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USMLE Step3 Gynecology Obstetrics

Subjects : health-sciences, usmle-step-3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. When do we screen gestational dm
They have glycogen deposition in myocardium mostly affected inthe interventricular septum
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided
Hepatic cirrhosis
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

2. congenital dilated cardiomyopathy
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
Lactating women
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Inherited metabolic disorders - intrauterine infections - cri du chat

3. Tx of PMS/PMDD

4. rate of transmission of HPV from anogenital wart during delivery
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
<1%; no special measure is taken if prevent transmission

5. first step in shoulder dystocia?

6. congenital hypoplastic left heart; normal at birth then develop heart failure
Clue cells in the vaginal smear
Hypoplastic left heart syndrom
Cervix hasn't dilated beyond 4 cm in 2 h
Intrauterine exposure to virus causing pericarditis

7. indication of chorionic villous sampling
95 and 120
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down

8. indication of cesarean section in breech?
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
Large fetus - hyperextended head - footling breech - fetal distress
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.
Route of delivery (3% of vaginal birth and 15-30% of c-section)

9. What is shoulder dystocia?
80% develop psychiatric illness - depression
On or after 37 weeks;
Failure of fetal shoulder to pass through maternal pelvis
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy

10. rec for folate supple during preg
Carbamazepine and valproate - ask why
Increase in pregnancy; decreases in preeclam/eclamsia
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
0.4-4mg daily for >1m prior conception to entire first trimester

11. Tx of UTI in pregnancy
Amoxi - cephalexin - nitrofurantoin
Inherited metabolic disorders - intrauterine infections - cri du chat
2g po single dose; discontinue breast feeding for 12-24 hours
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur

12. 6 cm cervical dilation - no improv in 2 h -fetus in zero station
X linked recessive due to deficiency of factor VIII
80% develop psychiatric illness - depression
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
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;

13. pregnancy risk category B drugs
Animal studies showed an adverse effect; but no studies done in pregnant women or animals
Long h/o pruritus - 65-75 - vulvar lump/mass
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
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women

14. HRT in postmenopausal women vs younger patient with premat ovarian failure
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)
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
Very bad. both animals and human studies showed fetal risk

15. How HIV risk of transmission to newborn is decreased
Giving zidovudine to pregnant and newborn; it deceased by 70%.
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
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
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization

16. time of last tetanus booster >10 or unknown
FSH - LH is increased at certain point of regular mens
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Amniocentesis
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID

17. Pap shows HGSIL
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
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

18. Tx of PID
Carbamazepine and valproate - ask why
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
FSH - LH is increased at certain point of regular mens
Incr perinatal mortality - pretem delivery - premature and LBW

19. 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.
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
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
Pregancy test

20. should patient continue antiepileptic during pregnancy?
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
Yea. except valproate. give high dose folic acid patient is conneuing preg
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID

21. time of last tetanus booster <10 yrs
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
Male phenotype - smalle testes - gynecomastia
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant

22. dx postpartum endometritis
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
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
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.

23. how lactating mother will get metronidazol
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;
FSH - LH is increased at certain point of regular mens
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
2g po single dose; discontinue breast feeding for 12-24 hours

24. complication of sickle cell during pregnancy
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Chorionic villous sampling or amniocentesis for fetal karyotyping
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy

25. pregnancy category X
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
Very bad. both animals and human studies showed fetal risk
Crosses placenta - cause bilat congenital deafness -
Failure of fetal shoulder to pass through maternal pelvis

26. when young female can develop osteoporosis?
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
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
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk

27. if ultrasound neg or inconclusive in increasd AFP - next step
Intrauterine exposure to virus causing pericarditis
Amniocentesis
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Pregnancy - contraception - STD - substance abuse - emotional illness

28. positive GBS culture in pregnancy
10 days course of ab x immediatly
Lactating women
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Amniocentesis

29. When to call a pap smear unsatisfactory?
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
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
<5000 well visualized squamus cells/contain blood

30. High anti D titre despite receiving anti-D immunoglobulin
Increase serum free T4; serum Tsh <0.01
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.
80% develop psychiatric illness - depression
If patient has positive PPD and no active TB in CXR or sputum

31. lower lobe pneumonia- possible etiology
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS
No.
Pregnancy - contraception - STD - substance abuse - emotional illness
Inherited metabolic disorders - intrauterine infections - cri du chat

32. what component of cervix has greatest risk for neoplasia?
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
Junction of squamus and glandular cells at the external cervical os
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Carbamazepine and valproate - ask why

33. what to test in perimenopause - FSH or LH
FSH - LH is increased at certain point of regular mens
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Platelet <50k - or develop early in pregnancy

34. How to dx down syndrom?
If patient doesn't improve in 48h to r/o perinephric abscess or calculi
Animal studies showed an adverse effect; but no studies done in pregnant women or animals
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
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)

35. bacteriuria diagnosed incidentaly during pregnancy with no symptoms
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
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
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1

36. When to dx ITP?
Semen - vaginal fluid - any fluids contain visible vlood; not applicable to urine - sweat - tears - sptum - vomitus - nasal secretio - feces with no visible lboo
Likely viral meningitis
Platelet <50k - or develop early in pregnancy
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w

37. risk factor for postpartum endometritis
<5000 well visualized squamus cells/contain blood
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Betamethason - dexamethason IM

38. can eisenmenger patient have pregnancy
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
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
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester

39. How to measure SAAG?
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
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
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx

40. failure rate of OCP
Nitrofurantoin-first gen cephalosporn
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Clue cells in the vaginal smear

41. complications of PMS?
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)
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
80% develop psychiatric illness - depression
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications

42. copious frothy green vaginal discharge - fishy odor - vulvar and vaginal pruritus - or dysuria
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Giving zidovudine to pregnant and newborn; it deceased by 70%.
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S

43. retroverted uterus

44. bugs for aspiration pneumonia?
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Mouth flora anerobes and aerobes
Amoxi - cephalexin - nitrofurantoin

45. vaginal disch - ph>4.5 - presence of clue cells in wet mount - foul smelling fishy odor - koh application-amine odor
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
Failure of fetal shoulder to pass through maternal pelvis
Very bad. both animals and human studies showed fetal risk
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy

46. How to confirm bacterial vaginosis
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
Participants selected are not representative; more or less in a particular population; prevention; randomization
Mouth flora anerobes and aerobes
Clue cells in the vaginal smear

47. patient on ocp - How to adjust levothyroxine dose?
Increase serum free T4; serum Tsh <0.01
Copper intrauterine device
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
Ultrasound. since helical CT scan is contraindicated

48. Klinefelter
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Eqinovarus foot - amniotic fluid loss
Male phenotype - smalle testes - gynecomastia
0.4-4mg daily for >1m prior conception to entire first trimester

49. Tx of chlamydia
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common

50. Tx of HELLP syndrome micorangi hem anemia - inc LFT - dec platelet
Long h/o pruritus - 65-75 - vulvar lump/mass
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Magneisium sulphate; give antihypergensive when bp >160/105