In the Name of God

OBS &GYN EXAM QUESTIONS, CASES AND NOTES

BY:

Mitra Ahmad Soltani References:

1-Williams Obstetrics / 22nd Edition/ MC. Graw Hill/ 2005 2-Novaks Gynecology/ 13 th Edition/ Williams and Wilkins/ 2002 3-Clinical Gynecology Endocrinology and Infertility/ 7 th Edition / Williams & Wilkins / 2005 4-TE Lindes (Operative Gynecology) 9 th Edition / Williams and Wilkins / 2003 5-Iranian Council for Graduate Medical. Education. Promotion and board Exam questions.(2000-2007)

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Fetal Monitoring

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1- For a patient who has labor pain, an abnormal NST mandates an int monitoring of FHR. Supraventricular arrhythmia is detected. The fetus looks healthy by ultrasonography. AF is clear. What step should be taken?

A- fetal echocardiography B- C/S C- Conservative management D-amiodarone

Ans:c
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2-In the second stage of labor ,you notice a persistent fetal heart rate bradycardia of 110 bpm. What is your management?

A- left lateral position, nasal oxygen, 1000 cc serum, fetal monitoring B- detecting fetal blood PH C-after 40 min intervention is needed D- It is a normal event in this stage . No further step is needed. Ans:D
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3-BPP of a 34-week pregnancy is 4. What step should be taken?

A-L/S should be determined . If it is below 2, the BPP should be repeated B-immediate pregnancy termination C-BPP should be repeated if it is below 6 , pregnancy termination D- BPP should be repeated 48 hours later and management is designed according to that score Ans:C
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Points to remember
NST: Favorable: Increase15 bpm for 15 seconds within 20 min of beginning the test (before 32 wks of GA we consider 10bpm lasting 10 seconds) BPP: Pregnancy termination for:
reduced AF Gestational age over 36 weeks Score of 2

Repeating the BPP test for:

Score below 6 + less than 36 weeks gestation/ low Bishop/ L/S>2
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+OCT: late decelerations following 50%

or more of contractions

3 or more contractions Lasting at least 40 seconds In a 10-min period By either spontaneous contractions or:
0.5 mU/min oxytocin Doubled every 20 minutes

Hyperstimulation: frequency more than every 2 min or lasting longer than 90 seconds
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normal fetal movement 10 movements in up to 2 hours

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4- What is the fetal heart rate pattern in a fetus with placental insufficiency?

A-late deceleration and loss of variability occurring concomitantly B-first late deceleration and then loss of variability C- first loss of variability and then late deceleration D-first accentuated variability and then late deceleration Ans:B
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5- Which statement is wrong about MCA Doppler?

A- compared to FHR monitoring , MCA Doppler is more sensitive to fetal hypoxia B- in an IUGR case, hypoxia causes reduction in Pulsatility Index (PI) C- in an anemic fetus because of Rh incompatibility velocity is reduced in MCA D- with pregnancy advancing there will be a normal increase in MCA velocity Ans:c
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Doppler systolic-diastolic waveform indices of blood flow velocity

S/D =S/D Ratio S-D/S= RESISTANCE INDEX S-D/MEAN= PULSATILTY INDEX

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6- After epidural procedure for a pregnant woman the fetal heart rate shows 12-14 waves of sinusoidal waves with acceleration. With regard to the following data, what is your management?: age:26 yrs/ GA:36 wks/ dil:3 cm/ eff=50%

A-pregnancy termination for hypoxia B-this is pseudo sinusoidal pattern normal after epidural procedure. No step is needed. C-change of position and oxygen to relieve pressure on the umbilical cord D-pregnancy termination for fetal hemorrhage Ans:B
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7- Amnioinfusion has been proposed to cure variable deceleration due to oligohydramnios. What has the least probability to occur during amnio infusion?

A-abruption B-uterine rupture C-uterine hypertonia D-cord prolaps Ans:A

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8- Silent oscillatory pattern refers to:

A- baseline variability of FHR of less than 5 bpm B- two or more acceleration of 15 bpm C-one acceleration of 15 bpm D-baseline FHR variability of more than 5 bpm Ans:A
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9-Which is wrong about late deceleration:

A-it occurs after the peak and nadir of uterine contraction B-lag phase represents fetal PO2 level not fetal blood PH C-the less the fetal PO2 before uterine contraction, the more is the lag phase before deceleration D-reduced fetal PO2 level below critical level activates chemoreceptors and decelerations Ans:C

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Points to remember
Positive OCT: 50% or more of uterine contractions accompany FHR decelerations Variable deceleration: occurs >= three times in a 20 min interval with FHR drop to 70 bpm Persistent deceleration: more than 30 bpm reduction in a 2-10 min interval Bradycardia: more than 30 bpm reduction of FHR in more than 10 min
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9- NST of a G2 / GA=37 wks/ cephalic presentation/ with a history of 2 IUFDs shows a 2-min deceleration. What is the best management?

A- daily BPP and observation B- C/S C- repeat of NST 24 hours later D-vaginal exam with continuous fetal monitoring Ans: B
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10-What is equivocal-suspicious result in OCT?

A-no late or significant variable deceleration B-late decelerations following 50% or more of contractions (even if the contraction frequency is fewer than three in 10 minutes) C- intermittent late decelerations or significant variable decelerations D-decelerations that occurs with contractions frequent than every 2 min or lasting 90 sec E- fewer than three contractions in 10 min or an uninterpretable tracing Ans:C
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11- Which is wrong about fetal heart rate deceleration?

A- maternal HTN can cause chronic placental dysfunction and late deceleration B- early deceleration of 20 bpm of baseline shows fetal hypoxia and acidemia C- increased afterload can activate chemoreceptors and cause late deceleration Ans:B
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12- A pregnant womans BPP shows a non-reactive NST, one inspiration in 3 min of 30 sec duration, 2 body movements, one Flex and Ext of limbs, AF of one vertical packet of 3 cm. What is your management?

A- pregnancy asphyxia and pregnancy termination B- repeating the test one week later w/o the possibility of fetal asphyxia C- repeating the test with the possibility of fetal asphyxia D- the possibility of asphyxia, repeat of the test on the spot and if abnormal, termination of pregnancy Ans:C
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Points to remember: score two, otherwise zero

1-Tone: 1
2-Respiration: 1 of 30 sec 3-AF: 1pocket more than 2 cm 4-NST: 2 of 15 bpm of 15 sec in a 20 min strip 5-Movement: 3 in 30 min
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13- Which one is acceptable in fetal health assessment?

A- negative predictive value for most tests is about 99.8% B- positive predictive value for abnormal tests is more than 80% C- management should be done based on true positive tests D- tests are based on many clinical trials Ans:A
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PPV= true sick/positives

sick

true positive

False negative

healthy

False positive

True negative

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Sensitivity= true positive /sick

sick

true positive

False negative

healthy

False positive

True negative

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14-Which can not reduce fetal respiratory effort?

A-hypoxia B-preterm labor C- maternal feeding D- at night (circadian effect) Ans:C

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15- Female 23 yrs G1 GA=36wks has gone through BPP for lupus. The fetus shows 3 movements/ one respiratory effort of 30 sec/one flex/non-reactive NST/AF of one pocket of 3 cm. What is your management?

A-pregnancy termination B-repeating the test one week later C-repeating the test immediately D-repeating the test 24 hours later

Ans:B
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16-Which is wrong about S/D ratio? (max sys flow velocity/min end-diastolic flow velocity)

A-S/D ratio increases gradually in the second half of pregnancy B-S/D ratio increases in lupus and HTN C- reversed diastolic flow can be seen in placental dysfunction D- Absent diastolic flow can be seen in cases of aneuploidy Ans:A
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17-G2 P1 28 yrs female comes to the clinic with the chief complaint of reduced fetal movement. Her gestational age is uncertain. In ultrasound AF is normal and the fetus is reported as term. What should be done for her?

A-Doppler velocimetry B-labor induction C- immediate C/S D- US twice weekly Ans:B

*Normal FAD: at least 10 movement sensation in 2 hours
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18-Which is not an ominous sign in NST?

A- No increase in FHR in 90 min B- non repeating variable deceleration of less than 30 sec C- deceleration that lasts more than one min D- variable deceleration less than 3 times in a 20-min interval Ans:B
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19- Fetal heart rate auscultation reveals FHR of 220 (PSVT). What is your management?

A-Digoxin B-echocardiography and fetal karyotyping C- This is an ominous sign of future hydrops and heart block of lupus pregnancy D-This is transitional. No treatment is needed

Ans:A
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20- In a diabetic woman of 37 wks, BPP shows no fetal movement -one respiratory effort of 30 sec -2 accelerations of 15 sec and one AF pocket of 2 cm. What is your management?

A- pregnancy termination B- repeating test on the same day C-repeating test in the third day D- amniocentesis Ans:B

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21- In a 20 yr old woman of a PIH case, more than 50 % of uterine contractions are accompanied with decelerations. What does this mean?

A- Recurrent deceleration B-significant variable deceleration C-prolonged deceleration D-long-term variability Ans:C

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22-The BPP of a 36 wk pregnant woman shows 1 respiratory effort, 2 movements with no acceleration, one flex and Ext of the limbs, and AFI of 10 cm. The repeat of the test after 24 hours later shows the same results. What is your management?

A- Pregnancy termination B- Pregnancy termination if bishop score is favorable C- twice a week BPP D-once a week BPP Ans:A
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23- Which pattern is a sign of fetal distress in a 43 wk pregnant woman ?

A- prolonged deceleration B-saltatory pattern C-variable deceleration D- late deceleration Ans: A

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24-What drug does not reduce beat to beat variability ?

A- narcotics B-barbiturates C-phenothiazine D- in the first hour after MgSO4 administration Ans:D Acidemia causes btb variability reduction Hypoxia causes btb variability increase
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25-What is the BPP score of : 3 movements in 30 min / one acceleration of more than 15 sec/3 movements/ one tonic activity/ AF pocket of more than 2 cm?

A- 8/10 B-8/12 C-10/12 D-6/10 Ans:D

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26-What is the indication for Doppler velocimetry?

A- IUGR B-postterm C-SLE D-APL antibody syndrome Ans:A

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Puerperium

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1-What is the change in the milk of ovulating women versus non-ovulating lactating women?

A- No difference B-lactose is more in ovulating women milk C-K and glucose is more D-Na and Cl is more Ans:D

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2-Which change can be seen in puerperium?

A-maternal heart beat is increased 2 days after delivery B- endometrium repair is resumed three weeks after delivery C- Ureters will return to non pregnant state after 8 weeks D- Vaginal rugae appear after 3 months from delivery Ans:C
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3-Which is true about puerpural changes?

A- total number of uterine muscular cells is not reduced B-vaginal rugae occur in the third month from delivery C-uterine connective tissue wont change D-uterine is re-epithelialized totally in the first week of pregnancy Ans:A
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4-Which organism is the least responsible in puerpural infection?

A- peptostreptococcus B-enterococcus C- chlamydia trachomatis D-mycoplasma Ans:D

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5-What is your management in a lactating mother who is a candidate for radioactive iodine administration?

A- lactation after two weeks from iodine exposure is safe B- lactating during iodine administration is safe because iodine is not secreted in the milk C-lactation during the first 15 hours is contraindicated D- lactation is contraindicated Ans:A
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6- A patient comes to the clinic because of fever 4 days after C/S which persists 72 hours from antibiotic administration. What is the most likely reason of antibiotic failure?

A- wound infection B- pelvic thrombophlebitis C- pyelonephritis D- adenexal infection Ans:A

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7-What is wrong about puerpural immunization?

A- tetanus and diphtheria vaccine before discharge from hospital is advocated B-a woman already injected measles vaccine does not need a booster dose C- Rh negative women with an Rh positive newborn should take RhoGam D- women who have never taken rubella vaccine should be vaccinated Ans:B
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8-Which is not a contraindication to lactation?

A- alcoholics and drug abusers B- HSV and HBV patients whose infants have taken IG against these viruses C- AIDS and active TB D- women under breast cancer treatment

Ans:B
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9-Which is wrong about OCP use in lactation period?

A- Oral progesterone can be used after 2-3 weeks from delivery B- Implants can be used immediately after delivery C- Depot medroxy Progesterone acetate can be used 6 weeks from delivery D- Combined OCP is used 6 weeks from delivery Ans:B
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10-What is wrong about antibiotic therapy of pelvic infection after C/S?

A- imipenem+cilastatin should be used in intractable cases B- clinda+genta is the standard treatment C- Genta+ pennicilin G are the first line therapy D- ampicillin is added when enterococcus is suspected Ans:C
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11-Which is wrong about infection after C/S?

A- there is no definite relationship between anemia and infection B-sexual practices definitely play a role in infection C- young age and pimigravidity is a risk factor D- three or more doses of betamethasone in preterm labor is a risk factor Ans:B
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12-Which is wrong about human lactation? A- a normal milk secretion is more than 60 cc per day B-Milk is isotonic to plasma and more than 50% of its osmotic pressure is due to its lactose C-milk lactose can leak to blood and urine and this may be mistaken as glucosuria D- Iron reserve affects milk iron content Ans:D

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13-Which is wrong about parametrial phlegmon? A-infection is unilateral and limited to broad ligament B-infection subsides with IV antibiotic but fever may exist 5-7 days C- If fever persists more than 72 hours despite antibiotic therapy the diagnosis is ruled out D-supracervical hysterectomy is recommended Ans:C
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14-What is wrong about weight loss after delivery?

A -5-6 kg weight loss after delivery is due to uterine evacuation and blood loss B-2-3 kg is lost because of diuresis C-2 kg is lost because of third space volume reduction D-most women reach to pre pregnancy weight by the second month after delivery Ans: D
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15- A 26 year old woman complains of vaginal bleeding for three months after delivery. In gynecologic exam uterine size is normal and cervix is closed. What is the first step to be taken?

A-ultrasonography B-beta subunit C-Doppler sonography D-curettage Ans:B

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16-On average what percent of drug can be secreted in human milk?

A-1% B_10% C-30% D-50% Ans:A

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17-Which is wrong about fever after delivery? A-fever more than 39 c in the first 24 hours after delivery is a sign of severe infection B-fever in bacterial mastitis usually is late and persistent C-pulmonary infection usually occurs in the first 24 hours mostly after C/S D-pyelonephritis is one of the most common reason of infection and is most often mistaken for pelvic infection Ans: D
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18- A woman has gone through C/S 7 days ago . Three days after the operation chills and fever (enigmatic fever) occured. She is given antibiotic with no improvement in her condition. She doesnt look ill. What is your diagnosis?

A-pelvic abscess B-parametrial phlegmon C-pelvic septic thrombophlebitis D-adenexal infection Ans:C
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19-Who can lactate?

A- mother of a galactosemic newborn B- mother with HBV C- mother with active untreated TB D-mother with breast herpetic lesions Ans:B

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20-Which is true about C/S abscess?

A-Fever will resume one week after surgery B-Mostly it happens after metritis C-Fever will answer to appropriate antibiotic therapy D-Wound culture is negative most of the time

Ans:B
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21- How to manage breast engorgement in women who does not choose breastfeeding her newborn?

A-oral analgesics B-warm compress C-broad spectrum antibiotic D-bromocriptine Ans:A

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22-An infection after C/S which is not responsive to clinda+genta is because of:

A-clostridium B-enterococcus C-bacteroid fargilis D-chlamydia trachomatis

Ans:B
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23- A week after NVD +episiotomy dehiscence occurs. When the dehiscence should be repaired?

A- immediately B-3 months later C- 6 months later D- 9 months later Ans:A

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24-A 28 yr old G2 P1 woman decides on contraception during lactation after the first week from delivery. What is the best choice?

A- Oral progesterone 2-3 weeks after delivery B-Depo-Provera 2 weeks after delivery C-Implants after 4 weeks from delivery D-oral OCP 4 weeks from delivery Ans:A

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25-Which is true about post C/S metritis? A- uterine culture helps to choose the best treatment B- blood culture is negative most of the time C- streptococcus beta hemolytic cause foul smelling secretions D-placental site is the site of transmission of infection Ans: B Blood culture of metritis is negative most of the time. Wound culture of C/S abscess is positive most of the time.
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26-What is true about lactation period mastitis?

A-It occurs in the last days of the first week B- Most of the time it is bilateral C-nose and throat of the newborn is the source of infection D-it is mostly a result of coagulase-negative staph Ans:C
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Abnormal labor

1-What is Robin maneuver to release shoulder dystocia?

A-rotation of post. shoulder to deliver ant. shoulder B- abduction of shoulders C- flex of mothers knees and suprapubic pressure D- rotation and extraction of ant. shoulder Ans:B Woods screw=A McRoberts m.=C Zavanelli m.= repositioning of fetal head back into the uterus and C/S
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2-Which is wrong in PGE2 administration for labor induction?

A-It reduces submucosal water content B- vaginal tablet is superior to vaginal gel C- It better affects on a cervix with Bishop score below 4 D-It can be used instead of oxytocin for cervical Bishop score of 5-7 Ans:A
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3-Which is wrong in breech delivery mechanism? A-ant hip has a more rapid decent than post hip B- ant hip is beneath the symphysis pubis and intertrochanteric diameter rotates around a 45 degree axis C- if post hip is beneath the symphysis pubis it has to go through 225 degree axis rotation D-for sacrum ant or post position, the axis of rotation is around 45 degrees Ans: C

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4-A woman 35 years old- P2 GA of 38 wks -EFW of 2 kg presents face and posterior shoulder presentation. How do you manage her delivery?

A-induction of labor B- internal rotation to make mentum ant position C- observation to allow spontaneous rotation D- C/S Ans:C

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5-Which is wrong about persistent occiput posterior?

A-Forceps can be applied B-manual rotation of the head can be done C- manual rotation of the head can be done D-there is no place for observation Ans:D

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6-A term pregnancy- dil=3cm- eff=50%-satation=-2 soft cervix in mid position has a Bishop score of:

A-5 B-7 C-9 D-10 Ans:B

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7-In high dose oxytocin labor stimulation, what is the maximum dose (mu/min) of oxytocin ?

A-20 B-30 C-42 D-60 Ans:C

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8- G4-L1-Ab2 / GA:38wks/full dil &eff/frank breech/ station=1 /WB=intact /FHR=100 BPM / x-ray shows flexion of the head. What is the best management?

A-Frank breech extraction B-C/S C-modified Prague maneuver D- observation for non assisted breech delivery Ans:A

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9-Which is wrong about face presentation?

A- This is a rare presentation above inlet B-brow presentation most of the time changes to face presentation C- decent mechanism is completely different from vertex presentation D-delivery is possible if mentum appears beneath the symphysis. Ans:C
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10- Under what condition is external cephalic version allowed in breech or transverse position,?

A- multiparity B-placenta previa C- presenting part engagement D- CPD Ans: A

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11-Which is true about pelvimetry of a breech presentation?

A-MRI is superior to CT scan B-MRI is faster than CT scan C- MRI is superior to CT scan only during labor D-MRI is not a good technique for imaging inlet and mid pelvis

Ans:A
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12-Which is wrong about misoprostol?

A- It is a synthetic PG E1 B-It is used for peptic ulcer C- It is used for contraception D- Its dose is 100 mcg intra cervical for labor induction

Ans:D
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13-Which criterion applies to low forceps?

A- the fetal head leading point should be on station=>2 B- the fetal head leading point should be above station=>2 C-The fetal head is on the pelvic floor D-Sagital suture is ant-post Ans:A
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14-Which is true about breech delivery?

A-labor duration is more lengthy than vertex presentation B-CP is not related to mode of delivery C- Breech presentation happens with no definite reason D-pelvimetry with MRI reduces C/S rate Ans:B
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15-Which is wrong about PGE2 gel?

A-The intracervical dose is 0.3-0.5 mg B-The vaginal dose is 3-5 mg C- The vaginal application releases 10 mg Q4h D-If contractions and FHR are normal in a 2 hour observation, the patient can be discharged Ans:C

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16- In breech presentation with a posterior shoulder ,What is the name of the maneuver: The shoulder is grasped by one hand and the legs are grasped by the other hand then the newborn is pooled toward mothers abdomen?

A-Pinard B- modified Prague C- Bracht D- Meuriceu Ans:B

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17-Which is wrong in shoulder dystocia? A-Most of shoulder dystocia cases can not be diagnosed or predicted B- Shoulder dystocia can be diagnosed with high accuracy using modern imaging studies C-ultrasound is not reliable D- C/S is recommended in diabetic mothers with babies more than 4500 gr and in non diabetic mothers with babies more than 5000 gr Ans:B

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18- A woman 34 yr G1 GA of 41wks is hospitalized. Which regiment is more effective to improve Bishop score?

A- vaginal misoprostol 50 mcg B- intracervical PGE2 (dinoprostone)0.5 mg C- Oral Misoprostol 50 mcg D-NS extra amniotic infusion

Ans:D
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Hypertensive Disorders in Pregnancy

1-What is the accepted screening test for diagnosis of PIH?

A-Rollover test B-nitric oxide measurement C-vascular endothelial growth factor D-angiotensin test

Ans:A
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2- For a case of severe preeclampsia (BP=180/95) Mg SO4 and C/S is ordered. An hour after C/S BP falls to 110/75. What is the reason of BP fall?

A-Delivery removes the effect of vasospasm B-anesthetic drugs C-hemorrhage D-MgSO4 effect Ans: C

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3-Which is true about edema of preeclmpsia?

A- it has an unknown etiology B-it is because of increased aldosterone level C- it worsens the prognosis of preeclampsia D- it is because of increased DOC Ans:A

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4- A woman 48 yrs old/ G3/ BP=150/115/ has a high cholesterol level . Her sister and brother had heart attacks in the age of 40. Which is wrong about the management of this case?

A-Beta blocker B- diet C-methyl dopa D-regular checking of lab results Ans: A

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5- In a woman with chronic HTN Which factor has the least effect in development of superimposed PIH?

A- PIH history B- low dose aspirin C- severity of HTN D-the need for combined drug therapy Ans:B

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6-What is the most common complication of eclampsia?

A- abruption B-aspiration pneumonia C-pulmonary edema D- direct maternal mortality Ans:A

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7-Which is true about blindness after eclampsia?

A-It has a bad prognosis B-It lasts about 1 month C-it is transient and lasts from 4 hours to 8 days D-in some people it causes permanent blindness Ans:C

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8-Which is wrong about eclampsia?

A- eclampsia can cause coma without seizure B- All patients with eclamsia have had signs of preeclampsia C-After seizures respiratory rate is reduced and cyanosis happens D- In all cases of eclampsia severe proteinuria is present Ans:C
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9-Which therapy can prevent preeclampsia?

A-Low dose aspirin B-calcium C-fish oil D-Antioxidants Ans:D

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10- A 40 years old woman / G3/P2 /GA=35 wks/ BP=210/110 is in seizure. What is the best way to control her seizure?

A-Phenytoin loading dose of 1000 mg/h IV B- Diazepam and creatinin measurement C- amobarbital sodium 250 mg IV D- MgSO4 4-6 gr as loading dose Ans:D

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11- What is the cause of platelet change in preeclampsia?

A- increased production B- decreased consumption C- increased platelet aggregation D- decreased platelet- adhering IG Ans:A

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12-A woman 25 years old / G1 suffers HELLP syndrome. What is true about her next pregnancy?

A- there is no increased risk in her next pregnancy B-the is increased risk of abruption and preeclampsia C-there is no increased risk of preterm labor or C/S D-there is no increased risk of IUGR Ans:B
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13-Which test has a more PPV for detecting PIH?

A-urinary excretion of Kallikrein B- roll over test C- angiotensin II D- hypocalciuria Ans:A

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14-A pregnant woman GA=29 wks / severe headache/ blurred vision/ BP= 200/120 has gone through routine tests and MgSO4 infusion. What other steps should be taken?

A-IV hydralazine 20 mg + IV verapamil 10 mg B-IV hydralazine 5 mg C- IV labetalol 80 mg D- sublingual nifedipine 10 mg +thiazide 10 mg Ans:B

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15-A case of eclampsia with seizure is given MgSO4. She is agitated. What drug is appropriate for her agitated state?

A-2 gr MgSO4 IV B- 250 mg amobarbital IV C- 10 mg diazepam IM D-no treatment is needed Ans:B A would be appropriate if a second seizure occurs
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16-A woman with high blood pressure, proteinuria, Cr>1.5 mg/dl, has an episode of seizure after 4 hours from her delivery. What treatment do you suggest?

A-14 gr of MgSO4as the loading dose and then 2.5 gr q4h up to 24 h after delivery B-7 gr of MgSO4 as the loading dose and then 2.5 grq4h up to 24 h after the last seizure C-14 gr of MgSO4 as the loading dose and then 2.5 gr q4h up to 24h after the last seizure D-7 gr of MgSO4 as the loading dose and then 2.5 gr q4h up to 24h after delivery Ans:C
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17-Which is not among pathophysiological changes of preeclampsia?

A-reduction in PGE2 B-reduction in prostacyclin C-increased thromboxane A2 D-increased resistance to angiotensin Ans: D

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18-Which is wrong about proteinuria of preeclampsia?

A-Some women deliver before proteinuria occurs B-1+ proteinuria equals 300 mg protein in a 24 hour sample C-NPV of a trace or negative dipstick test is about 30 % D-PPV of 3+/4+ proteinuria is 70% Ans:D
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19-For a primigravida in 30 weeks gestation a roll-over test is done. An increase of 35 mmHG has occurred in diastolic BP. Which is wrong for this case?

A- She has a high probability of developing HTN B-She is abnormally sensitive to angiotensin II C-increased BP is because of hyperactivity of parasympathetic system D-33% of these patients will develop preeclampsia Ans:C
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20-Which is wrong for visual disturbances of preeclampsia?

A-it is because of occipital region lesions B-if blindness does not resolve within a week , it will remain permanently C- It is because of retinal artery spasm that can resolve by MgSO4 D-it is because of retinal detachment that is most often unilateral Ans:B
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21-Which is wrong about superimposed preeclampsia?

A-it occurs earlier in pregnancy and most often is accompanied by IUGR B- BP changes remain through life C-some women have increased BP after 24 weeks gestation D- above 90% of them have a history of essential HTN Ans:B
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22-A woman GA=38 wks/G2/L1/history of chronic HTN is diagnosed as a case of severe preeclampsia. Her pregnancy is terminated. Her BP and proteinuria and edema are improved but she has developed orthopnea. What is your first diagnosis?

A-ATN and overload B- hypoalbuminemia C-peripartum cardiomyopathy D-MS signs aggravated by fluid shift Ans:C
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23-What drug has the complication of tachycardia?

A-methyl dopa B-propranolol C-nifedipine D-hydralazine Ans: D

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24-Which does not happen in preeclampsia?

A-reduced renal perfusion and GFR B-increased renin-angiotensin level C-constant electrolyte concentration D- increased microangiopathic hemolysis Ans:B

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25-A woman 32 years old/ NP /obese / 38 wks GA/ mild preeclampsia delivers her child . BP does not decrease after several IV doses of hydralazine. Which is not a good management?

A-Im hydralazine B-oral labetalol C-thiazides D-IV MgSO4 Ans:D

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Hemorrhage in Obstetrics

1- A woman 35 years old /G4 L3 presents with couvelaire uterus in C/S. When is hysterectomy indicated?

A-presence of hematoma in the broad ligament B-presence of hematoma in mesosalpinx C- atony retractable to treatment D- presence of blood in abdominal cavity Ans:C

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2-Which is wrong about platelet administration? A- Platelet can not be reserved more than 5 days B-platelets should be administered to patients with hemorrhage and platelet counts less than 50000/ml C-platelet should be administered after cross-match D- If there is no hemorrhage, platelets should be administered to patients with platelet counts less than 10000 /ml

Ans:D
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3-which is the most common reason of DIC in Obstetrics?

A-IUFD B-abruption C-AF emboli D- septic shock Ans:B

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4-what is the first step in treating a G2 with late postpartum hemorrhage (after stabilizing her condition)?

A-curettage B-uterotonics C-uterine artery ligation D-hypogastric artery ligation Ans:B

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5-A 16 year-old woman comes to you with heavy bleeding after a two month delay in her periods. Pregnancy test is negative. Ultrasound shows a thin endometrium. There is no coagulation or anatomical problem. Which is the best treatment?

A-high dose progesterone B-curettage C-IV conjugate estrogen D-diagnostic hysteroscopy Ans:C Conjugate estrogen 25-40 mg IV q6h or PO 2.5 mg q6h
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6- what is the stage of shock in a woman 70 kg / HR=130 bpm/AP=55mmHg/mod tachycardia/ urinary output=10cc in a min

A-first B-second C-third D-fourth Ans:c

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7-Which is true about hemorrhagic shock?

A- central venous catheter is not recommended B-lifting the feet is not recommended C-colloids are superior to crystalloids D-excess NS can cause alkalosis Ans:A

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8-A woman suffers intractable heavy vaginal bleeding after C/S. Laparatomy is performed. Retrovesical hematoma is evacuated and the site of bleeding is sutured. The bleeding does not stop. What is the second stage in management?

A-total hysterectomy B-bilateral uterine and ovarian arteries ligation C-bilateral hypogastric arteries ligation D-bilateral hypogastric and ovarian arteries ligation Ans:D Ovarian artery is situated in infundibulopelvic and mesosalpinx ligament
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9-Which is wrong in abruption?

A-It is more likely in heroin addicts than cocaine addicts B-fibroma is one of the causes C-positive past history is a risk factor D-there is no agreement on smoking as a risk factor Ans:A
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10-A G2 with GA=14 wks is referred for spotting. Ultrasound imaging shows twin pregnancy with one fetal demise. How the coagulation profile may change?

A- The profile is like that of DIC B-heavy bleeding will occur during labor because of hypofibrinogenemia C- repairable transient coagulopathy will occur D-the live infant in the uterine will develop coagulopathy Ans:C
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11-Which is true about uterine inversion?

A-BP and MgSO4 can be the reason B-it is more common in multiparas C-it is never fatal D-hemorrhage occurs with a delay Ans:A

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12-If there is a coagulopathy disorder, which is an indication for Heparin administration provided that circulation is intact?

A-IUFD B-Abruption C-septic abortion D-HELLP syndrome Ans:A Heparin dose 5000 units TDS for IUFD FFP and platelet for septic abortion
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13-Which is not an etiology of prepubertal females with vaginal bleeding?

A-endocervical polyps B-vaginitis C-muluscum contangiosum D-lichen sclerosis Ans:A

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14-What is the drug of choice in AUB after kidney and liver transplant?

A-desmopressin B-GnRH agonist C-antiprostaglandins D-estrogens Ans:B

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15-A 14 yr old girl has the chief complaint of heavy vaginal bleeding. Her Hb is 7 gr/dl . Coagulation tests and platelets and pelvic sonography are normal. What is your management after treating anemia?

A-HD OCP q6h for one week B- 25-50 mg progesterone q6h until bleeding is under control C- Conjugated estrogen 2.5 mg q6h PO until bleeding is controlled followed by medroxy progesterone D-daily medroxy progesterone acetate 20 mg Ans:C
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16-Which is wrong about stage II of hypovolemic shock?

A-Tachycardia is a constant finding B-blood loss is more than 1000cc C-systolic minus diastolic BP is increased D-BP at rest is normal Ans:C

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17- A 70 kg woman has massive hemorrhage during a pelvic surgery. Which is the best choice for blood loss compensation?

A- Packed cell +3 units of FFP+10 units of platelet B- Packed cell +2 units of FFP for each 6-8 units of PC+ 2 units of platelet if platelet count is below 100000/cc C-whole blood D- B and C Ans:D
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Points to remember
Whole blood 500cc

Plasma 250cc

250cc packed cell 4c

FFP 200 cc -18c Cryoprecipitate 15 cc

Platelet 50cc 20-24 c

18-What is the most common coagulopathy that is presented by AUB in adulthood?

A-Thalacemia major B- thalacemia minor C-von willebrand D-ITP Ans:D

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19-Which is true about int iliac artery ligation for controlling pelvic hemorrhage?

A-Ext iliac artery should be checked before ligation is attempted B-ureter should not be located C- both sides arteries should not be ligated D-the artery should be ligated proximal to parietal branch Ans:A
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20-A woman receives 12 units of whole blood because of hemorrhage after hysterectomy. 3 hours after operation Hb is 9 gr/dl, platelet 55000/cc fibrinogen 100 mg/dl. What do you suggest?

A-FFP B-platelet C-cryoprecipitate D-crystalloids Ans:D

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21-How PG f2-alfa is administered for uterine atony?

A-20 mg IM for max 3 doses by 15-90 min intervals B-500 mcg IV for max 4 doses IM by 30 min intervals C-1000 mcg IM single dose D-250 mcg IM for max 8 doses by 15-90 min intervals Ans:D
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22-In a 14 year old anemic girl with prolonged uterine spotting what should be done?

A- assurance, follow up and ferrus sulfate B- Low dose OCP q6h for 7 days C- Low dose OCP 21 days for 3-6 cycles D- conjugate estrogen 2.5 mg PO q6h for 7 days Ans:c

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23-A 40 year old woman is hospitalized for hemorrhagic shock. Her kidney function is normal. What is the most sensitive and reliable clinical criteria for determining severity of volume loss?

A- tachycardia B-tachypnea C-oliguria D-hypotension Ans:C

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24-What is the best management of great vessels laceration in sacral foramina?

A-Clamp and ligation of great vessels B- clipping the vessels C-electrocuttery D-packing the foramen by Gel foam Ans:D

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25-An extension of C/S incision causes vaginal artery laceration and heavy bleeding. What should be done for this case?

A-uterine artery ligation B-ovarian artery ligation C- hypogastric artery ligation D-hysterectomy Ans:C

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26- How many ml of blood does a soaked lap pad absorbs?

A-30 cc B-50 cc C-80 cc D-100 cc Ans:B

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27-What is wrong for blood loss management?

A-after an hour in a critical case only 20% of crystalloids remains in circulation B- the volume of crystalloids replacement is three times the volume of blood loss C-in all cases of blood loss a Hb of less than 8 gr/dl mandates whole blood transfusion D-colloids increase mortality rate Ans:C
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28-What is wrong about vaginal hematoma after delivery?

A-observation if hematoma is small B- an incision on the site if pain is severe and hematoma enlarges C-mattress suturing the bed of hematoma D-pressure dressing should be applied on the hematoma bed for 12-24 hours Ans:D
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29- A repeat C/S II has hemorrhage of the incision site. Which can best control hemorrhage?

A-ligation of placental site above and below the incision site B-ligation of uterine artery C- ligation of hypogastric artery D- embolization of uterine artery

Ans:A
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30-Where is the exact place of hypogastric artery ligation?

A- immediately distal to the bifurcation B-anterior branch distal to the bifurcation C- anterior branch distal to post parietal branch D- anterior and posterior branch Ans:C

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31-What is the diagnosis and treatment of a tender inflamed mass near the urethral opening in a 5 year old girl?

A-muluscum- analgesics and steroids B-condylomata acuminata- TCA acid C-prolaps of the urethra- topical estrogen D- Skene gland abscess-antibiotic and evacuation

Ans:C
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32-A 16 year old girl complains of heavy menstrual bleeding. She is anemic. Her VS is stable. Your diagnosis is DUB. What should be prescribed for her other than Iron supplements?

A-medroxy progesterone acetate 10 mg daily for 2 weeks for 3 cycles B-monophasic OCP q6h for 7 days C- conjugate estrogen 2.5 mg PO q6h until the hemorrhage stops D-LD OCP for 21 days
Ans:B
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33-Obturator artery is lacerated in a pelvic surgery. Which artery should be ligated?

A-int iliac B-lateral sacral C-int pudendal D-ilio lumbar Ans:A

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 Paravesical space contains accessory obturator artery from inf hypogastric Para rectal space contains lateral sacral and hemorrhoidal arteries Obturator artery is from int iliac artery

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34-Which is the last choice in Von Willebrand related AUB?

A-2.5 mg estrogen daily+ progesterone in the last 10 days of a menstrual cycle B-OCP C-GnRH nasal spray D-desmopressin infusion

Ans:D
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35-Which is more common in blood transfusion?

A-Hepatitis B B-Delayed red-cell hemolytic reaction C-Anaphylactic reaction D-HTLV Ans:B

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36- Which is wrong about fetal complications of abruption?

A- 20-25 percent of cases demise perinatally B-40 % are delivered prematurely C- 12-15 % are IUFD D-if the fetus doesnt die in uterus, there would be no serious neonatal complication

Ans:D
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37-A pregnant woman G2 GA=38 wks has the chief complaint of vaginal spotting. There is no sign of abruption or previa by ultrasound. What is the best management?

A- observation B-termination of pregnancy C-discharge D-referring patient to another center Ans:B

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38-Which is true about abruption?

A- The chance of repeated abruption is twice B-fetal assessment techniques can predict abruption with good precision C-there is no means to predict abruption D-The chance of repeated abruption is not different Ans:C
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39-Which is wrong in cases of placenta previa?

A-the safest means of diagnosing placenta previa is transabdominal ultrasound B-false positive results are because of full bladder C-low lying or total previa is best diagnosed by trans vaginal ultrasound D-NPV of transperineal ultrasound is 70 % Ans: D (its NPV is 100% )
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40-What is the first surgical step in a case of retractable uterine atony?

A-ligation of uterine and ovarian arteries B-ligation of hypogastric arteries C-subtotal hysterectomy D- uterine artery embolization Ans:A

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41-Which case does not need replacement therapy after massive transfusion?

A- platelet of 80000 in cc B-coagulation factor VIII of 40 % C-fibrinogen 90 mg/dl D- PT of 1.5 times normal level

Ans:B
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Preterm and postterm pregnancy

1-Which is wrong about the pathogenesis of preterm labor?

A-phospholipase A2 induced by bacteria B-PG induced by bacteria C- macrophage induced substances D-PAF induced by bacteria Ans:B

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2-Which is wrong about FFN?

A-it is a better indicator for preterm labor than ROM B-FFN> 30 ng /ml is considered positive C- amniotic fluid and maternal blood cause false results D-its NPV is more reliable than PPV Ans:B
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3- What is your management of : 25 yrs -G1 - GA = 41 wks- cephalic presentationFAD=normal favorable cervix?

A-C/S B-stripping of the cervix C-PG gel D- AFI twice a week Ans:D

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4-Which test is more sensitive for detecting bacteria in AF?

A-Gram staining of AF B-increased maternal WBC C-increased AF IL6 D-increased maternal CPR Ans:C

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5-Which is wrong about prolonged gestation?

A-placental apoptosis increases from 41-42 weeks gestation B-umbilical cord erythropoietin increases from 41 weeks C-Late deceleration is the most common finding in prolonged gestational age D-lack of vernix causes skin changes of post maturity Ans:C
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6-A 31 year old woman complains of premature labor. Dilatation is 2 cm and eff is 50%. Water bag is intact. Which is true about the management of this case?

A-beta agonists can cause MI and myocardial necrosis in mother B-terbutalin can post pone delivery for a week C-If MgSO4 can not stop labor, nifedipine is used D-PG inhibitors should not be used Ans:A

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7-What should be done in a post trem pregnancy when NST is normal?

A- repeat NST after 3 days B-CST C-AFI D- Doppler Ans:C

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8-Which is wrong in the management of a woman G1 GA=39 wks ROM Dil=2cm eff=40% HR=100 bpm T=37.5c ?

A-Control of BP and HR q4h B- Control of T q4h C- antibiotic D-induction of labor Ans: B T should be checked hourly
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9-Which is the most accurate way to detect ROM if ROM can not be detected by speculum or ultrasonography?

A-Nitrazine test B-Fern C-Indigo Carmine D-digital vaginal examination Ans:C

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10-In which group of patients MgSO4 is contraindicated?

A- Type I diabetes B- asthma C-hyperthyroidism D-myasthenia gravis Ans:D A patient with MG should receive Amide type anesthetics like Lidocaine and Bupivacaine
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11-Which combination therapy to stop labor pain is safe?

A-MgSO4+ indomethacin B-MgSO4+ terbutalin C-ritodrin+ nifedipin D-MgSO4 + nifedipin Ans:B

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12-Which is not a side effect of Ritodrine?

A- pulmonary edema B-hyper kalemia C-hyperglycemia D-hallucination Ans: B

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13-An induction for a 41 wk gestational age pregnancy failed. What should be done?

A- C/S B-starting induction 6 hours later C-Starting induction 3 days later D- fetal well-being monitoring for one week Ans:C

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IUGR

Definition
Intrauterine growth restriction (IUGR)
occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in weeks). The fetus is affected by a pathologic restriction in its ability to grow.

Low birth weight (LBW) means a baby

with a birth weight of less than 2500Gms, which could be due to IUGR or Prematurity
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Classification
Symmetricl
the baby's head and body are proportionately small. may occur when the fetus experiences a problem during early development.

Asymmetrical
baby's brain is abnormally large when compared to the liver. may occur when the fetus experiences a problem during later development

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In a normal infant, the brain weighs about three times more than the liver. In asymmetrical IUGR, the brain can weigh five or six times more than the liver.

Etiology
General- Racial / Ethnic origin,
Small maternal / paternal height / weight, Fetal sex

Maternal causes. Fetal causes. Placental causes. Idiopathic- In a majority of cases (40%) the cause is
unknown probably due to placental insufficiency.
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Maternal Risk Factors

Has had a previous baby who suffered from IUGR. Extremes of age Is small in size (Ht & Wt). Has poor weight gain and malnutrition during pregnancy. Is socially deprived. Uses substances (like tobacco, narcotics, alcohol) that can cause abnormal development or birth defects. Has a low total blood volume during early pregnancy.

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Maternal Risk Factors

Is pregnant with more than one baby. High altitude. Drugs like anticoagulants, anticonvulsants. Has a cardio-vascular disease-preeclampsia, hypertension, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions. Chronic kidney disease Chronic infection- UTI, Malaria, TB, genital infections Has an antibody problem that can make successful pregnancy difficult (antiphospholipid antibody syndrome, SLE).
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Fetal Risk Factors

Exposure to an infection-German measles (rubella),
cytomegalovirus, herpes simplex, tuberculosis, syphilis, or toxoplasmosis, TB, Malaria, Parvo virus B19.

A birth defect (cardiovascular, renal, anencephaly, limb defect, etc). A chromosome defect- trisomy-18 (Edwards

syndrome),21(Downs syndrome), 16, 13, xo (turners syndrome)

A primary disorder of bone or cartilage. A chronic lack of oxygen during development (hypoxia). Developed outside of the uterus. Placenta or umbilical cord defects.
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Placental Factors
Uteroplacental insufficiency resulting from -.
Improper / inadequate trophoblastic invasion and placentation in the first trimester. Lateral insertion of placenta. Reduced maternal blood flow to the placental bed.

Fetoplacetal insufficiency due to-.

Vascular anomalies of placenta and cord. Decreased placental functioning mass-.

Small placenta, abruptio placenta, placenta previa, post term pregnancy.

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Screening:
US fetal biometry: HC- BPD- AC

Uterine Doppler studies ( Doppler Velocimetry): bilateral notches and a mean resistance index of at least 0.55 Or Unilateral notches and a mean resistance index of at least 0.65 at 20 weeks.
Biochemistry: CRH level at 33 weeks
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Diagnosis
Neonatal Low ponderal index (Wt./Fl). Decreased subcutaneous fat. Presence / appearance of
Hypoglycemia, Hyperbilirubinemia, Necrotizing enterocolitis, Hyper viscosity syndrome
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A decrease in AFI may occur before there are changes in the non-stress test.

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While the biophysical profile is an useful test, when it becomes abnormal the fetus may have already suffered some damage

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1-which test is more sensitive to fetal acidosis?

A-NST B-BPP C-OCT D-Doppler velocimetry of umbilical artery Ans:D

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2-What should be done for a diabetic woman 28 yrs old G2 L1- AF=NL EFW=4600 gr GA=42 weeks

A-C/S B-AF measurement twice a week C-NST and OCT daily D-PG gel to ripen cervix Ans:A

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3-What is the most important reason for hypoglycemia of a SGA fetus?

A- increased fetal consumption B-decreased endogenous glucose production C-hyperinsulinemia D-reduced supply Ans: D

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4-What trisomy in the form of placental mosaicism causes IUGR?

A-13 B-16 C-18 D-21 Ans:B

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5-Which is wrong as an explanation for fetal growth? A-Insulin growth factor I & II play an important role B-fetal pancreas can secret insulin necessary for growth C- leptin , a protein that is found in maternal and fetal blood, is the product of obesity gene D-fetal leptin secreted in the third trimester of pregnancy is not related to fetal growth Ans:D

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6-What is CMV mechanism of action in IUGR?

A- direct cytolysis B-injury to small vessels endothelium C-reducing cell multiplication time D-inflammation and edema of perivascular tissue Ans:A

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7-Which one is not a cause of SGA?

A- Maternal SCA B-placenta previa C-living at the sea level D- positive maternal ACL antibody Ans:C

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8-Which is not a finding in IUGR fetus?

A- hyper TG B-thrombocytopenia C-increased plasma adenosine D-reduced placental arterial natriuretic peptide Ans:D

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9-What is the chromosomal defect in a newborn with horse shoe kidneys, prominent occiput, imperforated anus, VSD?

A- trisomy 13 B-turner C-trisomy 18 D-trisomy 21 Ans:C

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Multiple pregnancy

1- What is the best statement about ovulation induction? A- oral and injectable ovulation induction drugs have the same effect on inducing multiple pregnancy B-ovulation induction drugs increase the incidence of dizygotic twins C- ovulation induction drugs increase the incidence of monozygotic twins D-ovulation induction drugs increase the incidence of monozygotic and dizygotic twins Ans:D

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2-Which is wrong about chimeras?

A- It is the process in which two lines of cells appear in one organism B-A person is diagnosed as blood chimera when he has two BGs C-non disjunction in meiosis division is the probable cause of chimeras D- twins can share genetic materials via vascular anastomosis Ans:C
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3-Which is not a sign of twin to twin transfusion?

A-difference in weights more than 10% B-hydramnios in one fetus and oligohydramnios in the other C- difference in Hb more than 5 gr/dl D-monochorion with placental vascular anastomosis Ans:A
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4-Which age is the peak age for twin pregnancy?

A-puberty B-26 C-37 D-35 Ans:C

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5- Which is true for prenatal care of multiple pregnancy?

A- add 300 kcal daily B-Daily Iron 250 mg C-1 mg folic acid daily D-a multiple pregnancy should have a weight gain of 50 pounds

Ans: B
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6- What should be done for a woman 31 week gestation with twin pregnancy and one fetus dead?

A-prophylactic heparin for DIC prevention B- C/S C- observation D- tocolytics Ans:C

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7- What is third circulation in monochorionic twins?

A- superficial artery-artery anastomosis B- superficial vein- vein anastomosis C- deep artery- vein anastomosis D- deep artery-artery anastomosis Ans: C

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8- Twins rate of growth resembles singleton pregnancy up to gestational age of

A-20 weeks B-28-30 weeks C-34 weeks D- 36 weeks Ans:B

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9-Which is not because of vascular anastomosis in twin pregnancies?

A-microcephaly B-small intestines atresia C- Hip dislocation D- limb amputation Ans:C

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Amniotic membranes

1- 30 yrs GA=34 w max vertical pocket of AF=12 cm complains of dyspnea. What do you suggest?

A- Ace inhibitors B- daily diuretic and restricting salt consumption C-transvaginal amniotomy D-Indomethacin 1.5-2 mg/kg Ans:D

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2-A placenta that is totally covered by chorionic villi and its separation causes heavy bleeding that mandates hysterectomy is called?.

A-Succenturiate B-Fenestrated C-Extracorial D-membranous Ans:D The only placental abnormality detected by ultrasound is membranous placenta
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3-What is wrong about umbilical cord?

A- Its length is determined by fetal movement and AF volume B- In breech presentation its length is 5 cm less than vertex presentation C-vellamentous insertion always contain one umbilical artery D-30 % of newborns with one umbilical artery have congenital anomaly Ans:C
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4-which is related to prenatal hemorrhage, prenatal mortality, and abnormal fetus?

A- Circumvallate B-membranous C-Fenestrated D-Circummarginate Ans:A

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5-What is the least common complication of a large placental chorioangioma?

A- polycythemia B-heart failure C- DIC D- microangiopathic hemolytic anemia Ans:A

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6- What is not a reason of oligohydamnios in a woman GA=36w AFI=3cm with IUGR pregnancy?

A-reduced fetal urine B- increased swallowing of the fetus due to asphyxia C-reduced fetal renal blood perfusion D-reduced placental perfusion

Ans:B
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7-Which is the first stained by meconium in amniotic fluid?

A-chorion B-umbilical cord C-fetal skin D-amnion Ans: D

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8-What is the most common lesion of placenta?

A-Infarction B-calcification C-fetal arteries thrombosis D-inflammation Ans:A

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9-Which can not increase AFI?

A-high altitude B-maternal hydration C-vasopressin infusion D- maternal serum hyperosmolality Ans:D

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10-Which is wrong about Meconium Aspiration Syndrome?

A- It is fairly a common incidence B-it can happen to a fetus with normal oxygenation and normal AFI C-Hypercarbia is a risk factor for gasping and MAS D-It is preventable Ans:D The most common FHR abnormality with MAS is severe variable deceleration
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11-How chorionic artery can be differentiated from chorionic vein?

A- vasoactive substances are only effective on the artery B-the difference is in their diameter C-artery passes over the vein D-only by histological studies

Ans:C
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12-Which is true about the mechanism of action of indomethacin on AF?

A-reducing fetal urine B-increasing volume shift through fetal membranes C-reducing fluid production and absorption of fluid through fetal lungs D- increasing fetal swallowing Ans:D
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13-Which is wrong?

A-chorionic plate of placenta is part of placenta B-prenatal mortality is more in circumvallate placenta C-uterine infection is the main cause of circumvallate placenta D-circumvallate placenta accompanies congenital abnormality Ans:C
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14-Which is wrong about yellow round knots of 1-5 cm near cord insertion into placenta?

A-these are amnion nodusum B-these are made up of vernix, hair, sebaceous and scaling of the fetal skin C- These are not accompanied by fetal anomalies D-it can be seen in cases of prolonged ROM

Ans:C
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15- A woman is hospitalized for oligohydramnios. GA=34 w Fern=negative . What do you suggest?

A-pregnancy termination B-observation C-amnio infusion D-diuretics Ans:B

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16-Which kind of placenta can have accreta or percreta insertion into the uterine?
A-succenturiate B-ring shape C-membranous D-extracorial Ans:C
extracorial circumvallate
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circummarginate

17-Which is accompanied by long umbilical cord?

A-Dawn syndrome B-limb defects C-maternal systemic disease D-Potter syndrome Ans:C Long cord >70 cm
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18- What should be done for a term pregnancy, ROM for an hour with meconium staining?

A- amnio infusion B-C/S C-induction D-observation Ans: C

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Abortion

1-What is wrong about recurrent abortion?

A-HSG is the best method to R/O anatomical etiologies B-HSG is recommended several weeks after operative hysteroscopy C-vaginal ultrasonography and MRI are the best techniques to detect anatomical defects D-Septated uterus is the most common anatomical cause of recurrent abortion Ans:A
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2-Which is true about genetic factors in a case of recurrent abortion?

A- Sperm and ovum of donors can be used in couples with genetic abnormality B-the most important genetic cause is 45X monosomy C- genetic causes for recurrent abortion is R/O if karyotyping is normal D-the genetic cause of recurrent abortion can be cured Ans: A
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3-Which is a wrong treatment for abortion? A-200-600 mg mifepristone PO and then after 36-48 hrs 800 mg misoprostol vaginal B-50 mg/m MTX im and 24 hr later 800 mg misoprostol vaginal C- tamoxifen 20 mg daily for 4 days and then 800 mg misoprostol vaginal and if necessary repeating after 24 hrs D-800 mg misoprostol vaginal for 3 days for 1012 wk abortions Ans:B
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4-What is a mandatory test for a 29 year old woman with history of recurrent abortion?

A-ANA B-ACL C-anti paternal antibody D-HLA profile of the parents Ans:B

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Recurrent abortion tests

Karyotype HSG Luteal phase biopsy of endometrium TSH and prolactin level ACL ab LAC CBC
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5-Which is true about recurrent abortion? A- 8- 30% is because of genetic factors among which chromosome inversion is the most common B- 8- 30% is because of genetic factors among which balanced chromosomal rearrangement is the most common C-aneuploidy happens in old aged mothers D-in a mother below 35 aneuploidy is because of immunologic factors Ans:B
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For cases of abortion without fever: Doxy 100 mg bid or tetracycline 250 mg qid for 5-7 days

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6-Where is the discriminatory zone?

A-3000 IU/L HCG + abdominal US B-1000-1500 HCG + vaginal US C-a constant value of HCG for any type of US D-in multiple pregnancy it is lower than singleton pregnancy Ans:B
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7-RU486 can not attach to:

A-Progesterone receptor B-androgen receptor C-glucocorticosteroid receptor D-estrogen receptor Ans: D

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8-What is wrong about postabortal or redo syndrome?

A- It is a complication of suction curettage B- It is a painful cramp in the first 2 hours after curettage C-uterine bleeding is less than expected D-treatment is D&C under anesthesia

Ans:D
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9- During a sharp curettage of an incomplete abortion uterine is perforated. What is the first step of management?

A- curettage should be completed and patient should remain under observation B-laparatomy C-curettage should be stopped and patient should remain under observation D- if there is no hemorrhage in the first 24 hours after operation, the patient can be discharged Ans:B
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10- The clinical findings of a woman with GA=8 wks with the chief complaint of hemorrhage and clot passing is an open int os Uterine size about 8 wks and no bleeding. What should be done ?

A-No treatment is needed because abortion is complete B-it is a case of threatened abortion C-it is an inevitable abortion D-Ob sonography Ans:D
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11- A woman has undergone elective abortion one week ago. Now she comes to the clinic with the chief complaint of hemorrhage. In PE cervix is closed, uterine is contracted with no tenderness. Her temperature is normal . What is the best treatment?

A-Doxy 100 mg bid for two weeks B-clinda +genta C-observation and check of Hb and Hct D-hormone therapy Ans:D
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12- What is the most likely cause of abortion in a 27 year old woman with the past history of two abortions in 10 wks and one in 15 wks with normal Karyotype conceptus?

A- endocrine B-immunological C-anatomic D-infectious Ans:B The treatment of immunological recurrent abortion is low dose Heparin sc 5000 units bid+Aspirin 80 mg daily
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13-what is wrong about hereditary thrombophilia?

A- Factor V Laden is the most likely cause B-protein C resistance is because of mutation in factor V C-Protein C deficiency adds 3-10 % to the risk of thrombosis formation D- Protein S deficiency and thrombosis risk will be eradicated after delivery Ans:D
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Notes to Remember
The most common cause of thrombophilia syndrome is resistance to protein C.

Antithrombin III deficiency has the most thrombogenic property.

Fulminant purpura is because of protein C deficiency.

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14- What should be done for a woman 22 years old who has undergone suction curettage and now suffers severe pelvic cramps , sweating and tachycardia. Her uterus is large and tender. She also has spotting.

A-observation and oxytocin B-laparatomy C-dilation and suction curettage without anesthesia D- CT scan Ans:C
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15-What is the best way of pregnancy termination in a bicornuate uterus with a 14 w fetal death?
A-dilatation and curettage under US B-uterotonic drugs C-dilatation and curettage under laparascopy D-hysterotomy Ans:B Canula size in mm = GA in week minus one

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16- What is the management of a 32 year old woman who has undergone failed induced abortion by MTX + PG?

A-repeat of MTX one week later B-repeat of MTX the next day C-repeat of PG one week later D- repeat of PG the next day Ans:D

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17- Which is not among APL mechanism of action?

A-increased platelet aggregation B-increased prot C &S activity C- reduced PGE2 D- direct platelet destruction Ans:B

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18-What is the min size of empty gestational sac that indicates unviable fetus in vaginal US ?

A-17 mm B-13 mm C-10 mm D- 15 mm Ans:A >=13 mm if yolk sac can not be seen >=17mm if embryo can not be seen
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19- Which genetic abnormality is more common in IVF pregnancies that end with abortion?

A-trisomy B-protein C deficiency C-x-linked abnormalities D-translocation Ans:A

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20-Which is recommended in recurrent abortions due to infectious reasons?

A- cervical culture B-endometrium biopsy C-chlamydia serology D-empirical treatment of genital mycoplasma Ans:D

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21- For which utertonic drug to induce abortion placental retention is less likely?

A- oxytocin B- PGE2 C-oxytocin+PGE2 D-PG E1( misoprostol) Ans:D

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Ectopic Pregnancy

Beta HCG below 2000+ no visible intrauterine sac+ mass in tube below 3.5 cm ______________________
control of beta HCG q 48 h A-If a dead IP is confirmed (beta HCG increase less than
50% or below 1000mIu/mL- P below 5 ng/mL + visible intrauterine sac) then curettage B-If EP is confirmed (beta HCG more than 2000 and mass >3.5 cm) then laparascopy C-If a dead IP and EP is confirmed (beta HCG more than 2000 and mass < 3.5 cm) then MTX
FETUS SHOULD BE VISIBLE ON DAY 45 OF GESTATION
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1- What is your management of a 35 years old woman G1 GA=6 wks with an empty sac of 2.5 cm no heart beat and empty uterus in Ultrasound?

A-Laparatomy and salpingectomy and follow up B-MTX and leukovorin C-MTX and folic acid and iron supplement D-laparascopy abd salpingectomy

Ans:B
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Indication of MTX for EP

Hemodynamic stability No intra uterine pregnancy Max sac diameter not equal or more than 4 cm

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2-What is your management of a 36 year old woman who is pregnant after primary infertity. She is referring to you for spotting and hypogastric pain, beta HCG is 1500 mu/l and ultrasound of uterus and ovaries are normal.

A-laparatomy B-laparascopy C-repeat of vaginal sonography several days later D-progesterone measurement
Ans:C
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3- A 30 year old woman has become pregnant after 5 years of infertility with ovulation induction and a history of EP in the right tube 2 years ago. She has undergone laparatomy for ruptured right fallopian tube. What is the best technique for this surgery?

A-Milking B-linear salpingectomy C-right tube salpingectomy D-segmantal excision and delayed anastomosis Ans:C
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4- In a woman 31 years old who has undergone salpingectomy two weeks ago for EP, HCG level is increasing. What is your management?

A-MTX B-transvaginal sonography C-salpingectomy D-chest x-ray Ans:B

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5-What is your management for a woman with : HR=120 SBP=80 mmHg T=37.5c uterine size=8 wks beta HCG=2500 mIU/mL and no intrauterine pregnancy in sonography?

A-Laparatomy B- laparascopy C- D&C D-serum progesterone

Ans:A

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Adenexal mass< 3.5 cm MTX adenexal mass=> 3.5 cm -> laparascopy uncertain US + beta HCG increase less than 50% -> D&C unstable conditions->laparatomy

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6-Which is wrong about EP? A-Relaxin value in EP is less than abortion B- there is no definite knowledge about CA 125 value in EP and abortion C- AFP+ beta HCG+ progesterone+ estradiol can help diagnosing of EP D-maternal creatin kinase is less in EP versus normal pregnancy Ans: D Creatin kinase and AFP are more in EP.
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7-Which is wrong in detecting early EP? A-progesterone below 5-10 ng/mL contradicts normal pregnancy B-by vaginal sonography FHR can be detected in day 33 C-beta HCG level increase of 75 % after 48hrs is indicative of EP D-vaginal sonography + Doppler are 95% accurate in detecting EP Ans:C
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8- which is a predisposing factor for ovarian EP?

A-PID B-infertility history C-DES exposure D-present IUD Ans:D

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9-Which can reduce the number of false positive diagnosis of EP?

A-lab kits with 5 mIu/mL sensitivity B-use of 3rd IS for HCG rather than 2nd TS C-urine pregnancy test which can detect beta HCG below 1000 mIu/mL D-measuring beta HCG with serum creatin kinase Ans: C
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10-MTX single dose IM has been injected to a case of tubal pregnancy 10 days ago . The beta HCG level falls from 2000 mIu/mL to 1600 mIu/mL. But a severe pain persists. What is the next step?

A-beta HCG recheck B-vaginal sonography C-MTX reinjection D-serial measurement of Hct Ans:D

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11- A 17 year old woman is hospitalized for abdominal pain. Serum progesterone is 15ng/mL. Which is a true statement about her illness?

A-EP is R/O B-EP risk is about 90% C-EP and IP is R/O D-EP and IP can not be ruled out Ans:D

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12-All are among indications for conservative management of EP except::

A-ovarian EP B-reduced HCG level C-sac of less than 3 cm D-lack of noticeable intra abdominal hemorrhage

Ans:A
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13-Which is not a risk factor for persistent EP?

A-EP>2cm B-treatment of EP before 7 wks C-beta subunit>1000 mIu/mL D-EP in the proximal part of the tube Ans:D

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14- In a 39 year old woman with EP, MTX is injected as a single dose(50mg/m) Im. Three days after the injection beta HCG level decreased about 20%. Which is a correct follow up?

A- another MTX is injected on day seven B-control of HCG until it reaches 10 mIU/mL C-laparascopy D-MTX should be injected 1mg/kg for 5 days Ans:B
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15-What is peritrophoblastic flow?

A- high resistance- low velocity B-high velocity- low resistance C-high resistance-high velocity D-low velocity-low resistance Ans:B

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16- What is ring of fire in Doppler sonography?

A-placental site B-pelvic hyperemia C-fetal heart D-tubal rupture site Ans:A

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17- A 23 year old woman has the chief complaint of spotting. GA= 7 wks /beta HCG of two days ago =2500 / last beta HCG=2700 / no evidence of IP or EP in sonography. What is your management?

A-repeat of sonography two days later B- MTX C-laparascopy D-curettage Ans: D

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