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Obstetrics and Gynecology
PreTest® Self-Assessment and Review
 Notice
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Obstetrics and Gynecology
PreTest® Self-Assessment and Review
14th Edition

Shireen Madani Sims, MD

Associate Professor and Clerkship Director
Department of Obstetrics and Gynecology
University of Florida College of Medicine
Gainesville, Florida

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Student Reviewers
Samantha Baer
Third-Year Medical Student
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Class of 2016
Alexandra Monaco
Third-Year Medical Student
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v
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 Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Preconception Counseling, Genetics,

and Prenatal Diagnosis
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Maternal-Fetal Physiology and Placentation

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Antepartum Care and Fetal Surveillance

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Obstetrical Complications of Pregnancy

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Medical and Surgical Complications of Pregnancy

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Normal and Abnormal Labor and Delivery

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

The Puerperium, Lactation,

and Immediate Care of the Newborn
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

vii
viii  Contents

Preventive Care and Health Maintenance

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Benign and Malignant Disorders of the

Breast and Pelvis
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

Infertility, Endocrinology, and Menstrual Dysfunction

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Pelvic Relaxation and Urogynecology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

Human Sexuality and Contraception

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

Sexual Abuse and Intimate Partner Violence

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322

Ethical and Legal Issues in Obstetrics and Gynecology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
 Introduction
Obstetrics and Gynecology: PreTest® Self-Assessment and Review, 14th Edition,
is intended to provide medical students, as well as physicians, with a conve-
nient tool for assessing and improving their knowledge of obstetrics and gyne-
cology. The 504 questions in this book are similar in format and complexity to
those included in Step 2 of the United States Medical Licensing Examination
(USMLE). They may also be a useful study tool for Step 3.
Each question in this book has a corresponding answer, a reference to
a text that provides background for the answer, and a short discussion of
various issues raised by the question and its answer. A listing of references
for the entire book follows the last chapter. For multiple-choice questions,
the one best response to each question should be selected. For matching
sets, a group of questions will be preceded by a list of lettered options. For
each question in the matching set, select one lettered option that is most
closely associated with the question.
To simulate the time constraints imposed by the qualifying examina-
tions for which this book is intended as a practice guide, the student or
physician should allot about 1 minute for each question. After answering all
questions in a chapter, as much time as necessary should be spent review-
ing the explanations for each question at the end of the chapter. Atten-
tion should be given to all explanations, even if the examinee answered the
question correctly. Those seeking more information on a subject should
refer to the reference materials listed or to other standard texts in medicine.

ix
This page intentionally left blank
 Obstetrics
Preconception
Counseling, Genetics,
and Prenatal Diagnosis
Questions

1. After an initial pregnancy resulted in a spontaneous loss in the first tri-

mester, your patient is concerned about the possibility of this recurring.
Which of the following is the most appropriate answer regarding the risk of
recurrence after one miscarriage?
a. It depends on the genetic makeup of the prior abortus.
b. It is no different than it was prior to the miscarriage.
c. It has increased to approximately 50%.
d. It does not increase regardless of number of prior miscarriages.
e. It depends on the gender of the prior abortus.

2. A 24-year-old woman presents with a history of one first-trimester spon-

taneous abortion. Which of the following is the single most common spe-
cific chromosome abnormality associated with first trimester miscarriage?
a. 45 X (Turner syndrome)
b. Trisomy 21 (Down syndrome)
c. Trisomy 18
d. Trisomy 16
e. 46 XXY (Klinefelter syndrome)

1
2  Obstetrics and Gynecology

3. A 29-year-old G3P0 presents to your office for preconception counsel-

ing. All of her pregnancies were lost in the first trimester. She has no signifi-
cant past medical or surgical history. She should be counseled that without
evaluation and treatment her chance of having a live birth is which of the
following?
a. < 20%
b. 20% to 35%
c. 40% to 50%
d. 70% to 85%
e. > 85%

4. A 26-year-old G3P0030 has had three consecutive spontaneous abor-

tions in the first trimester. As part of an evaluation for this problem, which
of the following tests is most appropriate in the evaluation of this patient?
a. Hysterosalpingogram
b. Chromosomal analysis of the couple
c. Endometrial biopsy in the luteal phase
d. Postcoital test
e. Cervical length by ultrasonography

Questions 5 to 8

A 30-year-old G1P0 at 8 weeks’ gestation presents for her first prenatal visit.
She has no significant past medical or surgical history. A 29-year-old friend
of hers just had a baby with Down syndrome and she is concerned about
her risk of having a baby with the same problem. The patient reports no
family history of genetic disorders or birth defects.

5. You should tell her that she has an increased risk of having a baby with
Down syndrome in which of the following circumstances?
a. The age of the father of the baby is 40 years or older.
b. Her pregnancy was achieved by induction of ovulation and artificial insemination.
c. She has an incompetent cervix.
d. She has a luteal phase defect.
e. She has had three first-trimester spontaneous abortions.
 Preconception Counseling, Genetics, and Prenatal Diagnosis   3

6. You offer her a first trimester ultrasound looking for ultrasound mark-
ers associated with Down syndrome. Which of the following ultrasound
markers is most closely associated with Down syndrome?
a. Choriod plexus cyst
b. Ventriculomegaly
c. Increased nuchal translucency (NT)
d. Intracardiac echogenic focus
e. Echogenic bowel

7. In order to increase the detection rate for Down syndrome in the first
trimester, you may also offer her which of the following tests in addition to
the NT measurement?
a. α fetoprotein (AFP) serum screening
b. First trimester screen, which includes biochemical testing with serum markers
PAPP-A and free or total β-hCG, along with maternal age
c. Amniocentesis
d. Inhibin level serum screening
e. Fetal echocardiogram

8. The patient has an abnormal first trimester screen with increased risk of
Down syndrome reported. What is the most appropriate next step?
a. Offer termination of the pregnancy.
b. Tell the patient that the baby will have Down syndrome.
c. Refer the patient to a high-risk specialist.
d. Refer the patient to genetic counseling.
e. Refer the patient to genetic counseling, and offer her diagnostic testing by CVS
or a second-trimester genetic amniocentesis.
4  Obstetrics and Gynecology

9. A 20-year-old woman presents to your office for routine well-woman

examination. She has a history of acne, for which she takes minocycline
and isotretinoin on a daily basis. She has a history of epilepsy that is well-
controlled on valproic acid. She also takes a combined oral contraceptive
birth control pill containing norethindrone acetate and ethinyl estradiol.
She is a nonsmoker but drinks alcohol on a daily basis. She is concerned
about the effectiveness of her birth control pill, given all the medications
that she takes. She is particularly worried about the effects of her medica-
tions on a developing fetus in the event of an unintended pregnancy. Which
of the following substances that she ingests has the lowest potential to cause
birth defects?
a. Alcohol
b. Isotretinoin (accutane)
c. Tetracyclines
d. Progesterone
e. Valproic acid (Depakote)

10. A 24-year-old woman is in a car accident and is taken to an emergency

room, where she receives x-ray examinations of her neck, chest, and lower
spine. It is later discovered that she is 10 weeks pregnant. Which of the fol-
lowing is the most appropriate statement to make to the patient?
a. The fetus has received 50 rads of x-ray exposure and will likely abort.
b. Either chorionic villus sampling (CVS) or amniocentesis is advisable to check
for fetal chromosomal abnormalities.
c. At 10 weeks, the fetus is particularly susceptible to derangements of the central
nervous system (CNS).
d. The fetus has received less than the assumed threshold for radiation damage.
e. The risk that this fetus will develop leukemia as a child is raised.

Questions 11 to 12

A 25-year-old G0 presents to your office for preconception counseling. She

is a long-distance runner and wants to continue to train should she con-
ceive. She wants to know whether there are any potential adverse effects to a
developing fetus if she were to pursue a program of regular exercise during
her pregnancy.
 Preconception Counseling, Genetics, and Prenatal Diagnosis   5

11. You provide her with the following counseling about exercise during
pregnancy?
a. During pregnancy, she should stop exercising because such activity is commonly
associated with intrauterine growth retardation in the fetus.
b. She should perform exercises in the supine position to maximize venous return
and cardiac output.
c. She may continue to exercise throughout pregnancy as long as her heart rate
does not exceed 160 beats per minute.
d. She should only perform nonweight-bearing exercises because they minimize
the risks of maternal and fetal injuries.
e. She should reduce her daily exercise routine by one-half during the pregnancy
but following delivery, she may resume her activities to pre-pregnancy levels.

12. She asks you what other exercises would be appropriate during preg-
nancy. You counsel her that which of the following exercises would also be
safe during pregnancy?
a. Riding a stationary bicycle
b. Horseback riding
c. Downhill skiing
d. Ice hockey
e. Scuba diving

13. Your patient presents for her first prenatal visit. She is 27-year-old and
this is her first pregnancy. She is an achondroplastic dwarf. Her husband
is of normal stature. Which of the following statements should you tell her
regarding achondroplasia?
a. The inheritance pattern is autosomal recessive therefore there is a one-in-four
chance that her child will be affected.
b. Achondroplasia is caused by a new genetic mutation therefore it cannot be
passed on to her child.
c. Because she has achondroplasia she has a low risk of cesarean section for
delivery.
d. She is fortunate to have lived to reproductive age.
e. She likely has some degree of spinal stenosis which could present a difficulty
with spinal or epidural anesthesia.
6  Obstetrics and Gynecology

14. A 25-year-old G3P0 presents for preconception counseling. She has

had three first-trimester pregnancy losses. As part of her evaluation for
recurrent abortion, she had karyotyping done on herself and her husband.
Her husband is 46, XY. She carries a balanced 13;13 translocation. What is
the likelihood that her next baby will have an abnormal karyotype?
a. < 5%
b. 10%
c. 25%
d. 50%
e. 100%

15. A 31-year-old G1P0 presents to your office at 22 weeks’ gestation for

a second opinion. She was told that her baby has a birth defect. She has
copies of the ultrasound films and asks you to review them for her. The
ultrasound image shows the birth defect. Which of the following is the most
likely defect?
 Preconception Counseling, Genetics, and Prenatal Diagnosis   7

a. Cystic hygroma
b. Encephalocele
c. Hydrocephaly
d. Anencephaly
e. Omphalocele

Questions 16 to 18

A 24-year-old white woman has a maternal serum α-fetoprotein (MSAFP)

level at 17 weeks’ gestation of 6.0 multiples of the median (MOM). She had
an ultrasound the same day that appeared normal.

16. Which of the following is the most appropriate next step in management?
a. Offer her a second MSAFP test
b. Reassure her that the baby does not have a neural tube defect (NTD)
c. Recommend an amniocentesis
d. Perform an amniography
e. Offer her termination of pregnancy due to a lethal fetal anomaly

17. The fetus is confirmed to have an open NTD with a diagnosis of spina
bifida. What is the most appropriate counseling for this woman regarding
future pregnancies?
a. She has a 50% risk of having an affected child in the future, because anencephaly
is an autosomal dominant trait.
b. She has a decreased risk of having another baby with anencephaly because she is
younger than 30 years of age.
c. When she becomes pregnant, she should undergo diagnostic testing for fetal
NTDs with a first-trimester CVS.
d. Prior to becoming pregnant again she should begin folic acid supplementation.
e. She has a recurrence risk of having another baby with a NTD of less than 1%.

18. The patient asks how the diagnosis of spina bifida will impact her
obstetric management and delivery. You should counsel her that:
a. She should be delivered by cesarean to prevent damage to the open NTD.
b. She should be delivered preterm to improve fetal neurologic outcomes.
c. She should be delivered in a tertiary care facility with a neonatal intensive care
unit and personnel capable of managing the spinal defect and any immediate
complications.
d. She should plan to deliver vaginally, even if the fetus is breech, as this will limit
trauma to the defect.
e. She should be referred to a specialized center to undergo fetal surgery to close
the NTD.
8  Obstetrics and Gynecology

19. A 41-year-old woman had a baby with Down syndrome 10 years ago.
She is anxious to know the chromosome status of fetus in her current preg-
nancy. She is currently at 8 weeks of gestation. Which of the following tests
will provide the most rapid and reliable diagnosis of Down syndrome?
a. Amniocentesis
b. Multiple maternal serum marker analysis (Quad Screen)
c. Chorionic villi sampling (CVS)
d. First trimester screening using nuchal fold measurements and maternal serum
markers
e. Cell free fetal DNA testing

20. A 44-year-old pregnant woman is trying to choose CVS versus amnio-

centesis for prenatal diagnosis due to her increased risk of having a child
with a chromosomal anomaly. Which of the following is an advantage of
amniocentesis over CVS?
a. Amniocentesis can be performed earlier in pregnancy than CVS.
b. First-trimester amniocentesis has a lower complication rate than CVS.
c. A second-trimester diagnosis of an abnormal karyotype afforded by amnio-
centesis allows for safer options for termination of pregnancy if desired by the
patient.
d. Mid-trimester amniocentesis has a lower complication rate than CVS.
e. Amniocentesis in any trimester is less painful than CVS.

21. A patient presents for prenatal care in the second trimester. She was
born outside the United States and has never had any routine vaccinations.
Which of the following vaccines is contraindicated in pregnancy?
a. Injectable influenza vaccine
b. Tetanus toxoid
c. Reduced diphtheria toxoid and acellular pertussis (Tdap)
d. Hepatitis B
e. Measles, mumps, and rubella (MMR)

22. A patient presents to your office at term with no prenatal care. An

ultrasound is performed and shows the fetus to be in the third trimester
and to have multiple congenital anomalies, including microcephaly, cardiac
anomalies, and growth retardation. You should question the patient if she
has abused which of the following substances during her pregnancy?
a. Alcohol
b. Benzodiazepines
c. Heroin
d. Methadone
e. Marijuana
 Preconception Counseling, Genetics, and Prenatal Diagnosis   9

23. Your 25-year-old patient is pregnant at 36 weeks’ gestation. She has an

acute urinary tract infection (UTI). Which of the following antibiotics is
contraindicated in the treatment of this patient?
a. Ampicillin
b. Nitrofurantoin
c. Trimethoprim/sulfamethoxazole
d. Cephalexin
e. Amoxicillin/clavulanate

24. You diagnose a 21-year-old woman at 12 weeks’ gestation with gonor-

rhea cervicitis. Which of the following is the most appropriate treatment
for her infection?
a. Doxycycline
b. Chloramphenicol
c. Tetracycline
d. Minocycline
e. Ceftriaxone

25. An obese, 25-year-old G1P0 comes to your office at 8 weeks’ gesta-

tional age for her first prenatal visit. She is currently 5 ft 2 in tall and weighs
300 lb. Which of the following is the best advice to give this patient regarding
obesity and pregnancy?
a. Marked obesity in pregnancy does not cause any additional risks.
b. She should gain at least 25 lb during the pregnancy because, although she is
obese, nutritional deprivation can result in impaired fetal brain development
and intrauterine fetal growth retardation.
c. She should try not to gain weight because obese women still have adequate fetal
growth in the absence of any weight gain during pregnancy.
d. She should immediately initiate a vigorous exercise program to improve her
health and help her lose weight.
e. She should try to lose weight during the pregnancy in order to limit the size of
her baby, because obesity places her at an increased risk of requiring a cesarean
delivery for fetal macrosomia.
10  Obstetrics and Gynecology

26. A 26-year-old G2P1 presents to your office for her first prenatal visit.
Social history reveals that she smokes one pack of cigarettes each day. Which
of the following statements is true regarding tobacco and pregnancy?
a. Consuming small amounts of tobacco is probably safe; only heavy smokers incur
increased risk of complications with their pregnancy.
b. Pregnant women are often motivated to stop smoking, so this is a good oppor-
tunity to provide counseling regarding smoking cessation.
c. Pregnant women should be encouraged to stop smoking during their pregnancy,
but can be reassured they may restart as soon as the baby is born.
d. Tobacco use has been associated with an increased risk of congenital anomalies.
e. Tobacco use in pregnancy is a common cause of mental retardation and devel-
opmental delay in neonates.

27. A 36-year-old G0 who has been epileptic for many years is contem-
plating pregnancy. She wants to stop taking her phenytoin because she is
concerned about the adverse effects that the medication may have on her
unborn fetus. She has not had a seizure in the past 5 years. Which of the
following is the most appropriate statement to make to the patient?
a. Babies born to epileptic mothers have an increased risk of structural anomalies
even in the absence of anticonvulsant medications.
b. She should see her neurologist to change from phenytoin to valproic acid
because valproic acid is not associated with fetal anomalies.
c. She should discontinue her phenytoin because it is associated with a 1% to 2%
risk of spina bifida.
d. Vitamin C supplementation reduces the risk of congenital anomalies in fetuses
of epileptic women taking anticonvulsants.
e. The most frequently reported congenital anomalies in fetuses of epileptic women
are limb defects.

Questions 28 to 30

A 26-year-old P0 who works as a nurse in the surgery intensive care unit

comes to see you for her annual gynecologic examination. She tells you
that she plans to discontinue her oral contraceptives because she wants to
become pregnant in the next few months. She has many questions regard-
ing the immunizations required by her hospital and whether or not she can
do this while pregnant.
 Preconception Counseling, Genetics, and Prenatal Diagnosis   11

28. Which of the following is the most appropriate recommendation

regarding MMR vaccination?
a. She should be checked for immunity against the rubella virus prior to conception
and vaccinated at least 28 days prior to conception because the rubella vaccine
contains a live virus and should not be given during pregnancy.
b. She can receive the MMR vaccine after completion of the first trimester.
c. The MMR vaccine has been clearly associated with development of congenital
fetal anomalies when given during the first trimester.
d. The MMR vaccine is an inactivated virus, and therefore can be given during any
trimester of pregnancy.
e. The MMR vaccine may be safely given in third trimester, after completion of
organogenesis.

29. What is the most appropriate counseling regarding the tetanus toxoid,
reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during
pregnancy?
a. The Tdap should be avoided during pregnancy because whooping cough is not a
major health issue.
b. The Tdap should be avoided during pregnancy because it is a live virus.
c. The Tdap is an inactivated vaccine that may be given during pregnancy during
any trimester.
d. The Tdap is an inactivated vaccine that is currently recommended in each preg-
nancy between 27 and 36 weeks’ gestation.
e. Family members do not need to receive Tdap.

30. What should you tell this patient about the annual influenza vaccine
that is required by her hospital?
a. Pregnant women may receive the influenza vaccine during any trimester of
pregnancy.
b. She should defer the influenza vaccine this year if she becomes pregnant.
c. Pregnant women are not at risk for severe complications from influenza, and
therefore she should not receive this vaccine if pregnant or planning to become
pregnant soon.
d. Influenza vaccine is a live virus that has been associated with fetal congenital
anomalies.
12  Obstetrics and Gynecology

31. An Ashkenazi Jewish couple comes in to see you for preconception

counseling. They are concerned that they might be at an increased risk for
certain genetic disorders because of their ethnic background. The woman is
28 years old and tells you that neither side of the family has a history of any
genetic disorders. Which one of the following statements is the best advice
for this couple?
a. They are at an increased risk of having a child with β-thalassemia.
b. They are at an increased risk of having a baby born with a NTD.
c. They do not need to undergo additional screening if there is no history of
affected children in either family.
d. They should be screened for cystic fibrosis only if there is a known family
history.
e. Tay-Sachs disease has a carrier frequency of 1/30 in the Jewish population, and
the couple therefore should be screened for this genetic disease.

32. You have a patient who is very health conscious and regularly ingests
several vitamins in megadoses and herbal therapies on a daily basis. She
recently became a strict vegetarian because she heard it is the best diet for
the developing fetus. She is going to attempt pregnancy and wants your
advice regarding her diet and nutrition intake. Which of the following
should you recommend during her pregnancy?
a. Because herbal medications are natural, she may continue these dietary supple-
ments during pregnancy.
b. She should resume an omnivorous diet during pregnancy since animal sources
provide the most desirable combination of proteins.
c. She should continue to take large doses of vitamin A supplements during preg-
nancy because dietary intake alone does not provide sufficient amounts needed
during pregnancy.
d. During pregnancy, her vegetarian diet provides sufficient amounts of vitamin B12
needed for the developing fetus.
e. She should avoid vitamin C supplementation in pregnancy because excessive
levels can result in fetal malformations.

Questions 33 to 37

Match each clinical situation described with the appropriate inheritance

pattern. Each lettered option may be used once, more than once, or not
at all.
 Preconception Counseling, Genetics, and Prenatal Diagnosis   13

a. Autosomal dominant
b. Autosomal recessive
c. X-linked recessive
d. Codominant
e. Multifactorial

33. An African-American woman presents to your office for her annual

examination. She reports she was just released from the hospital after being
treated for acute pain requiring narcotics.

34. A pregnant patient presents to you for prenatal care. Her parents are
from Greece. She has a 2-year-old son, who was diagnosed with hemolytic
anemia after he was treated for otitis media with a sulfonamide antibiotic.
Her pediatrician gave her a list of antibiotics and foods that may trigger her
son’s anemia.

35. A patient presents to you for a well-woman examination. On physical

examination she has a café au lait lesion on her back, along with multiple
smooth, flesh-colored, dome-shaped papules scattered over her entire body.

36. A patient has a 2-year-old son with chronic pulmonary disease. His
recent sweat test showed an elevated chloride level.

37. Your patient’s father was just diagnosed with dementia associated with
emotional disturbances and choreiform body movements. She was told his
disease is hereditary.
14  Obstetrics and Gynecology

Questions 38 to 46

For each sonographic image, select one diagnosis or diagnostic indicator.

Each lettered option may be used once, more than once, or not at all.
a. Obstructed urethra and bladder
b. Nonspinal marker for spina bifida
c. Blighted ovum
d. Marker for Down syndrome (trisomy 21)
e. Cystic hygroma
f. Osteogenesis imperfecta
g. Mesomelic dwarfism
h. Anencephaly
i. Prune belly syndrome
j. Hydrocephalus
k. Spina bifida with meningocele

38.
 Preconception Counseling, Genetics, and Prenatal Diagnosis   15

39.

40.
16  Obstetrics and Gynecology

41.

42.
 Preconception Counseling, Genetics, and Prenatal Diagnosis   17

43.

44.
18  Obstetrics and Gynecology

45.

46.
 Preconception Counseling, Genetics, and Prenatal Diagnosis   19

Questions 47 to 50

Match the appropriate scenario with the antibiotic most likely responsible
for the clinical findings presented. Each lettered option may be used once,
more than once, or not at all.
a. Tetracycline
b. Streptomycin
c. Nitrofurantoin
d. Chloramphenicol
e. Sulfonamides

47. At 1 year of age, a child has six deciduous teeth, which are discolored
and have hypoplasia of the enamel.

48. A 1-week-old baby boy is brought in to the emergency department by

his mother. For the past few days he has been lethargic. The day before he
did not eat well and in the morning of the day of presentation he started
vomiting. On the way to the hospital the baby had a seizure. On examina-
tion, the baby is jaundiced.

49. During routine auditory testing of a 2-day-old baby, the baby failed to
respond to high-pitched tones.

50. A 2-week-old neonate who was delivered at 28 weeks’ gestation devel-

oped pallid cyanosis, abdominal distension, and vascular collapse after
exposure to an antibiotic. A few days later the baby died.

Questions 51 to 55

For each disease, select the recommendation regarding vaccination during

pregnancy. Each lettered option may be used once, more than once, or not
at all.
a. Recommended
b. Recommended after known exposure or before travel to endemic areas
c. Recommended if the patient is at high risk for the disease
d. Not recommended
e. Contraindicated
20  Obstetrics and Gynecology

51. Varicella

52. Measles, mumps, and rubella (MMR)

53. Influenza

54. Hepatitis B

55. Human papillomavirus (HPV)

 Preconception
Counseling, Genetics,
and Prenatal Diagnosis
Answers
1. The answer is b. An initial spontaneous abortion, regardless of the
karyotype or gender of the child, does not change the risk of recurrence
in a future pregnancy. The rate is commonly quoted as 15% of all known
pregnancies.

2. The answer is a. Chromosomal abnormalities are found in approximately

50% of spontaneous abortions in the first trimester. Chromosome abnormalities
become less common in advancing pregnancy, and are found in approximately
one-third of second trimester losses and 5% of third trimester losses.
Autosomal trisomy is the most common group of chromosomal anomalies
leading to first trimester miscarriage. However, 45 X (Turner syndrome) is
the most common single abnormality found.

3. The answer is c. Miscarriage risk rises with the number of prior

spontaneous abortions. Without treatment, the live birth rate approaches
50%. With treatment, successful pregnancy rates of 70% to 85% are possible
in a patient with a diagnosis of habitual abortion, depending on the
underlying cause. When cervical incompetence is present and a cerclage is
placed, success rates can approach 90%.

4. The answer is b. A major cause of spontaneous abortions in the first

trimester is chromosomal abnormalities. Parental chromosome anomalies
account for 2% to 4% of recurrent losses; therefore, karyotype evaluation of
the parents is an important part of the evaluation. The causes of losses in the
second trimester are more likely to be uterine or environmental in origin.
Patients should also be screened for thyroid function, diabetes mellitus, and
collagen vascular disorders. There is also a correlation between patients with
a positive lupus anticoagulant and recurrent miscarriages. For recurrent

21
22  Obstetrics and Gynecology

second-trimester losses, a hysterosalpingogram should be ordered to rule

out uterine structural abnormalities, such as bicornuate uterus, septate
uterus, or unicornuate uterus. Endometrial biopsy is performed to rule out
an insufficiency of the luteal phase or evidence of chronic endometritis. A
postcoital test may be useful during an infertility evaluation for couples who
cannot conceive, but does not address postconception losses. Measuring the
cervical length by ultrasonography is helpful in the management of patients
with recurrent second-trimester losses caused by cervical incompetence.

5. The answer is e. The risk of aneuploidy is increased with multiple

miscarriages not attributable to other causes such as endocrine abnormalities
or cervical incompetence. Paternal age does not contribute significantly
to aneuploidy until around age 55, and most risks of paternal age are
for point mutations. A 45 X karyotype results from loss of chromosome
material and does not involve increased risks for nondisjunctional errors.
Similarly, induced ovulation does not result in increased nondisjunction,
and hypermodel conceptions (triploidy) do not increase risk for future
pregnancies.

6. The answer is c. All of the markers listed are associated in some

degree with Down syndrome as well as other genetic abnormalities, but
increased NT is most closely and consistently associated. Increased NT is
an early presenting feature of Down syndrome. Guidelines for systemic
measurement of NT are standardized. Specific training and ongoing
audits of examination quality are required for screening programs in order
to ensure the expected detection rate. The optimal time to schedule NT
measurement is between 12 and 13 weeks, but results are considered valid
between 10 4/7 and 13 6/7 weeks. This results in Down syndrome detection
rates of 72% at a screen positive rate of 5%. Most centers use a thickness of
>/= 3 mm to define abnormal.

7. The answer is b. Several large, multicenter trials have shown that, in

the first trimester, a combination of NT measurement, maternal age, and
serum markers (PAPP-A and free or total β-hCG) is a reliable test for
Down syndrome, with a detection rate of approximately 84%. Serum AFP
is available as a screen for NTDs, and should be ordered after 15 weeks.
Inhibin level alone is not a screen for Down syndrome, but may be part of
a Quad screen. Amniocentesis cannot be offered until the second trimester.
Fetal echocardiogram is not reliable in the first trimester, may not show
Preconception Counseling, Genetics, and Prenatal Diagnosis     Answers  23

cardiac defects in the first trimester, and is not considered a screening test
for Down syndrome. It may be ordered in fetuses suspected to have Down
syndrome based on abnormal diagnostic testing.

8. The answer is e. The patient should be referred for genetic counseling

and offered a diagnostic test such as CVS or amniocentesis. Genetic
counseling alone is not adequate, and referral to a high-risk specialist is
not indicated at this time. The patient should not be told that the baby has
Down syndrome, as the first trimester screen has a 5% false positive rate,
and requires follow-up diagnostic testing. The patient should not be offered
termination at this point, but it would be reasonable to offer termination if
diagnostic testing confirmed Down syndrome.

9. The answer is d. Alcohol is an enormous contributor to otherwise

preventable birth defects. Sequelae include retardation of intrauterine
growth, craniofacial abnormalities, and mental retardation. The occasional
drink in pregnancy has not been proved to be deleterious, but is still not
recommended. Isotretinoin (accutane) is a powerful drug for acne that has
enormous potential for producing congenital anomalies when ingested
in early pregnancy; it should never be used in pregnancy. Tetracyclines
interfere with development of bone and can lead to stained teeth in
children. Progesterones have been implicated in multiple birth defects, but
controlled studies have failed to demonstrate a significant association with
increased risk. Patients who have inadvertently become pregnant while on
birth control pills should be reassured that the incidence of birth defects is
no higher for them than for the general population. Valproic acid is used for
epilepsy and can be associated with a spectrum of abnormalities, including
NTDs and abnormal facial features.

10. The answer is d. While a 50-rad exposure in the first trimester of

pregnancy would be expected to entail a high likelihood of serious fetal
damage and wastage, the anticipated fetal exposure for chest x-ray and one
film of the lower spine would be less than 1 rad. This is well below the
threshold for increased fetal risk, which is generally thought to be 10 rads.
High doses of radiation in the first trimester primarily affect developing
organ systems such as the heart and limbs; in later pregnancy, the brain
is more sensitive. The chromosomes are determined at the moment of
conception. Radiation does not alter the karyotype, and determination
of the karyotype is not normally indicated for a 24-year-old patient. The
24  Obstetrics and Gynecology

incidence of leukemia is raised in children receiving radiation therapy or

those exposed to the atomic bomb, but not from such a minimal exposure
as here.

11. The answer is d. Women with uncomplicated pregnancies can

continue to exercise during pregnancy if they had previously been
accustomed to exercising prior to becoming pregnant. Studies indicate that
well-conditioned women who maintain an antepartum exercise program
consisting of aerobics or running have improved pregnancy outcomes
in terms of shorter active labors, fewer cesarean section deliveries, less
meconium-stained amniotic fluid, and less fetal distress in labor. On
average, women who run regularly during pregnancy have babies that
weigh 310 g less than women who do not exercise during pregnancy. Even
though birth weight is reduced in exercising pregnant women, there is not
an increased incidence of intrauterine growth retardation. The American
College of Obstetricians and Gynecologists recommends that women
avoid exercising while in the supine position to avoid a decrease in venous
return to the heart, which results in decreased cardiac output. In addition,
women should modify their exercise based on symptoms. There is no set
pulse above which exercise is to be avoided; rather, women should decrease
exercise intensity when experiencing symptoms of fatigue. Nonweight-
bearing exercises will minimize the risk of injury. Since the physiologic
changes associated with pregnancy will persist from 4 to 6 weeks following
delivery, women should not resume the intensity of pre-pregnancy exercise
regimens immediately following delivery.

12. The answer is a. There are many recreational activities that are considered
to be safe during pregnancy. Riding a stationary bike, swimming, and
walking are examples. Participation in sports with a high risk of abdominal
trauma due to contact or due to falling is not recommended. These sports
include competitive ice hockey or soccer, horseback riding, and downhill
skiing. Scuba diving should be avoided during pregnancy because it places
the fetus at an increased risk for decompression sickness due to the inability
of the fetal pulmonary circulation to filter bubble formation.

13. The answer is e. Achondroplasia, a congenital disorder of cartilage

formation characterized by dwarfism, is associated with an autosomal
dominant pattern of inheritance. However, new mutations account for
90% of all cases of the disorder. Affected women almost always require
Preconception Counseling, Genetics, and Prenatal Diagnosis     Answers  25

cesarean delivery due to the distorted shape of the pelvis. Achondroplastic

fetuses, when prenatally diagnosed, should also be delivered by cesarean
to minimize trauma to the fetal neck. Women who have achondroplasia
and receive adequate treatment for its associated complications generally
have a normal life expectancy. The most common medical complaint in
adulthood in patients with achondroplasia is symptomatic spinal stenosis.

14. The answer is e. Carriers of balanced translocations of the same

chromosome are phenotypically normal. However, in the process of gamete
formation (either sperm or ova), the translocated chromosome cannot
divide, and therefore the meiosis products end up with either two copies
or no copies of the particular chromosome. In the former case, fertilization
leads to trisomy of that chromosome. Many trisomies are lethal in utero.
Trisomies of chromosomes 13, 18, and 21 lead to classic syndromes. In
the latter case, a monosomy is produced, and all except for monosomy X
(Turner syndrome) are lethal in utero.

15. The answer is b. An encephalocele is a version of a NTD that

involves an outpouching of neural tissue through a defect in the skull.
A cystic hygroma, with which encephalocele can often be confused on
ultrasound, emerges from the base of the neck with an intact skull present.
Hydrocephalus is related to the size of the lateral ventricles. Anencephaly
would require absence of a much larger proportion of the skull with
diminished neural tissues. An omphalocele is a defect in the abdominal
wall at the insertion of the umbilical cord, which may lead to herniation of
the abdominal contents. Omphaloceles are associated with various other
birth defects and chromosomal abnormalities.

16. The answer is c. The MSAFP may be performed between 15 and

21 weeks’ gestation to screen for NTDs. The screen positive cut-off is usually
set at 2.5 MoM, which results in a screen positive rate of 5% or less, and
identifies 85% of NTDs. In the past, if the patient had only a moderately
elevated value, a second MSAFP value could be drawn, as a small number
of these patients will have a normal test and therefore drop back into the
“low risk” category. Ultrasound evaluation may have high sensitivity and
specificity in detecting fetal NTDs in specialized centers; however, in less
experienced hands, there is a higher false negative rate. Therefore, you
cannot reassure the patient that the fetus does not have a NTD. Ultrasound
will help identify other reasons for elevated MSAFP, such as anencephaly,
26  Obstetrics and Gynecology

twins, wrong gestational age of the fetus, or fetal demise. The traditional
diagnostic test to offer women with positive MSAFP results is genetic
amniocentesis. Testing may be done to evaluate for elevated AFP in the
amniotic fluid, as well as elevated acetylcholinesterase. In the setting where
both of these amniotic fluid levels are elevated, this test has been shown
to identify 100% of cases of anencephaly and open NTDs, as well as 20%
of ventral wall defects. The other benefit of amniocentesis is that amniotic
fluid may be used for karyotype assessment, as several studies have shown
that elevated MSAFP independently increases the risk of fetal aneuploidy.
Amniography is an outdated procedure in which radiopaque dye is injected
into the amniotic cavity for the purpose of taking x-rays. Termination of
pregnancy should not be recommended on the basis of MSAFP testing
alone. MSAFP is a screening test used to define who is at risk, and requires
further diagnostic testing in order to confirm or rule out a diagnosis.

17. The answer is d. The incidence of NTDs in the general population

is approximately 1.4 to 2.0/1000. It is a multifactorial defect and is not
influenced by maternal age. Women who have a previously affected child
have a NTD recurrence risk of about 3% to 4%. This patient is at increased
risk of having another child with a NTD and, therefore, should be offered
prenatal diagnosis with an amniocentesis and targeted ultrasound. A CVS
will determine a fetus’ chromosomal makeup but will give no information
regarding AFP levels or risk for a NTD. Woman with a previously affected
fetus should take 4 mg of folic acid daily before conception and through the
first trimester, as this has been shown to result in a 72% reduction in the
recurrence risk. The neural tube is almost formed by the time of a missed
period, and therefore, beginning supplementation with folic acid when a
woman finds out she is pregnant is not sufficient to decrease the risk of
NTDs. Women with no prior history of NTD who are of childbearing age
should be encouraged to take 400μg of folic acid daily.

18. The answer is c. There is good data that outcomes are better when
these neonates are delivered in settings that offer specialized personnel
and neonatal intensive care facilities. Delivery at term is preferred, and
preterm delivery is not known to improve neurologic outcomes. Breech
presentation is common in pregnancies complicated by fetal spina bifida,
resulting from either hydrocephalus with an enlarged head, or from fetal
neurologic compromise. These infants should be delivered by cesarean. The
Preconception Counseling, Genetics, and Prenatal Diagnosis     Answers  27

best delivery route for a cephalic fetus is controversial, but several studies
suggest that vaginal delivery does not adversely impact fetal outcome. The
role of fetal surgery for repair of spina bifida is considered investigational.
The studies in this field were not randomized and were largely limited
to fetuses with lesions at or below the thoracic spine. Data suggested no
improvement in bowel or bladder function or ambulatory ability. There
may be a modest improvement in the degree of hindbrain herniation.

19. The answer is c. Amniocentesis and CVS are techniques of obtaining

fetal cells for cytogenetic analysis. Amniotic fluid cells (obtained by
amniocentesis at 15-20 weeks) require tissue culture to obtain adequate
cell numbers for analysis. CVS at 10 to 13 weeks, either by transcervical
or transabdominal access to the placenta, will provide the earliest results
in order to diagnose Down syndrome. Multiple maternal serum marker
analysis (Quad screen) may be done between 15 and 21 weeks, but it
is primarily used for screening otherwise low-risk women for Down
syndrome. Similarly, first trimester screening with NT measurements and
maternal serum markers is not a diagnostic test. Neither of these tests are
the most correct choice in this patient of advanced maternal age with a
prior affected child. Cell free fetal DNA testing may be ordered as early as
10 weeks’ gestation, and has a sensitivity of 98% with low false positive rates
(< 0.5%), but is still a screening test. A normal screen would be reassuring,
but an abnormal screen would still require diagnostic testing. Therefore,
CVS is the best choice in this setting.

20. The answer is d. CVS has many advantages over amniocentesis,

including its earlier performance and quicker results. Normal results
provide early reassurance, while abnormal results may allow for earlier and
safer options for pregnancy termination. However, CVS does have a higher
complication rate. Mid-trimester amniocentesis carries a procedure-related
fetal loss rate of 1 in 300 to 500. This may be even lower in experienced
hands. The procedure-related loss rate for CVS is probably similar to that
of amniocentesis; however, the overall pregnancy loss rate for CVS is higher
than for amniocentesis due to the increased baseline loss rate between 9
and 16 weeks’ gestation. First-trimester amniocentesis has a complication
rate higher than that for CVS, and has been shown to have an increased risk
of amniotic fluid culture failures and membrane rupture. For these reasons,
early amniocentesis should not be offered.
28  Obstetrics and Gynecology

21. The answer is e. There is a benefit for some women to be vaccinated

against certain conditions during pregnancy. Live, attenuated virus
vaccines, such as the MMR or the nasally delivered influenza vaccine,
are not recommended during pregnancy. Vaccines that contain killed
antigens, virus-like particles, or noninfectious components of bacteria, are
considered safe in pregnancy. Examples include tetanus toxoid, Tdap, and
the injectable influenza vaccine. Pregnancy is not a contraindication to the
hepatitis B vaccine, and pregnant women identified as being at high risk for
HBV infection should be vaccinated.

22. The answer is a. Chronic alcohol abuse, which can cause liver disease,
folate deficiency, and many other disorders in a pregnant woman, also
can lead to the development of congenital abnormalities in the child. Ethyl
alcohol is one of the most potent teratogens known. The chief abnormalities
associated with the fetal alcohol syndrome (FAS) are cardiac anomalies
and joint defects FAS may also be associated with growth problems (either
before or after pregnancy), mental or behavioral problems, and abnormal
facial features. There is no known “safe” amount of alcohol that a woman
may drink during pregnancy. Women who drink heavily both before and
during pregnancy are at the highest risk of giving birth to a child with
FAS. Heroin, benzodiazepines, marijuana, and methadone are not major
teratogens.

23 and 24. The answers are 23-c, 24-e. These two questions address the
question of the teratogenicity of antibiotics. Tetracycline may cause fetal dental
anomalies and inhibition of bone growth if administered during the second
and third trimesters, and it is a potential teratogen to first-trimester fetuses.
Administration of tetracyclines can also cause severe hepatic decompensation
in the mother, especially during the third trimester. Chloramphenicol may
cause the gray baby syndrome (symptoms of which include vomiting,
impaired respiration, hypothermia, and, finally, cardiovascular collapse)
in neonates who have received large doses of the drug. No notable adverse
effects have been associated with the use of penicillins or cephalosporins.
Trimethoprim-sulfamethoxazole (bactrim) should not be used in the third
trimester because sulfa drugs can cause kernicterus.

25. The answer is c. Women who are markedly obese are at increased risk
of developing complications during pregnancy. Obese women are more
likely to develop gestational diabetes and preeclampsia during pregnancy.
Preconception Counseling, Genetics, and Prenatal Diagnosis     Answers  29

In addition, these women are more likely to develop fetal macrosomia and
require cesarean delivery, which is associated with an increased risk of
infectious and operative morbidity. This may include problems establishing
and recovering from anesthesia, prolonged operating times, increased
blood loss, higher rates of wound infection, and thromboembolism. Obese
patients are less likely to have a successful vaginal birth after a cesarean
delivery. Maternal obesity also has implications for the fetus, including
increased risk of congenital anomalies, growth abnormalities, miscarriage,
and stillbirth. Morbidly obese women who do not gain weight during
pregnancy are not at risk for having a fetus with growth abnormalities,
and therefore they do not need to gain the 25 lb to 35 lb recommended
for women of normal weight. Although it is not recommended that obese
women gain weight during pregnancy, diet restriction and weight loss are
to be avoided. In addition, as with all women, it is not recommended that
obese women initiate a rigorous exercise program during pregnancy.

26. The answer is b. There are many potential teratogens in cigarette smoke,
including nicotine, carbon monoxide, cadmium, lead, and hydrocarbons.
Smoking has been shown to cause fetal growth restriction and to be related to
increased incidences of subfertility, spontaneous abortions, placenta previa,
abruption, and preterm delivery. The mechanisms for these adverse effects
include increased fetal carboxyhemoglobin levels, reduced uteroplacental
blood flow, and fetal hypoxia. Most studies do not indicate that tobacco
use is related to an increased risk of congenital malformations, mental
retardation, or developmental delay. Almost half of women who smoke quit
directly before or during pregnancy. An office-based protocol that offers
treatment or referral for smoking cessation has been proven to increase
quit rates. The 5A’s is an office based intervention to help pregnant women
quit smoking. These are as follows: (1) Ask the patient about smoking, (2)
Advise the patient to stop, (3) Assess the patient’s willingness to attempt to
quit, (4) Assist the patient who is interested by providing smoking cessation
materials, (5) Arrange follow-up visits to track the progress of the patient’s
attempt to stop smoking. Patients should be encouraged to remain smoke
free. Children born to mothers who smoke are at an increased risk of
asthma, obesity, and colic.

27. The answer is a. Offspring of women with epilepsy have two to three
times the risk of congenital anomalies even in the absence of anticonvulsant
medications, because seizures cause a transient reduction in uterine blood
30  Obstetrics and Gynecology

flow and fetal oxygenation. When anticonvulsant medications are used,

pregnant women have an even greater risk of congenital malformations.
It is recommended that women undergo a trial of being weaned off their
medications prior to becoming pregnant. If antiseizure medications must
be used, monotherapy is preferred to minimize the risk to the fetus, since
the incidence of fetal anomalies increases as additional anticonvulsants
are consumed. Many anticonvulsants have been found to impair folate
metabolism, and folate supplementation in pregnancy has been associated
with a decreased incidence of congenital anomalies in epileptic women taking
antiseizure medications. Fetal exposure to valproic acid has been associated
with a 1% to 2% risk of spina bifida.

28. The answer is a. In general, it is ideal for women to be up to date on

routine adult vaccines before becoming pregnant. Live vaccines, such as
MMR, should be given at least 1 month before pregnancy, due to theoretic
risks to the fetus. Women should be offered testing for immunity to rubella
during preconception counseling visits, and offered immunization prior
to pregnancy if needed. Pregnant women who are found to be rubella
nonimmune may be given the MMR vaccine immediately postpartum.

29. The answer is d. The Tdap should be offered to all pregnant women
during each pregnancy between 27 and 36 weeks, regardless of the patient’s
prior history of receiving Tdap. Pertussis, or whooping cough, is a common
vaccine-preventable disease that can be very serious for newborns. The level
of pertussis antibodies decreases over time, hence the recommendation to
administer during every pregnancy. In addition, all family members and
caregivers of infants should be vaccinated with Tdap. Vaccinating pregnant
women helps prevent the mother from acquiring the disease and passing it
to her newborn, and also provides passive immunity to the infant. Tdap is
an inactivated vaccine.

30. The answer is a. Influenza is an inactivated vaccine that is recommended

for all women who are pregnant or who may be pregnant during flu season.
It may be given in any trimester. Pregnant women who get the flu are at
increased risk for severe complications requiring hospitalization. Flu
season in the United States is generally from early October to late March.

31. The answer is e. Certain autosomal recessive diseases are more common
in individuals of Eastern European Jewish ancestry. ACOG recommends
Preconception Counseling, Genetics, and Prenatal Diagnosis     Answers  31

carrier screening for Tay-Sachs disease (carrier frequency 1/30), Canavan

disease (carrier frequency 1/40), familial dysautonomia (carrier frequency
1/32), and cystic fibrosis (carrier frequency 1/29). Carrier screening tests
are also available for several diseases that are less common, such as Fanconi
anemia, Niemann-Pick disease, Bloom syndrome, and Gaucher disease.
When only one partner is of Ashkenazi Jewish descent, that partner should
be screened first. If this individual is found to be a carrier, then the partner
should be offered screening. β-Thalassemias are hemoglobinopathies
especially prevalent in individuals of Mediterranean or Asian heritage. The
couple described is not at an increased risk of β-thalassemia and therefore
does not need to undergo screening with hemoglobin electrophoresis.
Based on ethnic background, this couple is not at increased risk of having a
baby with a NTD. NTD follows a multifactorial inheritance pattern.

32. The answer is b. The use of herbal remedies is not recommended during
pregnancy because such products are classified as dietary supplements and
therefore are not FDA-regulated for purity, safety, and efficacy. In fact, the
actual ingredients of many herbal substances are not even known. There is
almost no data regarding the teratogenic potential of herbal medications in
humans. Although a carefully planned vegetarian diet provides sufficient
amino acids for pregnancy, it is not recommended that women assume
a vegetarian diet during pregnancy. Animal sources of protein such as
meat, poultry, fish, and eggs contain amino acids in the most desirable
combinations. Strict vegetarians can give birth to infants who are low in
vitamin B12, because vitamin B12 occurs naturally only in foods of animal
origin. Pregnant women do not need to take vitamin A supplements
because adequate amounts can be obtained in the diet; in addition, a very
high intake of vitamin A has been associated with the type of congenital
malformations seen with oral accutane use. Adequate vitamin C levels
needed for pregnancy can be provided in a reasonable diet. No known
fetal anomalies have been reported with vitamin C supplementation in
pregnancy.

33 to 37. The answers are 33-b, 34-c, 35-a, 36-b, 37-a. Sickle cell anemia
is an autosomal recessive condition that is common in people of African
origin. In low-oxygen conditions, the red cells become distorted (sickle),
and this can lead to vasoocclusive crisis causing severe pain. Glucose-
6-phosphate dehydrogenase (G6PD) deficiency is X-linked recessive and
is found predominantly in males of African and Mediterranean origin.
32  Obstetrics and Gynecology

Although the causes of clinical manifestations in G6PD deficiency are

multifactorial (eg, sulfa drugs), the inheritance is not. Neurofibromatosis,
whose occurrence is often sporadic (ie, a spontaneous mutation in 50%), is
inherited as an autosomal dominant trait once the gene is in a family. The
severity of the condition can be quite variable even within the same family.
Cystic fibrosis is the most common autosomal recessive disorder in the
white European population. Huntington disease is autosomal dominant.

38 to 46. The answers are 38-f, 39-h, 40-e, 41-a, 42-c, 43-b, 44-d, 45-j,
46-k. The diagnosis of osteogenesis imperfecta can be made by visualizing
fractures in utero by ultrasound. The ultrasound in question 38 shows
a crumpling of the tibia and fibula and curvature of the thigh such that
proper extension of the foot does not occur.
The sonographic image in question 39 was done at approximately
15 weeks’ gestation and shows two orbits, a mouth, and a central nose,
but there is clearly no forehead and no cranial contents. Anencephaly is
incompatible with life.
The sonographic image in question 40 shows a 13-week-old fetus
with a large NT (double arrows) and early hydrops, sometimes called a
cystic hygroma. In the second and third trimesters, cystic hygromas are
commonly associated with Turner syndrome (45, X). In early pregnancy,
however, 50% of cases will be associated with a trisomy, usually trisomy 21,
trisomy 18, or trisomy 13. Of those cases that are chromosomally normal,
most of these nuchal translucencies disappear, and the fetus goes on to have
perfectly normal development.
In question 41, the transverse cut through the bladder shows megacystis
(ie, the bladder is markedly enlarged) and the distal portion of the urethra
can be visualized up to the point of urinary blockage. The blocked urethra
acts as a dam that causes the bladder to fill up, then the ureters, and finally
the kidneys (hydronephrosis). There is oligohydramnios noted in this picture
because by 16 weeks—the gestational age at which this picture was taken—
the vast majority of amniotic fluid comes from fetal urine. These pregnancies
are usually associated with fetal death due to pulmonary hypoplasia, because
the early oligohydramnios does not allow for proper lung development.
The sonographic image in question 42 was performed at approximately
8 weeks after the last menstrual period and shows a placenta but no fetal
pole—the classic blighted ovum. Traditionally, 50% of first-trimester
spontaneous abortions are said to be chromosomally abnormal. However,
more recent evidence suggests that, particularly with advancing age of the
Preconception Counseling, Genetics, and Prenatal Diagnosis     Answers  33

mother (ie, in women who are likely to have early ultrasonography for
potential CVS), the risk of fetal chromosomal abnormalities is in fact much
higher, in many cases approaching even 90% of first-trimester spontaneous
abortions.
The cross-section through the fetal head in question 43 shows a classic
lemon sign; that is, there is a frontal bossing of the forehead such that the
sides of the forehead are actually pulled in. This is because of the pull on
the cisterna magna from spina bifida that is distorting the intracranial
contents. This so-called lemon sign has a very high degree of sensitivity,
although it is not perfect. The lemon sign disappears in the third trimester
and is therefore not useful late in pregnancy.
The longitudinal sonographic image in question 44 shows the double
bubble sign indicating duodenal atresia. The two bubbles are the stomach
and the jejunum. This finding is classic for trisomy 21. Approximately one-
third of fetuses who have this finding will be found to have trisomy 21,
and in this situation, prenatal diagnosis should be offered to document the
chromosomes regardless of any other indication the patient may have.
The ultrasound in question 45 demonstrates dilation of the lateral
ventricles consistent with hydrocephalous. In question 46 the ultrasound
shows splaying of the lumbar spine consistent with spina bifida.

47 to 50. The answers are 47-a, 48-e, 49-b, 50-d. The teratogenicity
of antibiotics after fetal exposure depends on many factors such as
gestational age, protein binding, lipid solubility, pH, molecular weight,
degree of ionization, and concentration gradient. Some antibiotics are even
concentrated in the fetal compartment. Tetracycline is contraindicated
in all three trimesters. It has been associated with skeletal abnormalities,
staining and hypoplasia of budding fetal teeth, bone hypoplasia, and
fatal maternal liver decompensation. Sulfonamides are associated with
kernicterus in the newborn. They compete with bilirubin for binding
sites on albumin, thereby leaving more bilirubin free for diffusion into
tissues. Sulfonamides should be withheld during the last 2 to 6 weeks of
pregnancy. With prolonged treatment of tuberculosis (TB) in pregnancy,
streptomycin has been associated with fetal hearing loss. Its use is restricted
to complicated cases of TB. Nitrofurantoin can cause maternal and fetal
hemolytic anemia if glucose 6-phosphate dehydrogenase deficiency is
present. Chloramphenicol is noted for causing the gray baby syndrome.
Infants are unable to properly metabolize the drug, which reaches toxic
levels in about 4 days and can lead to neonatal death within 1 to 2 days.
34  Obstetrics and Gynecology

51 to 55. The answers are 51-e, 52-e, 53-a, 54-c, 55-d. Pregnant women
should not be vaccinated against varicella or MMR during pregnancy,
because the effects on the fetus are unknown. Women should wait 1 month
after vaccination to become pregnant. Influenza vaccine is recommended
for all pregnant women during all trimesters, due to the potential
severe effects of the disease on pregnant women. Pregnancy is not a
contraindication to hepatitis B vaccination. Limited data suggest that there
are not adverse fetal effects due to this vaccine. It should be considered in
pregnant women who are at increased risk for hepatitis B. HPV vaccination
is not recommended during pregnancy. If a women is found to be pregnant
during administration of the vaccine (which requires three doses), the
remainder of the series should be delayed until pregnancy is complete.

Suggested Readings
American College of Obstetricians and Gynecologists. Bariatric Surgery and
Pregnancy. Practice Bulletin Number 105, June 2009, reaffirmed 2013.
American College of Obstetricians and Gynecologists. Exercise During
Pregnancy and the Postpartum Period. Committee Opinion Number
267, January 2002, reaffirmed 2009.
American College of Obstetricians and Gynecologists. Invasive Prenatal
Testing for Aneuploidy. Practice Bulletin Number 88, December 2007,
reaffirmed 2014.
American College of Obstetricians and Gynecologists. Neural Tube Defects.
Practice Bulletin Number 44, July 2003, reaffirmed 2014.
American College of Obstetricians and Gynecologists. Noninvasive Pre-
natal Testing for Fetal Aneuploidy. Committee Opinion Number 545,
December 2012.
American College of Obstetricians and Gynecologists. Preconception and
Prenatal Carrier Screening for Genetic Diseases in Individuals of Eastern
European Jewish Descent. Committee Opinion Number 442, October
2009, reaffirmed 2014.
American College of Obstetricians and Gynecologists. Screening for Fetal
Chromosome Abnormalities. Practice Bulletin Number 77, January
2007, reaffirmed 2013.
American College of Obstetricians and Gynecologists. Smoking Cessation
During Pregnancy. Committee Opinion Number 471, November 2010,
reaffirmed 2013.
Another Random Scribd Document
with Unrelated Content
duties, two millions to be paid down, and two millions to be reserved
and distributed to the American claimants who could prove their
injuries. With the two millions to be placed in the hands of the
constitutional government, it was expected that it would be able to
expel the usurping government from the capital and establish itself
over the whole territory of the republic. All acquisition of further
Mexican territory was thus avoided. If this treaty had been approved
by the Senate of the United States, the empire of Maximilian would
never have been heard of. The American negotiator, Mr. McLane, in
his despatch to the Secretary of State, dated on the day this treaty
and convention were signed at Vera Cruz, expressed his
apprehension that if they were not ratified, further anarchy would
prevail in Mexico, until it should be ended by interference from some
other quarter. The President submitted the treaty and the convention
to the Senate on the 24th of January, 1860. They were neither of
them approved. Mexico was left to the interference of Louis
Napoleon; the establishment of an empire, under Maximilian, a
prince of the House of Hapsburg, followed, for the embarrassment of
President Lincoln’s administration while we were in the throes of our
civil war, and the claims of American citizens were to all appearance
indefinitely postponed.
The relations of the United States with Spain at the
commencement of Mr. Buchanan’s administration, and the manner in
which he dealt with them, have been described by him as follows:

Our relations with Spain were in a very unsatisfactory condition on

his accession to power. Our flag had been insulted, and numerous
injuries had been inflicted on the persons and property of American
citizens by Spanish officials acting under the direct control of the
Captain General of Cuba. These gave rise to many but unavailing
reclamations for redress and indemnity against the Spanish
government. Our successive ministers at Madrid had for years ably
presented and enforced these claims, but all without effect. Their
efforts were continually baffled on different pretexts. There was a
class of these claims called the “Cuban claims,” of a nature so plainly
just that they could not be gainsayed. In these more than one
hundred of our citizens were directly interested. In 1844 duties were
illegally exacted from their vessels at different custom houses in
Cuba, and they appealed to the Government to have these duties
refunded. Their amount could be easily ascertained by the Cuban
officials themselves, who were in possession of all the necessary
documents. The validity of these claims was eventually recognized
by Spain, but not until after a delay of ten years. The amount due
was fixed, according to her own statement, with which the claimants
were satisfied, at the sum of $128,635.54. Just at the moment when
the claimants were expecting to receive this amount without further
delay, the Spanish government proposed to pay, not the whole, but
only one-third of it, and this provided we should accept it in full
satisfaction of the entire claim. They added that this offer was made,
not in strict justice, but as a special favor.
Under these circumstances, the time had arrived when the
President deemed it his duty to employ strong and vigorous
remonstrances to bring all our claims against Spain to a satisfactory
conclusion. In this he succeeded in a manner gratifying to himself,
and it is believed to all the claimants, but unfortunately not to the
Senate of the United States. A convention was concluded at Madrid
on the 5th March, 1860, establishing a joint commission for the final
adjudication and payment of all the claims of the respective parties.
By this the validity and amount of the Cuban claims were expressly
admitted, and their speedy payment was placed beyond question.
The convention was transmitted to the Senate for their constitutional
action on the 3d May, 1860, but on the 27th June they determined,
greatly to the surprise of the President, and the disappointment of
the claimants, that they would “not advise and consent” to its
ratification.
The reason for this decision, because made in executive session,
cannot be positively known. This, as stated and believed at the time,
was because the convention had authorized the Spanish government
to present its Amistad claim, like any other claim, before the Board
of Commissioners for decision. This claim, it will be recollected, was
for the payment to the Spanish owners of the value of certain slaves,
for which the Spanish government held the United States to be
responsible under the treaty with Spain of the 27th October, 1795.
Such was the evidence in its favor, that three Presidents of the
United States had recommended to Congress to make an
appropriation for its payment, and a bill for this purpose had passed
the Senate. The validity of the claim, it is proper to observe, was not
recognized by the convention. In this respect it was placed on the
same footing with all the other claims of the parties, with the
exception of the Cuban claims. All the Spanish government obtained
for it was simply a hearing before the Board, and this could not be
denied with any show of impartiality. Besides, it is quite certain that
no convention could have been concluded without such a provision.
It was most probably the extreme views of the Senate at the time
against slavery, and their reluctance to recognize it even so far as to
permit a foreign claimant, although under the sanction of a treaty, to
raise a question before the Board which might involve its existence,
that caused the rejection of the convention. Under the impulse of
such sentiments, the claims of our fellow-citizens have been
postponed if not finally defeated. Indeed, the Cuban claimants,
learning that the objections in the Senate arose from the Amistad
claim, made a formal offer to remove the difficulty by deducting its
amount from the sum due to them, but this of course could not be
accepted.[44]

The following account of an expedition which President Buchanan

found it necessary to send to Paraguay, is also taken from his
Defence of his Administration:

The hostile attitude of the government of Paraguay toward the

United States early commanded the attention of the President. That
government had, upon frivolous and even insulting pretexts, refused
to ratify the treaty of friendship, commerce and navigation,
concluded with it on the 4th March, 1853, as amended by the
Senate, though this only in mere matters of form. It had seized and
appropriated the property of American citizens residing in Paraguay,
in a violent and arbitrary manner; and finally, by order of President
Lopez, it had fired upon the United States steamer Water Witch (1st
February, 1855), under Commander Thomas J. Page of the navy, and
killed the sailor at the helm, whilst she was peacefully employed in
surveying the Parana river, to ascertain its fitness for steam
navigation. The honor, as well as the interests of the country,
demanded satisfaction.
The President brought the subject to the notice of Congress in his
first annual message (8th December, 1857). In this he informed
them that he would make a demand for redress on the government
of Paraguay, in a firm but conciliatory manner, but at the same time
observed, that “this will the more probably be granted, if the
Executive shall have authority to use other means in the event of a
refusal. This is accordingly recommended.” Congress responded
favorably to this recommendation. On the 2d June, 1858,[45] they
passed a joint resolution authorizing the President “to adopt such
measures, and use such force as, in his judgment, may be necessary
and advisable, in the event of a refusal of just satisfaction by the
government of Paraguay, in connection with the attack on the United
States steamer Water Witch, and with other matters referred to in
the annual message.”[46] They also made an appropriation to defray
the expenses of a commissioner to Paraguay, should he deem it
proper to appoint one, “for the adjustment of difficulties” with that
republic.
Paraguay is situated far in the interior of South America, and its
capital, the city of Asuncion, on the left bank of the river Paraguay, is
more than a thousand miles from the mouth of the La Plata.
The stern policy of Dr. Francia, formerly the Dictator of Paraguay,
had been to exclude all the rest of the world from his dominions,
and in this he had succeeded by the most severe and arbitrary
measures. His successor, President Lopez, found it necessary, in
some degree, to relax this jealous policy; but, animated by the same
spirit, he imposed harsh restrictions in his intercourse with
foreigners. Protected by his remote and secluded position, he but
little apprehended that a navy from our far distant country could
ascend the La Plata, the Parana, and the Paraguay, and reach his
capital. This was doubtless the reason why he had ventured to place
us at defiance. Under these circumstances, the President deemed it
advisable to send with our commissioner to Paraguay, Hon. James B.
Bowlin, a naval force sufficient to exact justice should negotiation
fail.[47] This consisted of nineteen armed vessels, great and small,
carrying two hundred guns and twenty-five hundred sailors and
marines, all under the command of the veteran and gallant Shubrick.
Soon after the arrival of the expedition at Montevideo, Commissioner
Bowlin and Commodore Shubrick proceeded (30th December, 1858)
to ascend the rivers to Asuncion in the steamer Fulton, accompanied
by the Water Witch. Meanwhile the remaining vessels rendezvoused
in the Parana, near Rosario, a position from which they could act
promptly, in case of need.
The commissioner arrived at Asuncion on the 25th January, 1859,
and left it on the 10th February. Within this brief period he had ably
and successfully accomplished all the objects of his mission. In
addition to ample apologies, he obtained from President Lopez the
payment of $10,000 for the family of the seaman (Chaney) who had
been killed in the attack on the Water Witch, and also concluded
satisfactory treaties of indemnity and of navigation and commerce
with the Paraguayan government.[48] Thus the President was enabled
to announce to Congress, in his annual message (December, 1859),
that “all our difficulties with Paraguay had been satisfactorily
adjusted.”
Even in this brief summary it would be unjust to withhold from
Secretary Toucey a commendation for the economy and efficiency he
displayed in fitting out this expedition.[49] It is a remarkable fact in
our history, that its entire expenses were defrayed out of the
ordinary appropriations for the naval service. Not a dollar was
appropriated by Congress for this purpose, unless we may except
the sum of $289,000 for the purchase of seven small steamers of
light draft, worth more than their cost, and which were afterwards
usefully employed in the ordinary naval service.
It may be remarked that the President, in his message already
referred to, justly observes, “that the appearance of so large a force,
fitted out in such a prompt manner, in the far distant waters of the
La Plata, and the admirable conduct of the officers and men
employed in it, have had a happy effect in favor of our country
throughout all that remote portion of the world.”

The relations between the United States and China had been
governed for twelve years by the treaty made in 1844, by Mr. Caleb
Cushing, under the instructions of Mr. Webster as Secretary of State.
This treaty had provided for its own amendment at the expiration of
twelve years from its date, and it devolved on Mr. Buchanan’s
administration to institute the negotiations for this purpose, His own
account of these negotiations, although greatly condensed, is all that
need be here given:

The same success attended our negotiations with China.[50] The

treaty of July, 1844, with that empire, had provided for its own
revision and amendment at the expiration of twelve years from its
date, should experience render this necessary. Changes in its
provisions had now become indispensable for the security and
extension of our commerce. Besides, our merchants had just claims
against the Chinese government, for injuries sustained in violation of
the treaty. To effect these changes, and to obtain indemnity for
these injuries, the Hon. William B. Reed was sent as minister to
China. His position proved to be one of great delicacy. England and
France were engaged in war against China, and urged the United
States to become a party to it. They alleged that it had been
undertaken to accomplish objects in which we had a common
interest with themselves. This was the fact; but the President did not
believe that our grievances, although serious, would justify a resort
to hostilities. Whilst Mr. Reed was, therefore, directed to preserve a
strict neutrality between the belligerents, he was instructed to
coöperate cordially with the ministers of England and France in all
peaceful measures to secure by treaty those just concessions to
commerce which the civilized nations of the world had a right to
expect from China. The Russian government, also, pursued the same
line of policy.
The difficulty, then, was to obtain for our country, whilst remaining
at peace, the same commercial advantages which England and
France might acquire by war. This task our minister performed with
tact, ability and success, by the conclusion of the treaty of Tientsin
of the 18th June, 1858, and the two supplemental conventions of
Shanghae of the 8th November following.[51] These have placed our
commercial relations with China on the same satisfactory footing
with those of England and France, and have resulted in the actual
payment of the full amount of all the just claims of our citizens,
leaving a surplus to the credit of the Treasury. This object has been
accomplished, whilst our friendly relations with the Chinese
government were never for a moment interrupted, but on the
contrary have been greatly strengthened.
 CHAPTER XI.
1858-1860.

COMPLIMENTARY GIFT FROM PRINCE ALBERT TO MR. BUCHANAN

—VISIT OF THE PRINCE OF WALES—CORRESPONDENCE WITH
THE QUEEN—MINOR INCIDENTS OF THE ADMINISTRATION—
TRAITS OF CHARACTER—LETTERS TO MISS LANE—MARRIAGE
OF A YOUNG FRIEND.

There are good reasons for believing that the regard which was
always expressed by the members of the royal family of England for
Mr. Buchanan and his niece was something more than a dictate of
policy towards the great nation that he had represented at their
court. One token of this regard, which came after he had been made
President, was certainly intended as a personal reminder of the
pleasant intercourse which he had with the queen and her husband,
and of the liking for him which their eldest daughter had often and
artlessly manifested. When the Princess Royal was married to the
crown prince of Prussia in 1858, her father sent, not to the President
of the United States, but to Mr. Buchanan, a copy of the medal
struck in honor of the marriage, accompanied by this note:

[PRINCE ALBERT TO MR. BUCHANAN.]

Buckingham Palace, Feb. 16, 1858.
My Dear Mr. Buchanan:—
The belief that your recollection of the time passed by you in
England will have made you feel an interest in the late happy
marriage of our eldest daughter, induces me to send for your
acceptance a medal struck in commemoration of that event. You will,
I think, be able easily to recognize the Princess Royal’s features; the
likeness of Prince Frederick William is also very good.
Trusting that your health continues unimpaired, notwithstanding
the manifold duties of your high and responsible office, in which
hope the queen joins with me, I remain, ever, my dear Mr.
Buchanan, yours truly,
Albert.

[MR. BUCHANAN TO PRINCE ALBERT.]

Washington City, March 13, 1858.
Sir:—
I have had the honor to receive from Lord Napier your very kind
note of the 13th ultimo, with the medal struck in commemoration of
the marriage of the Princess Royal with Prince Frederick William.
Whilst in England I had upon one or two occasions the privilege of
meeting and conversing with the Princess Royal, which caused me to
form a very high estimate of the excellence of her character, and to
feel a deep interest in her prosperity and happiness. May her destiny
prove fortunate, and her married life be crowned by a kind
Providence with all the blessings which it is the lot of humanity to
enjoy.
With my most respectful regards to the queen. I remain truly
yours,
James Buchanan.

When the President in June, 1860, learned that the Prince of

Wales would visit Canada, he hastened to write to the queen, and to
extend a national invitation to the Prince to come to Washington.
The following are the letters which passed between the President
and the queen:

[THE PRESIDENT TO QUEEN VICTORIA.]

Washington City, June 4, 1860.
To Her Majesty Queen Victoria:—
 I have learned from the public journals that the Prince of Wales is
about to visit your Majesty’s North American dominions. Should it be
the intention of His Royal Highness to extend his visit to the United
States, I need not say how happy I shall be to give him a cordial
welcome to Washington. You may be well assured that everywhere
in this country he will be greeted by the American people in such a
manner as cannot fail to prove gratifying to your Majesty. In this
they will manifest their deep sense of your domestic virtues, as well
as the conviction of your merits as a wise, patriotic, and
constitutional sovereign.
Your Majesty’s most obedient servant,
James Buchanan.

[QUEEN VICTORIA TO THE PRESIDENT.]

Buckingham Palace, June 22, 1860.
My Good Friend:—
I have been much gratified at the feelings which prompted you to
write to me inviting the Prince of Wales to come to Washington. He
intends to return from Canada through the United States, and it will
give him great pleasure to have an opportunity of testifying to you in
person that those feelings are fully reciprocated by him. He will thus
be able at the same time to mark the respect which he entertains for
the Chief Magistrate of a great and friendly state and kindred nation.
The Prince will drop all royal state on leaving my dominions, and
travel under the name of Lord Renfrew, as he has done when
travelling on the continent of Europe.
The Prince Consort wishes to be kindly remembered to you.
I remain ever your good friend,
Victoria Ra.

The Prince arrived in Washington early in October, 1860, and he

and the principal persons in his suite became the guests of the
President at the White House, where they remained until the 6th of
that month. During this visit there was an excursion to Mount
Vernon, to afford the Prince an opportunity to see the tomb of
Washington. The Prince and his suite, accompanied by a
considerable number of invited guests, were taken to Mount Vernon
on the revenue cutter, Harriet Lane, a vessel of the revenue service,
which had been named for the President’s niece by the Secretary of
the Treasury. The President and Miss Lane were of the party. The
incidents of the visit are well known, but there is an anecdote
connected with it which should be repeated here, because it
illustrates Mr. Buchanan’s scrupulous care in regard to public money.
The Secretary of the Treasury had given liberal orders for a supply of
refreshments to be put on board the cutter. When the President
heard that the bills for this and other expenses of the excursion
were about to be audited and paid at the Treasury, he directed them
to be sent to him. They were not paid at the Treasury, but the whole
expense was defrayed by a private arrangement between the
President and Mr. Cobb, the Secretary.[52]

[THE PRESIDENT TO QUEEN VICTORIA.]

Washington, October 6, 1860.
To Her Majesty, Queen Victoria:—
When I had the honor of addressing your Majesty in June last, I
confidently predicted a cordial welcome for the Prince of Wales
throughout this country, should he pay us a visit on his return from
Canada to England. What was then prophecy has now become
history. He has been everywhere received with enthusiasm, and this
is attributed not only to the very high regard entertained for your
Majesty, but also to his own noble and manly bearing. He has
passed through a trying ordeal for a person of his years, and his
conduct throughout has been such as became his age and station.
Dignified, frank and affable, he has conciliated wherever he has
been the kindness and respect of a sensitive and discriminating
people.
His visit thus far, has been all your Majesty could have desired,
and I have no doubt it will so continue to the end.
The Prince left us for Richmond this morning with the Duke of
Newcastle and the other members of his wisely selected suite. I
should gladly have prolonged his visit had this been possible
consistently with previous engagements. In our domestic circle he
won all hearts. His free and ingenuous intercourse with myself
evinced both a kind heart and good understanding. I shall ever
cherish the warmest wishes for his welfare.
The visit of the Prince to the tomb of Washington and the simple
but solemn ceremonies at this consecrated spot will become a
historical event and cannot fail to exert a happy influence on the
kindred people of the two countries.
With my respectful regards for the Prince Consort,
I remain your Majesty’s friend and obedient servant,
James Buchanan.

[SIR HENRY HOLLAND TO THE PRESIDENT.]

Brook Street, London, November 2, 1860.
My dear Mr. President:—
In writing to you thus soon after my return to England, my first
and foremost object is, to thank you once again, which I do very
warmly, for all your kindness during my last visit at Washington. In
the course of a life somewhat checquered with various incidents, in
various places, I know not that I ever enjoyed five days so much;—
including under this expression both the time of the royal visit, and
that which I afterwards passed with you alone. The Executive
Mansion is lost to me for the future, if even I ever return to America;
but you I trust will preserve to me hereafter the regard and
friendship which it is pleasant to me to possess.
The letter you entrusted to my care was in the hands of the queen
exactly fourteen days after I had received it from you. It will give
you pleasure, I know, to learn (which I presume you will afterwards
do in some way from the queen herself), how very much she was
gratified by it. Both Lord Palmerston and Lord John Russell have
expressly and strongly mentioned this to me.
All England, as far as I can see and hear, is delighted with the
reception of the Prince in the United States. It has produced a
strong impression here;—reciprocated I hope and believe in
America.
The squadron which brings him home has not yet been heard of;
but as they have now been twelve or thirteen days at sea, the arrival
can not be long delayed. Probably to-day may bring some
intelligence. I shall be impatient to see again the several members of
the Prince’s suite, and to hear their detail of all that followed after
our parting at Washington. They will all, I am persuaded, come back
with the same strong sentiment they had at that time regarding their
reception in the United States.
You will see that the European continent is still laboring under the
same strange political complications;—enlivened, if I may so phrase
it, by an occasional battle, but obscured by a dark haze over the
future. Lord Palmerston tells me that he believes it will all end
rightly, and I am willing to believe him, though I do not see my way
towards this result. Many games are evidently at this moment played
underhand—not like the open and frank bowling of the ten-pin
courts. Our excellent ally, Louis Napoleon, comes under this
suspicion, while some suspect that he, between Church and State
affairs, is under as much perplexity as his neighbors. It seems even
doubtful whether the compulsory concession of the Emperor of
Austria will satisfy Hungary, or leave him free for the contingencies
of an Italian campaign. If a general war can be avoided, it is the
utmost the most sanguine dare hope for. For the present the great
interest is concentrated on the spot where the King of Naples still
makes a show of resistance to the King of Sardinia and Garibaldi,—a
matter that a few days must decide. Then comes the question of the
Pope and Rome,—a still more complex and delicate affair, with
interests rooted all over Europe.
In England we are happy and prosperous, despite our indifferent
harvest,—better, however, than at one time expected. But we shall
be fed out of your abundance, if need there be.
The telegraphic news from China seems good as far as it goes,
but we shall need the details to know its full import. Lord Palmerston
tells me that the last despatches led them to believe that the
Emperor of China was very desirous, or at least not unwilling, that
his army should be defeated, to rescue himself from the hands of a
war party at Pekin, which overruled him in his own wishes. Chinese
rumors are very apocryphal documents.
I must not intrude further upon your time, by what, after all, is
little more than may be drawn from the newspapers of the day. In
bidding you farewell, my dear Mr. President, I have but again to
repeat the expressions of acknowledgment for kindnesses received,
and of cordial regard and respect, with which I remain,
Ever yours most faithfully,
H. Holland.

[QUEEN VICTORIA TO THE PRESIDENT.]

Windsor Castle, November 19, 1860.
My Good Friend:—
Your letter of the 6th ultimo has afforded me the greatest
pleasure, containing, as it does, such kind expressions with regard to
my son, and assuring me that the character and object of his visit to
you and to the United States have been fully appreciated, and that
his demeanor and the feelings evinced by him have secured to him
your esteem and the general good will of your countrymen.
I purposely delayed the answer to your letter until I should be
able to couple it with the announcement of the Prince of Wales’s
safe return to his home. Contrary winds and stress of weather have
much retarded his arrival, but we have been fully compensated for
the anxiety which this long delay has naturally caused us, by finding
him in such excellent health and spirits, and so delighted with all
that he has seen and experienced in his travels.
He cannot sufficiently praise the great cordiality with which he has
been everywhere greeted in your country, and the friendly manner in
which you received him; and whilst, as a mother, I am grateful for
the kindness shown him, I feel impelled to express, at the same
time, how deeply I have been touched by the many demonstrations
of affection personally toward myself, which his presence has called
forth.
 I fully reciprocate towards your nation the feelings thus made
apparent, and look upon them as forming an important link to
cement two nations of kindred origin and character, whose mutual
esteem and friendship must always have so material an influence
upon their respective development and prosperity.
The interesting and touching scene at the grave of General
Washington, to which you allude, may be fitly taken as the type of
our present feeling, and I trust of our future relations.
The Prince Consort, who heartily joins in the expressions
contained in this letter, wishes to be kindly remembered to you, as
we both wish to be to Miss Lane.
Believe me always your good friend,
Victoria R.

It is noteworthy that this graceful and cordial letter was written on

the eve of that great convulsion which was so soon to put in
imminent peril the perpetuity of this Union and the very existence of
our Government. To the feelings of the queen and her husband
towards this country, secured by President Buchanan’s wise and
well-timed reception of the Prince of Wales, and the demonstrations
everywhere made towards him in this country, the queen’s subjects
and the people of the United States owe it, that in the dark and
dangerous hour of our civil war, the many irritating causes of
alienation were not allowed by the sovereign of England to disrupt
the bonds of peace or the neutrality of her government between the
warring sections of this Republic. When we look back to the state of
feeling that at one time existed in England towards our Government,
and remember how many British statesmen of great consequence
made serious mistakes, it is but simple historical justice to impute to
the queen and her husband a moderating and restraining influence;
and if that influence had been wanting, there can be no rational
doubt that there would have been a recognition of the Confederate
States, not merely as a belligerent and a de facto power, but as a
permanent and established government, and possibly as an ally of
Great Britain.
 [FROM B. MORAN.]
London, June 29th, 1860.
My Dear Sir:—
The publication of your invitation to the Prince of Wales to become
your guest has caused a great deal of happiness in England, and the
newspapers generally speak highly of the act. I send, herewith, an
editorial from the Morning Chronicle of to-day, in which there are
some deserved and well-expressed compliments. The British people
have more respect for you than for any President since Washington,
and I have never seen a personal attack on you in any English
journal. Whenever you are spoken of, it is in a tone of regard, and
never in a carping spirit.
We are almost run down with visitors from home. From forty to
seventy are here daily, and I have to see them all. I have my hands
full. This is comfort to me, for I would be unhappy without
employment.
...... I hope you will not take offence when I say that I hope the
Baltimore Convention have nominated you, notwithstanding your
declinature to be a candidate. And if such be the case, you will be
elected triumphantly. We are anxiously waiting for news on this
point.
With best regards to yourself and Miss Lane, I am
Ever faithfully yours,
B. Moran.[53]

Both with reference to this visit of the Prince of Wales, and to

some other incidents of the administration, and to certain traits of
Mr. Buchanan’s character, I insert here an extract from Mr. J.
Buchanan Henry’s communication to me, before I proceed to the
trying period of “secession,” which is to occupy a large part of the
remaining pages of this volume.

As private secretary, I had to be in my office, a room on the

southwest corner of the second story adjoining that of the President,
whenever he was there, which was from eight in the morning until
luncheon at one o’clock, and from that time until five, when, with
rare exceptions, he took an hour’s walk. I doubt whether Mr.
Buchanan used his coach and horses a dozen times a year, except
during the summer when he was at the “Soldier’s Home;” then he
drove in to the executive mansion in the morning and out in the
evening. He greatly preferred the exercise of walking, with its
exchange of kindly personal greetings with friends. On returning
from this daily exercise he dined with the members of his household.
It was not then etiquette for the President to accept dinner or other
invitations, for the wise reason, I believe, that any discrimination
would have been impossible without giving offence, and universal
acceptance would have been impossible. Once a week Mr. Buchanan
caused some of the Cabinet members and their wives to be invited
to dinner “en famille” and as there was but little ceremony and all
were agreeable guests, with common and identical interests for the
most part, I remember that these were most pleasant little
entertainments. During the winter, or properly during the session of
Congress, there was what might be called a State dinner, once a
week, an entertainment of a much more formal and formidable
character, in the large dining-room, capable of seating about forty
persons. The first of these dinners was, I think, given to the Justices
of the Supreme Court, the next to the Diplomatic Corps, then to the
members of the Senate, and the House of Representatives, including
each member in his turn, according to official seniority, except in a
very few cases where individuals had by discourtesy or offence
rendered such an invitation improper. Miss Lane and I attended to
the details of these social matters, including dinner and party
attending, making visits, etc., for the President. Among the most
troublesome of these duties was the proper assigning of precedence
to the guests at these so-called state dinners; a delicate task in
these Washington entertainments, as any neglect would pretty
surely give offence. Miss Lane, from natural aptitude and tact and
the experience she had in London whilst her uncle was minister
there, managed these details very cleverly. I had the difficult and
worrying task at these dinners, in the short time between the arrival
of the forty odd guests in the drawing-room and the procession into
the great dining-room, of ascertaining the name of each gentleman
and telling him what lady he was to take in, and probably
introducing the parties to each other. It was sometimes a very
mauvaise quart d’heure of expectation for me; as I was pretty sure
to find at the last moment, when the President was leading the
procession to the table, that some male guest, perhaps not
accustomed to such matters, had strayed away from his intended
partner, leaving the lady standing alone and much embarrassed. I
had then to give them a fresh start.
As private secretary I was charged with the expenditure of the
library fund, the payment of the steward, messengers, and also of
the expenditures of the household which were paid out of the
President’s private purse. I might here mention that these latter
expenditures generally exceeded the President’s salary in the winter
months, because President Buchanan enjoyed entertaining and
entertained liberally from inclination. In summer the social
entertaining being much less, and the President being at the
Soldier’s Home, a modest but pretty stone cottage on the hills near
Washington, the expenses were much less. Taking the year through,
the salary of $25,000 was nearly sufficient to pay the actual
expenses of the executive mansion, but nothing beyond that, or to
allow the President to save any part of it; but on the contrary, I think
he had to draw upon his private means to a considerable extent.
My first duty was to organize the private secretary’s office. I had a
set of books or records carefully prepared, in which could be briefly
entered the date of receipt of any letter or communication addressed
to the President, the name of the writer—subject-matter condensed
to the utmost—dates and substance of answer, if any, to what
department referred, and date of such reference. If the letter
contained a recommendation for appointment to office, these
records indicated the office, the name of the applicant and by whom
recommended. Such communications as the President ought to see I
folded and briefed and took them to him every morning at eight
o’clock and received his instructions as to the answer I should make,
and in some instances he would answer them himself, if of a purely
personal nature. Either he or I would then endorse upon all letters
“Respectfully referred to the Secretary of State,” War, or otherwise,
according as the communication in subject matter related to the
business of that department; and once a day I would enclose them,
as they accumulated, in large envelopes, with printed addresses, and
despatch them by the messenger to the several departments. By this
system I could recall any letter or communication of any kind by
reference to the entries on my books, whenever the President
desired them for action. This was the routine of the Executive Office.
It will hardly be credited that this simple and natural course of
business gave the pretext at a later day, and I can scarcely suppress
my indignation as I think of it, for that infamous “mare’s nest,”
discovered by Covode of Pennsylvania, a member of the House of
Representatives, and for the investigation of which he obtained a
committee with full powers. The letters of General Patterson and
others to which it related, were simply referred to the Secretary of
the Navy according to the ordinary and proper routine of business in
the Executive Office, as I have above described, and were endorsed
exactly as thousands of others had been either by the President or
by me, and such endorsement had therefore no signification
whatever. It was a cruel and malicious pretence to infer that the
Secretary of the Navy would attach any importance whatever to the
mere act of reference by the President himself because a multitude
of such papers were similarly endorsed either by him or by me every
day.
There would have been no room to keep such a mass of papers in
the White House, and they would have been out of place there, as
they related to the business of the several cabinet officers, and yet
upon this miserable basis was the “Covode investigation” erected,
and the first attempt ever made to soil a spotless public life,
extending over more than forty years in every exalted station of our
Government, as member of the legislature of Pennsylvania, many
years member of the House of Representatives, Senator of the
United States, twice diplomatic representative of the nation at the
two principal courts of Europe, Secretary of State of the United
States, and finally President of the Republic. The meagre partisan
fruits of the investigation when made, and the refusal, to its credit
be it said, of a bitterly hostile opposition in the House to propose
even a censure, clearly showed its baseless character.
The committee, with well simulated delicacy, never summoned me
to appear and testify, but sent for my clerk, and after examining him
were glad, it seems, to drop it. I dwell upon this matter, because in a
long career of public service it is the only attempt ever made to
impeach Mr. Buchanan’s public or private integrity. He himself felt it
very bitterly, and I think it will be admitted that he administered a
wholesome and deserved rebuke to the House in his special
message of protest. Although the result demonstrated that there
was not the most gossamer pretext for the charge made by Covode,
I think Mr. Buchanan’s friends can be well pleased at its having been
made, and its futility exposed, as it leads to the fair conclusion for
history, that Mr. Buchanan was invulnerable to any assaults upon the
honor of his public or private life. Surely this is much to be able to
say of a public servant, and a nation capable of breeding many such
public men can justly congratulate itself.
Another feature of Mr. Buchanan’s public life I will refer to, which
possibly may not now be esteemed a great virtue. I mean his dislike
of nepotism. Not unnaturally, there were members of our family who
would have been very glad to have obtained civil or other
appointments during his administration. But such was Mr.
Buchanan’s freely expressed repugnance to using his public authority
for the advantage of his relatives, that I am not aware that any of
them even made application to him for office of any kind. Public
policy clearly indicates the propriety and desirability of the
President’s private secretary being, if possible, a blood relation, upon
the ground that the honor and interests of the President and his high
office can be most safely entrusted to one having an interest in his
good name and fame, and therefore more guarded against
temptation of any kind. I therefore do not consider the selection of
myself, or my cousin Mr. James Buchanan, who followed me, as any
exception to what I have stated. To such an extent did I know that
my uncle disliked the appointing of relatives to office, that I never
dared to tell him of my desire to be appointed to the paymaster
corps of the navy, a position which from my nomadic tastes I had
long coveted, and I concluded to save myself the mortification of a
refusal. I could exercise no influence with him for myself. As an
instance of this, I will mention that when the Hon. John Cadwalader,
late Judge of United States Circuit Court of Eastern Pennsylvania,
was appointed to that judgeship by Mr. Buchanan, he tendered me
the clerkship of his court, a permanent and honorable position, and
one that I should have been willing to accept. Judge Cadwalader had
been my legal preceptor, and for years my warm personal friend, so
that the proffered position would have been in every way agreeable
and proper. Although I was then residing in New York as a private
citizen, I consulted Mr. Buchanan as to its acceptance by me, and on
finding that he entertained serious reasonable objections to my
doing so, I declined the compliment. The President said the public
might justly infer that there had been some previous understanding
between him and the new judge, and that however erroneous such
a conclusion would be, it would be natural. Inasmuch, therefore, as
my acceptance might work injury, both to the President and his
excellent appointee, I quickly made my decision. These little events,
unknown to the public, will serve to illustrate the delicate sense of
right and the very appearance of right, which so strongly marked his
public service.
Among the minor but interesting incidents of the administration, I
may mention the receipt of the first message by the new ocean
telegraph from the British sovereign, and the President’s reply to it.
As the cable became silent almost immediately after, the public were
for a long time in doubt whether any message had really been
transmitted over the wonderful wire under the sea. I well remember
the reception of the message, and I had it and the draft of the
President’s reply in my possession for years afterwards as a curiosity.
You doubtless know all about the visit of the Prince of Wales to
President Buchanan, and the pleasant social incidents following in its
train. The Duke of Newcastle, Lord St. Germains and Sir Henry
Holland—the latter an old friend of the President’s—in the Prince’s
suite, were also guests at the White House. I was then residing in
New York, and was sent for by my uncle to my old quarters in
Washington, to assist in entertaining these distinguished persons,
who, though entertained at the private expense of Mr. Buchanan,
were nevertheless looked upon, and properly so, as the guests of
the nation.
Probably among the most interesting, and I may say touching,
incidents of this visit, was a trip made by the royal guest and suite,
in company with the President, to Mount Vernon. I well remember
the whole party—the tall, venerable form of the President, the
youthful Prince, and the other guests representing the highest social
order in Great Britain, standing bare-headed in front of the tomb of
Washington. It was a most impressive and singular spectacle, and I
have often thought it would make a very striking subject for a large
historical painting. The Prince planted a small tree near the tomb in
commemoration of his visit, but I have never learned whether it
grew. Many interesting incidents occurred in this visit, but I shall not
repeat them. I will only say that I never saw a more agreeable or
unrestrained intercourse of a social character—for the visit had no
political significance whatever, and the Queen and the Prince
subsequently expressed their appreciation of the President’s
hospitality, the former in an autograph letter, and the latter both by
letter and the presentation of a three-quarter length portrait, painted
by one of Britain’s greatest artists. The value of this was enhanced
by the delicacy which marked its presentation after Mr. Buchanan
had retired to private life as a simple citizen. These letters and
portrait are now in the possession of my cousin, and also the
autograph letter of the Prince Consort to Mr. Buchanan on the
occasion of the marriage of the Princess Royal, in which he uses
some pleasant expressions of a personal character, and referring
back to Mr. Buchanan’s residence in London as minister. I think the
era of good feeling between America and England, and especially
the enduring friendship of the Queen herself for the United States,
so decidedly shown by her during our terrible war, may be traced as
one of the happy results of the visit of the Prince of Wales to the
President. The kindly feelings of these two great nations towards
each other, a rapprochement, now so marked, had, I think, its
beginning at that period.
 Another trait of Mr. Buchanan I must not omit alluding to. He
made it an invariable rule, as President, to accept no gifts or
presents of any value, even from the most intimate friends, and it
was part of my duty to return them at once, with a kind but
emphatic declination, telling the donor that the President had made
it a rule, not to be broken, that he could accept no gifts; and I was
directed, at the same time, to express his thanks for the friendly
intentions in all cases where it seemed probable that it was not a
bold effort to purchase favor, and from purely selfish motives. A
number of costly gifts were thus returned.
After a personal intercourse with Mr. Buchanan from my boyhood,
more or less intimate, and therefore having had an opportunity to
judge, I can conscientiously say that I never knew a man of purer
private life, or one actuated by nobler or more upright motives. He
was, to us around him, an object of unbroken respect and
reverence. I can truly aver that I never heard him express an ignoble
sentiment, or do an act that could diminish that respect and
reverence. He was strong willed, rather austere, and somewhat
exacting to those around him, but always and in all things the
Christian gentleman. This was the impression made upon me as a
youth, and now, as I look back from later life, I see no cause to
change or modify my estimate of his character. His only fault, if fault
it be, was a too great readiness to forgive and conciliate those who
had been his enemies, regarding it as a triumph for his principles
and a vindication of his motives. And yet this has been at times
attributed to him as a weakness.
Mr. Buchanan had an extraordinary memory, and could repeat
verbatim much of the classic authors of his college days, and I
remember he often put me to shame, when I was yet in the midst of
my books, by questions that I failed to answer to my satisfaction. He
was also a remarkably fluent and agreeable conversationalist—a rare
and valuable gift—and it was one of my greatest pleasures to listen
to him, when in congenial company, relating anecdotes of his great
contemporaries in public life at home, and incidents occurring during
his missions in St. Petersburgh and later in London. This quality
made him a most agreeable companion among men, and an especial
favorite with the fair sex, whose friendship in turn he appreciated
and enjoyed to the end of his life. The correctness of his own private
life, and his association with only the nobler of the other sex,
resulted in his never entertaining or expressing cynical views of
them, so common in men’s later years.
I do not know if you have any account of Mr. Buchanan’s personal
appearance or dress. The best likeness of him is a miniature portrait
on ivory, by Brown of Philadelphia, now in the possession of his
brother, the Rev. Dr. Buchanan. I have an oil photograph painted in
1857, which is excellent; also a bust in marble by a Boston sculptor,
which is good. My cousin has a half-length portrait, painted by
Eicholtz about the year 1833. His figure and general appearance
whilst President is very accurately represented in a full-length
engraving by Buttre of New York. On the whole, I think it is the best
average representation of him extant. Healy executed a portrait of
Mr. Buchanan at the White House, but he was an impatient sitter,
and I do not think it was very successful.
Mr. Buchanan, in his sketch of the four last months of his
administration, gives a short account of a remarkable naval
expedition ordered by him to Paraguay, to settle certain difficulties
with that republic. This naval demonstration on a considerable scale
was entirely successful, and resulted in a permanent peace with that
country ever since. It had, however, this most uncommon feature to
distinguish it, that it cost the United States not one dollar beyond
the usual small annual appropriation for the navy. I sometimes
wonder whether any other such expedition of its size and
importance, in this or any other country, can show such an example
of economy, honesty and efficiency and success combined, as did
this.

[TO MISS LANE, IN NEW YORK.]

Washington, May 20th, 1858.
My Dear Harriet:—
Learning that you were about to purchase furniture in New York
[for the White House], I requested Doctor Blake to furnish me a
statement of the balance of the appropriation unexpended. This
balance is $8,369.02. In making your purchases, therefore, I wish
you to consider that this sum must answer our purpose until the end
of my term. I wish you, therefore, not to expend the whole of it, but
to leave enough to meet all contingencies up till 4th March, 1861.
Any sum which may be expended above the appropriation I shall
most certainly pay out of my own pocket. I shall never ask Congress
for the deficiency.
Who should make his appearance this morning but Mr. Keitt.[54]
After talking about other matters for some time, he said he was
married. I expressed strong doubts upon the subject, when he
insisted that he was actually and bona fide married. The lady is Miss
Sparks, whom he has been so long addressing.
With my kind regards to Mr. and Mrs. R., I remain, etc.

[TO MISS LANE, IN PHILADELPHIA.]

October 15th, 1858.
We have not yet heard from you since you left us. I hope you
arrived safely in Philadelphia, and did not contract a hoarseness in
talking on the way. We get along very nicely since your absence and
will give a big dinner on Thursday next. I have not seen any of your
lady friends since your departure, and can therefore give you no
news.
Well! we have met the enemy in Pennsylvania and we are theirs.
This I have anticipated for three months, and was not taken by
surprise, except as to the extent of our defeat. I am astonished at
myself for bearing it with so much philosophy.
The conspirators against poor Jones have at length succeeded in
hunting him down. Ever since my election the hounds have been in
pursuit of him. I now deeply regret—but I shall say no more. With
the blessing of Providence, I shall endeavor to raise him up and
place him in some position where they can not reach him.
Judge Black, General Anderson of Tennessee, Mr. Brenner, and Mr.
Van Dyke dined with me yesterday, and we had a merry time of it,
laughing, among other things, over our crushing defeat. It is so
great that it is almost absurd.
We will present a record of success at the meeting of Congress
which has rarely been equalled. We have hitherto succeeded in all
our undertakings.
Poor bleeding Kansas is quiet, and is behaving herself in an
orderly manner; but her wrongs have melted the hearts of the
sympathetic Pennsylvanians, or rather Philadelphians. In the interior
of the State the tariff was the damaging question, and in defeating
Jones, the iron interest have prostrated a man who could render
them more service than all the Republican Representatives from
Pennsylvania. He will be a loss to the whole country in the House of
Representatives.
I have heard nothing of the good and excellent Robert since you
left us. He is a man among a thousand. I wish I could say so much
for his brother.
It is growing late and I must retire. I sleep much better now, but
not near so well as at the Soldiers’ Home.

May 13th, 1859.

I send you an oration received from Hon. William Porcher Miles,[55]
and franked by him to yourself. A precious recognition!......
I wrote a long letter to Mrs. Roosevelt, ten days ago, and left it on
my table open. It marvellously disappeared, and I had neither
courage nor time to copy it from memory. I know not what has
become of it, but it contains nothing which might not be published in
the New York Herald. My respect and admiration for Mrs. Roosevelt,
to be sure, appear in the letter; but this is well known and does me
honor. It is possible that in clearing my own table I may have by
mistake torn this letter up with other manuscripts; but I can not
believe it.
I have but little news. Mr. Magraw came to us on Saturday last
and still remains, much to my gratification. We get along very
comfortably and quietly. Miss Hetty is very busy. Washington, they
say, is extremely dull. I called yesterday at Mr. Thompson’s, just
before dinner. The lady was not at home. She had gone to a
travelling circus and show in company with Mrs. Gwin, her sister and
Miss Lucy. I made no remark to Mr. Thompson on receiving the
information, except that you would certainly have been of the party
had you been in Washington.
I met Mrs. Conrad and her daughters on the street the other day
and walked with them some distance. She does not appear to have
seen much of Lord Lyons. I think he keeps himself very much to
himself. Count Sartiges has been here several times. I shall miss him
more than I would any of the foreign ministers.

May 14th, 1859.

I send you the enclosed letter from Mr. ——, of New York. It
speaks for itself. He seems to be a warm-hearted German, and I
would advise you to address him a few lines. In acknowledging the
compliment, I have said I would send his letter to you at Judge
Roosevelt’s. You have been hailed as “The Great Mother of the
Indians,” and it must gratify you to learn that your adopted
countrymen desire to perpetuate your name by giving it to their
children.
Two of the Secretaries and myself were to have visited Baltimore
to-day to select a site for the Federal Courts; but we agreed to
postpone our visit until Monday to enable them to attend a dinner
given by Lord Lyons to-day to the members of the cabinet. It is quite
probable we shall be accompanied on Monday by Mrs. Thompson,
Mrs. Gwin and other ladies.
What means the ominous conjunction between Mr. Van Buren and
Mr. Douglas at the —— Hotel. I do not, however, consider it ominous
at all, though others do.
Sir William ought to have been very careful in obeying his
instructions, especially after his former experience in South America.
The British government are not at all pleased with him. We know
this from Lord Lyons.
Here I was called away after ten at night, to hear the music of the
Knights Templars. It was, I think, excellent; though I am, as you
know, no great judge. Good-night! My affectionate regards to Mrs.
Roosevelt and my respectful compliments to the Judge.
 Mr. Thompson and myself intend to set out for Chapel Hill on
Monday, 10th instant. I think Mr. Magraw will accompany us. They
are making great preparations to receive us. I hope you are enjoying
yourself. Stay as long as it affords you pleasure. We are getting
along very well. Miss Hetty is very busy in having things put in order
for the summer.

May 18th, 1859.

I return Lady Ouseley’s letter. When you write please to remember
me to her in the very kindest terms. I should be sorry indeed to
think I should never meet her again.
The conduct of Sir William has been most decidedly disapproved
by Lord Malmesbury. Of this we have the official evidence. I am truly
sorry he did not obey his instructions. But of this say nothing to Mrs.
Roosevelt.
Our two successful diplomatists, Messrs. Reed and Bowden, with
their ladies, are to dine with me to-day en famille. Mr. Cobb now
dines here regularly.
I never laughed as much on any one day as on Monday last at
Baltimore and on the way.
Remember me always most affectionately to Mrs. Roosevelt, and
very kindly to the Judge.

June 10th, 1859.

I have received your favor of yesterday. We returned to
Washington on Tuesday morning last from our visit to North
Carolina. On Wednesday morning Miss Hetty left for Wheatland with
my full and entire approbation, and I wish to say to you
emphatically, that you need not return home on my account. I shall
be rejoiced to see you whenever you may think proper to return; but
I get along both comfortably and happily in the absence both of Miss
Hetty and yourself.
I am sorry to find that your excursion to West Point on the Harriet
Lane, has been made the subject of newspaper criticism on yourself.
This is most ungallant and ungentlemanly. The practice, however, of
employing national vessels on pleasure excursions, to gratify any
class of people, is a fair subject of public criticism. You know how
much I condemned your former trip on the same vessel, and I did
not expect you would fall into a second error. The thing, however, is
past and gone, and let it pass. After a fair time shall have elapsed, it
is my purpose to cause general orders to be issued by the Treasury
and Navy Departments to put a stop to the practice.
I am truly rejoiced to learn that James Henry is succeeding in his
practice.
I have not the least idea of paying the price you mention for a
cane. Let it pass for the present. I will get Mr. Baker to attend to it.
Washington has been very quiet but very agreeable since you left.
I dined yesterday with Mrs. Thompson. Mrs. Gwin and her sister and
Mr. Cobb were the only persons present out of the family. We had a
merry time of it. The same party are to dine with Mrs. Gwin on
Tuesday next.
It was with the utmost reluctance I removed Mr. ——, though his
removal was inevitable. His brother —— has done him much injury. I
have known him long, and can say with truth that I know not a more
unprincipled man in the United States. I wished to avoid the
publication of Mr. Holt’s report, but Mr. —— and his brother made
this impossible. The trio are now all together in happy communion, I
mean ——, ——, and ——, the last the most contemptible of the set.
I have just had long and interesting letters from Jones and
Preston. They are both pleased, and both get along well. The former
evidently stands well with the Austrian government, and gives us
valuable information.
I remain, yours affectionately, etc.

Bedford Springs, August 22, 1860.

I have only time to write a line before Mr. Wagner, the messenger
of Mr. Thompson, leaves. I am well, and the water is producing its
usual good effect. The company is reduced very much, though what
remains is agreeable and respectable. My visits from the
neighborhood are numerous.
Give my love to Lily. If things proceed as from appearances we
might anticipate she will soon be on the diplomatic corps, but I yet
entertain doubts whether she will stand fire at the decisive moment.
Many inquiries have been made about you here, and regrets
expressed that you did not accompany me. In haste, yours
affectionately,

[FROM MISS MACALESTER.]

Glengarry, Torrisdale, Oct. 8, 1860.
My Dear Mr. Buchanan:—
You have always evinced such a kind and anxious interest in
regard to my matrimonial arrangements, that I feel it a duty, as well
as a pleasure, to relieve your solicitude on the subject, by assuring
you that I at last really am engaged. I consider you entirely
responsible for this result, my dear Mr. Buchanan, for you so terrified
me last spring and summer by your forebodings, and made me so
fully realize my almost hopeless condition and approaching
superannuation, that I determined to trifle no longer with time. I
think, therefore, I may fairly claim your kind wishes and
congratulations upon my escape from the prospect of a dreary
spinsterhood, and in due season I shall also claim your fulfillment of
a promise made long ago, and frequently repeated since, to be
present at my wedding when that incomprehensible event takes
place. En attendant, believe me always, my dear Mr. Buchanan,
With truest love yours,
Lily L. Macalester.

[TO MISS MACALESTER.[56]]

Washington, October 10, 1860.
My Dear Lily:—
I have received your favor of the 10th, announcing your
engagement, and most sincerely and ardently do I hope that your
marriage may prove auspicious and secure your future happiness
and prosperity. I need not assure you that I feel all the interest
which devoted friendship can inspire in your permanent welfare.
I had thought that “the prospect of a dreary spinsterhood” would
not have impelled you into an engagement, without saying a word to
your superannuated bachelor friend, but when young ladies have
determined to marry they will go ahead.
May you enjoy all the blessings in your matrimonial state which I
ardently desire, and you so richly deserve. Always your friend,
James Buchanan.
 CHAPTER XII.
1860—March and June.

THE SO-CALLED “COVODE INVESTIGATION.”

Reference has been made by Mr. Henry, in a part of his

communication quoted in the last chapter, to a proceeding in the
House of Representatives, which has been called the “Covode
Investigation.” It is proper that a detailed account of this occurrence
should be here given.
Among the lower, or rather the lowest, political tactics, inculpation
of a retiring administration has often been resorted to for promoting
the success of the opposite party, and it seems not infrequently to
have been the calculation that the effect produced would be in
proportion to the grossness of the imputations. Mr. Buchanan could
not hope to escape calumny. None of his predecessors, not even the
most illustrious of them all, not even Washington himself, had
escaped it. Scarcely any of them, however, had been made the
object of this kind of attack, by a method so base and by means so
foul, as those to which President Buchanan was now to be
subjected. Before any of the troubles of secession arrived, before
either of the political parties had made its nomination for the next
Presidential election, it was determined that an assault should be
made upon him that would render him and his administration odious
to the people of the country.
It is certainly unavoidable, perhaps it is well, that free
governments should be administered by parties. In a vigilant, jealous
and active opposition, there is great security against the misuse of
power by those who hold it. But the freedom of opposition, like the
freedom of the press, can easily degenerate into licentiousness; and
the greater the latitude allowed by the political maxims or habits of a
people, the greater will be the danger of abuse of that right of
criticism and inculpation which is essential to liberty, to purity, and to
the public interests. Happily, there are some restraints upon the
exercise of this right, imposed by the forms of procedure which our
Constitution has prescribed when the conduct of the executive
branch of the Government is to be called in question by the House of
Representatives. When these restraints are violated, as they were
violated against President Buchanan, there is but one judgment for
history to pronounce. Those who institute a proceeding that is out of
the limits of their constitutional function, for the purpose of exciting
hatred of one who fills for the time a coördinate and independent
department of the Government, and who conduct such a proceeding
in secret, leave upon the records of the country a condemnation of
themselves; and it is some evidence of the progress which a people
are making in freeing their partisan warfare from such abuses, if we
are able to say, as probably we can say, that such a proceeding
would not be tolerated at the present day by any portion of the
people of this country, as that which was begun and prosecuted
against President Buchanan in the spring and summer of 1860.
The House of Representatives was at this time under the control
of a majority held by the opponents of the administration. If they
had reason to believe that the President had been guilty of an
exercise, or of any attempt at an exercise, of improper influence
over legislation, or that he or any of his subordinate executive
officers had defeated, or attempted to defeat, the execution of any
law, or that he had failed or refused to execute any law, their course
was plain. In regard to the President, it was their duty to make a
specific charge, to investigate it openly, and to impeach him before
the Senate, if the evidence afforded reasonable ground to believe
that the charge could be substantiated. In regard to his
subordinates, their power to investigate was somewhat broader,
because, as a legislative body, the House of Representatives might
have occasion to remedy by legislation any future wrongs of the
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