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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. complication of sickle cell during pregnancy
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk

2. most common cause of hyperthyroidism in pregnant women
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
<1%; no special measure is taken if prevent transmission
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester

3. Why fluoroquinoloes contraindicate in pregnancy?
Pregnancy - contraception - STD - substance abuse - emotional illness
Lactating women
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down
Cross placenta--concentrate in amniotic fluid---fetal arthopathy

4. ASCUS on pap smear
0.4-4mg daily for >1m prior conception to entire first trimester
Not encouraged; no clear study
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
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required

5. criteria of hyperthyroidism in pregnancy?
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;
Magneisium sulphate; give antihypergensive when bp >160/105
Increase serum free T4; serum Tsh <0.01
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

6. hemophillia- mom carrier and dad healthy
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Long h/o pruritus - 65-75 - vulvar lump/mass
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable

7. first step in shoulder dystocia?

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8. What is the complication of chorionic villous sampling
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%

9. When to call a pap smear unsatisfactory?
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
<5000 well visualized squamus cells/contain blood
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m

10. risk factor for postpartum endometritis
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Lactating women
Mother taken lithium during pregnancy

11. how maternal dm cause HOCM in infants
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
They have glycogen deposition in myocardium mostly affected inthe interventricular septum
Likely viral meningitis
FSH - LH is increased at certain point of regular mens

12. emergency contraception
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
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.

13. Klinefelter
Male phenotype - smalle testes - gynecomastia
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
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

14. criteria for gestational transient thyrotoxicosis?
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
Cervix hasn't dilated beyond 4 cm in 2 h
Trichomonas; petetchia in vagina and cervix

15. How HIV risk of transmission to newborn is decreased
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
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
X linked recessive due to deficiency of factor VIII
Giving zidovudine to pregnant and newborn; it deceased by 70%.

16. Pap shows HGSIL
If patient has positive PPD and no active TB in CXR or sputum
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
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
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.

17. risks of maternal DM
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
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
Chorionic villous sampling or amniocentesis for fetal karyotyping
Carbamazepine and valproate - ask why

18. teratogenicity of sulphonylurea?
Increase serum free T4; serum Tsh <0.01
RCT shows no fetal risk or possiblity
Ultrasound. since helical CT scan is contraindicated
Fetal hyperinsulinemia and hypoglycemia and macrosomia

19. parameters measured in subsequent visit of pregnancy?
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
2g po single dose; discontinue breast feeding for 12-24 hours
Pregancy test
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)

20. if AFP inc - next step?
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
Ultrasound for detail anatomic survey

21. What are the absolute contraindication of OCP?
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Decreases risk of breast and ovarian ca

22. breast feeding with anti-epileptic drugs?
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
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.
Ultrasound for detail anatomic survey

23. congenital dilated cardiomyopathy
<1%; no special measure is taken if prevent transmission
Inherited metabolic disorders - intrauterine infections - cri du chat
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
Male phenotype - smalle testes - gynecomastia

24. bilateraal breast discharge
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Mother taken lithium during pregnancy
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy

25. what drugs used to tx UTI in pregnacy
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
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Nitrofurantoin-first gen cephalosporn
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient

26. What HIV med cause crystal induced nephropathy?
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Indinavir; it precipitate in urine and obstruct urinary flow.
Amoxi - cephalexin - nitrofurantoin
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI

27. straberry cervix
Pregnancy - contraception - STD - substance abuse - emotional illness
Trichomonas; petetchia in vagina and cervix
X linked recessive due to deficiency of factor VIII
Low risk women with satisfactory pap and negative cytology result

28. 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
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
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)
Amniocentesis

29. Tx of UTI in pregnancy
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Long h/o pruritus - 65-75 - vulvar lump/mass
Amoxi - cephalexin - nitrofurantoin
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

30. Is ocp contraindicated in migraine?
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Large fetus - hyperextended head - footling breech - fetal distress
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy
Retinal hemorrahge. represents vascular damage -

31. What is centor's criteria?
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
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
Pregancy test

32. budd chiairi syndrom
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow

33. how lactating mother will get metronidazol
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
2g po single dose; discontinue breast feeding for 12-24 hours
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.

34. differential trichominiasis and cadiidiasis?
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Inherited metabolic disorders - intrauterine infections - cri du chat
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
Magneisium sulphate; give antihypergensive when bp >160/105

35. hemophillia
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
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
10 days course of ab x immediatly
X linked recessive due to deficiency of factor VIII

36. rec for folate supple during preg
Mouth flora anerobes and aerobes
0.4-4mg daily for >1m prior conception to entire first trimester
95 and 120
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI

37. history of preeclampsia
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Carbamazepine and valproate - ask why
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow

38. pruritus in pregnancy
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used

39. rate of transmission of HPV from anogenital wart during delivery
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
Result is influenced by observer's prior knowledge of the details of studs
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
<1%; no special measure is taken if prevent transmission

40. what drugs are used to decrease riks of infant resp distress syndrome in cases of preterm delivery
Betamethason - dexamethason IM
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
Mother taken lithium during pregnancy

41. herpes gestationis or pemphigoid gestationis
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur

42. patient on ocp - How to adjust levothyroxine dose?
Self sufficient - no longer living with parent. parents of children
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
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
If patient has positive PPD and no active TB in CXR or sputum

43. What is shoulder dystocia?
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Self sufficient - no longer living with parent. parents of children
Failure of fetal shoulder to pass through maternal pelvis

44. 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
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
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
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w

45. When to dx ttp?
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
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;
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI

46. standard test performed in prenatal visit?
Chorionic villous sampling or amniocentesis for fetal karyotyping
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap

47. breast development but no pubic/axillary hair

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48. unilateral breast discharges
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Very bad. both animals and human studies showed fetal risk
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy

49. when an adolescent will get care without parental consent
On or after 37 weeks;
Pregnancy - contraception - STD - substance abuse - emotional illness
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc

50. When to give INH prophylaxis
If patient has positive PPD and no active TB in CXR or sputum
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Carbamazepine and valproate - ask why
10 days course of ab x immediatly