SPEX Exam Obstetrics and Gynecology 6

Question 1

A 34-year-old woman at 28 weeks gestation presents with severe headache, visual disturbances, and BP of 158/106 mmHg. Labs show platelets 89,000/μL, AST 210 U/L, ALT 198 U/L, and LDH 780 U/L. Urinalysis reveals 3+ protein. Which of the following best describes the MOST appropriate next step in management?

Accepted Answer

Administer magnesium sulfate and corticosteroids, then plan delivery within 24–48 hours regardless of fetal lung maturity

Answer

This patient has HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) superimposed on severe-feature preeclampsia at 28 weeks. HELLP syndrome is an obstetric emergency. The correct approach is to stabilize the mother with magnesium sulfate (seizure prophylaxis) and antihypertensives, administer corticosteroids for fetal lung maturity, and plan delivery within 24–48 hours. Unlike isolated preterm preeclampsia without severe features, HELLP syndrome does not permit prolonged expectant management due to rapid maternal deterioration risk (DIC, hepatic rupture, placental abruption).

Question 2

A 29-year-old G2P1 presents at 16 weeks with a cervical length of 18 mm on transvaginal ultrasound and a history of spontaneous preterm birth at 23 weeks in her prior pregnancy. She has no uterine contractions and cervical os appears closed on digital exam. Which intervention has the strongest evidence for reducing recurrent preterm birth in this specific clinical scenario?

Accepted Answer

Cervical cerclage placement

Answer

In a patient with a prior spontaneous preterm birth AND a short cervix (≤25 mm) on second-trimester ultrasound, history-indicated or ultrasound-indicated cerclage has the strongest evidence. ACOG supports cerclage in this singleton pregnancy scenario with both risk factors present. Vaginal progesterone is indicated for short cervix without prior PTB history. IM 17-OHPC is indicated for prior PTB without necessarily addressing concurrent short cervix—evidence for its use weakened after the PROLONG trial. Pessary lacks sufficient evidence in singleton gestations in U.S. guidelines.

Question 3

A 52-year-old postmenopausal woman undergoes hysteroscopy for abnormal uterine bleeding. Pathology returns endometrial adenocarcinoma, FIGO grade 2, with myometrial invasion involving 60% of the myometrial thickness, no cervical involvement, and no extrauterine extension on imaging. Lymphovascular space invasion (LVSI) is present. What is the most appropriate surgical staging and adjuvant treatment recommendation?

Accepted Answer

Total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, followed by adjuvant chemotherapy plus vaginal brachytherapy

Answer

This is FIGO Stage IB (≥50% myometrial invasion), grade 2 endometrial carcinoma with LVSI—a high-intermediate risk profile. Surgical staging includes TAH-BSO and lymph node evaluation (pelvic ± para-aortic). The presence of LVSI upgrades adjuvant treatment recommendations. Per GOG and ESMO guidelines, patients with high-intermediate risk features (deep invasion, grade 2–3, LVSI) benefit from adjuvant chemotherapy (carboplatin/paclitaxel) combined with brachytherapy or external beam radiation—not radiation alone or observation. Sentinel lymph node mapping is acceptable but full dissection is preferred when LVSI is present.

Question 4

A 38-year-old woman with a known bicornuate uterus and two prior uterine surgeries presents at 22 weeks with an anterior placenta previa. MRI reveals loss of the normal retroplacental clear zone with irregular uterine serosa and placental tissue extending into the bladder wall. Which of the following best describes the optimal delivery plan?

Accepted Answer

Scheduled cesarean hysterectomy at 34–35 weeks with urology on standby and cell saver available, at a center with massive transfusion protocol capability

Answer

This presentation is consistent with placenta percreta (Accreta Spectrum Disorder grade 3) with bladder invasion—the most severe form. Optimal management involves planned cesarean hysterectomy at 34–35 weeks (balancing fetal maturity against increasing hemorrhage risk as pregnancy advances), performed at a center of excellence with a multidisciplinary team including urology, blood bank with MTP capability, and interventional radiology. Attempting uterine conservation (triple-P) is not appropriate when bladder invasion is confirmed on MRI. Emergency delivery or waiting until term significantly increases maternal mortality risk.

Question 5

A 24-year-old woman presents with cyclic pelvic pain, dyspareunia, and infertility for 3 years. Laparoscopy reveals superficial peritoneal endometriosis only (revised ASRM Stage I). After surgical excision, she attempts conception for 12 months without success. Semen analysis is normal, ovarian reserve testing is normal, and hysterosalpingography shows bilateral tubal patency. Which is the MOST evidence-based next step?

Accepted Answer

Initiate controlled ovarian hyperstimulation with intrauterine insemination (COH-IUI)

Answer

In Stage I–II endometriosis-associated infertility with normal semen analysis and tubal patency after surgical treatment, COH-IUI is the preferred first-line fertility intervention. It offers improved fecundity rates over expectant management and is less invasive and costly than IVF. GnRH agonist therapy post-surgery has not been shown to improve fertility outcomes and delays conception. IVF should be reserved for failed IUI cycles, tubal factor, or severe/Stage III–IV disease. Repeat laparoscopy without a therapeutic indication adds surgical risk without improving outcomes.

SPEX Exam Practice Test

SPEX Exam Practice Test

SPEX Exam Obstetrics and Gynecology 6