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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. What is most common cause of ascitis in us
Hepatic cirrhosis
Animal studies showed an adverse effect; but no studies done in pregnant women or animals
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided

2. time of last tetanus booster >10 or unknown
Long h/o pruritus - 65-75 - vulvar lump/mass
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
X linked recessive due to deficiency of factor VIII

3. pregnant women with positive FTA-ABS or treponemal tests
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
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
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient

4. pruritus in pregnancy
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC

5. if ultrasound neg or inconclusive in increasd AFP - next step
Mouth flora anerobes and aerobes
Ultrasound for detail anatomic survey
Chorionic villous sampling or amniocentesis for fetal karyotyping
Amniocentesis

6. Tx of chlamydia
Nitrofurantoin-first gen cephalosporn
Decreases risk of breast and ovarian ca
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
X linked recessive due to deficiency of factor VIII

7. pregnancy risk category A
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.
RCT shows no fetal risk or possiblity
Very bad. both animals and human studies showed fetal risk
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester

8. long term prognosis of congenital HOCM
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Large fetus - hyperextended head - footling breech - fetal distress
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
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously

9. How to dx overflow incontinence?
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;
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Crosses placenta - cause bilat congenital deafness -

10. when endometrial bx indicated in perimenopause?
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Indinavir; it precipitate in urine and obstruct urinary flow.
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx

11. What is likelihood ratio?
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out
Not encouraged; no clear study

12. How to measure SAAG?
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
<1%; no special measure is taken if prevent transmission
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Pregancy test

13. How to dx neural tube defects on baby
2g po single dose; discontinue breast feeding for 12-24 hours
1-2% chance of cervical ca already occured; do colposcopy with endo cervial currettage - if unsatisfactory - LEEP/cone - if satisfactory - cin 2/3 - cryotherapy; other cases-leep/cone or coloposcopy at 6m
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.

14. when an adolescent will get care without parental consent
Pregnancy - contraception - STD - substance abuse - emotional illness
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications

15. How HIV risk of transmission to newborn is decreased
Giving zidovudine to pregnant and newborn; it deceased by 70%.
FSH - LH is increased at certain point of regular mens
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS
Pregnancy - contraception - STD - substance abuse - emotional illness

16. What is extremely ominous sign of preecalmsia/eclampsia
Inherited metabolic disorders - intrauterine infections - cri du chat
Ultrasound for detail anatomic survey
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Retinal hemorrahge. represents vascular damage -

17. What is internal podalic version
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Nitrofurantoin-first gen cephalosporn

18. selection bias
Warty projection in vaginal or ana area; p/w pruritus - bleeding -burning - tenderness - vaginal disch and pain. large lession can p/w difficulty in defecation - intercourse; apply acetic acid to lesion - if it turns white - confirms dx
Participants selected are not representative; more or less in a particular population; prevention; randomization
Clue cells in the vaginal smear
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF

19. Can patient with sickle cell disesase get ocp?
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
Not encouraged; no clear study
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms

20. most common cause of hyperthyroidism in pregnant women
95 and 120
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap

21. When to dx ITP?
Platelet <50k - or develop early in pregnancy
Failure of fetal shoulder to pass through maternal pelvis
Betamethason - dexamethason IM
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI

22. standard test performed in prenatal visit?
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine

23. parameters measured in subsequent visit of pregnancy?
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
Cross placenta--concentrate in amniotic fluid---fetal arthopathy
80% develop psychiatric illness - depression
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk

24. Tx of UTI in pregnancy
Amoxi - cephalexin - nitrofurantoin
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Not encouraged; no clear study
Platelet <50k - or develop early in pregnancy

25. Who uses progesterone only pills or mini pill
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate
Ca 1200mg and vitamin 400-80o IU
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Lactating women

26. should patient continue antiepileptic during pregnancy?
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
Yea. except valproate. give high dose folic acid patient is conneuing preg
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy

27. When to repeat pap in 12 months
2g po single dose; discontinue breast feeding for 12-24 hours
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Low risk women with satisfactory pap and negative cytology result
Retinal hemorrahge. represents vascular damage -

28. what insulin is given in pregnancy?
Indinavir; it precipitate in urine and obstruct urinary flow.
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
<5000 well visualized squamus cells/contain blood

29. complication of sickle cell during pregnancy
80% develop psychiatric illness - depression
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Large fetus - hyperextended head - footling breech - fetal distress
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications

30. How to dx septic abortion
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
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)
0.4-4mg daily for >1m prior conception to entire first trimester
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

31. observer bias

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32. What is cdc recommendation for chlamydia screen in pregnancy
Atrophic vaginitis 50-60%; endometrial ca 10%
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
1-2% chance of cervical ca already occured; do colposcopy with endo cervial currettage - if unsatisfactory - LEEP/cone - if satisfactory - cin 2/3 - cryotherapy; other cases-leep/cone or coloposcopy at 6m
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream

33. criteria for gestational transient thyrotoxicosis?
Copper intrauterine device
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
Atrophic vaginitis 50-60%; endometrial ca 10%

34. dx postpartum endometritis
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy

35. Tx of complicated UTI (fever/flank pain)
RCT shows no fetal risk or possiblity
Ultrasound for detail anatomic survey
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream

36. hemophillia- mom carrier and dad healthy
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
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

37. excessive mentrual bleeding in adolescent
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
DUB resulting from anovulation. anovulation means no progesterone release from C luteum--so unopposed estrogen causes excessive endometrial growth and ultimately outgrows blood supply...tear them down...cause heavy bleeding tx; ocp
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities

38. What is definitive dx of down syndrome?
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Cervix hasn't dilated beyond 4 cm in 2 h
Chorionic villous sampling or amniocentesis for fetal karyotyping
Pregancy test

39. HRT in postmenopausal women vs younger patient with premat ovarian failure
X linked recessive due to deficiency of factor VIII
Do hpv testing --if neg - routine f/you every year - if positive colposcopy---cin2/cin3--tx; if CIN1--repeat pap in 6/12 months---two negative smear--- f/you routine screening - if ASCUS again--colposcopy
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
Increase serum free T4; serum Tsh <0.01

40. retroverted uterus

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41. ebstein anomaly or atrialized right ventricle; p/w cyanosis in infancy
Long h/o pruritus - 65-75 - vulvar lump/mass
Mother taken lithium during pregnancy
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Hypoplastic left heart syndrom

42. differential dx of increased AFP in pregnant mom?
Ca 1200mg and vitamin 400-80o IU
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
Increase serum free T4; serum Tsh <0.01
On or after 37 weeks;

43. what component of cervix has greatest risk for neoplasia?
Junction of squamus and glandular cells at the external cervical os
Large fetus - hyperextended head - footling breech - fetal distress
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Copper intrauterine device

44. copious frothy green vaginal discharge - fishy odor - vulvar and vaginal pruritus - or dysuria
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis

45. Tx of HELLP syndrome micorangi hem anemia - inc LFT - dec platelet
Magneisium sulphate; give antihypergensive when bp >160/105
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Male phenotype - smalle testes - gynecomastia

46. what drugs are used to decrease riks of infant resp distress syndrome in cases of preterm delivery
Magneisium sulphate; give antihypergensive when bp >160/105
Betamethason - dexamethason IM
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1

47. does normal HbA1c eliminate need for dm screening
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
No.
Warty projection in vaginal or ana area; p/w pruritus - bleeding -burning - tenderness - vaginal disch and pain. large lession can p/w difficulty in defecation - intercourse; apply acetic acid to lesion - if it turns white - confirms dx
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester

48. What are the absolute contraindication of OCP?
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
Control group gets tx or intervention - thus decreases difference between control vs tx
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)

49. vulvar ca
<1%; no special measure is taken if prevent transmission
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Long h/o pruritus - 65-75 - vulvar lump/mass
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

50. When to give INH prophylaxis
If patient has positive PPD and no active TB in CXR or sputum
Lactating women
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap