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Office Practice
resistant B streptococci have not been identified. However, erythromycin and clindamycin resistance has been found. For the interested reader, ACOG Committee Opinion No. 173, June 1996, entitled Prevention of Early-Onset Group B Streptococcal Disease in Newborns, contains CDC and ACOG recommendations for antibiotic prophylaxis. l
.
l
Wisncr KL, GeIcnbe~ AJ, Leonard H, Zarin D, Frank E. Pharmacologic treatment of depression during pregnancy. JAMA 1999; 282~1264-9.
Synopsis: This meta-analysisof prospective controlled trials was undertaken to identi+ risk f&tots associated with treatment of major depressionduring pregnancy. Question 98: In a large study of women presentingto an urban hospital, what percent of these women had episodes of depression during pregnancy or within the first 3 months postpartum? Answer: b) 9%. In a 1393 report, Wisner, Peindl, and Hanusa found that 9% of women had episodes of depression during pregnancy or within 3 months after delivery. Question 99: The riskof which of the following conditions is increased by ph~macolo~c treatment of depression during pregnancy? Answer: d) Neonatal withdrawal symptoms. The possible toxic ef5xt.s of antidepressiondrug treatment during pregnancy to the fetus have been divided into five areas: intrauterine death, malformations,growth impairment, behavioralteratology, and neonatal toxicity. No significant association between aicyclic antidepressants and congenital malfunctionshas been identified.There is no evidence of increased risk of intrauterine fetal death, growth impairment, or major birth defects. There have been reports of neonatal withdrawal. Question 100: If a woman has been treated with tricyclic antidepressants during pregnancy, what dose should she receive in the immediate postpartum period? Answer: b) Dosage taken when not pregnant. After delivery a woman who has taken antidepressants should be continued on her prepregnancy dosage.
OFFICE PRACTICE Ametican CoIIege of Obstetricians and Gynccoiogists. Domestic violence. ACOG EducationaI Bulletin No. 257. Washington, DC: ACOG, 1999.
Synopsis: Thii Educational Bulletin was developed to describe the epidemiology, screening, documentation, and intervention aspects of domestic violence. It includes legal issues and the problem as related to special populations. Question 101:Which of the following is the LEAST likelycharacteristic of domestic violence? Answer: c) Ratio of female to male victims approximately 2:l. Although domestic violence occurs against both males and females, the cases overwhelmingly involve female victims.
Synopsist Migraine headaches are a common occurrence. This review outlines the diagnosis, treatment, and preventive therapy. Question 106~ Which of the following signs and symptoms is the LEAST common cause fbr concern in awoman with known migraine headaches? Answer: a) Lack of associated aura. A migraine without aura is more common in women. The lack of aura does not affect the diagnosis or indicate a different degree of seriousness. Question 107: The prevalence of migraine headaches is MOST common in which of the following age groups? Answer: b) 25-55. In agiven year 15-20% of women and 7-100/o of men will have at least one migraine headache. The incidence is highest among those of age 25-55 years.
Question 102: Which of the following anatomic areas is LEAST likely to be the site of a physical injury secondary to domestic violence? Answer: b) Extremities. When injuries occur they most commonly involve the head, l&e, breasts, and abdomen. In pregnant victims, injuries tend to be of the breast and abdomen.
Question 108~ Which of the following is NOT a major emphasis in the treatment of migraine headache? Answer: d) Emphasis on fluid and electrolyte balance. Early treatment of an attack is the mainstay of therapy. Avoidance of trigger (if known) and useof medication are also desirable.
Question 103: The prevalence of violence during pregnancy reported in MOST studies is Answer: b) 4-g%. The prevalence of violence during pregnancy ranges from 1% to 20%. Most studies identify 4-g% as the usual rate.
Question 109%Which of the following is the LEAST common trigger for a migraine attack in women? Answer: d) Darkness. Many f&ztors havebeenassociatedwithinitiation of a migraineattack These includealcohol, fL&ng, oral contraozptives,hormone replacementtherapy,ca&ine and its withdrawal,stress, too little sleep, menstruation,fdtigue,etc.
Question 104: This article suggests that the time of highest prevalenceof domestic violence associated with pregnancy is MOIST likely to be Answer: d) Postpartum period. There is evidence that the pattern of violence will escalate during pregnancy and become most prevalent during the postpartum period. vialence in pregnancy is more prevalent than gestational diabetes or preeclampsia. Question 105: This article sqgests screening which group of women for domestic violence? Answer:d) All women. Screening all patients is the key to identifying abuse. There is no period of a woman’s life when abuse cannot occur. . . . Bar&son JD. Treatment of migraine hcadaches. Mayn CIln Proc 1999;74:702-8.
QueAon 110: Which of the following drugs is LEAST effective for preventive antimigraine therapy? Answer: c) Methysergiddansert. Several types of medication can be considered to prevent migraines. The most common are /3-adrenergic blockers such as propranolol, divalproex sodium, nonsteroidal antiinflammatory drugs such as naproxen, calcium-channel blockers, and tricyclic antidepressants. Although effective, methysergide is rarely used because of side effects. However, because it is used ABOG gave credit for all answers. . . . HaydenFG, Atmar RI+ SchiIIing M, et aI. Use of the s&ctivc 0raI neuraminidasc in-
L
10
l
ACOG CLINICAL
REVIEW
l
March/April 2001
02001
by the American College of Obstetricians and Gynecoilylists Published by Elsewer Sctence Inc. 1085~~1~.~
hibitor oseltamivir to prevent influenza. N EngI J Mcd 1999;341:1336-43. Cox NJ, Hughes JM. New options for the prevention of influenza [editorial]. N EngI J Med 1999;341:1387-8. Synopsis:
This study was undertaken to explore osehamivir as an agent to prevent infection with influenza A and B viruses. The medication was determined to be safe and effective.
Que&on 111: Currently, the MOST effective measure to reduce the public health impact of influenza is Answer: a) Vaccination. Yearly immunization is currently the most important measure to prevent infection with influenza. Question 112: In this study, the primary side effect of oral osehamivir is Answer: a) Gastrointestinal symptoms. Oseltamivir is generally well tolerated. The most common side effects were upper gastrointestinal disturbances and headaches. Question 113: The rate (expressed by percentage) of laboratory-confirmed influenza infection was how much lower with oseltamivir than with placebo? Answer: d) One-half. The rate of laboratory confirmed influenza infection was 10.6% in the placebo-treated patients and 5.3% in those treated with oseltamivir. Question 114: The protective effrcacy of oseltamivir in the two activetreatment groups in all sites was what percent? Answer: c) 74%. In this study the drug gave 74% protective efficacy in overall reduction and 87% efficacy in culture-proved disease. . . . Joshi N, Caputo GM, Weitekamp MR, Karchmer AW. Infections in patients with diabetes me&us. N Engl J Med 1999;341: 1906-12.
Synopsis: This
review article discusses diabetes and infection. It describes the common infection and related organisms. Question 115: Which of the follow-
ing infections of the urinary tract is NOT mentioned in this article as having a higher incidence in women with diabetes than in nondiabetic women? Answer: c) Nonspecific urethritis. Diabetic women have been found to have a higher incidence of bacteri0Z’M)l by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1065~6662/01/56.00
uria by a factor of two to four. They are also predisposed to upper urinary tract infections including pyelonephritis and when a fungus is the in&ting agent, emphysematous cystitis. Question 116: The MOST common
soft tissue infection in women with diabetes is an infection ofwhich of the following? Answer: d) Foot. Soft tissue infections in diabetic women include necrotizing fasciitis of the arms, legs, or abdominal wall, and foot infections. The foot is the most common site. Question 117: Which of the follow-
ing is the BEST method to detect gas in the soft tissue of a woman with necrotizing fasciitis? Answer: b) Plain radiograph. Although crepitus can be palpated, the condition is noted in only about 50% of the cases. Soft tissue x-rays are more effective in diagnosing the gas. . . . Seibel MM. The role of nutrition and nutritional supplements in women’s health. FertiI sterlI1999;72:579-91.
Synopsis: This article reviews the cur-
rent literature on nutrition to give physicians a better understanding of how nutrition and nutritional supplements may reduce illness. Question 118: Which of the follow-
ing is NOT a fat-soluble vitamin? Answer: d) Folic acid. Of the I3 essential vitamins that have been identified, those that are f$t soluble are vitamins A, D, E, and K. Beta-carotene is also fat soluble. Question 119: For each gram of pro-
tein a teenager consumes, how much calcium is lost in the urine? Answer: b) 1.0 mg. Protein increases the acid load of urine and thus requires calcium to act as a buffer. Sodium also contributes to urinary calcium loss. Question 120: Which of the follow-
ing groups of women is LEAST likely to need a daily supplement of vitamin C? Answer: d) Vegetarians. Vitamin C is a water-soluble vitamin that is essential to many of the body’s metabolic pmcesses. Women who are smokers, have excessive alcohol intake, or are long-term oral contraceptive users need additional vitamin C intake.
I
1
GYNECOLOGY American College of Obstetricians and Gynecologists. Management of anovulatory bleeding. ACOG Practice Bulletin No. 14. Washington, DC: ACOG, 2000.
Synopsis: Anovulatory
bleeding is the most common form of noncyclic uterine bleeding. The choice of treatment once the diagnosis is confirmed depends on several factors such as age, severity, and fertility desires. This document provides management guidelines. Question 121: In this article, menor-
rhagia is defined as uterine bleeding at regular intervals with blood loss of greater than how many mL per menstrual cycle? Answer: d) 80 mL. Menorrhagia is defined as prolonged or excessive bleeding in excess of 80 mL of blood or bleeding that lasts for more than 7 days. Qudon
122: Screening for coagulation disorders is MOST appropriate in which age group (years of age) of women with anovulatory bleeding? Answer: a) 13-18. Studies have demonstrated a prevalence of blood dyscrasia in adolescents of ages 13-18 years ranging from 5% to 200/6 of those hospitalized. Question 123: Which of the follow-
ing is the LEAST compelling indication to perform endometrial assessment in a 32-year-old woman with abnormal bleeding? Answer: c) High parity. Although endometrial carcinoma is rare in women ages 19-39 years, patients who fail to respond to medical therapy or have prolonged periods of unopposed estrogen secondary to anovulation should have an endometrial assessment. Question 124: Endometrial ablation with the thermal balloon results in an amenorrhea rate of approximately what percent? Answer: b) 15%. The surgical options include hysterectomy and endometrial ablation. Endometrial ablation by use of a thermal balloon heated to approximately 85°C results in an incidence of amenorrhea of 15%
March/April 2001
l
ACOG CLINICAL
REVIEW
l
11
.
l
Wisncr KL, GeIcnbe~ AJ, Leonard H, Zarin D, Frank E. Pharmacologic treatment of depression during pregnancy. JAMA 1999; 282~1264-9.
Synopsis: This meta-analysisof prospective controlled trials was undertaken to identi+ risk f&tots associated with treatment of major depressionduring pregnancy. Question 98: In a large study of women presentingto an urban hospital, what percent of these women had episodes of depression during pregnancy or within the first 3 months postpartum? Answer: b) 9%. In a 1393 report, Wisner, Peindl, and Hanusa found that 9% of women had episodes of depression during pregnancy or within 3 months after delivery. Question 99: The riskof which of the following conditions is increased by ph~macolo~c treatment of depression during pregnancy? Answer: d) Neonatal withdrawal symptoms. The possible toxic ef5xt.s of antidepressiondrug treatment during pregnancy to the fetus have been divided into five areas: intrauterine death, malformations,growth impairment, behavioralteratology, and neonatal toxicity. No significant association between aicyclic antidepressants and congenital malfunctionshas been identified.There is no evidence of increased risk of intrauterine fetal death, growth impairment, or major birth defects. There have been reports of neonatal withdrawal. Question 100: If a woman has been treated with tricyclic antidepressants during pregnancy, what dose should she receive in the immediate postpartum period? Answer: b) Dosage taken when not pregnant. After delivery a woman who has taken antidepressants should be continued on her prepregnancy dosage.
OFFICE PRACTICE Ametican CoIIege of Obstetricians and Gynccoiogists. Domestic violence. ACOG EducationaI Bulletin No. 257. Washington, DC: ACOG, 1999.
Synopsis: Thii Educational Bulletin was developed to describe the epidemiology, screening, documentation, and intervention aspects of domestic violence. It includes legal issues and the problem as related to special populations. Question 101:Which of the following is the LEAST likelycharacteristic of domestic violence? Answer: c) Ratio of female to male victims approximately 2:l. Although domestic violence occurs against both males and females, the cases overwhelmingly involve female victims.
Synopsist Migraine headaches are a common occurrence. This review outlines the diagnosis, treatment, and preventive therapy. Question 106~ Which of the following signs and symptoms is the LEAST common cause fbr concern in awoman with known migraine headaches? Answer: a) Lack of associated aura. A migraine without aura is more common in women. The lack of aura does not affect the diagnosis or indicate a different degree of seriousness. Question 107: The prevalence of migraine headaches is MOST common in which of the following age groups? Answer: b) 25-55. In agiven year 15-20% of women and 7-100/o of men will have at least one migraine headache. The incidence is highest among those of age 25-55 years.
Question 102: Which of the following anatomic areas is LEAST likely to be the site of a physical injury secondary to domestic violence? Answer: b) Extremities. When injuries occur they most commonly involve the head, l&e, breasts, and abdomen. In pregnant victims, injuries tend to be of the breast and abdomen.
Question 108~ Which of the following is NOT a major emphasis in the treatment of migraine headache? Answer: d) Emphasis on fluid and electrolyte balance. Early treatment of an attack is the mainstay of therapy. Avoidance of trigger (if known) and useof medication are also desirable.
Question 103: The prevalence of violence during pregnancy reported in MOST studies is Answer: b) 4-g%. The prevalence of violence during pregnancy ranges from 1% to 20%. Most studies identify 4-g% as the usual rate.
Question 109%Which of the following is the LEAST common trigger for a migraine attack in women? Answer: d) Darkness. Many f&ztors havebeenassociatedwithinitiation of a migraineattack These includealcohol, fL&ng, oral contraozptives,hormone replacementtherapy,ca&ine and its withdrawal,stress, too little sleep, menstruation,fdtigue,etc.
Question 104: This article suggests that the time of highest prevalenceof domestic violence associated with pregnancy is MOIST likely to be Answer: d) Postpartum period. There is evidence that the pattern of violence will escalate during pregnancy and become most prevalent during the postpartum period. vialence in pregnancy is more prevalent than gestational diabetes or preeclampsia. Question 105: This article sqgests screening which group of women for domestic violence? Answer:d) All women. Screening all patients is the key to identifying abuse. There is no period of a woman’s life when abuse cannot occur. . . . Bar&son JD. Treatment of migraine hcadaches. Mayn CIln Proc 1999;74:702-8.
QueAon 110: Which of the following drugs is LEAST effective for preventive antimigraine therapy? Answer: c) Methysergiddansert. Several types of medication can be considered to prevent migraines. The most common are /3-adrenergic blockers such as propranolol, divalproex sodium, nonsteroidal antiinflammatory drugs such as naproxen, calcium-channel blockers, and tricyclic antidepressants. Although effective, methysergide is rarely used because of side effects. However, because it is used ABOG gave credit for all answers. . . . HaydenFG, Atmar RI+ SchiIIing M, et aI. Use of the s&ctivc 0raI neuraminidasc in-
L
10
l
ACOG CLINICAL
REVIEW
l
March/April 2001
02001
by the American College of Obstetricians and Gynecoilylists Published by Elsewer Sctence Inc. 1085~~1~.~
hibitor oseltamivir to prevent influenza. N EngI J Mcd 1999;341:1336-43. Cox NJ, Hughes JM. New options for the prevention of influenza [editorial]. N EngI J Med 1999;341:1387-8. Synopsis:
This study was undertaken to explore osehamivir as an agent to prevent infection with influenza A and B viruses. The medication was determined to be safe and effective.
Que&on 111: Currently, the MOST effective measure to reduce the public health impact of influenza is Answer: a) Vaccination. Yearly immunization is currently the most important measure to prevent infection with influenza. Question 112: In this study, the primary side effect of oral osehamivir is Answer: a) Gastrointestinal symptoms. Oseltamivir is generally well tolerated. The most common side effects were upper gastrointestinal disturbances and headaches. Question 113: The rate (expressed by percentage) of laboratory-confirmed influenza infection was how much lower with oseltamivir than with placebo? Answer: d) One-half. The rate of laboratory confirmed influenza infection was 10.6% in the placebo-treated patients and 5.3% in those treated with oseltamivir. Question 114: The protective effrcacy of oseltamivir in the two activetreatment groups in all sites was what percent? Answer: c) 74%. In this study the drug gave 74% protective efficacy in overall reduction and 87% efficacy in culture-proved disease. . . . Joshi N, Caputo GM, Weitekamp MR, Karchmer AW. Infections in patients with diabetes me&us. N Engl J Med 1999;341: 1906-12.
Synopsis: This
review article discusses diabetes and infection. It describes the common infection and related organisms. Question 115: Which of the follow-
ing infections of the urinary tract is NOT mentioned in this article as having a higher incidence in women with diabetes than in nondiabetic women? Answer: c) Nonspecific urethritis. Diabetic women have been found to have a higher incidence of bacteri0Z’M)l by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1065~6662/01/56.00
uria by a factor of two to four. They are also predisposed to upper urinary tract infections including pyelonephritis and when a fungus is the in&ting agent, emphysematous cystitis. Question 116: The MOST common
soft tissue infection in women with diabetes is an infection ofwhich of the following? Answer: d) Foot. Soft tissue infections in diabetic women include necrotizing fasciitis of the arms, legs, or abdominal wall, and foot infections. The foot is the most common site. Question 117: Which of the follow-
ing is the BEST method to detect gas in the soft tissue of a woman with necrotizing fasciitis? Answer: b) Plain radiograph. Although crepitus can be palpated, the condition is noted in only about 50% of the cases. Soft tissue x-rays are more effective in diagnosing the gas. . . . Seibel MM. The role of nutrition and nutritional supplements in women’s health. FertiI sterlI1999;72:579-91.
Synopsis: This article reviews the cur-
rent literature on nutrition to give physicians a better understanding of how nutrition and nutritional supplements may reduce illness. Question 118: Which of the follow-
ing is NOT a fat-soluble vitamin? Answer: d) Folic acid. Of the I3 essential vitamins that have been identified, those that are f$t soluble are vitamins A, D, E, and K. Beta-carotene is also fat soluble. Question 119: For each gram of pro-
tein a teenager consumes, how much calcium is lost in the urine? Answer: b) 1.0 mg. Protein increases the acid load of urine and thus requires calcium to act as a buffer. Sodium also contributes to urinary calcium loss. Question 120: Which of the follow-
ing groups of women is LEAST likely to need a daily supplement of vitamin C? Answer: d) Vegetarians. Vitamin C is a water-soluble vitamin that is essential to many of the body’s metabolic pmcesses. Women who are smokers, have excessive alcohol intake, or are long-term oral contraceptive users need additional vitamin C intake.
I
1
GYNECOLOGY American College of Obstetricians and Gynecologists. Management of anovulatory bleeding. ACOG Practice Bulletin No. 14. Washington, DC: ACOG, 2000.
Synopsis: Anovulatory
bleeding is the most common form of noncyclic uterine bleeding. The choice of treatment once the diagnosis is confirmed depends on several factors such as age, severity, and fertility desires. This document provides management guidelines. Question 121: In this article, menor-
rhagia is defined as uterine bleeding at regular intervals with blood loss of greater than how many mL per menstrual cycle? Answer: d) 80 mL. Menorrhagia is defined as prolonged or excessive bleeding in excess of 80 mL of blood or bleeding that lasts for more than 7 days. Qudon
122: Screening for coagulation disorders is MOST appropriate in which age group (years of age) of women with anovulatory bleeding? Answer: a) 13-18. Studies have demonstrated a prevalence of blood dyscrasia in adolescents of ages 13-18 years ranging from 5% to 200/6 of those hospitalized. Question 123: Which of the follow-
ing is the LEAST compelling indication to perform endometrial assessment in a 32-year-old woman with abnormal bleeding? Answer: c) High parity. Although endometrial carcinoma is rare in women ages 19-39 years, patients who fail to respond to medical therapy or have prolonged periods of unopposed estrogen secondary to anovulation should have an endometrial assessment. Question 124: Endometrial ablation with the thermal balloon results in an amenorrhea rate of approximately what percent? Answer: b) 15%. The surgical options include hysterectomy and endometrial ablation. Endometrial ablation by use of a thermal balloon heated to approximately 85°C results in an incidence of amenorrhea of 15%
March/April 2001
l
ACOG CLINICAL
REVIEW
l
11