Tutorial NL 2

Obstetrics & Gynecology

By Med 34

1. 32 G2P1 GA 24 week

a) Fasting blood sugar

b) 50 g OGTT

c) 100 g OGTT
d) Random glucose

e) Urine sugar

Ans : b)
potential DM

GST 50

g 1-hour OGTT
> 140 mg%

100 g 3-hours OGTT

< 140
mg%
GA 24 28 wk

Fasting

105

1 hr

190

2 hr

165

3 hr

145

> = A2

> 2/3 = A1

Potential DM
FH
Hx of macrosomia, still birth or
malformation
Obesity
> 35 yrs
HT
Urine sugar +ve

2.
G1P0 GA 32 wk

sterile speculum

fluid posterior fornix fern test

+ve

a) Tocolytic drug

b) Dexamethasone
c) IV prophylactic ATB

d) Observe sign of chrioamnionitis

e) PV to F/U cervical progression

Ans : e)
Case PPROM GA < 34 wk
expectant Mx IV ATB,
Dexamethasone, Tocolytic drug (as need)
Observe clinical of chroioamnionitis ex fetal
tachycardia, maternal fever, ,
leukocytosis foul smell AF
sign of

chroioamnionitis or GA > 34 wk
induction
expectant Mx
PV induce

infection

ATB in PPROM
Expectant Mx Ampli 2 g q 6 h x 2 d /
Amoxy 500 mg tid x 5 d + Erythro qid x 7 d
Induction of labor Ampli 2 g stat with 1
g qid until deliver (GBS prophylaxis)
Tx Chorioamnionitis Ampli (1 g q 6 h) +
Genta, if C/S add Metro

Dx PROM
1. sterile dry speculum + cough test
2. Nitrazine paper test ( pH > 7 ;
)

False +ve Urine, semen BV

3. Fern test NaCl

3.
G2P1 GA 38 wk uterine contraction
3 30 cervix dilate 3
cm, 50% effacement station 0 membrane
intact PV

a) Amniotomy
b) Syntocinon
c) U/S
d) Observe
e) C/S

Ans : d)
Case G2P1 GA 38 Wk in active phase of 1st
stage of labor
Problem list
- contraction Duration (need augmentation
ex ARM or synto?)
- Presentation Compound ; Mx = observe
or push its hand upward

Stage of labor
latent

active
1st

2nd 3rd

Abnomal labor pattern

Abnormal
pattern

G1

G2

Prolonged
latent
phase

> 20 hr

> 14 hr

R/O false labor Observe

pain
MO

< 1.5
cm/hr

CPD,
malposition,
poor
contraction

Observe
Synto or
ARM

CPD,
Obstructed
labor

C/S

Protacted
active
phase
dilatation
2nd arrest
of
dilatation

< 1.2
cm/hr
> 2 hr

cause

Mx

Abnomal labor pattern

Abnormal
pattern
Arrest of
descent

G1

G2

> 1 hr

> 1 hr

Prolonged
deceleration > 3 hr
phase

> 1 hr

> 2 hr

> 1 hr

Prolonged
2nd stage

cause

CPD,
Obstructed
labor

Mx

C/S

Abnormal presentation

Transverse lie C/S

Breech C/S
Compound Observe
Face Observe Exc : Mentoposterior
Brow Convert to vertex or face
Transverse lie asso c placenta previa
Face, brow, breech asso c anencephaly

4.
28 Mitral stenosis

a)

b)

c)

tertiary care
d)

e)

Ans : c)
Case G1P0 GA 8 Wk with MS

class II

CHF

Class I

Continue

Class II

Class III

Class IV

pregnancy

Terminate
pregnancy

Mx of preg with heart dz

ANC
Sleep > 10 hr/d + hr post meal
hard work
Na+
Stop smoking
Control anemia, PIH, infection and wt. gain

Intrapartum
Vaginal delivery

Mx of preg with heart dz

Intrapartum
ATB prophylaxis
pain
Semi fowler
O2
Prophylaxis F/E (short 2nd stage)
Monitor V/S (RR,PR) dig. / lasix

Post partum TR, can give BF


5.

a)

b) Suprapubic area
c)

d)

Ans : a)
case shouder dystocia Mx

McRoberts maneuver (
)
Suprapubic pressure
Rubin maneuver

Cleidotomy

(Modified Crede maneuver)
PPH

Macrosomia
C/P
Shoulder dystocia
BPI (C5-6)

Fx clavicle
Cephalhematoma

6. 26 GA 8 wk U/S

GA

a) Femur length
b) BPD
c) CRL
d) Abdominal circumference
e) Head circumference

Ans : c)
GA

5-6.5 wk

MSD

7d

7-13 wk
(1st trimester)

CRL (Crownrump length)

5-7 d

2nd trimester

BPD, HC, AC, FL

2 wk

3rd trimester

BPD, HC, AC, FL

3 wk

GA CRL ; CRL(mm) + 6.5 =

GA(wk)

7. 24 G1P1 polyhydramnios
Oxytocic
vaginal

delivery bleeding 1500 ml

PE :
bleeding
Uterus 2/4 FH > umbilicus

PPH
a)

b) polyhydramnios

c)
d) Oxytocin

Ans : b)
Case G1P1.. PPH PE Uterine fundus
2/4 > Umbilicus ( Uterine fundus
= Umbilicus +
) +

tear
Vg PPH


Uterine atony Risk fc

Over distention Uterus

(Polyhydramnios) synto

b)

Synto

Ut. Atony

Risk fc of
Ut. Atony

Post partum hemorrhage

Def : bleed > 500 cc (NL), > 1000 cc (C/S)
Early (< 24 hr) / Late (24 hr to 1-2 wk)
Early
Uterine atony
Tear Vg & Cx
Retain placenta
Uterine inversion
Coagulopathy

Post partum hemorrhage

Late
Retain piece of placenta
Endometritis

Uterine atony
Cause
Prolonged labor or short 2nd stage of labor
Over distention of uterus Ex Twin,
Polyhydramnios, Macrosomia
Under GA (esp. Halogenated hydrocarbon)
Usage of oxytocin
Multiparity
Hx of Uterine atony

Uterine atony
Mx

Cath.
Uterine massage
Oxytocin iv drip 200 mu/min
Methergin 0.2 mg im
PGs analog (Cytotec) 200 ug (4-5 tab rectal suppo)
IV fluid resus. + Blood transfusion
Bimanual Ut.compression then refer for Hysterectomy
or Internal iliac ligation/embolization

8. G4P3 GA 38 wk true labor PV : OS

open 7 cm cord fetus normal most
approp Mx?
C/S
9.
PE valva Mx?

C/S

Definite Indication for C/S

Failed induction
CPD
Failure to progress in labor
Fetal distress
Placenta previa
Prolapse cord
Obstructed tumor
Active genital herpes
Conjoined twins

10. 28 G1P0 GA 38 wk

. 2 hr FH > umbilicus, FHR

150 at RLQ, OS closed, U/S mass 8

cm at lower uterine segment

a) NL
b) C/S
c) C/S + myomectomy
d) C/S + hysterectomy

Ans : b)
Obstructed labor definite indication for
C/S !!


HbH disease
11.

profile

Hct 37 MCV 87 reti count 0.5

Hct 38 MCV 72 reti 1

Hb

a)

- - /
b)
/
c)
/ -
0
d)

B
/
B

e)
B / B+

Ans : a)
Hb H disease

RBC indices

(RBC
,
,

Reticulocyte count
)

gene alpha 1
trait

gene alpha 2
trait

Thalassemia screening

CBC
OF or MCV
DCIP (for detect Hb E)
Hb typing
PCR (detect alpha-thalassemia or prenatal
diagnosis of major thalassemia)
Therapeutic abortion

Hb typing
A2A A2 < 3.5%
A2A A2 > 3.5%

normal
beta trait

EA E < 25%
EA E 25 35%
EE E > 80%

beta E with alpha trait

A2A H Bart

Hb H dz

beta E without alpha trait

Homo beta E

R/O alpha trait

Hb typing

PCR

12.
PV:
40
graynish pH 6, Clue cell > 20%,
a) Clinda 500 mg bid x 7 day
b) Doxy 100 mg bid x 7 day
c) Azithromyzin 1 g
d) Ceftriaxone 125 mg

Ans : a)
Dx = Bacterial vaginosis ; Org. = Gardnerella
vaginalis

Clinical =

1. Homogenous graynish D/C

2. pH > 4.5 (amino acid amine)

Whiff test)

3. Amine or fishlike odor ( Sex or

4. Clue cell (wet smear)

Tx = Metro / Clinda (Preg.)

Bacterial vaganosis

Leukorrhea
Candida , Curd like, KOH,
Cotrimazole
TV , strawberry cervix, Pair
shape Org. c flag (wet smear)
Metronidazole
GC , , Dx
by&C/S
Cef-3
+
Doxy
TV
GCorG/S,
STD

W/U for HIV VDRL

+ Tx partner (60 d)

13. Pt. preg. GA 33 Wk ANC BP

170/110 (repeated) urine protein 2+

Vertex

presentation Mx

a) Emergency C/S
b) Induction
Oxytocin

c) Induction Dexa dose 24 hr.

d) Observe GA 34 wk.
e) Observe GA 37 wk.

Ans : b)

Dx = Severe preclamsia ; Mx = Terminate

preg.
GA try Vg. Delivery

fail or fetal distress C/S

1. Admit, NPO, IV fluid, On monitor, CBC c
plt., UA, Urine 24 hr, BUN/Cr, LFT, U/S, Xmatch for PRC, On Foleys cath., Observe
Clinical V/S & reflex

2. Dexa (Pt. GA 34 wk)

6 mg im q 12 h x 4 dose

3. MgSO4 4 g iv drip 1 g/min

5 g x 2 im buttocks 2
; 5 g im q 4 h 24

hr

Mg reflex
RR > 16/min Uo >

100 cc/4hr
10% calcium

gluconate
antidote
4. Anti HT role case


diastolic BP > 110
hydralazine or nifedipine

Preg. Induced HT
1) Non proteinuric
gestational HT

BP 140 / 90 x 2 times
after 6 hr

2) Mild preclamsia

1) + UA prot. +ve 1+ x 2
times after 6 hr or 300
mg in 24 hr urine

3) Severe preclamsia

2) + one of these
BP 160 / 110
UA prot. +ve 2+ x 2
times after 6 hr or 2 g
in 24 hr urine

Preg. Induced HT
3) Severe preclamsia

Headache
Epigastrium pain
Visual disturbance
Oliguria
Cr
Liver enz.
Thrombocytopenia
Fetal growth restriction
Pulmonary edema

4) Eclamsia

2) Or 3) + seizure

Preg. Induced HT
Mx.
1) Terminate at GA = 37 Wk
2) Terminate at GA = 37 Wk + Give MgSO4
during labor
3) + 4) Terminate immediately + Give
MgSO4 during labor

14. G4GA 39 oxytocin 20 cc/hr

uterine contraction : interval 3 min, duration
50 sec
30

, FHS


BP 80/60

Dx

a) Abruptio placenta
b) Placenta previa
c) Uterine rupture
d) Vasa previa
e) Prolapsed cord

Ans : c)
classic uterine rupture

Antipartum hemorrhage,

,
BP drop & tachycardia,
fetal bradycardia

Risk fc = C/S (classical > inverted T > low
transverse)
Induced or Augmented labor

Bandls ring =
?

Antipartum hemorrhage
Most common 50% = idiopathic

Placenta previa

associated with abnormal

precentation C/S
GA > 37 wk
Abruptio placenta

supportive( fluid/) +
if fetal distress C/S +
coagulopathy
Ruptured vasa previa

Antipartum hemorrhage
Painful

Painless

Fetal distress

Fetal well-being

Abruptiovasa
placenta
Rupture
previa

Placenta previa

APH PV
U/S
R/O placenta

previa

15. 26 G1 GA 33 wk GDM
A1 labor pain interval
2

urine protein 1+

a) Preterm labor
b) GDM c preterm

c) Mild preclampsia
d) Abruptio placenta

Ans : d)
Antipartum hemorrhage painful bleeding
Ut. Contraction
abruptio

placenta

GDM
risk
Urine protien mild preclampsia
(preclampsia risk abruptio
placenta )
Dx
BP

mild
preclampsia

abruptio placenta

Abruptio placenta
Cause and risk Fc
Vessel : HT, GDM, Myoma, smoking
Force
External : Trauma
Internal : Polyhydramnios,

16. G1P0 GA 12 wks

PE: PV
cervical os , no cervix excitation , uterus
8 wks , mild tenderness, adnexal no mass
not tender Diagnosis
a) threaten abortion
b) incomplete abortion
c) inevitable abortion
d) imminent abortion
e) complete abortion

Ans : e)
abort

Bleed /
pain

Hx of
conception

Cx

Size of
Ut

Threaten

closed -

=GA

inevitable

++

open

=GA

incomplete ++

open

<GA

complete

closed +

<GA

+/-

C/P of fetal death in utero (>4wk) is

consumptive coagulopathy

Abnormal vaginal hemorrhage

Abortion
Ectopic preg. (Ampulla)
6 wk, pelvic pain (Lt. or Rt.), spot bleeding, shock,
cervical motion pain, tender at adnexal
Ix = UPT, U/S (not found sac in Ut.TVS may found mass
at adnexa) ,bHCG (>1500 or rising up less than 66% in
48 hr) Culdocentesis and Laparo
Tx = hemo unstable = Salphingectomy
hemo stble = MTX or Sx

Molar preg.

17.
20 LMP 6wk.PTA
6hr

PTA. PE : normal , PV

vagina , uterus Rt.

Adnexa Cervix

mass => Dx?

a)

b) ectopic

c) Twisted Rt. Ovarian cyst

d) Appendicitis
e) endometriotic cyst

18. 26 G1P0 GA 6 wks

tranvaginal
U/S double desidual sac sign
a) Embryonic demise
b) intrauterine implantation
= Blighted ovum
c) ectopic pregnancy
d) Anembryonic pregnancy
e) implant bleeding

19.
GA 20 wk LMP

fundal height umbilicus

a) U/S
b) void

Large for date

1. 2. 3.
4. myoma 5.

6.

7. mass 8.

20.
19 nulliparous

Vaginal
bleeding. PE: BP 150/110, UA alb 2+ , UPT
+ve, LMP 16wk.
fundal height

a) Twin preg
b) Molar preg
c) Leiomyoma
d) Adnexal mass
e) Fetal macrosomia

Ans : b)
Pt.
large for date
Vg. Bleeding
PIH

Molar

pregnancy
PIH
20 wk

Twin

Hydrop or Molar
20 wk

induce
DIC vascular resistant
HT

Molar pregnancy

N/V( HCG), passing
of mole, hyperthyroid (HCG =
TSH) U/S = snow storm
theca lutein cyst

Molar pregnancy

S/C
)
Hysterectomy (

F/U bHCG, PV, CXR 1

( choriocarcinoma)

21. Term
, station 0, FHR 140,
8
Fully dilate, 1 hr.

a)
b) C/S
c) V/E
d) F/E

22.
35 GA 40 wks
3500 mg
PV

4 cm station 0 ; 3

a) C/S
b) Vaccuum
c) Oxytocin
d) Consult

23. Face presentation

a) Hydrocephalus
b) Anencephaly
c) Twins
d) DM

24. 36 G1P0A0 GA 34 wk

transverse lie

a) multiparity
b) advanced maternal age
c) placenta previa
d) transverse vaginal septum
e) oligohydramnios

25. 38 G4P3 GA 39 wks in labor with

mucous bloody show , 2 hr PTA PE: FH 4/4
>umbilicus EFW 3,900 gm
interval 5 min, duration 50 sec , station -2

, FHS 120 /min cervix 7 cm, eff

80%

a) expectant
b) drip oxytocin
c) partial breech assisting
d) complete breech delivery
e) Emergency C/S

26.
IUD
6 wk

a) Ultrasound
b) X - ray
c) UPT
d) hook

IUD

e) IUD

Ans : c)
Pt.

R/O Pregnancy

off IUD (under
ultrasound)
Off 30% ; Off
50%
off

If chief complaint =

R/O

IUD perforation by U/S + film abdomen

27.

21
25
HBsAg+ HB antibody-

a)
b) IUD
c)
d)
e)

 23 6
28.

2 2

a)

b)
c)
d)
e)

29.
51 12

a) Weight bearing exercise
b)
c) High protein diet
d) Hormonal therapy
e) Bone mass density

Ans : e)

(


)

a.

( risk

b.

vasomotor symptom
(flushing, night sweting)
psychological
symptom (,
)

hormonal therapy

d.

(menopause)

indication BMD (standard = DEXA

: dual energy X-ray absorptiometry )

Indication for BMD

Suspicion of osteoporosis (age > 65,
menopause, TAH c BSO )

Hx of pathological Fx
Drug (T4)
U/D (CKD, Thyrotox.)
F/U osteoporosis yearly

Hormonal therapy
Benefit
menopausal symptom
risk osteoporosis

Risk
DVT
CA breast (mammo yearly)
CA endometrium ?

C/I of hormonaltherapy

/
DVT
/
relative C/I
30. Ca mg
1000 mg

31. 55

6

a) oral estrogen
b) estrogen pad
c) estrogen cream vagina
d) androgen cream vagina
e) oral estrogen and progesterone

Ans : c)
case atrophic vaginitis estrogen
topical

topical


32.
32 GA 20 wk

vaginal bleeding

.. 7
20

a)

b)
c) .. 20

d) .. 7 20
e)

Ans : a)
. . 303

...

...(

)...

...(

)...

()

()

()

()

()

()

()

31. 28 G_P_ C/S

day 2 , ,
breast engorged

, lochia rubra , C/S

no oozing, PV tender on cervix
motion, tender adnexa ; Dx = ?
a) Breast abscess
b) Mastitis
c) Pelvic infection
d) TOA
e) C/S wound infection

Ans : c)
breast engorged

sign of
inflamation

a) b)
C/S wound
sign of inflamation
oozing

e)

PID
cervical motion
pain adx. tenderness PID
complication PID

U/S adnexal mass

PID
Minimum criteria
Cervical motion pain
Uterine tenderness
Adnexal tenderness

Additional criteria
Fever
Cervical mucopurulent D/C WBC in wet
smear
ESR / CRP

Mx
OPD case
Ofloxacin(200) 2x2 + Metronidazole(500) 1x2
14 days

IPD case
Regimen A : Cefoxitin 2 g IV q 6 h +
Doxycyclin 100 mg IV or PO q 12 h
Regimen B : Clindamycin 900 mg IV q 8 h +
Gentamycin loading dose 2 mg/kg
maintenance 1.5 mg/kg o.d.

Mx
Re evaluation in 72 hr
W/U other STD ex HIV, hepatitis
Tx sexual partner(s) (60 d)

C/P
TOA
Infertile
Ectopic preg.
Chronic pelvic pain


33. 21 LMP = 6 wk

+
PV :

uterine normal size, soft, no adx mass, not

tender TVS : no intrauterine sac, no mass,
Mx = ?
a) D&C
b) Serum bHCG
c) Exploratory laparotomy
d) Diagnostic laparotory
e) MTX injection

Ans : b)

DDX

Abortion

Ectopic pregnancy

definite Dx

serum bHCG if > 1,500
intrauterine sac
Diag lap gold standard for Dx ectopic
pregnancy

invasive procedure
Dx

D&C = Mx of abortion

Indication for MTX injection

Hemodynamic stable, with no signs or symptoms
of active bleeding or hemoperitoneum.
Its greatest dimension is not exceed 3.5 cm at &
no cardiac motion on US measurement
bHCG is not exceed 3,000
Have no any contraindications to the use of
methotrexate.
compliant, and able to return for follow-up

34. 28

3

swelling, tender, red labia minora 2.5
cm
Tx = ?
a) Incision Biopsy

b) Excision Biopsy
c) Marsupialization

d) I&D
e) Needle aspiration

Ans : c)
Dx = Bartholin abscess (these paired glands are approximately
0.5 cm in diameter and are found in the labia minora in the 4- and 8-oclock
positions.)

Organism = Neisseria gonorrhoeae and Chlamydia

trachomatis

Tx = Marsupialization (This procedure consists of a

wide incision of the mass followed by suturing the
inner edge of the incision to external mucosa.)
Uncomplicated abscesses in otherwise healthy
women may not require antibiotic therapy after
successful drainage.


35. GA 38 wk term

mucous bloody show, cervix dilate 3 cm.

Vx, FHR 144/min
Mx = ?
a) Go on Normal labour

b) podophyllin
NL
c) TCA
NL

d) AgNO3
NL
e) C/S

Ans : a)
Dx = vaginal candidiasis Tx = Clotrimazole Vg
tab suppo h.s. x 6 day
For recurrent candidiasis ( 4
)
Fluconazole Ketoconazole
(6 )
(Ex on HRT,

immunosuppressive drug, ATB, DM)

Condyloma acuminata

HPV 6, 11
Tx Podophyllin or TCA Once a week
Podophyllin Not for using in pregnancy
Risk of laryngeal papilloma in child
C/S doesnt lower incidence
C/S plays role in large warts that cause
bleeding or obstructed labor.

36. 30 3

EGD DU
a) Omeprazole
b) Misoprostal
c) Sucralfate
d) Ranitidine
e) Cimetidine

Ans : b) or d)
Omeprazole -> CAT C
Sucralfate & Ranitidine -> CAT B
Misoprostal or Cytotec (an E1 prostaglandin
analogue)

37. 60
9
2 V/S stable

a) F/U 6 Month

b) Colposcopy
c) Endometrium ablation

d) Endometrium sampling
e) OCP

Ans : d)
Pt. 40
AUB
F&C

R/O CA endometrium
most common cause AUB

1. Atrophic Endometrium (60-80%)
2. Endometrial hyperplasia (~15%)

3. Endometrial carcinoma (~15%)

4. Endometrial polyp (2-8%)

AUB
Organic
Preg.
Abortion, ectopic preg.

Non preg.

Myoma, Adenomyosis (hypermenorrhea)

CA endometrium, hyperplasia, polyp
PID
CA cervix (post coital bleeding)
Systemic bleedind

Functional / OC

AUB
Infant
Childhood
Adolescence & Perimenopause

Adult
Post menopause

Atrophic (R/O CA)

Organic

DUB
Estrogen withdrawal
Vaginal FB

DUB
80% Anovulation (bleed from estrogen
withdrawal or estrogen breakthrough)
Patho = proliferative endometrial
Tx
Progestrin 10 mg 10 14 d (Ex day 19 28 )
3 6 cycle
OCP 3 6 cycle

Endometrial hyperplasia
% turn to
CA

simple

complex

typical

atypical

29

Mx
Progestin 10 mg 14 day x 3 6 cycle
Atypical complex in post menopause advice hysterectomy

38. 28
3
2 wk

a)

b)
c)


d) conjugated estrogens 0.625 mg
21

Ans : e)
Pt.
OCP 3
estrogen withdrawal
Mx = advice Pt. +

estrogen Ex Premarin 1.25

mg x 7 day
Pt.



(progestrogen breakthrough)

39. 14

8

progesterone challenge test: negative

estrogen-progesterone challenge test:
negative

a) Ovarian failure
b) PCOS
c) Exercise amenorrhea
d) Ashermans syndrome

R/O
physiology

Ans : d)
Ashermans syndrome
Cause = Curettage, Uterine surgery
S/S = miscarriage, dysmenorrhea,
hypomenorrhea
Dx = HSG, hysteroscope

Mx = Sx for breaking adhesion

Amenorrhea
Uterus

Ashermans syndrome
Mullerian anormalies
Imperforated hymen
Testicular feminization

Ovary
Turners syndrome
Premature ovarian
failure

Pituitary gland
Sheehans syndrome
Prolactinoma

Hypothalamus
PCOS
Stress induced
Exercise induced

40.

webbed neck, wide nipple distance and low
hair line

a) Decrease Insulin
b) Decrease GH
c) Increase estrogen
d) Increase GnRH
e) Decrease PTH

41. 14 3

abdomen : tense cystic

mass, 1/3 > suprapubic, labia majora :

normal, Gaping labia minora with purple
tissue, PV : pelvic mass 12 cm, cystic
consistency
a) Vulva CA

b) Ovarian tumor
c) Imperforated hymen

Ans : c)

Sarcoid botryoides = a
malignant tumor of
striated muscle that
resembles a bunch of
grapes and occurs
especially in the
urogenital tract of young
children

42. 23 G0 P0

3-4 /1

u/s

( < 1 cm) 15-20
2
1

a)
adrenal hyperplasia
b)

c)

d)

e)

Ans : b)

IGF
theca cell

insulin
FSH
receptor
LH

testoserone

estrone

Polycystic
Ovarian

risk
CA
endometruim

PCOS
Treatment

OCP LH
MPA LH

androgen
Metformin

insulin
Clomiphene citrate

43. pt. dysmenorrhea

cystic mass at adnexa with

multiple nodule in cul-de-sac Dx = ?
endometriosis

44. pt. 40 G1P0 GA 16 wk

amniocentesis increased AFP risk
?
Neural tube defect
45.
?
44. risk

folate

The most severe of NTD is

anencephaly

Dysmenorrhea
Primary
Ov. Cycle first 6 months to 2 years
First day severe, no more than 48 hrs
Complex symptom (mood change, headache, N/V,
breast tenderness)
Family history

Secondary
Endometriosis
Adenomyosis
Myoma uteri

Endometriosis
Triads = dysmenorrhea, dyspareunia and
infertility
Tender nodule at cul-de-sac and us ligament,
endometrioma as palpable adx mass
Gold standard = diag lap.
Tx = NSAIDs, DMPA, GnRH agonist, TAH c
BSO or SO (pain Mx)
= Sx for lysis adhesion, IUI, IVF, ICSI
(infertility Mx)

46.
30
6

Uterus size 12 wk U/S intramural

myoma

a)

F/U 3
b)

c)

d)

e)

Ans : b)
Uterus 12 wks size
indication for Sx
Indication for Sx

Subserous


Cant R/O Ovarian tumor

Pressure effect

= ...
+

+ 1
yr

Myoma vs Adenomyosis
Myoma
35 50 yrs
Irregular surface, firm
consistency
Size may be > 12 wks
Dysmenorrhea
Asso. with infertility
U/S

Adenomyosis
40 50 yrs
Globular
shape,smooth surface
Size < 12 wks
Dysmenorrhea
Have usually had
children
U/S

Hypermenorrhea, pressure effect (Ex

Figure 5 : Adenomyosis. Longitudinal sonogram

demonstrating numerous hypoechoic, 'venetian blind' striations
in the posterior myometrium. While these striations may be
seen in myomatous disease, the absence of a focal myoma
and the presence of other features make this more
characteristic of adenomyosis.

Figure 3 : Appearance of uterine fibroids. Longitudinal

sonogram in a patient with multiple uterine fibroids. The
normal morphology of the uterus is markedly distorted. The
endometrium could not be identified. An anterior subserosal
fibroid (arrow) is projecting into the urinary bladder.

47. A 41 year-old woman comes to the

physician because of increasing menses
over the past 3 years. Her menses occur at
regular intervals and now last 12 days.
Pelvic examination shows a firm irregular
pelvic mass
For each patient with pelvic mass. Select the
most likely diagnosis
a) Leiomyoma uteri
b) Dermoid cyst
c) Adenomyosis
d) Endometrioma
e) Follicular cyst

48. 45
3
hypermenorrhea

PV : uterus 8 wk size globular
shape
a) adenomyosis
b) endometriosis
c) endometrial polyp
d) myoma uteri

49. A 26 year-old woman comes to the physician for

a routine health maintainance examination. Pelvic
examination shows a 6 cm cystic adnexal mass.
An x-ray film of the abdomen shows
calcifications. For each patient with pelvic mass,
select the most likely diagnosis
a) Cystadenocarcinoma
b) Dermoid cyst
c) Cytstadenoma
d) Endometrioma
e) Follicular cyst

Ans : b)
Follicular cyst =
+

follicle


5 cm,
U/S = hypoechoic without internal content, Tx =
OCP + F/U 1 cycle or F/U 3 cycle
Theca lutein cyst = ... (Back)
Dermoid cyst or Cystic teratomas =

uterus
Cystadenoma = 5 20 cm, content = mucinous or

serous

50. 18 U/S mass Rt. Adnexal

hypoecoic without internal content
a) functional ovarion cyst
b) PCOS
51. GA 10 wk
VDRL 1:8

a) VDRL

b) TPHA

c)

Penicillin
d)

Ans : b)

Preg with SY
VDRL +ve
TPHA or FTA-ABS +ve

Tx = Penicillin + U/S check

fetal anolmalies at 20 wk


Preg with
Hep B
HBeAg +ve
HBsAg +ve
HBeAg -ve

Advice Ig

HBV at
0,1,6,12
Month +- Ig
W/U if HBsAg + Anti-HBsAg ve =
Vaccination


Preg.
with HIV

ELISA +ve

Confirm
ELISA or Western

blot +ve

CD4
12 wk
> 250 ARV
28 Wk 7-10

< 250 = consult

med start ARV
14 wk

52. 24 GA 10 wk
HIV

HIV

advice

a)
ve 1

b)
ve

c)
+ve

d)
+ve
CD4+

e)
+ve termination

53.

HIV Pregnancy

a)
HIV

b) HIV RNA
perinatal

transmission


c) CD4

d)

HIV
e) antibody

HIV

HIV

Ans : b)
c) CD4

d)

prognosis

Being pregnant may cause a drop in your CD4 count.. This drop is only
temporary. Your CD4 count will generally return to your pre-pregnancy
level soon after the baby is born.

e) anti-HIV
protective antibody
a)
HIV

( trimester 3

b) HIV RNA

DNA
1
HIV

Anti-HIV
18

false +ve anti-HIV

54. Pap smear ASCUS

?
Suggest inflammation
F/U Pap smear 6
Months

Abnormal Pap smear

Suggest inflammation
AS-CUS
F/U Pap smear 6
Months
Others : AS-H, LSIL, HSIL
PV
or Invasive SCC
Not seen lesion

Seen lesion

Colposcopy or Schillers test

Punch Bx

Abnormal Pap smear

Colposcopy or Schillers test
satisfactory
CIN

Tx

MIC

Unsatisfactory
Invasive
SCC

Other

Clinical
staging

Diag.
Conization

55. GA 35 wk GDM
insulin

100-110 mg% 2 hr
130-150 mg%

a) phenobarbital
b) pethidine
c) nifedipine
d) salbutamol
e) magnesium sulfate

Ans : c)
inhibit



B2 agonist
Brycanyl (Terbutaline),
Ventolin (Salbutamol) martenal
tachycardia (

U/D heart
hyperthyroid), Hyperglycemia (

DM), HypoK, arrythmia, pulmonary edema

CCB
Nefidipine (Adalat)
vasodilate + BP drop = Headache, dizzy,
flushing (
monitor BP FHR

56. C/S 39 C

fundal height 2/4 tender

PV : os open 1 cm, foul smell blood
discharge, tender uterus, parametrium
tender both side

ATB
a) genta + cloxa
b) ampi + genta + metro
c) genta + vanco
d) genta + clarithro
e) cef-3 + high dose penicillin

57.
1
33 GA 36 wk

hr 30 min Cx full dilate,

mentoposterior

a) manual rotation
b) forcep rotation
c) C/S
d) F/E
e) V/E

+5 wk EFW 3000 g
58.
GA
41

PV : os dilate 1 FB, no effacement,

Uterus midposition

a)

b)
c) fetal surveillance
d) F/U 1 wk
e) amniotomy

Ans : c)

59. 40 PAP ASCUS

a) cryotherapy
b)

c) HPV vaccine
d) Pap 6
e) HPV

Pap 6
HPV
Colposcopy

60. 30 G4P0A3 GA 10 wk

4,5 6

a) chromosome study
b) progesterone
c) AFP
d) cervix 14 wk
e) U/S

Ans : d)

(3 )

cervical incompetent

midtrimester
(

suggest =

= cervical cerclage (
) GA 12 wk

=
, Corpus luteal
insufficiency (Tx = Progestrogen

menses 20 wk ) 1st

61. 41 U/D
GDM
BP

140-150/80-90

mmHg

10

a) DM
b) HT
c)
d)

e)

62. G1 GA 41 wk
I 20 min, D

30-40 sec
NST :
late

deceleration, fetal heart baseline 145/min

PV : 2 cm, 50%, -2, MR and thick
meconium
manage

a) load IV
b) amnioinfusion
c) C/S
d) close observe
e) change maternal position

Ans : c)

late deceleration

Thick mec.
fetal
distress UPI GA
41 wks

IUR (

, IV, O2, off synto(

))

Observe 30

IUR 2 choice
contraction



assume

63. 28 10

38 C

manage
a)

b)

c) ATB S.aureus
d) drain
e)

Ans : c)
Dx = mastitis sign of inflammation
(
form abscess) > 24 hr

Breast engorged
ATB Tx of choice
Cloxa, Dicloxa or nafcillin cover staph

, breastfeeding or breast pumping

Definite indication breastfeeding

case breast abscess

64.
31 Preg. 32 wks.
ANC
1 wks.

ANC BP = 130/90
mmHg. U/A Protine 1+ 1+

ANC BP= 160/110 mmHg.

U/A Protine 3+
(compre. 2)
a) MgSO4
b) Pethedine
c) Oxytocin
d) Diazepam
e)

65.
12

VDRL: 1:64

a) syphilis 1

b) syphilis 1

c) syphilis
2

d) syphilis 2

e) latent

Ans : d)

66.
20

abdomen tenderness

guarding ,

rebound tenderness positive

a) Acute appendicitis
b) Acute enteritis
c) PID
d) CA ovary
e) Myoma uteri

67. 65

Hormone

investigate

a) Laparoscope
b) FSH , LH level
c) Fractional curettage
d) CA-125
e) Ultrasound

68. Pt.

strawberry cervix
a)
iodine

b)

metronidazole

c) metro

d)

metro metro

e) metro

69. Pt. 21 yr. GA 35 wk. G1P0

BP 160/100 ,UA protein 1+

,LFT

a) MgSo4
b)
c) bed rest
d)


e) C/S

70. GA 35 wk PROM 4 hr. Cx 5 cm. Eff 80%

station 0
a) tocolytics agent
b) forceps
c) V/E
d) C/S
e) Go on labor

Preterm labor
4 times in 20 min or 8 times in 1 hr +
cervical dilate 1 cm or efface > 80 %
Ix = U/S, monitor, W/U infection (CBC, UA,
Cervical C/S, Wet mount and GBS C/S )
Tx = Bed rest, Hydration, Tx infecton,
Dexa (<34 wk), Tocolytic drug (C/I in
active phase cervical dilate 4 cm)

71.

35

40 1 cm ,
effectment 50 %

a)
b) tocolytic
c) cesarean section
d) steroid
e) absolute rest

 24

72.

cervix

dilate 2 cm effecement 80% station 0

2 .

cervix

a) observe
b) IV fluid
c) Morphine
d) Oxytocin
e) C/S

73.
20

a)

b)
c)

d)

74. . 18 GA 12 wk

4-6 pads

PE : T 39 C RR 20 / min PR
100 /min BP 100/70 mm.Hg , tender at
lower abdomen PV : foul smell, bloody
dischage , OS 1 FB ,uterine enlarge 1012 wk size, markly tenderness, adnexa :
no palpable mass

a) penicillin + gentamicin + metronidazole
b) misoprostal intravagina
c) oxytocin iv drip
d) immidate uterine curettage
e) hysterectomy

Ans : a)
Dx = Septic abortion (

+ + sign

Ex Foul smell bloody D/C,

Uterine tenderness

Complication = , , Septic
shock, toxin
bacteria Gram ve, Gas gangrene

clostridium welchii
Mx

1. Admit

Mx
3. ATB (Cover Gram +ve, -ve anaerobe - Ampli + Genta + Metro )
4.

GA < 12 wk D&C

GA 12 16 wk E&C

GA > 16 wk Oxytocin 20 u + 5% DN/2 1000

cc iv drip

5. Counseling