At the time of her annual examination, you find an approximately 10-week-sized irregular uterus on an asymptomatic 40-year-old woman. Her last exam 1 year prior was normal.
Your next step in the management of this patient is:
Correct Answer C:
Management of an asymptomatic 40-year-old with leiomyomata: abdominal ultrasound at this time for diagnosis and reexamine in 6 months. Leiomyomas are a frequent finding in a reproductive age woman. If they are asymptomatic (absence of pain, menorrhagia, urinary symptoms, gastrointestinal symptoms), and if they are small and not rapidly changing in size, then they can be followed. Since her last exam 1 year ago was reportedly normal, reexamination in less than 1 year would be appropriate.
A. Indicated for symptomatic fibroid uterus in a woman who does not desire fertility.
B. Necessary only if the woman is having abnormal uterine bleeding.
D. See answer to B.
E. Can be used for symptomatic leiomyomas in a reproductive age woman, but no more than 6 months of continuous therapy. This woman is without symptoms.
A 35-year-old female is planning a second pregnancy. Her last pregnancy was complicated by placental abruption caused by a large fibroid tumor of the uterus, which is still present.
Which one of the following would be the most appropriate treatment for the fibroid tumor?
Correct Answer A:
There are numerous options for the treatment of uterine fibroids. When pregnancy is desired, myomectomy offers the best chance for a successful pregnancy when prior pregnancies have been marked by fibroid-related complications. Endometrial ablation eliminates fertility, and there is a lack of long-term data on fertility after uterine artery embolization. Observation without treatment would not remove the risk for recurrent complications during subsequent pregnancies.
Which one of the following is the strongest risk factor for preterm birth?
Correct Answer A: Preterm delivery (20-37 weeks gestation) is three to four times more likely in women who have had a prior preterm delivery (choice A). Multiple gestation also makes preterm delivery more likely.
There are some known risk factors for premature birth:
→ Being overweight (choice B) is a risk factor of preterm birth but previous premature birth is a stronger risk factor.
→ First trimester bleeding (choice C) is not as strong a risk factor as second and third trimester bleeding for preterm birth. Natural pregnancy loss in the first trimester is not called preterm birth, it is called spontaneous abortion.Preterm birth applies to delivery occurring after the 20th week of gestation but before the 37th week.
→ Smoking before pregnancy (choice D) is a risk factor of premature birth, but prior premature birth is the strongest risk factor of all.
→ Blood pressure 130/85 (choice E) is pre-hypertension but is not a strong risk factor for preterm delivery like prior preterm birth.
What is the test used to diagnose cervical incompetence in a pregnant woman?
Correct Answer D:
Cervical incompetence is painless cervical dilation resulting in delivery of a live fetus between 16 and 22 weeks.
In women with weak cervical tissue, the enlarging products of conception cause the cervix to dilate prematurely. Overall risk of recurrence of cervical incompetence is probably ≤ 30%. Risk is greatest for women with ≥ 3 prior 2nd-trimester fetal losses.
Cervical incompetence is diagnosed clinically. There is increased use of routine second trimester transvaginal ultrasound to diagnose.
Cerclage (reinforcement of the cervical ring with suture material) appears to prevent preterm delivery in patients with ≥ 3 prior 2nd-trimester fetal losses.
A 72-year-old woman complains of a lump protruding through the vagina with local pressure symptoms. On examination, there is a visible uterine prolapse.
All of the following may be etiologic factors, except:
Uterine prolapse is descent of the uterus toward or past the introitus. Vaginal prolapse is descent of the vagina or vaginal cuff after hysterectomy. Symptoms include vaginal pressure and fullness. Diagnosis is clinical. Treatment includes reduction, pessaries, and surgery.
A prolapsed uterus is graded based on level of descent: to the upper vagina (1st degree), to the introitus (2nd degree), or external to the introitus (3rd degree or total, sometimes referred to as procidentia). Vaginal prolapse may be 2nd or 3rd degree.
Pregnancy and trauma incurred during childbirth (choice A), particularly with large babies (choice C) or after a difficult labor and delivery, are the main causes of muscle weakness leading to uterine prolapse. Loss of muscle tone associated with aging and reduced amounts of circulating estrogen (choice D is incorrect) after menopause (choice E) also may contribute to uterine prolapse. In rare circumstances, uterine prolapse may be caused by a tumor in the pelvic cavity.
Smoking (which causes chronic cough) (choice B) and genetics also may play a role. Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent.
Symptoms tend to be minimal with 1st-degree uterine prolapse. In 2nd- or 3rd-degree uterine prolapse, fullness, pressure, and a sensation of organs falling out are common. Diagnosis is confirmed by speculum or bimanual pelvic examination.
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