Transcript Short questions

• It must include nearly all parts in the
cutticulum
• Do not put 2 answers for the same question.
• There are many different models.
• Read the questions precisely , take care of
the words ( EXCPT, CORRECT, INCORRECT )
• Sources ( Study guide, Lange case file, Obs. &
Gyne. Books , Text books )
‫‪Cases + Short questions‬‬
‫‪ 4‬حاالت( ‪ 2‬نساء و ‪ 2‬والدة ) و كل حالة ‪ 5‬أسئلة =‬
‫‪ 20‬سؤال‬
‫كل سؤال ‪ 5‬درجات تقريبا( ألن ممكن سؤال ‪ 4‬و ممكن‬
‫سؤال ‪ 6‬درجات مثال ) لذا ‪ 100 =20x5‬درجة‬
‫‪ 10‬أسئلة قصيرة كل سؤال ‪ 5‬درجات = ‪ 50‬درجة‬
‫‪‬لذا المجموع ‪ 30‬سؤال‬
‫‪‬كل سؤال من ال ‪ 30‬سؤال تقريبا‬
‫‪ 3.5‬دقائق يصل مجموع الوقت الى ‪ 105‬ق‬
‫‪ ‬المراجعة ‪ 15‬ق‬
Cases + Short questions
4 Cases ( 2 gynae, 2 Obs. )
5 questions for every case, 5 marks for each
questions= 4x5x5 = 100 marks
10 short questions , 5 marks for each question
So 10x5= 50 marks
MCQs
Benign cystic teratoma (dermoid cyst):
All are INCORRECT EXCEPT
A. It is the commonest ovarian tumor during
menopause.
B. It causes no harm to the patient when ruptures.
C. Are germ cell tumors. 
D. Never turn into malignant tumor.
E. Conservative follow up is an option.
Risk factors of endometrial hyperplasia DO NOT
include:
A.
B.
C.
D.
E.
Anovulatory disorders.
Chronic endometritis. 
Obesity
Tamoxifen.
Unopposed excessive estrogen.
Fibroid uterus may be associated with the
following EXCEPT:
A.
B.
C.
D.
E.
Precocious puberty 
Menorrhagia
Metrorrhagia
Postmenopausal bleeding
Frequency of micturition
The following is the essential step in diagnosis and
staging of pelvic endometriosis:
A.
B.
C.
D.
E.
Laparoscopy 
CA-125
Biopsy form the suspicious nodules
Ultrasonography
Hysteroscopy
The INCORRECT statement regarding
uretrovaginal fistula:
A. Might happen during complicated vaginal surgery
in third degree uterine prolapse.
B. Might happen during surgery for broad ligament
tumors.
C. Obstetric causes are the most common cause. 
D. Injury of the ureter may be at the level of the
pelvic brim
E. Surgical treatment involves laparotomy.
Regarding tuberculosis of the genital tract all the
following are correct EXCEPT:
A.
B.
C.
D.
E.
The tubes are the commonest site.
It is detected in 5% of infertile patients.
Infection is usually sexually transmitted. 
The treatment is mainly medical.
Menstrual disorders are common.
As regards follicle stimulating hormone, all the
following are correct EXCEPT:
A. It stimulates spermatogenesis.
B. Its plasma concentration is high in Klinefelter
syndrome.
C. It stimulates ovarian estrogen production.
D. It is secreted by basophilic cells of the
adenohypophysis.
E. It prevents regression of the corpus luteum. 
The following is characteristic of
Sheehan syndrome:
– Profuse lactation
– Amenorrhea 
– Hyperthyroidism
– Renal insufficiency
– Cushinoid faces
The following are contraindications to using
combined oral contraceptives EXCEPT:
A.
B.
C.
D.
E.
Pulmonary embolus
Porphyria
Sickle-cell disease
DVT
Depression 
The following vessels are branches of the
internal iliac artery EXCEPT:
A.
B.
C.
D.
E.
Uterine artery.
Obliterated umbilical artery.
Pudendal artery.
Superior rectal artery. 
Vaginal artery.
The following about Candidal infection are
correct EXCEPT:
A.
B.
C.
D.
E.
The infection is common with pregnancy
Vaginal PH is usually alkaline. 
Vulval itching may occur.
Vaginal isoconazole or miconazole are effective.
The organism is yeast-like.
Symptoms of adenomyosis uteri include all the
following except
A.
B.
C.
D.
E.
Menorrhagia
Dysmenorrhea
Diurnal frequency
Abdominal swelling
hot flushes 
A 32-year-old woman complains of a vulval fishy odor
and a vaginal discharge. The speculum examination
reveals an erythematous vagina and punctuations of the
cervix. Which is the MOST LIKELY diagnosis?
A.
B.
C.
D.
E.
Candidal vaginitis
Trichomonal vaginitis 
Bacterial vaginosis
Human papilloma virus
Herpes simplex virus
He correct statement about the
decidua is:
A. It is modified endometrium of pregnancy.
B. It is due to action of estrogen on the
endometrium.
C. The decidua basalis is the part overlying the
embryo.
D. Does not protect against the invasive power of
trophoblast.
E. Is anatomically divided into four parts.
Sure signs of pregnancy include all of the following
EXCEPT:
A.
B.
C.
D.
Palpation of fetal parts.
Inspection & palpation of fetal movements.
Auscultation of uterine soufflé.
Detection of fetus by ultrasonography.
All of the following are causes of oversized
uterus EXCEPT:
A.
B.
C.
D.
E.
Incorrect dates.
Transverse lie.
Macrosomic fetus.
Hydrocephalus.
Polyhydramnios.
Warning symptoms during pregnancy
DO NOT include:
A.
B.
C.
D.
E.
Bleeding per vagina.
Sudden loss of fluid per vagina.
Abdominal pain.
Leg cramps.
Decreased fetal kicks.
Indications of amniocentesis include:
A.
B.
C.
D.
E.
Diagnosis of chromosomal anomalies.
Bilirubin estimation in Rh isoimmunization.
Estimation of fetal lung maturity.
All of the above.
B & C only.
The following statements regarding obstetric
ultrasound are correct EXCEPT:
A.
B.
C.
D.
It can be used with amniocentesis.
It might induce a significant risk to the fetus. 
It can diagnose placental grading.
It is a useful tool in the assessment of amniotic
fluid volume.
E. It could estimate the approximate intrauterine
fetal weight.
The occipto frontal diameter:
A. Extends from occipital protuberance to center of
bregma.
B. Measures 9.5 cm at term.
C. Is the diameter of engagement in after coming
head of breech.
D. Is the diameter of engagement in face
presentation with a fully extended head.
Caput succedaneum
A. is due to prolonged pressure on fetal head by
maternal tissues. 
B. is always few millimeters in thickness.
C. does not cross suture lines.
D. indicates that the fetus was dead during labor.
In management of multifetal pregnancy, the
following is true:
A. Twin pregnancy is considered as a high risk
pregnancy. 
B. The lower the fetal weight, the safer the vaginal
route of delivery.
C. The larger the fetal number, the more small the fetal
weight and the safer vaginal route of delivery.
D. Mono-amniotic twins are associated have less
perinatal mortality than diamniotic twins.
E. If the first twin is presenting by the breech internal
podalic version is indicated.
Cord presentation is
A. Descent of the umbilical cord below the
presenting part after ROM.
B. Descent of the umbilical cord below the
presenting part before ROM.
C. Presence of the umbilical cord beside the
presenting part.
D. Presence of the umbilical cord above the
presenting part.
Regarding shoulder dystocia, which is
CORRECT?
A.
B.
C.
D.
E.
It is not related to maternal diabetes mellitus.
Arrest occurs at pelvic inlet.
Oligohydramnios is a predisposing condition.
Most cases can be resolved by fundal pressure.
Facial palsy is a possible complication.
The CORRECT statement regarding ruptured
uterus:
A. More common in nulliparous than multiparous
women.
B. More common with malpresentations. 
C. Is classified into mild, moderate and severe.
D. Previous uterine scar must rupture in
consequence to vaginal delivery.
E. Increases the fetal mortality but not the
maternal mortality.
The following IS NOT a risk factor for primary
postpartum hemorrhage:
A.
B.
C.
D.
E.
Maternal anemia.
Intrauterine growth retardation. 
History of a previous postpartum hemorrhage.
Uterine fibroids.
Mismanagement of 3rdstage of labor.
As regards acute uterine inversion, the
INCORRECT statement is:
A. It only occurs with a relaxed uterus.
B. It is usually caused by applying fundal pressure.
C. It is managed by immediate removal of placenta
before reposition of the uterus. 
D. It can be managed by increasing the hydrostatic
pressure in the vagina.
E. Maintaining sufficient intravenous lines is
essential.
Coagulation failure IS NOT a major
complication of the following:
A.
B.
C.
D.
E.
Amniotic fluid embolus.
Abruptio placenta.
Placenta previa.
Gram-negative septicemia.
HELLP syndrome.
Causes of acute abdomen during pregnancy
include the following EXCEPT:
A.
B.
C.
D.
E.
Placenta abruption.
Complicated fibroid.
Ruptured tubal pregnancy.
Complicated ovarian cyst.
Placenta previa.
Maternal mortality refers to the number of maternal
deaths that occur as the result of the reproductive
process per:
A.
B.
C.
D.
E.
1000 births.
10.000 births.
100.000 births.
10.000 live births.
100.000 live births.
Which IS NOT a sign of hyaline membrane
disease (RDS):
A.
B.
C.
D.
E.
Increased respiratory rate.
Grunting respiration.
Chest wall retraction during inspiration.
Retraction of the subsoctal area.
Jaundice.
Uterine stimulants include all of the following
EXCEPT:
A.
B.
C.
D.
Oxytocin.
Ritodrine.
Ergometrine.
Prostaglandins.
A 30-year-old G1 P1 who underwent a cesarean
section 3 days previously has a fever of 40˚ C. The
wound is indurated and erythematous. Which of the
following is the best management?
A.
B.
C.
D.
E.
Initiation of intravenous ampicillin.
Initiation of intravenous heparin.
Corticosteroids therapy.
Placement of a warm compress on the wound.
Wound drainage.
Cases + Short questions
Take care of the Language
mistakes & the Fatal
mistakes
Case number 1
• A 22 year old Primigravida, pregnant at 35 weeks , BL.P
110/70 ,pulse 120 bpm, DROWZY, severe abd. Pain,
tender rigid abdomen, FHS( Fetal heart sounds ) not
heard , mild dark brown vag. Bleeding, Albuminuria +++,
edema up to the knees
1. What is your provisional diagnosis ?
2. Explain why there is apparantly normal Bl.P with
tachycardia ?
3. What is the cause of inability to hear FHS?
4. Enumerate four important investigations required for
this case ?
5. Enumerate lines of treatment
Answer
1. provisional diagnosis is PG, 35 weeks gestation, severe
PET,complicated by accidental haemorrhage & IUFD
2. The pt was having severe PET ( severe HT is one of its
criteria ) & The haemorrhage (which occurred due to
premature separation of the placenta) made the high
BL.P as this apparantly normal Bl.P now , this drop in
BL.P was associated with tachycardia.
3. the cause of inability to hear FHS is accidental
haemorrhage ( Mostly most if not all the placenta is
separated ) this needs to be confirmed by US
4. four important investigations
• A-U/S: To rule out placenta previa before vaginal
examination.
• B-Blood tests , Coagulation profile
Blood type & cross matching, Rh.
CBC, PT, PTT, Fibrinogen, FDPs.
A “poor man’s clot” or “bed side test” consists of
placing a specimen of whole blood in a closed tube,
the blood should clot in less than 10min, longer
clotting times suggest DIC and if the clot dissolves in
less than 5 minute means  fibrinolytic activity and
increase FDPs.
• C-Kidney functions if needed.
• D-Apt test to differentiate between fetal blood and
maternal blood
5-Lines of treatment
• As the Bleeding is severe manifested by maternal
shock & fetal death  Immediate Anti shock
measures + immediate C.S. + ecbolics to treat
uterine atony.
• Sometimes hysterectomy is needed in:
• Severely lacerated uterus after failure of
ecbolic.
• Failure of the uterus to contract.
• Correction of the PET + the use of MGSO4 to
guard against eclamptic fits, better in the ICU +
TTT of other complications if occur as DIC , ARF
Case number 2
• A 46-year-old gravida 3 para 3, presented with
menorrhagia with dysmenorrhea for the last 5 months. The
menstrual flow lasts for about 10 days with unusually
heavy flow. She looked pale.
• Clinical examination did not reveal any pelvic pathology
apart from symmetrically enlarged bulky uterus around 10
weeks pregnancy size.
1.
2.
3.
4.
5.
Mention the commonest four possible causes?
What laboratory investigations to be ordered?
What imaging techniques are useful?
What is the possibility of malignant genital disease in such case?
Mention the role of surgery in the management of this case?
Answer
1- Four possible causes
DUB & Endometrial hyperplasia
Ut. Leiomyomata ( Mostly Submucus )
Adenomyosis uteri
Iatrogenic ( IUD complications if it was there )
General causes(As advanced liver D,
Hypothyroidism )
Blood disorders ( rare ),
V. rarely End. Carcinoma.
2-Laboratory investigations
Investigations for general causes ( liver f.
tests, thyroid hormones, TSH )
CBC
Coagulation Profile as ---Vaginal and cervical smear for --Hormonal assay as E2,
Kid. F. tests ( preop prep.)
3-Imaging techniques
 Transabd. or better Transvaginal ultrasound:
Evaluate all pelvic organs & the
endometrial, myometrial thickness , ?
Doppler velocimetry on uterine vs.
 CT scan or better MRI on the pelvic organs
 X-ray abdomen for calcified fibroid ??
4-Very rare possibility of endometrial carcinoma
or Cervical cancer but must be excluded
through previous lab. & imaging procedures.
5-The role of surgery
According to the cause
– D&C biopsy better hysteroscopically guided.
– Myomectomy ( Fibroid, ,,,, ) or Embolotherapy
– Hysterectomy ( IF adenomyosis u., submucus F, DUB
with endomet. Hyperplasia with atypia , End.
carcinoma ( rare )
– Endometrial ablation ( as Thermal balloon ) or
hysteroscopic endometrial resection ( If DUB )
Case number 3
• A 19-year-old G1 P0 woman at 20 weeks’ gestation
complains of the acute onset of pleuritic chest
pain and severe dyspnea. She denies a history of
obstructive airway disease or cough.
• On examination, her temperature is 36.6°C, heart
rate 120 bpm, blood pressure 130/70 mm Hg, and
respiratory rate (RR) 40 breaths per minute.
• The lung examination reveals clear lungs
bilaterally. The heart examination shows
tachycardia.
• The fetal heart tones are in the 140- to 150-bpm
range.
• The oxygen saturation level is 82%. Supplemental
oxygen is given.
1. What recent test would most likely lead to the
diagnosis? What were the other tests ?
2. What is your concern? What supports your
diagnosis?
3. Why is the pregnant woman predisposed to such
disease ?
4. The lungs are clear on auscultation. What are the
diseases excluded by this information?
5. What are the immediate treatments which should
be given in this case ? What are their values ?
Answer
1.
Test most likely to lead to the diagnosis: Spiral computed
tomography or magnetic resonance angiography scan of the lungs.
Other tests are arterial blood gas, chest radiograph, electrocardiograph
Previously ventilation-perfusion (V/Q) scans were recommended in
pregnancy; however, recent evidence indicates that V/Q scan exposes
the fetus to slightly more radiation and is associated with a high rate
of indeterminate cases.
2. Concern: Pulmonary embolism. Supported by
 Pleuritic chest pain and severe dyspnea are common presenting
symptoms of pulmonary embolism
 The physical examination confirms the respiratory distress due to the
tachycardia and tachypnea
 The patient has significant hypoxia with oxygen saturation of 85%.
3. The pregnant woman is predisposed to to such disease due to
 Pregnancy causes venous obstruction & DVT due to the mechanical
effect of the uterus on the vena cava.
 Additionally, the high estrogen level induces a hypercoagulable state
due to the increase in clotting factors, particularly fibrinogen.
4. The lungs are clear on auscultation, which rules
out reactive airway disease or significant
pneumonia or pulmonary edema.
5. If the imaging confirms pulmonary embolism,
then the patient should receive anticoagulation
to help stabilize the deep venous thrombosis
and decrease the likelihood of further
embolization.
Case number 4
• A 25-year-old ,P2 desires contraception for the next 4 years. She
reports that she had a deep venous thrombosis when she took the
combination oral contraceptive pill 2 years ago.
• She cannot remember to take the pill every day and wants
contraception that will allow her to be spontaneous.
• She does not take any medications and has no known allergies to
medications.
• Menstrual cycle is every 28 days, lasting for 10 days. She has blood
clots in the first 3 days of her menstrual cycle.
• She denies any sexually transmitted infections.
• She refused injectable contraception for personal factors.
• Her blood pressure is 120/70 mm Hg, heart rate 80 beats per
minute (bpm), and temperature 37.2°C. Heart and lung
examinations are normal.
• The abdomen is non tender and without masses.
• P/V reveals a normal AVF uterus and no adnexal masses.
1. What would be the best contraceptive agent for
this patient?
2. Why do you choose this method specifically ?
3. What is the mechanism of action of such method ?
4. What would be contraindications to the proposed
contraceptive agent?
5. Can this method be used as an emergency
contraception ? What is the time limits ?
Answer
1- Best contraceptive agent for this patient: The
levonorgestrel releasing intrauterine device.
2- Because of the history of DVT, estrogen-containing
contraception agents would be contraindicated.
The desire for spontaneity would make barrier methods
less desirable.
Options for this patient would include (Depot provera)
or the levonorgestrel IUD.
Because of the heavy menses, this 25 year old would
most benefit from a levonorgestrel-releasing
intrauterine device, since the progestin would cause
the endometrial lining to be thinner and decrease
the amount of menstrual bleeding. In addition , she
refused intake of injectable contraception.
3. Mechanism of action(Neither ovulation nor
steroidogenesis is affected)
Local reaction in uterine cavity( Aseptic
endometritis )  hostile to sperm and possibly
to the ovum.
 Interference with ovum transport
The physical characters of the cervical
mucus changes  impermeable to sperms
(as well as to harmful microorganisms thus
limiting ascending infection).
Partial suppression of ovulation.
4. Contraindications to the proposed contraceptive
agent: Contraindications for an IUD include
recent sexually transmitted infection,
 abnormal size and shape of the (Uterine distortion
that prevents correct IUD placement: e.g. subseptate
uterus.
 Unexplained vaginal bleeding ( this may be due to the
presence of submucus myoma,
5- Yes ( for all IUDs), it can . But must be within 72 hours of
unprotected intercourse. appears to be even more
effective than estrogens or estrogen/progestin
preparations.
Case number 5
• A 32-year-old G4P3 with no prenatal care presents to the hospital at
40 weeks stating that her membranes ruptured the day before and
her contractions began about 8 hours prior to this admission.
• For the past 4 hours she has noted progressively severe pain and
decreased fetal movements. She states that her first delivery was by
cesarean section, second was a normal vaginal delivery, and third was
by cesarean section.
• She denies diabetes, hypertension, or any chronic medical illnesses.
She does not smoke. Both of her parents are obese with diabetes and
hypertension.
• On physical examination she is in moderate distress with frequent
contractions and complains that her right shoulder hurts.
• The maternal H.R. is 140 bpm. Her Bl.P is 80/40 mmHg. Her
temperature is normal. She is having a BMI of 35 kg/m2.
• Her fundal height is difficult to measure, but appears near term.
• Her abdomen is mildly tender in all quadrants.
• The FHR by external Doppler is 140 bpm with absent variability and
no accelerations.
• On P/V she is 8 cm dilated, 90% effaced, and the fetal vertex is
floating above the pelvic inlet.
1. What is the most likely diagnosis? What is the
cause of these vital signs ? What is the cause of
shoulder pain ?
2. What is the differential diagnosis?
3. Mention three risk factors in this case which
lead to that condition.
4. What is the significance of that the FHR is the
same as the mother’s HR, What is needed
urgently to be done at such point?
5. What are your next steps in caring for this
patient?
Answer
1- Most likely diagnosis: P3 ( First and third by c.s. ), NT, cephalic,
in labour , Hypovelemic shock , Uterine rupture ( mostly
ruptured scar ).
Internal haemorrhage and hypovolemic shock is the cause of these
vital signs .
Referred pain to the shoulder from phrenic nerve irritation
( from internal Hage ) is the cause of shoulder pain .
2.
A.
B.
C.
D.
E.
F.
G.
Differential diagnosis
Uterine rupture
Abruptio placenta
Chorioamnionitis with sepsis
Pyelonephritis
Appendicitis
Cholecystitis or
Other intra-abdominal acute processes
3. Three risk factors in this case which lead to that
condition.
A. This is a patient with two prior cesareans, one
prior vaginal delivery
B. Current risk factors for ? macrosomia ( Obese
woman, F/H , increased Fundal height)
C. The patient was reaching near the end of the
first stage of labour ( contracting uterus on
previous two uterine scars of C.S.)
4. As the fetal heart rate is the same as the
mother’s, the fetus may be alive and this is
truly his heart rate & may be dead after the
uterine rupture and what you are hearing is
maternal and not fetal heart So a quick
ultrasound to assess fetal viability should be
obtained but should not delay the next steps.
5. Next steps: This is a life-threatening emergency for both, the mother
and the fetus.
A. Quickly notify essential personnel such as anesthesia, operating
room staff, blood bank, and laboratory services.
B. Immediately obtain large bore IV access.
C. Simultaneously obtain blood for cross match and coagulation studies
to observe for clotting.
D. Resuscitation with volume repletion is important while assessing the
mother and determining fetal status.
A.
B.
C.
While continuing to resuscitate the mother, the patient should be
immediately moved to the operating room as surgical management is
imperative at this point even if the fetus is already dead.
Usually, a general anesthetic is indicated, as this clinical situation
does not permit the time required for a regional anesthetic.
Surgical treatment will be through Mid line laparotomy, getting the
fetus & the placenta out then mostly emergency ( supravaginal )
hysterectomy , rarely repair of the site of rupture.
Case number 6
• 46 years 0ld lady , Para 4 ( Last 2 were by C.S. ) was
complaining of severe DUB, Vaginal Hysterectomy was
performed with some difficulty during surgery.
• Postoperatively by 4 hours Bl.p was 80/40 Pulse 120/m ,
oliguria
• Laparotomy was done , Internal Haemorrhage was found
,some surgical maneuvres were performed to secure
haemostasis & the pt received 4 units of Bl. Transfusion
• Post operative improvement of the general condition , but
4 days later she started to c/o severe lower abdomen Pain
radiating to the back for which she received strong
analgesics ,
• 20 days later ,she c/o leakage of watery vaginal discharge.
1. What is the most probable cause of this general
condition 4hours post-operatively?
2. What is the surgical maneuvres done during the
laparotomy?
3. What is the cause of lower abdominal pain and
the leakage of watery vaginal discharge ?
4. What are the investigations required to prove
your diagnosis?
5. What is the treatment of such condition at the
end ? When can you perform this and why ?
Answer
1.
Haemorrhagic shock due to blood loss from ? slipped ligature during
vaginal hysterectomy on major blood vessels as uterine or ovarian
arteries
2.
Ensuring haemostasis by resuturing the pedicles especially those
containing bleeding vessels as uterine arteries or ovarian arteries.
3.
This injury to the ureter makes back pressure on the kidney of the
affected side ( ? hydronehrosis ) leading to loin pain ( stormy postoperative course )
The leakage is mostly due to the occurance of uretero-vaginal fistula following
urinoma formation at that side
A.
B.
C.
4. The investigations required to prove the diagnosis
Methylene blue test to exclude Vesico-vaginal fistula
IVP ( IVU ) will detect the affected ureter and even the site of injury
Cystoscopy to detect any bladder injury & to exclude Vesico-vaginal fistula +
performing ureteric catheterization as a diagnostic test for uretero-vaginal
fistula and sometimes therapeutic for its treatment.
5. The treatment of such condition at the end is by exploratory
laparotomy
Surgery for ureteric fistulas: The possibilities of the surgery
A. Repair of the ureter + putting ureteric catheter.
B. Transplantation of upper cut end into the bladder( uretero-vesical
reimplantation) or into a rolled flap of the bladder.
C. Replacement of the defect by a loop of ileum.
When We can perform this intervention
• It is important to defer any reconstruction for 3-6 months after the initial injury
to allow all tissue reaction ( as edema ) to subside. It is important to treat any
infection before the operation.