itching in the area of her pubic hair; on examination, you think you see red “moles”
that are moving.
40. A patient reports having had intercourse with a new sexual partner approximately 8 days ago and now complains of general malaise and fever, vulvar pain, pruritus, and vaginal discharge; genital
examination shows tender inguinal lymphadenopathy and vesicles and ulcers on the labia majora bilaterally.
41. A 41-year-old woman returns from a job on a Caribbean cruise ship. She had several new sexual partners during the 3-week cruise. A few days before coming to see you, she noticed the growth of an asymptomatic vulvar nodule. The skin ulcerated over the nodule, and she now has a beefy-red ulcer.
She thinks additional nodules may be developing. The ulcer is painless, and there are no associated
groin lesions or enlarged lymph nodes.
42. Caused by Hemophilus ducreyi, the disease is characterized by a painful ulcer, most commonly of the vaginal vestibule.
43. Frequently isolated from the cervix and vagina, its role as a cervical pathogen is unclear.
Answers and Explanations
1. (A) The diagnosis of intra-amniotic infection (also called chorioamnionitis) is often one of the exclusions. The most common physical findings are fever, maternal/fetal tachycardia, uterine
tenderness, foul-smelling vaginal discharge, and preterm labor. The most common causative organisms are bacteria and probably most often are polymicrobial. Organisms include group B streptococcus, Gardnerella vaginalis, and Mycoplasma hominis. The primary treatment is delivery and secondarily initiation of broad-spectrum antibiotic therapy. The most common neonatal sequela is pneumonia.
2. (E) This is a classic presentation of puerperal mastitis with a localized breast abscess. The most common causative organism is S. aureus from the infants’ normal mouth flora. Approximately 10% of women with mastitis will develop an abscess. The abscess needs to be drained and an appropriate antibiotic, such as dicloxacillin or erythromycin, should be given to the mother. Women with mastitis or abscess should continue to evacuate the breast frequently by nursing or pumping, if possible.
3. (B) The infant is very likely to have a C. trachomatis conjunctivitis from passage through the birth canal of the infected mother. It causes conjunctivitis 1 to 2 weeks after delivery in the infant and may be an indolent organism that causes pelvic infection in the mother. The diagnosis is made from
immunologic enzyme assay in most cases. The mother can be treated with a tetracycline or preferably with erythromycin if she is breast-feeding. The infant should be treated with oral erythromycin and/or sulfa ointment to the eyes. Tetracycline can stain the infant’s permanent teeth.
4. (A) While not pathognomonic, the finding of gram-negative intracellular diplococci combined with the history of intrauterine instrumentation makes the likelihood of gonorrhea approximately 100%. A syphilitic lesion should be sought on all patients with venereal disease, but it is not a high-prevalence STD in most settings. Given the likelihood of gonorrhea as the causative organism, the patient and all recent partners should be treated.
5. (A) The incidence of syphilis has been increasing in recent years in the United States. It is due to
spirochete T. pallidum. Because of fetal im-munocompetence, these organisms seldom clinically affect the fetus before 18 weeks’ gestation. The fetus can acquire syphilis via placental passage or via contact with vaginal or vulvar lesions at the time of delivery. Women diagnosed and treated early may avoid any negative effect on their fetus. Maternal treatment would consist of immediate parenteral penicillin G. There are no proven alternatives to penicillin during pregnancy and women with penicillin allergy should undergo skin testing to confirm risk of anaphylaxis and then undergo desensitization. Fetal ultrasound may be suggestive of infection with hydrops, ascites, and hepatomegaly; however, some infected fetuses will be sonographi-cally normal.
6. (C) Listeriosis is characterized by abortion, stillbirth, septicemia, and encephalitis. It has a
characteristic rash in infants that is often described as petechial or granulomatous in appearance and is a good candidate for the stillbirth. It causes overwhelming sepsis in infants much like group B
streptococcus. Maternal septicemia is also common. It is unusual for listeriosis to cause repetitive pregnancy loss.
7. (B) Polio vaccine is generally a vaccine made from an inactive virus and, therefore, safe to receive
during pregnancy. Mumps, rabies, rubella, and rubeola are live virus vaccines and, therefore, not
generally felt to be as safe in pregnancy. Other inactive virus vaccines include hepatitis B and influenza vaccines. Killed bacterial vaccines include pertussis, typhoid, typhus, cholera, meningococcus, and rickettsia. Toxoids include diphtheria and tetanus. Killed bacteria vaccines and toxoids are also thought to be safe during pregnancy.
8. (C) Genital herpes is usually symptomatic in mothers when infants are overtly infected. Genital lesions can usually be found. Transmission rates to infants are probably approximately 30% in mothers who have primary outbreak late in pregnancy and only 3% when maternal infections are recurrent. Infant infection is associated with high neonatal mortality rates, nearly 50% among nontreated infants.
Preexisting antibody to HSV-2 but not to HSV-1 reduces the risk of vertical transmission of HSV-2.
Acyclovir has been demonstrated to be effective in diminishing the rate of recurrent genital herpes outbreaks.
9. (B) CMV is an asymptomatic maternal infection passed to the infant during gestation. Virus can be isolated from any body fluid. Nearly all of the infected infants will be asymptomatic at birth, but 5% to 15% will develop the central nervous system manifestations during early childhood. Vitamin K
deficiency causes neonatal coagulopathy. Late-onset group B streptococcal infection is typically manifested by bacteremia, meningitis, and pneumonia. In utero infection with parvovirus is a cause of fetal hydrops. Infection in young children is generally associated with fever, malaise, adenopathy, and a characteristic rash.
10. (E) Varicella zoster is a highly contagious virus that causes chickenpox. It is a more severe disease in adults than in children and has been reported to cause pneumonia in 10% of infected pregnant women.
Approximately 10% of fetuses can become infected in utero when the gravida is exposed in early pregnancy. Severe congenital malformation of the limbs, chorioretinitis, and cerebral cortical atrophy are possible as a result of exposure. The administration of VZIG within 96 hours of exposure will attenuate most infections. Before administering VZIG, maternal serum can be tested to see if the patient is immune.
11. (C) This is a classic presentation of measles (rubeola), especially the pathognomonic (Kop-lik) spots.
It seldom has an effect in midgesta-tion. Vaccination is not indicated during pregnancy, and if you already have the infection, vaccination is of no value. Some authorities would recommend passive immunity.
12. (A) Congenital rubella is teratogenic and often fatal to the fetus or neonate. Eighty percent of fetuses will be affected if the mother was infected during the first trimester and manifested a rash. By the end of the trimester, the fetal infection rate drops to 25%. Maternal symptoms are usually quite mild with low-grade fever and maculopapular rash; however, 50% are subclinical. It is seldom dangerous to the gravida but has been increasing in frequency in recent years. Vaccination is the key to prevention and should be performed shortly after pregnancy or when adequate contraception is being used. Vaccination during pregnancy is not recommended.
13. (D) Those who eat raw meat and those who handle cat feces (litter box cleaners) are at greatest risk for toxoplasmosis infection during pregnancy. The cat breeder is at greatest risk. The rate of primary infection in pregnancy is low (approximately 1 per 1,000) and only 10% of those infected will have serious neonatal sequelae. Women who desire to be tested for this disease will show appropriate