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USMLE Step3 Gynecology Obstetrics

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. time of last tetanus booster >10 or unknown
Route of delivery (3% of vaginal birth and 15-30% of c-section)
No.
Hypoplastic left heart syndrom
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID

2. What is most common cause of ascitis in us
95 and 120
0.4-4mg daily for >1m prior conception to entire first trimester
Animal studies showed an adverse effect; but no studies done in pregnant women or animals
Hepatic cirrhosis

3. Can patient with sickle cell disesase get ocp?
0.4-4mg daily for >1m prior conception to entire first trimester
Indinavir; it precipitate in urine and obstruct urinary flow.
Not encouraged; no clear study
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk

4. Major cause of PPH
Young females - due to inadequate urethral support. incr intra abd pressure--leakage of urine; dx ask patient to give vigorous cough - leakage of urine..suggest stress incontinence
On or after 37 weeks;
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc

5. unilateral breast discharges
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
Decreases risk of breast and ovarian ca
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
Intrauterine exposure to virus causing pericarditis

6. what anti-TB drugs are contraindicated in pregnancy?
Trichomonas; petetchia in vagina and cervix
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;

7. how maternal dm cause HOCM in infants
They have glycogen deposition in myocardium mostly affected inthe interventricular septum
Very bad. both animals and human studies showed fetal risk
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine
10 days course of ab x immediatly

8. how lactating mother will get metronidazol
2g po single dose; discontinue breast feeding for 12-24 hours
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
Atrophic vaginitis 50-60%; endometrial ca 10%
<1%; no special measure is taken if prevent transmission

9. Why fluoroquinoloes contraindicate in pregnancy?
Failure of fetal shoulder to pass through maternal pelvis
Congenital L to R shunt (VSD/PDA/ASD) untreated for long; pulmonary vascular resistance exceed systemic vascular system--reversal of shunt (R to L) and cyanosis
Cross placenta--concentrate in amniotic fluid---fetal arthopathy
Prenatal screening; us at 10 weeks for measurement of nuchal translucency; serum markers first trimester (papp-A); and 2nd trimester (alpha feto protein - hcg - unconjugated estriol - dimeric inhibin-A)

10. How to dx down syndrom?
Prenatal screening; us at 10 weeks for measurement of nuchal translucency; serum markers first trimester (papp-A); and 2nd trimester (alpha feto protein - hcg - unconjugated estriol - dimeric inhibin-A)
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose

11. association of myelomeningocele?
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
Junction of squamus and glandular cells at the external cervical os
2g po single dose; discontinue breast feeding for 12-24 hours

12. complication of sickle cell during pregnancy
Copper intrauterine device
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications

13. Should women continue HAART during pregnancy?
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Semen - vaginal fluid - any fluids contain visible vlood; not applicable to urine - sweat - tears - sptum - vomitus - nasal secretio - feces with no visible lboo
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided
Indinavir; it precipitate in urine and obstruct urinary flow.

14. patient with eclamsia - MOST effective strategy
Nitrofurantoin-first gen cephalosporn
Androgen insensitvity due to mutation of AR gene; 46xy but testosterone doesn't work and converted to estrogen. female phenotype - pw amenorrhoes - inguinal mass (testes) - bind vaginal pouch
2g po single dose; discontinue breast feeding for 12-24 hours
Speed vaginal delivery - nothing as effective as this. if they ask What is the next step answer is mag suplph - hydralazin/labetolol for bp control;

15. primary and secondary HIV thrombocytopenia and
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI
Measure tsh levels 12 weeks after ocp - increase levo dose accordingly - estrogen component of levo increases TBG - increases in total t4 and decrease in free t4. hypothyroid unable to produce more hormone in response to low free t4. levo dose needs
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Ultrasound for detail anatomic survey

16. Tx of HELLP syndrome micorangi hem anemia - inc LFT - dec platelet
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
Magneisium sulphate; give antihypergensive when bp >160/105
Pregnancy - contraception - STD - substance abuse - emotional illness

17. should patient continue antiepileptic during pregnancy?
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Yea. except valproate. give high dose folic acid patient is conneuing preg
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Failure of fetal shoulder to pass through maternal pelvis

18. How HIV risk of transmission to newborn is decreased
Giving zidovudine to pregnant and newborn; it deceased by 70%.
No.
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%

19. HRT in postmenopausal women vs younger patient with premat ovarian failure
Women with low body weight develop amenorrhoea if they engaged in sports/physical activity; exercise ---dec pulsatile secretion of LH---dec estrogen---osteopenia/osteoporosis/amenorrhoea
X linked recessive due to deficiency of factor VIII
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur

20. What is extremely ominous sign of preecalmsia/eclampsia
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Retinal hemorrahge. represents vascular damage -
Ultrasound for detail anatomic survey
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli

21. Tx of complicated UTI (fever/flank pain)
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Self sufficient - no longer living with parent. parents of children
Amniocentesis
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg

22. hemophillia- mom carrier and dad healthy
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down
Amoxi - cephalexin - nitrofurantoin
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient

23. eisenmenger syndrome
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided
Congenital L to R shunt (VSD/PDA/ASD) untreated for long; pulmonary vascular resistance exceed systemic vascular system--reversal of shunt (R to L) and cyanosis
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Animal studies showed an adverse effect; but no studies done in pregnant women or animals

24. rate of transmission of HPV from anogenital wart during delivery
Ultrasound. since helical CT scan is contraindicated
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
<1%; no special measure is taken if prevent transmission
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

25. herpes gestationis or pemphigoid gestationis
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Magneisium sulphate; give antihypergensive when bp >160/105
Self sufficient - no longer living with parent. parents of children
Incr perinatal mortality - pretem delivery - premature and LBW

26. fetus in breech presentation in 28 weeks
Most will be in cephalic by 34-36 weeks - by 36 weeks 6% will be in breech and one third will be convert to cephalic during delivery
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided
Failure of fetal shoulder to pass through maternal pelvis

27. criteria for gestational transient thyrotoxicosis?
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Incr perinatal mortality - pretem delivery - premature and LBW
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties

28. How to evaluate nephrolithiasis in pregnancy?
Retinal hemorrahge. represents vascular damage -
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
Ultrasound for detail anatomic survey
Ultrasound. since helical CT scan is contraindicated

29. How to confirm bacterial vaginosis
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Clue cells in the vaginal smear
Failure of fetal shoulder to pass through maternal pelvis

30. What is the complication of chorionic villous sampling
No.
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Amoxi - cephalexin - nitrofurantoin
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%

31. When to renal US in complicated UTI in preg

32. risk factor for postpartum endometritis
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Indinavir; it precipitate in urine and obstruct urinary flow.
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
Received inadequate dose post partum in the events of fetomaternal hemorrhage; rosette test-qualiatively detemine and Kleihauer-Betke use cytometry of fetal red cells; dose of anti-D should adjusted based on KB test.

33. what if patient has less than 2 of centor criteria
Likely viral meningitis
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate
Androgen insensitvity due to mutation of AR gene; 46xy but testosterone doesn't work and converted to estrogen. female phenotype - pw amenorrhoes - inguinal mass (testes) - bind vaginal pouch
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.

34. Is ocp contraindicated in migraine?
Betamethason - dexamethason IM
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID

35. what test is absolutely necessary before treating an woman at reproductive age
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Pregancy test
Lactating women
Amoxi - cephalexin - nitrofurantoin

36. What is the recommendation for Ca and vitamin supplement >50yrs women
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Ca 1200mg and vitamin 400-80o IU
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Ultrasound. since helical CT scan is contraindicated

37. hemophillia
X linked recessive due to deficiency of factor VIII
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;

38. long term prognosis of congenital HOCM
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.

39. When to repeat pap in 12 months
Low risk women with satisfactory pap and negative cytology result
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common

40. Tx of LSIL
Atrophic vaginitis 50-60%; endometrial ca 10%
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
Most will be in cephalic by 34-36 weeks - by 36 weeks 6% will be in breech and one third will be convert to cephalic during delivery

41. Klinefelter
Animal studies showed an adverse effect; but no studies done in pregnant women or animals
Male phenotype - smalle testes - gynecomastia
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Betamethason - dexamethason IM

42. pregnancy category C drugs
Animal studies showed an adverse effect; but no studies done in pregnant women or animals
Magneisium sulphate; give antihypergensive when bp >160/105
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Received inadequate dose post partum in the events of fetomaternal hemorrhage; rosette test-qualiatively detemine and Kleihauer-Betke use cytometry of fetal red cells; dose of anti-D should adjusted based on KB test.

43. what component of cervix has greatest risk for neoplasia?
Junction of squamus and glandular cells at the external cervical os
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI

44. SAAG <1.1
Incr perinatal mortality - pretem delivery - premature and LBW
Result is influenced by observer's prior knowledge of the details of studs
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation

45. How to measure SAAG?
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Ca 1200mg and vitamin 400-80o IU
Androgen insensitvity due to mutation of AR gene; 46xy but testosterone doesn't work and converted to estrogen. female phenotype - pw amenorrhoes - inguinal mass (testes) - bind vaginal pouch

46. How to tx anogenital warts

47. retroverted uterus

48. laser cone biopsy for CIN and hx of spont abortion
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
24-28w; screeing at first with 50g GTT - >140 BG after 1h - should have 3h GTT with 100gm on a fasting state. measure at 0 -1 -2 -3 hr; values more than 95 - 180 - 155 - 140 are abnormal; more than 2 values diagnostic
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required

49. pregnancy risk category B drugs
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Mother taken lithium during pregnancy
Cross placenta--concentrate in amniotic fluid---fetal arthopathy

50. Tx of chlamydia in pregnancy
Prenatal screening; us at 10 weeks for measurement of nuchal translucency; serum markers first trimester (papp-A); and 2nd trimester (alpha feto protein - hcg - unconjugated estriol - dimeric inhibin-A)
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Crosses placenta - cause bilat congenital deafness -
Nitrofurantoin-first gen cephalosporn