OB-GYN

Obstetrics

1. Pregnancy and Prenatal care 63%

a. Pregnancy products of conception implanted somewhere, terminated by abortion
i. Diagnosis
1. In Pt with regular menstrual cycles and is sexually active, delay of
menses is suggestive of pregnancy
2. OTC urine pregnancy tests have high sensitivity
a. Detect hCG, peaks at 100k at 10 weeks, drops and levels out at
20-30k in 3rd trimester
3. Confirmed on transvaginal US, gestational sac visible at 5 weeks, fetal
heart motion at 6 weeks
ii. Terms
1. Aging
a. 0-10 weeks GA Embryo
b. 10 weeks to delivery fetus
c. Delivery to 1 year infant
2. Trimesters
a. 1st 0-12/14
b. 2nd 12/14-24/28
c. 3rd 24/28-birth
3. Delivery
a. 0-24 weeks previable
b. 24-37 weeks preterm
c. 38-42 weeks term
d. 42+ postterm
4. Others
a. Gravidity number of times pregnant
b. Parity number of pregnancies that lead to birth
c. Grand multip 5+ parity
d. Gestational age age since beginning of last menstrual period
e. Developmental age age since fertilization
i. Usually two weeks less than gestational, as fertilization
typically happens 2 weeks after LMP
ii. Important because need to decide whether or not to
resuscitate at 23/24 weeks (edge of viability) or whether
to induce delivery.
f. Nagele rule for estimating delivery: subtract 3 months and add 7
days from day of LMP.
iii. Physiology
1. CO increases 30-50%, SV, then increase in HR. SBP decreases 2/2
progesterone smooth muscle relaxation SBP by 5-10 and DBP
10-15. Both hit nadir at 24 weeks and returns to normal by end of 3 rd
trimester
 2. Tidal volume, decreased expiratory reserve. PO2 rises, PCO2 drops to
30mmHg. Facilitates oxygen delivery and CO2 removal from fetus.
a. Think increased minute ventilation. Results in respiratory
alkalosis
b. Physiologic dyspnea of pregnancy seen in 75% of pregnant
patients
3. Morning sickness caused by elevation of estrogen/progesterone/hCG or
hypoglycemia. Hyperemesis gravidarum is morning sickness
accompanied by weight loss.
4. Nutrition
a. Weight gain
i. <19.8 28-40 pounds
ii. >29 11-20 pounds
b. Macros
i. 70g of protein
5. GFR increases, leads to ureteral dilation
a. Left cushioned by sigmoid
b. Right compressed by dextroversion of the uterus and by the
dilation of the right ovarian vein
6. Progesterone causes smooth muscle relaxation
b. Prenatal
i. Gestational diabetes
1. 1 hr cutoff 135/140
2. GTT Fasting 95 mg/dL, 1 hr 180mg/dL, 2 hr 155 mg/dL, 3 hr 140mg/dL
ii. Folate supplementation
1. Start if the woman is even thinking about pregnancy 400mcg dose to
supplement diet
a. Lowers homocysteine levels
c. Routine Problems
i. Back Pain
ii. Constipation
iii. Contractions
iv. Dehydration
1. May lead to contractions due to cross-reaction of vasopressin with
oxytocin.
v. Edema
vi. GERD
vii. Hemorrhoids
viii. Pica
ix. Round Ligament Pain
x. Urinary Frequency
xi. Varicose Veins
d. Prenatal Assessment of Fetus
i. US
1. Malformations at 18-20 weeks
2. Cardiac abnormalities in pregestational diabetics
ii. Antenatal testing of fetal well-being
 1. Nonstress test at 32-34 weeks in high risk, 40-41 in undelivered
2. oxytocin challenge if FHT worrisome
iii. Fetal Blood sampling
1.
iv. Fetal Lung Maturity
1. L/S >2
e. Radiation exposure
i. Limit to 5 rads
f. Vaccinations
i. MMR and varicella vaccinations contraindicated during and within 4 weeks of
pregnancy
2. Early Pregnancy and Complications 63%
a. Ectopic Pregnancy
i. IUP should be seen with B-hCG between 1500-2000, and fetal heart rate should
be seen 5k+
ii. Treat with MTX if ectopic pregnancy is <4cm, fetal B-hCG <5k, and no heart beat
1. Assess baseline transaminase/creatinine, serial B-hCG, and
intramuscular methotrexate
b. Spontaneous Abortion
c. First Trimester Abortion
i. DDx for 1st trimester bleeding
1. SAB, extrusion of molar pregnancy, Ectopic, postcoital, Vaginal/cervical
lesions, nonpregnancy causes
ii. Tx D&C, prostaglandins
d. Second Trimester Abortion
i. Often caused by anatomic abnormalities, trauma, systemic dz, infxn
ii. Tx D&E, prostaglandins, oxytocic agents
e. Incompetent Cervix
f. Recurrent Pregnancy Loss
3. Prenatal screening, diagnosis, and treatment 50%
a. Screening patients for genetic diseases
b. Chromosomal abnormalities
i. Trisomy 21 Down syndrome
1. Signs down-sloping palpebral fissures, epicanthal folds, simian crease,
excess skin in back of neck, flattened nasolabial/malar region, and
sandle-gap toes
2. Cell-free DNA test has the highest detection rate
a. Can be done at 9 weeks onwards
c. Sex chromosomal abnormalities
i. Fragile X
1. Most common inherited cause of mental retardation
d. Fetal Congenital anomalies
i. AFP
1. Associated with neural tube defects, abdominal wall defects, fetal death,
and twin gestation
ii. Omphalocele
1. Detected on US
e. Prenatal screening
i. African americans should be screened for sickle cell dz with hgb electrophoresis
ii. Most common genetic disease in non-hispanic whites is gauchers dz
iii. AFP
1. Most common cause of elevated AFP is underestimation of gestational
age
a. US dates the fetus and assesses for structural/neural tube
deformities
f. Noninvasive testing
i. Chorionic villous sampling
1. Samples the mitotically active villi of the placenta
2. Can detect karyotype and CF
3. Done between weeks 7-12
a. Higher complication rate than amniocentesis, more cells
removed (1% miscarriage)
b. Associated with preterm labor, pprom, previable delivery of
fetus, limb abnormalities
ii. Amniocentesis
1. Best test to assess for aneuploidy after routine screening
4. Normal Labor and Delivery 94%
a. Labor and Delivery
i. Episiotomy
1. Indicated to hasten delivery and avoid shoulder dystocia
2. Not indicated to prevent perineal trauma, as episiotomy has been
associated with 3rd and 4th degree lacerations
b. Normal Labor
i. Progresses at 1cm/hr in nulliparous pt
ii. Cesarean Delivery
1. Elective cesarean deliveries should be performed at 39 weeks
2. Rates of cesareans are going up because fewer physicians are
performing vaginal birth after cesarean
iii. FHRM
1. If fetal heart rate cant be determined using external methods, scalp
electrodes can be placed
2. Dont need to check it if baby is on the way; get it out.
iv. Bleeding
1. Small amounts of bleeding can be caused by tears in the highly vascular
cervix as it dilates. This is called bloody show
c. Post
i. APGAR
1. Appearance, pulse, grimace, activity, respirations
a. 2 points each
5. Antepartum Hemorrhage 50%
a. Placenta Previa
i. Persistent previa with anterior placenta and prior c-section suggests placenta
accrete
1. C-sections are a large risk factor for placenta accreta
ii. Complete placenta previa necessitates pelvic rest, not bed rest
1. If the pt goes into labor, tocolyze so you have enough time to administer
steroids
iii. Sinusoidal patter on FHT suggests fetal anemia
b. Placental abruption
i. Risk factors- htn and preeclampsia
ii. Associated with tachysystole on tocometer and fetal anemia
1. Fetal anemia associated with tachycardia and sinusoidal FHT
c. Uterine Rupture
i. C-sections increase risk, but still <5% even with 4 c-sections
d. Fetal Vessel Rupture
e. Nonobstetric causes
f. Other
i. Smoking
1. Increases risk of abruption, previa, preeclampsia, growth restriction,
infection
6. Complications of Labor and Delivery 75%
a. Preterm Labor
i. Acute pulmonary edema in pregnancy can be a result of tocolytic use, cardiac
disease, fluid overload, and pre-eclampsia
b. Tocolysis
c. Preterm and PROM
d. Obstruction/Malpresentation/Malposition
i. Cord Prolapse
1. Elevate the fetuss head to prevent compression of cord, and then call
for a cesarean delivery
ii. Breech presentation
1. Polyhydramnios, uterine structural anomalies, prematurity, and placenta
previa are associated with breech presentation
iii. Prolonged latent phase of labor
1. >20hrs in nulliparous, >14 in multiparous
iv. Arrest of station in active phase of labor
1. >4 hours, amniotomy if water hasnt broken, then supplement
contractions with oxytocin
e. Obstetric Emergencies
i. Eclampsia
1. Start by giving mag sulfate, then control BP
ii. On placement of IUPC, if there is a large rush of blood/fluid that comes out, then
theres a high likelihood of placental separation or uterine perforation
1. In these cases, withdraw catheter, assure fetal wellbeing, and then
replace if fetus is ok
f. FHTs
i. VEAL CHOP
1. Variable compression
2. Early head compression
3. Late uteroplacental insufficiency
g. Other
i. Endometritis associated with c-sections, prolonged delivery, prolonged rupture
of membranes, multiple vaginal exams, removal of placenta manually
1. Associated with mixed aerobic/anaerobic flora
7. Fetal Complications of Pregnancy 56%
a. Disorders of Fetal Growth
i. Supplement folate to avoid NTD
1. .6mg in non-high risk patients
2. 4mg in pt with prior pregnancy with NTD
ii. Radiation exposure between 8-15 weeks can lead to microcephaly and
intellectual disability
b. Disorders of amniotic fluid
c. Rh incompatibility and alloimmunization
i. Risk of alloimmunization is 2% antepartum, 7% during delivery, and 7% with
subsequent pregnancy
ii. Fetal anemia as a result of red cell alloimmunization can be tested for using
dopplers to measure middle cerebral artery peak systolic velocity
iii. Hydrops is a severe complication
1. Fluid will collect as ascites, pericardial or pleural effusion, and scalp
edema
iv. Give RhoGAM
1. 300mcg neutralizes 30cc of fetal blood
2. When to give If father is not RH-negative,
a. At 28 weeks
b. Within 72 hrs of delivering Rh-Positive baby
c. Following SAB
d. Following antepartum hemorrhage
e. Following amniocentesis or CVS
d. Fetal demise
i. Immune hydrops
1. Severe disease associated with Kell and Duffy ab
a. Rising incidence because RhoGAM keeping Rh factor in check
2. Lewis Ab is IgM and doesnt cross the placenta
a. Associated with mild hemolysis
3. Tx
a. If anemia is particularly severe, were able to transfuse blood
into fetus through the umbilical vein. Intraperitoneal if this fails
i. If we arent able to transfuse, maternal plasmapheresis
is next option
ii. Stillbirth
1. Factor V leiden common cause of stillbirth
e. Post-term pregnancy
f. Multiple gestations
i. AFP will be almost double expected
ii. US markers
1. Dividing membrane >2mm, twin peak, different genders, and separate
placentas
iii. Twin infant death rate is 5x that of singleton pregnancies
iv. Rate of congenital abnormalities is increased as well
v. Presentation
1. Ideal scenario is both vertex proceed vaginally
 2. If first twin in in breech position, best mode of delivery is c-section
3. If second twin is in breech, you have the option of trying external
cephalic maneuvers, but chances are you will do c-section
vi. Twin-twin transfusion syndrome
1. One twin will be plethoric, polycythemic, fluid overloaded with
cardiomegaly, glomerulotubular hypertrophy, edema, and ascites
2. The other twin will be small, anemic, with oligohydramnios and IUGR.
8. Hypertension and Pregnancy -63%
a. Gestational HTN
b. Preeclampsia
i. Mild
1. Diagnostic Criteria
a. SBP >140 or DBP >90
b. >300mg/24 hr urine, 1+ or 2+ on urine dipstick
ii. Severe
1. Diagnostic Criteria any combination
a. Neuro
i. Headache, Visual changes
b. CV
i. SBP >160, DBP >110 on two occasions at least 6 hrs
apart CI for expectant mgmt if on 2 anti-htn
c. Pulm
i. Pulmonary edema
d. Renal
i. Acute renal failure with rising creatinine
ii. Urine output <500mL/24 hour CI for Expectant Mgmt
iii. Urine protein >5g/24 hr urine, or 3+ on dipstick
e. GI
i. RUQ pain
ii. ALT/AST x2 normal CI to expectant mgmt
f. Heme
i. Hemolytic anemia
ii. Thrombocytopenia <100k CI for expectant mgmt
iii. DIC
g. Fetal
i. IUGR, abnormal umbilical dopplers
iii. Tx
1. If at term or confirmed fetal lung maturity, then definitive treatment is
delivery
2. Mg
a. Magnesium toxicity
i. Muscle weakness, loss of DTR, nausea, and respiratory
depression
1. If these signs are seen, discontinue the Mg and
give calcium gluconate to protect the heart
3. Control BP if severe
a. Labetalol, hydralazine, nifedipine
b. Bring DBP down to 90-100 to reduce risk of maternal stroke or
abruption without compromising uterine perfusion
iv. Risk factors
1. Prior history of preeclampsia, multiple gestational pregnancy, parity
c. Eclampsia
i. Preeclampsia with seizures
ii. Tx
 1. Control BP with hydralazine, labetalol, nifedipine
2. Decrease hyperreflexivity and raise seizure threshold using 12-24 hours
of MgSO4
3. Delivery
a. Should only be done once the eclampsia has been controlled
d. Chronic HTN
9. Diabetes during pregnancy -86%
a. Gestational diabetes mellitus
i. Testing cutoffs
1. 1 hr cutoff 135 or 140
2. GTT Fasting 95 mg/dL, 1 hr 180mg/dL, 2 hr 155 mg/dL, 3 hr 140mg/dL
ii. Risks
1. Elevated A1c in pregestational period and during organogenesis puts
fetus at risk for CNS malformation (NTD) and cardiac anomalies
2. 3 effects to remember polyhydramnios, preeclampsia, and fetal
macrosomia
iii. Babies
1. Will suffer from macrosomia, hypoglycemia, polycythemia,
hyperbilirubinemia, hypocalcemia, and respiratory distress
b. Pregestational diabetes
i. T1DM not associated with macrosomia babies more likely to be too small
10. ID in pregnancy 60%
a. UTI
b. Bacterial Vaginosis
c. GBS
i. Rectovaginal swab taken at 35-37 weeks, unless the pt has history of GBS
bacteriuria or neonatal GBS
ii. Tx
1. Treat all preterm
2. 37+ weeks, treat depending on risk factors like PPROM
d. Chorioamnionitis
i. Associated with neonatal sepsis
1. Baby will appear lethargic, pale, with high temp. FHT will show elevated
HR with lower variability
e. Infxns affecting fetus
i. HIV
1. Give AZT on delivery
2. HIV testing at 24hrs of life
11. Other Medical complications of pregnancy 73%
a. Hyperemesis gravidarum
b. Sz disorders
c. Maternal cardiac dz
d. Maternal renal dz
e. Coag disorders
f. Maternal thyroid dz
g. SLE
h. Substance abuse
i. Medicines
i. ACEi, paroxetine, warfarin contraindated
ii. Ibuprofen contraindicated after 32 weeks since it can cause patent ductus
arteriosus
iii. Valproic acid causes neural tube defects
1. US at 16-18 weeks recommended
12. Postpartum Care and Complications 75%
a. Routine Postpartum Care
i. Breast feed exclusively for 6 months
1. Physiology
a. estrogen + progesterone after delivery removes inhibition
of alpha-lactalbumin production by progesterone prolactin
stimulate alpha-lactalbumin production in RER alpha-
lactalbumin increases lactose synthesis
b. Prolactin stimulates milk production, oxytocin promotes milk
ejection
i. Suckling better than pumping for oxytocin release
2. Associated with lower rates of ovarian cancer
3. Contraindications HIV, Hep B, TB, Herpetic breast lesion, galactosemia
4. Irritation associated with poor positioning of infant optimal is belly-to-
belly
b. Postpartum Complications
i. Pregnancy is hypercoaguable state, returns to normal 6-8 weeks
ii. Postpartum hemorrhage is 500mL for vaginal delivery, 1L for C-section
1. Most common cause is uterine atony
iii. Mastitis often caused by staph/strep, treated with dicloxacillin
1. HOWEVER, isolated pain to the nipples associated with candida
infection.
a. Tx with topical antifungal, antibiotic for coinfection with staph,
and steroids to speed recovery.
b. Cotreat mother and baby. topical nystatin oral fluconazole for
baby
iv. Meconium aspiration syndrome
1. Amniotic fluid can be stained by meconium
2. Only indication for intervention is intubation with sub-epiglottic suction
in neonates who are respiratorily depressed
a. Suction at the perineum has been associated with vocal cord
trauma
v. Psych
1. Postpartum blues resolves in 2 weeks
2. Postpartum depression often associated with ambivalence towards the
newborn
 13. Benign Disorders of the lower genital tract 77%
a. Congenital anomalies of the vulva and vagina
b. Benign epithelial disorders of the vulva and vagina
c. Benign solid tumors of the vulva and vagina
d. Benign cervical lesions

V1

1. Ex
2. A
3. Cx
4. Ex

V2

1. E
2. C
3. C

V3

1. D
2. D
3. E

V4

1. C
2. E
3. D
 14. Benign disorders of the Upper Genital Tract 73%
a. Congenital Mullerian anomalies
b. Uterine Leiomyoma
c. Endometrial polyps
d. Ovarian cysts

V1

1. C
2. D
3. Ax
4. A

V2

1. C
2. E
3. A
4. B

V3

1. Dx
2. B
3. Dx
4. D

V4

1. B
2. D
3. A x
 15. Endometriosis and Adenomyosis 75%
a. Endometriosis
b. Adenomyosis

V1

1. E x
2. D
3. E

V2

1. D x
2. A x
3. B

V3

1. C
2. D
3. B

V4

1. E
2. E
3. D
16. Infections of the Lower Female Reproductive Tract -75%
a. General
i. When a patient presents with STIs, assume coinfection and test accordingly
b. Urinary Tract Infections
c. The External anogenital region
i. Herpes
1. Dx associated with multinucleated giant cells and inflammation
a. Virus can be isolated from primary and recurrent infections,
though culture must be taken early in the course. Cultures
specific but not sensitive; have a 10-20% false negative rate
d. Ulcerated lesions
i. Syphilis
1. Non-specific treponemal tests VDRL and RPR
2. Specific treponemal tests FTA-ABS and TPPA
e. Nonulcerative lesions
f. Vaginal Infections
i. Trichomoniasis
1. Yellow-green discharge and associated with strawberry cervix
g. Infections of the cervix
17. Upper Female Reproductive Tract and Systemic Infections - 87.5%
a. The upper female reproductive tract
i. PID
1. any combination of endometritis, salpingitis, tubo-ovarian abscess, and
pelvic peritonitis
2. caused primarily by N. gonorrhoeae and C. trachomatis
3. Treated with cefoxitin or cefotetan + doxy
a. Low threshold for treatment as infertility is a complication
 18. Pelvic Organ Prolapse -89%
a. Pelvic Organ Prolapse

V1

1. A
2. D
3. C

V2

4. A
5. B

V3

6. E
7. D

V4

8. B x
9. D
 19. Urinary Incontinence 86.6%
a. Urinary incontinence
b. Stress Incontinence
c. Urgency incontinence
d. Overflow Incontinence
e. Bypass Incontinence
f. Functional Incontinence

V1

1. C
2. A
3. B
4. D

V2

1. C
2. D
3. C

V3

1. Ex
2. C
3. Dx
4. C

V4

1. A
2. C
3. C
4. C
20. Puberty, the Menstrual Cycle, and Menopause - 83%
a. Puberty
b. The menstrual cycle
c. Perimenopause
d. Menopause and postmenopause
i. Osteoporosis
1. Happens naturally after the age of 50, as bone resorption outpaces bone
deposition
2. Biggest risk factor for osteoporosis is positive family history
 21. Amenorrhea -62.5%
a. Primary Amenorrhea
b. Secondary Amenorrhea

V1.

1. B
2. C
3. Cx
4. Dx

V2

1. C
2. A
3. A x

V3

1. C
2. Dx
3. Bx
4. Cx

V4

1. D
2. B
3. C
4. A
5. B
 22. Abnormalities of the Menstrual Cycle -66%
a. Dysmenorrhea
b. Premenstrual Syndrome and Premenstrual Dysphoric Disorder
c. Abnormal Uterine Bleeding
d. Dysfunctional Uterine Bleeding
e. Postmenopausal bleeding

V1

1. C
2. E x
3. C

V2

1. A
2. B
3. E

V3

1. C
2. E x
3. D x

V4

1. C x
2. A
3. E x
 23. Hirsutism and Virilism 81.25%
a. Normal Androgen Synthesis
b. Adrenal Disorders
c. Functional Ovarian Disorders
d. Drugs and Exogenous hormones

V1

1. A
2. B
3. C
4. C

V2

1. D
2. A
3. E
4. D
5. E

V3

1. E x
2. C
3. A x

V4

1. A
2. B
3. D
4. Ax
 24. Contraception and sterilization 83%
a. General
i. The most effective contraception methods, with pregnancy rates <1%, include
depo provera, sterilization (male and female), and long acting reversible
contraception such as IUD, nexplanon
b. Natural Methods
c. Barrier Methods and Spermicides
d. Intrauterine devices
e. Hormonal Contraceptive methods
f. Emergency Contraception
g. Surgical Sterilization

V1

1. E
2. C
3. E

V2

1. A
2. D
3. C

V3

1. D
2. A
3. E

V4

1. E
2. E x
3. A x
25. Elective Termination of Pregnancy - 87%
a. First Trimester Options
b. Second Trimester Options
 26. Infertility and Assisted Reproductive Techniques 100%
a. Female Factor Infertility
b. Male Factor Infertility
c. Unexplained Infertility
d. Assisted Reproductive Technologies

V1

1. B
2. D
3. C

V2

1. C
2. B
3. E
 27. Neoplastic Diseases of the Vulva and Vagina -66%
a. Preinvasive neoplastic disease of the vulva
b. Cancer of the vulva
c. Preinvasive neoplastic disease of the vagina
d. Cancer of the Vagina

V1

1. E
2. A x
3. C

V2

1. D x
2. A
3. C

V3

1. E
2. D
3. B

V4

1. A x
2. A x
3. C
28. Cervical Neoplasia and Cervical Cancer 64%
a. Cervical Intraepithelial Neoplasia
i. Abnormal Pap smear management
1. Normal pap, high risk HPV positive repeat both in 1 year, or screen for
HPV 16/18. If either is positive, then go to colposcopy
2. ASCUS
a. high risk HPV negative or undetermined continue regular
screening
b. high risk HPV positive colposcopy with cervical biopsies
3. ASC-H colposcopy with biopsies
4. LSIL colposcopy with biopsies
5. HSIL colposcopy with biopsies
6. SCC colposcopy with biopsies, HPV screen, cold knife conization
7. AGC colposcopy with biopsies, EMB
ii. Cervical intraepithelial neoplasia management
1. CIN I pap smear q6mo x 1y OR HPV screen in 1 y
a. If persistent x2y, LEEP
2. CIN II LEEP
a. If young, pap and colpo q6mo x 2y
3. CIN III - LEEP
b. Cervical Cancer
 29. Endometrial Cancer 63.6%
a. Pathogenesis
b. Epidemiology
c. Risk Factors
d. Clinical Manifestations
e. Diagnostic Evaluation
f. Treatment
g. Follow up

V1

1. Bx
2. D
3. E
4. C

V2

1. C x
2. C
3. D x

V3

1. A x
2. A

V4

1. D
2. A
 30. Ovarian and Fallopian Tube Tumors 75%
a. Tumors of the Ovaries
b. Epithelial Tumors
c. Germ Cell Tumors
d. Sex Cord-Stromal Tumors
e. Cancer of the Fallopian Tubes

V1

1. D x
2. C x
3. A

V2

1. E
2. C
3. D

V3

1. A
2. C
3. C x

V4

1. D
2. C
3. E
31. Gestational Trophoblastic Disease 77%
a. Benign Gestational Trophoblastic Disease
b. Complete Molar pregnancy
i. Do CXR as first step once molar pregnancy has been confirmed, as lungs are
most common site of metastatic disease
c. Partial Molar Pregnancy
d. Malignant Gestational trophoblastic disease
e. Persistent/Invasive moles
f. Choriocarcinoma
g. Placental site trophoblastic tumors
 32. Benign Breast Disease and Breast Cancer 83%
a. Anatomy
b. Physiology
c. Evaluation of the Breast
d. Benign Breast Disease

V1.

1. A
2. A
3. B x

V2

1. B
2. C
3. C

V3

1. D
2. E
3. B

V4

1. D x
2. A
3. D