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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. susceptibility bias
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version

2. first step in shoulder dystocia?

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3. complication of sickle cell during pregnancy
Intrauterine exposure to virus causing pericarditis
Low risk women with satisfactory pap and negative cytology result
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out

4. what drugs are used to decrease riks of infant resp distress syndrome in cases of preterm delivery
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
X linked recessive due to deficiency of factor VIII
Betamethason - dexamethason IM
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%

5. pregnancy category X
Atrophic vaginitis 50-60%; endometrial ca 10%
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.
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Very bad. both animals and human studies showed fetal risk

6. vaccine sched for infants of HepB pos mother
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Participants selected are not representative; more or less in a particular population; prevention; randomization
Ca 1200mg and vitamin 400-80o IU
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI

7. selection bias
Large fetus - hyperextended head - footling breech - fetal distress
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Amniocentesis
Participants selected are not representative; more or less in a particular population; prevention; randomization

8. Tx of UTI in pregnancy
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
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
Copper intrauterine device
Amoxi - cephalexin - nitrofurantoin

9. OCP
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Decreases risk of breast and ovarian ca

10. pregnancy risk category A
Giving zidovudine to pregnant and newborn; it deceased by 70%.
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
RCT shows no fetal risk or possiblity

11. pg I2 and throboxane A2 ratio
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
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
Increase in pregnancy; decreases in preeclam/eclamsia
Inherited metabolic disorders - intrauterine infections - cri du chat

12. indication of cesarean section in breech?
Increase in pregnancy; decreases in preeclam/eclamsia
Large fetus - hyperextended head - footling breech - fetal distress
RCT shows no fetal risk or possiblity
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

13. contamination bias
Control group gets tx or intervention - thus decreases difference between control vs tx
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
2g po single dose; discontinue breast feeding for 12-24 hours
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy

14. Should women continue HAART during pregnancy?
Low risk women with satisfactory pap and negative cytology result
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided
95 and 120
Magneisium sulphate; give antihypergensive when bp >160/105

15. differences between PMS and PMDD
Retinal hemorrahge. represents vascular damage -
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down

16. budd chiairi syndrom
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1

17. What is most common cause of ascitis in us
Hepatic cirrhosis
On or after 37 weeks;
<5000 well visualized squamus cells/contain blood
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.

18. What HIV med cause crystal induced nephropathy?
Indinavir; it precipitate in urine and obstruct urinary flow.
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
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
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.

19. How to evaluate nephrolithiasis in pregnancy?
Ultrasound. since helical CT scan is contraindicated
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Copper intrauterine device
Indinavir; it precipitate in urine and obstruct urinary flow.

20. Tx of PMS/PMDD

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21. retroverted uterus

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22. differential trichominiasis and cadiidiasis?
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
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

23. breast feeding with anti-epileptic drugs?
If patient doesn't improve in 48h to r/o perinephric abscess or calculi
Nitrofurantoin-first gen cephalosporn
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms

24. lower lobe pneumonia- possible etiology
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
FSH - LH is increased at certain point of regular mens

25. What contraception is best for sickle cell patient
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Very bad. both animals and human studies showed fetal risk
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream

26. How to dx down syndrom?
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
Not encouraged; no clear study
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)
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S

27. congenital dilated cardiomyopathy
Inherited metabolic disorders - intrauterine infections - cri du chat
Nitrofurantoin-first gen cephalosporn
10 days course of ab x immediatly
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess

28. herpes gestationis or pemphigoid gestationis
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Magneisium sulphate; give antihypergensive when bp >160/105
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine

29. dysmenorrhoea after years of painless menstruation
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
<1%; no special measure is taken if prevent transmission

30. How to confirm bacterial vaginosis
Copper intrauterine device
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
<5000 well visualized squamus cells/contain blood
Clue cells in the vaginal smear

31. atrophic vaginitis
Amniocentesis
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
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
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream

32. Is ocp contraindicated in migraine?
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Amniocentesis
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk

33. What is shoulder dystocia?
Very bad. both animals and human studies showed fetal risk
Failure of fetal shoulder to pass through maternal pelvis
2g po single dose; discontinue breast feeding for 12-24 hours
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS

34. How to dx overflow incontinence?
Hypoplastic left heart syndrom
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow

35. association of myelomeningocele?
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
Decreases risk of breast and ovarian ca
If patient doesn't improve in 48h to r/o perinephric abscess or calculi
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

36. stress incontinence
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
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
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine

37. When to repeat pap in 12 months
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
Low risk women with satisfactory pap and negative cytology result
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Increase in pregnancy; decreases in preeclam/eclamsia

38. Tx of chlamydia in pregnancy
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
Likely viral meningitis
Hypoplastic left heart syndrom

39. standard test performed in prenatal visit?
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)
Failure of fetal shoulder to pass through maternal pelvis
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
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap

40. does normal HbA1c eliminate need for dm screening
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Ultrasound. since helical CT scan is contraindicated
No.
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m

41. ASCUS on pap smear
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
Junction of squamus and glandular cells at the external cervical os
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Control group gets tx or intervention - thus decreases difference between control vs tx

42. what if patient has less than 2 of centor criteria
Likely viral meningitis
Not encouraged; no clear study
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products

43. Can patient with sickle cell disesase get ocp?
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Incr perinatal mortality - pretem delivery - premature and LBW
Not encouraged; no clear study

44. When to dx gestational thrombocytopenia?
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;

45. teratogenicity of genta
Crosses placenta - cause bilat congenital deafness -
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.
Chorionic villous sampling or amniocentesis for fetal karyotyping
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%

46. What is likelihood ratio?
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out
X linked recessive due to deficiency of factor VIII
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;
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester

47. eisenmenger syndrome
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
0.4-4mg daily for >1m prior conception to entire first trimester
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester

48. When to give INH prophylaxis
If patient has positive PPD and no active TB in CXR or sputum
Very bad. both animals and human studies showed fetal risk
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
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

49. pregnancy category D drugs
10 days course of ab x immediatly
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Indinavir; it precipitate in urine and obstruct urinary flow.
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow

50. complications of PMS?
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
Retinal hemorrahge. represents vascular damage -
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
80% develop psychiatric illness - depression