Question 71
25-year-old woman is G2 P1. Her first pregnancy resulted in a normal term birth. Now at 15 weeks gestation, a prenatal checkup reveals that she has a blood pressure of 140/90 mm Hg. An ultrasound is performed that reveals no fetal cardiac motion. Misoprostol induction is performed for termination of the pregnancy. Examination of the malformed stillborn fetus reveals that it is small for gestational age and has 3,4 syndactyly bilaterally, an indented nasal bridge, and a two vessel cord. The placenta is small for gestation and has scattered 0.5 cm grape-like villi. A chromosome analysis performed on the placental tissue will most likely demonstrate which of the following karyotypes?
A 46, XX
B 69, XXY
C 45, X
D 47, XX, +18
E 23, X
F 47, XYY
G 47, XXX
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(B) CORRECT. In a partial mole, a fetus is present but malformed and small for gestational age. Only occasional villi, or none at all, may be grape-like, but there is trophoblastic proliferation typical of molar pregnancy.(A) Incorrect. The 46, XX karyotype would be appropriate for a normal female fetus. It could also be seen with a complete mole in which no fetus would be present.(C) Incorrect. The 45, X karyotype is seen with Turner syndrome, one of the more common chromosomal abnormalities seen with fetal losses. It is not accompanied by placental changes of molar pregnancy.(D) Incorrect. Trisomy 18 leads to an abnormal appearing fetus with clenched hands (not syndactyly), and the placenta may be small, but does not show changes of molar pregnancy.(E) Incorrect. The 23, X karyotype is that of an unfertilized ovum or a sperm.(F) Incorrect. This karyotype is indicative of Klinfelter syndrome, seen in nearly normal appearing males with oligospermia.(G) Incorrect. This is the 'superfemale' karyotype with only mild mental retardation.
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Question 72
A 16-year-old girl has not begun menstruation. Physical examination reveals that she has breast development, but a short vagina and no palpable uterus or adnexa, only bilateral inguinal masses. She appears otherwise normally developed. Which of the following laboratory tests would be most appropriate to order on this girl?
A Chromosome analysis
B Serum estrogen
C Assay for luteinizing hormone
D Serum cortisol
E Serum testosterone
F Magnetic resonance imaging of brain
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(A) CORRECT. The findings point to testicular feminization (androgen insensitivity syndrome), with a karyotype of 46, XY. The inguinal masses are the testes.(B) Incorrect. This would be more useful for workup of secondary amenorrhea.(C) Incorrect. This would be more useful for workup of secondary amenorrhea.(D) Incorrect. A serum cortisol would be useful for workup of congenital adrenal hyperplasia.(E) Incorrect. This is more useful for workup of male infertility or developmental problems.(F) Incorrect. It is unlikely that her problems can be explained by a neoplasm of the brain, including the pituitary.
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Question 73
A 38-year-old healthy woman has had a white, curd-like vaginal discharge for the past week. There is no bleeding. A Pap smear demonstrates normal appearing squamous epithelial cells along with scattered neutrophils and budding cells with pseudohyphae. Which of the following infectious agents is most likely to be present in this woman?
A Treponema pallidum
B Neisseria gonorrhea
C Chlamydia trachomatis
D Herpes simplex virus
E Escherichia coli
F Gardnerella vaginalis
G Trichomonas vaginalis
H Candida albicans
I Human papillomavirus
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(H) CORRECT. Vaginal yeast infections are quite common. Fungal vulvovaginitis is the second most common cause of vaginal infections in the U.S. (Bacterial vaginosis is the most frequent cause).(A) Incorrect. This is the causative agent for syphilis, which as a primary lesion causes a hard chancre.(B) Incorrect. Gonorrhea is more of a cause for vaginitis in children.(C) Incorrect. Chlamydia trachomatis is a sexually transmitted disease that is unlikely to produce a marked vaginal exudate.(D) Incorrect. HSV infection leads to the recurrent appearance of crops of painful vesicles, typically on the external genitalia.(E) Incorrect. Gram negative enteric bacterial infections are not common at this site.(F) Bacterial vaginosis is caused by overgrowth of a variety of bacteria (Gardnerella vaginalis, Prevotella, Mobiluncus, Peptostreptococcus, Mycoplasma hominis, etc.) in the vagina. It differs from fungal vulvovaginitis in that (1) there is usually a rather unpleasant and quite noticeable 'fishy' odor; (2) the vaginal discharge is homogenous, lower in viscosity, and uniformly coats the vaginal walls; and (3) the vaginal pH is usually >4.5.(G) Incorrect. Trichomonas vulvovaginitis is caused by the protozoan Trhicomonas vaginalis. It differs from fungal vulvovaginitis in that there is a profuse, homogenous vaginal discharge that usually has a yellow or greenish-yellow color. Vaginal pH is usually > 5.0, and the 'fishy' odor may or may not be present. Trichomonas vulvovaginitis is diagnosed by observation of motile trichomonads and large numbers of PMNs in a vaginal smear.(I) Incorrect. HPV is a cause for condyloma and for squamous dysplasias and carcinomas, not vaginosis.
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Question 74
A 35-year-old woman has had dull pelvic pain for 4 months. A pelvic examination reveals a normal appearing cervix, a normal sized uterus, and a large tender right adnexal mass. Ultrasound reveals an 8 cm cystic, fluid-filled mass involving the right adnexal region. At laparotomy, there are many filmy fibrous adhesions in the pelvis. The mass is excised and on gross examination is found to have a thin wall and is filled with purulent exudate. Microscopically, there are thin remnants of fallopian tube and ovary comprising the wall of the mass, with numerous neutrophils filling the lumen. Which of the following infectious agents is most likely to have produced these findings?
A Human papillomavirus
B Mycobacterium tuberculosis
C Trichomonas vaginalis
D Candida albicans
E Neisseria gonorrheae
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(E) CORRECT. She has findings of pelvic inflammatory disease complicated by a tubo-ovarian abscess. These are potential complications of sexually transmitted diseases caused by gonorrhea or chlamydia most often.(A) Incorrect. HPV is a sexually transmitted disease that affects the external genitalia and cervix.(B) Incorrect. Tuberculosis is a rare infection of the female genital tract that can produce a chronic endometritis or a chronic salpingitis.(C) Incorrect. Trichomonal infections are not very severe. They typically involve the vagina.(D) Incorrect. Yeast infections are a nuisance, but not severe, and involve the vagina.
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Question 75
Abnormal uterine bleeding for the past 5 months prompts a 62-year-old woman to see her physician. She has never been pregnant and went through menopause 10 years previously. On physical examination her BMI is 33. There are no abnormal findings on physical examination. An endometrial biopsy is performed and on microscopic examination shows a well-differentiated endometrial adenocarcinoma. Which of the following ovarian neoplasms is she most likely to have?
A Papillary serous cystadenocarcinoma
B Krukenberg tumor
C Mucinous cystadenoma
D Granulosa cell tumor
E Immature teratoma
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(D) CORRECT. She could have an ovarian tumor producing estrogen, and the granulosa cell tumor is most likely to do that, of the ones listed.(A) Incorrect. Cystadenocarcinomas are epithelial tumors unlikely to secrete estrogen.(B) Incorrect. A Krukenberg tumor represents metastatic disease of the ovary, most often from a gastrointestinal malignancy (such as primary gastric adenocarcinoma).(C) Incorrect. Cystadenomas, which are of epithelial origin, are not likely to secrete estrogen.(E) Incorrect. Immature teratomas contain primitive elements with neural differentiation and are unlikely to secrete estrogens.
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