Women's Health EOR practice questions

Why tetanus, diphtheria, and acellular pertussis (Tdap) is correct

• Tdap is recommended during every pregnancy, given at 27–36 weeks
• Timing maximizes maternal immunoglobulin G (IgG) antibody transfer to the newborn, protecting them from pertussis before their first diphtheria, tetanus, and acellular pertussis (DTaP) vaccine at 2 months

Why the others are wrong

• A) Live attenuated influenza vaccine — the inactivated influenza vaccine (not live attenuated influenza vaccine (LAIV)) is safe in all trimesters; LAIV is contraindicated in pregnancy
• B) Measles, mumps, and rubella (MMR) — live vaccine; contraindicated in pregnancy
• D) Varicella — live vaccine; contraindicated in pregnancy

Why folic acid 400–800 mcg daily is correct

• Folic acid 400–800 mcg daily should be started at least 1 month before conception and continued through the first 12 weeks of pregnancy
• This supplementation reduces neural tube defect (NTD) risk by 50–70%
• The neural tube closes by day 28 of gestation, before many women know they are pregnant, making preconceptional supplementation critical
• Women with a prior NTD-affected pregnancy or who are on anticonvulsants should take a higher dose of 4 mg daily

Why elevated plasma phenylalanine is correct

• The clinical picture of a light-pigmented infant with a musty odor missed by newborn screening is classic for phenylketonuria (PKU)
• PKU is an autosomal recessive deficiency of phenylalanine hydroxylase
• Accumulation of phenylalanine and its metabolites (phenylacetate) causes the musty odor and hypopigmentation from impaired tyrosine/melanin synthesis
• Progressive intellectual disability occurs if untreated
• Diagnosis is confirmed by markedly elevated plasma phenylalanine with low tyrosine
• Treatment is a lifelong low-phenylalanine diet to prevent neurologic injury

Why the others are wrong

• B) Elevated urine homocystine — indicates homocystinuria, which causes lens dislocation and Marfanoid habitus, not a musty odor
• D) Elevated plasma branched-chain amino acids — signifies maple syrup urine disease, which presents with a sweet maple-syrup odor and early encephalopathy
• A) Elevated urine orotic acid — suggests urea cycle disorders such as ornithine transcarbamylase deficiency, which presents with hyperammonemia and vomiting rather than hypopigmentation

Why Sertraline plus psychotherapy referral is correct

• This patient has postpartum depression (PPD): PHQ-9 score of 16, 3 weeks of symptoms, and difficulty bonding with her infant.
• First-line treatment is a selective serotonin reuptake inhibitor (SSRI) plus psychotherapy (cognitive behavioral therapy (CBT)).
• Sertraline is first-line in breastfeeding women: extensive safety data, low milk transfer.
• Other breastfeeding-safe SSRIs include escitalopram and paroxetine.

Why the others are wrong

• B) Discontinue breastfeeding and initiate fluoxetine — Discontinuing breastfeeding is not required; sertraline is safe during breastfeeding.
• C) Inpatient psychiatric hospitalization — Hospitalization is indicated for suicidal ideation (SI), psychosis, or inability to care for the infant; this patient denies SI and is functioning.
• D) Reassurance and watchful waiting — Appropriate for postpartum blues (days 1–14, mild, self-limited); this patient's PHQ-9 of 16 and 3 weeks of impairing symptoms meet criteria for PPD and require treatment.

Additional high-yield points

• Postpartum blues: onset days 1–14, mild, self-limited.
• Postpartum depression (PPD): onset within the first year postpartum, PHQ-9 ≥10, persistent and impairs functioning.

Why IgE-mediated food allergy is correct

• The diagnosis rests on rapid onset (minutes to 2 hours) of urticaria, angioedema, and vomiting after first known exposure to a top allergen (egg) in an atopic child
• Prompt response to antihistamine further supports IgE-mediated mechanism
• Skin prick or serum egg-specific IgE testing confirms sensitization

Why the others are wrong

• C) Food protein-induced enterocolitis syndrome — FPIES is non-IgE mediated and presents with profuse repetitive vomiting 1–4 hours after ingestion accompanied by lethargy or pallor, without urticaria or angioedema
• A) Eosinophilic esophagitis — eosinophilic esophagitis is a chronic, food-triggered disorder presenting with feeding difficulty, reflux, or dysphagia over weeks to months, not acute urticaria
• D) Viral exanthem with coincident feeding — a viral exanthem would not produce perioral angioedema temporally linked to a first food exposure and would not resolve with a single antihistamine dose

Additional high-yield points

• Management: strict egg avoidance, epinephrine autoinjector prescription, and allergy referral

Why alendronate 70mg weekly is correct

• Osteoporosis pharmacologic treatment is indicated when any of three criteria are met: (1) T-score ≤-2.5 at lumbar spine or femoral neck; (2) prior fragility fracture; (3) Fracture Risk Assessment Tool (FRAX) 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%
• This patient meets criterion 1 (T-score -2.8 lumbar spine, -2.6 femoral neck) and criterion 3 (FRAX 10-year hip fracture risk 5.2%)
• First-line therapy is an oral bisphosphonate: alendronate 70mg weekly or risedronate 35mg weekly

Why the others are wrong

• B) Teriparatide — teriparatide is an anabolic agent reserved for severe osteoporosis or failure of antiresorptive therapy; not first-line here
• C) Estrogen-only hormone replacement therapy (HRT) — not the standard first-line pharmacologic choice for osteoporosis in this setting
• D) Continue calcium and vitamin D only — calcium and vitamin D are adjuncts, not sufficient as sole therapy when pharmacologic treatment criteria are met

Additional high-yield points

• Alternative pharmacologic options include IV zoledronic acid (annual infusion) and denosumab (6-monthly injection)
• Calcium 1,200mg and vitamin D 800 IU daily should be continued as adjuncts alongside pharmacologic therapy