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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. pregnancy risk category A
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
RCT shows no fetal risk or possiblity
Giving zidovudine to pregnant and newborn; it deceased by 70%.

2. Tx of UTI in pregnancy
Participants selected are not representative; more or less in a particular population; prevention; randomization
2g po single dose; discontinue breast feeding for 12-24 hours
Amoxi - cephalexin - nitrofurantoin
Low risk women with satisfactory pap and negative cytology result

3. Who uses progesterone only pills or mini pill
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Lactating women
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

4. how ppd works?
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
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

5. for what drugs do you need supplementation of high dose folic acid during pregnancy
Carbamazepine and valproate - ask why
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided
<5000 well visualized squamus cells/contain blood

6. contamination bias
Long h/o pruritus - 65-75 - vulvar lump/mass
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Control group gets tx or intervention - thus decreases difference between control vs tx

7. breast feeding with anti-epileptic drugs?
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Ultrasound. since helical CT scan is contraindicated
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Carbamazepine and valproate - ask why

8. SAAG <1.1
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI

9. What is the cause infertility in PCOD
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Trichomonas; petetchia in vagina and cervix
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD

10. ASCUS on pap smear
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
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
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream

11. breast development but no pubic/axillary hair

12. criteria for gestational transient thyrotoxicosis?
Chorionic villous sampling or amniocentesis for fetal karyotyping
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms

13. what if patient has less than 2 of centor criteria
0.4-4mg daily for >1m prior conception to entire first trimester
Likely viral meningitis
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
Mother taken lithium during pregnancy

14. differential dx of increased AFP in pregnant mom?
Male phenotype - smalle testes - gynecomastia
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
Route of delivery (3% of vaginal birth and 15-30% of c-section)
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)

15. How to evaluate nephrolithiasis in pregnancy?
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
Ultrasound. since helical CT scan is contraindicated
Cervix hasn't dilated beyond 4 cm in 2 h
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination

16. differences between PMS and PMDD
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
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
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present

17. lower lobe pneumonia- possible etiology
On or after 37 weeks;
Likely viral meningitis
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS
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

18. rec for folate supple during preg
X linked recessive due to deficiency of factor VIII
0.4-4mg daily for >1m prior conception to entire first trimester
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
Low risk women with satisfactory pap and negative cytology result

19. if ultrasound neg or inconclusive in increasd AFP - next step
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
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Self sufficient - no longer living with parent. parents of children
Amniocentesis

20. rate of transmission of HPV from anogenital wart during delivery
<1%; no special measure is taken if prevent transmission
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
0.4-4mg daily for >1m prior conception to entire first trimester

21. 6 cm cervical dilation - no improv in 2 h -fetus in zero station
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Atrophic vaginitis 50-60%; endometrial ca 10%
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Not encouraged; no clear study

22. vaginal disch - ph>4.5 - presence of clue cells in wet mount - foul smelling fishy odor - koh application-amine odor
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Hypoplastic left heart syndrom
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
Atrophic vaginitis 50-60%; endometrial ca 10%

23. positive GBS culture in pregnancy
10 days course of ab x immediatly
If patient has positive PPD and no active TB in CXR or sputum
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Junction of squamus and glandular cells at the external cervical os

24. dysmenorrhoea after years of painless menstruation
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
X linked recessive due to deficiency of factor VIII
Very bad. both animals and human studies showed fetal risk
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy

25. congenital dilated cardiomyopathy
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Inherited metabolic disorders - intrauterine infections - cri du chat
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy

26. Why fluoroquinoloes contraindicate in pregnancy?
Cross placenta--concentrate in amniotic fluid---fetal arthopathy
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties

27. What contraception is best for sickle cell patient
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases

28. Tx of HELLP syndrome micorangi hem anemia - inc LFT - dec platelet
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
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
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%

29. rectocele
No.
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.

30. pregnant adolescent
RCT shows no fetal risk or possiblity
Incr perinatal mortality - pretem delivery - premature and LBW
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

31. How to dx overflow incontinence?
Yea. except valproate. give high dose folic acid patient is conneuing preg
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
Ca 1200mg and vitamin 400-80o IU
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx

32. bacteriuria diagnosed incidentaly during pregnancy with no symptoms
Chorionic villous sampling or amniocentesis for fetal karyotyping
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
0.4-4mg daily for >1m prior conception to entire first trimester

33. criteria of hyperthyroidism in pregnancy?
Incr perinatal mortality - pretem delivery - premature and LBW
2g po single dose; discontinue breast feeding for 12-24 hours
Increase serum free T4; serum Tsh <0.01
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth

34. Pap shows HGSIL
Carbamazepine and valproate - ask why
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
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
Participants selected are not representative; more or less in a particular population; prevention; randomization

35. when an adolescent will get care without parental consent
Pregnancy - contraception - STD - substance abuse - emotional illness
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
X linked recessive due to deficiency of factor VIII
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk

36. How to dx neural tube defects on baby
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI
0.4-4mg daily for >1m prior conception to entire first trimester
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.

37. When do we screen gestational dm
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
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
Junction of squamus and glandular cells at the external cervical os
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common

38. Is ocp contraindicated in migraine?
Hepatic cirrhosis
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Ultrasound for detail anatomic survey

39. What is perimenopause?
Participants selected are not representative; more or less in a particular population; prevention; randomization
Large fetus - hyperextended head - footling breech - fetal distress
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

40. What HIV med cause crystal induced nephropathy?
Copper intrauterine device
Indinavir; it precipitate in urine and obstruct urinary flow.
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester

41. What is the complication of chorionic villous sampling
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
If patient doesn't improve in 48h to r/o perinephric abscess or calculi
Amoxi - cephalexin - nitrofurantoin

42. When to renal US in complicated UTI in preg

43. 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
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd

44. differential trichominiasis and cadiidiasis?
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Ultrasound. since helical CT scan is contraindicated
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
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant

45. When to dx ITP?
Platelet <50k - or develop early in pregnancy
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy
Indinavir; it precipitate in urine and obstruct urinary flow.

46. How to dx anogenital warts (condyloma acuminata)
Participants selected are not representative; more or less in a particular population; prevention; randomization
Pregnancy - contraception - STD - substance abuse - emotional illness
Amniocentesis
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

47. OCP
Decreases risk of breast and ovarian ca
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth

48. What is most frequent vaginal infecton
Magneisium sulphate; give antihypergensive when bp >160/105
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%
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

49. can eisenmenger patient have pregnancy
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
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
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Mouth flora anerobes and aerobes

50. Tx of LSIL
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m
No.
Ultrasound for detail anatomic survey
Mother taken lithium during pregnancy