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PRE – Licensure EXAM ORIENTATION COURSE DR LOULA MOHAMED A SALIH.

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Presentation on theme: "PRE – Licensure EXAM ORIENTATION COURSE DR LOULA MOHAMED A SALIH."— Presentation transcript:

1 PRE – Licensure EXAM ORIENTATION COURSE DR LOULA MOHAMED A SALIH

2 IMPORTANT SUBJECTS TO REVIEW NORMAL LABOR

3 ABNORMAL LABOR 1-Abnormal presentation breech presentation & ECV 2-Abnormal lie 3-Prolonged labour (dystocia) 4-Cephalo-pelvic disproportion (CPD)

4 5-Shoulder dystocia 6-Cord prolapse 7-Instrumental deliveries 8-Ceserian section, indications,pre & post oprative management 9-Fetal distress & abnormal fetal monitoring PPROM & 10-Preterm labor

5 ANTE-PARTUM HEAMORRHAGE 1-Placenta preveia 2-Abruptio placenta 3-Trauma in obstetrics

6 POT-PARTUM HEAMORRHAGE OBSTETRIC EMERGENCY

7 PET & ECLAMPSIA OBSTETRIC EMERGENCY

8 MEDICAL PROPLEMS WITH PREGNANCY 1-DM 2-HTN 3-UTI 4-CARDIOVASCULAR DISEASES 5-ANEMIA IN PREGNANCY 6-GESTITIONAL THROMBOCTOPENIA 7-THROMBOSIS WITH PREGNANCY

9 GYNAECOLOGY bleeding early in pregnancy 1-ECTOPIC PREGNANCY; obstetric emergency 2-ABORTION/MISSCARRIAGE

10 GYNAECOLOGY *DUB *POST MENPAUSAL BLEEDING *MENSTRUAL ABNORMALITIS; e.g.; -Amenorrhea -Menorrhagia

11 Other Important Subjects 1-ANC & Prepregnancy counseling 2-Fetal growth (IUGR & SGA) 3-Contraception 4-purpurium & puerperal sepsis

12 5-Vaginitis & vaginal discharges 6-Drugs & Anesthesia in pregnancy 7-General knowledge of maternal physiology & changes in pregnancy 8-Oncoloogy screening

13 MCQS

14 MCQ INSTRUCTIONS

15 MCQs – Study Guide Test strategies:` Read the directions carefully Know if each question has one or more correct option Know if you are penalized for guessing Know how much time is allowed (this governs your strategy) Preview the test Read through the test quickly and answer the easiest questions first Mark those you think you know in some way that is appropriate Read through the test a second time and answer more difficult questions You may pick up cues for answers from the first reading, or become more comfortable in the testing situation If time allows, review both questions and answers It is possible you mis-read questions the first time

16 Answering options Improve your odds, think critically: *Cover the options, read the stem, and try to answer *Select the option that most closely matches your answer *Read the stem with each option *Treat each option as a true-false question, and choose the "most true“

17 Strategies to answer difficult questions: Eliminate options you know to be incorrect If allowed, mark words or alternatives in questions that eliminate the option Give each option of a question the "true-false test:" This may reduce your selection to the best answer Question options that grammatically don't fit with the stem Question options that are totally unfamiliar to you Question options that contain negative or absolute words. Try substituting a qualified term for the absolute one, like frequently for always; or typical for every to see if you can eliminate it

18 "All of the above:" If you know two of three options seem correct, "all of the above" is a strong possibility Number answers: toss out the high and low and consider the middle range numbers "Look alike options" probably one is correct; choose the best but eliminate choices that mean basically the same thing, and thus cancel each other out

19 Echo options: If two options are opposite each other, chances are one of them is correct The result is longer, more inclusive items that better fill the role of the answer If two alternatives seem correct, compare them for differences, then refer to the stem to find your best answer

20 Guessing: Always guess when there is no penalty for guessing or you can eliminate option Don't guess if you are penalized for guessing and if you have no basis for your choice Use hints from questions you know to answer questions you do not. Change your first answers when you are sure of the correction, or other cues in the test cue you to change.

21 Remember that you are looking for the best answer, not only a correct one, and not one which must be true all of the time, in all cases, and without exception

22 MCQ EXAM

23 1-A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy? a)Ampicillin b)Ampicillin-gentamicin c)Clindamycin-gentamicin d)Clindamycin-metronidazole e)Metronidazole

24 2-. A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery? a) 0% b) 25% c)50% d)70% e) 100

25 3-.A 32-year-old woman, gravida 3, Para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response? a)There is no evidence that breast-feeding increases HCV transmission b)There is strong evidence that breast-feeding increases HCV transmission c)Complete isolation is not needed but breast-feeding is prohibited d)The patient should be completely isolated from the baby e)Casual contact with the baby is prohibited

26 4-.A 25-year-old woman, gravida 2, Para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management? a) No further treatment or diagnostic study is necessary b)Prophylactic antibiotics for the remainder of the pregnancy c)Intravenous antibiotics for the remainder of the pregnancy d)Intravenous pyelogram e)Abdominal CT Scan

27 5- A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nulliparity, and early age at menarche. She takes no other medications. Examination is within normal limits. Which of the following is this patient most likely to develop while taking tamoxifen? a) Breast cancer b)Elevated LDL cholesterol c)Endometrial changes d)Myocardial infarction e)Osteoporosis

28 6 -.A 39-year-old woman, gravida 3, Para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient? a)Administer antibiotics to the mother after vaginal delivery b)Administer antibiotics to the mother now and allow vaginal delivery c)Perform cesarean delivery d) Perform cesarean delivery and then administer antibiotics to the mother e)Perform intra-amniotic injection of antibiotics

29 7-. A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response? a) Gestational diabetes is associated with fetal anomalies b)Gestational diabetes is associated with intrauterine growth restriction c)Gestational diabetes is associated with macrosomia d)Gestational diabetes is not associated with future diabetes e)Gestational diabetes with normal fasting glucose is associated with stillbirth

30 8-. A 36-year-old primigravid woman at 36 weeks' gestation comes to the physician for a prenatal visit. She is experiencing good fetal movement and has had no loss of fluid, bleeding from the vagina, or contractions. She has no complaints. Her past medical history is significant for mitral stenosis, which she developed after an episode of rheumatic fever as a child. She also has asthma for which she uses an albuterol inhaler daily. She has herpes outbreaks approximately once a year. At her last visit she was found to be positive for Group B Streptococcus colonization. For which of the following disease processes would this patient benefit by having a forceps-assisted vaginal delivery at the time of delivery? a)Asthma b)Group B Streptococcus (GBS) colonization c)Herpes d)Mitral stenosis e)This patient would not benefit from a forceps-assisted vaginal delivery

31 9- A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management? a)Offer elective cesarean section after amniocentesis to determine lung maturity b)Offer elective cesarean section at 38 weeks c)Offer elective cesarean section at 34 weeks d)Recommend forceps-assisted vaginal delivery e) Recommend vaginal delivery

32 10. A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis? a) Constitutional delay b) Dysfunctional uterine bleeding c)Dysmenorrhea d)Primary amenorrhea e)Secondary amenorrhea

33 11.A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5 centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5 centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management? a)Expectant management b)Intravenous oxytocin c)Cesarean delivery d)Forceps-assisted vaginal delivery e)Vacuum-assisted vaginal delivery

34 12-.A 24-year-old woman comes to the physician because of right lower quadrant abdominal pain. She has had the pain off and on for the past month, but it is now increasing. She has no other symptoms and no medical problems. Examination reveals a mildly tender, right adnexal mass. Pelvic ultrasound shows a 7 cm right adnexal complex cyst. Urine hCG is negative. The patient is taken to the operating room for laparotomy and right ovarian cystectomy. Microscopically the cyst has cartilage, adipose tissue, intestinal glands, hair, and a calcification that appears to be a tooth. There is also a large amount of thyroid tissue. Which of the following is the most likely diagnosis? a)Corpus luteum b)Ectopic pregnancy c)Gastric carcinoma d)Struma ovarii e) Thyroid carcinoma

35 13. A 62-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman in no apparent distress. Pelvic examination is unremarkable. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. Which of the following is the most appropriate next step in management? a) Chemotherapy b)Cone biopsy c)Dilation and curettage d)Hysteroscopy e)Hysterectomy

36 14 -.A 35-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward after a gush of clear fluid from the vagina. After the gush, she has had increasing contractions. Sterile speculum examination shows a pool of clear fluid in the vagina that is nitrazine positive. Cervical examination shows that the patient is 5 cm dilated, with the fetal face presenting in a mentum anterior position. External uterine monitoring shows that the patient is contracting every 2 minutes, and external fetal monitoring shows that the fetal heart rate is in the 140s and reactive. Which of the following is the most appropriate next step in management? a)Expectant management b)Oxytocin augmentation c)Forceps delivery d)Vacuum delivery e)Cesarean section

37 15 -.A 36-year-old woman, gravida 3, para 2, at 33 weeks' gestation comes to the physician for a prenatal visit. She has some fatigue but no other complaints. Her current pregnancy has been complicated by a Group B Streptococcus urine infection at 16 weeks. Her past obstetric history is significant for a primary, classic cesarean delivery 5 years ago for a non- reassuring fetal tracing. Two years ago, she had a repeat cesarean delivery. Past surgical history is significant for an appendectomy 10 years ago. Which of the following is the major contraindication to a vaginal birth after cesarean (VBAC) in this patient? a) Classic uterine scar b)Group B Streptococcus urine infection c)Previous appendectomy d)Prior cesarean delivery for non-reassuring fetal tracing e)Two prior cesarean deliveries

38 16 -.A patient who has been taking tamoxifen to prevent breast cancer for the past 6 months presents complaining of irregular vaginal bleeding. An endometrial biopsy is performed that demonstrates atypical hyperplasia. Which of the following is the most appropriate next step in management? a)Discontinue the tamoxifen b)Increase the tamoxifen dose c)Repeat the endometrial biopsy d)Schedule a pelvic ultrasound e)Switch the patient to estrogen

39 17-.A 18-year-old woman comes to the physician for an annual examination. She has no complaints. She has been sexually active for the past 2 years. She uses the oral contraceptive pill for contraception. She has depression for which she takes fluoxetine. She takes no other medications and has no allergies to medications. Her family history is negative for cancer and cardiac disease. Examination is unremarkable. Which of the following screening tests should this patient most likely have? a) Colonoscopy b)Mammogram c)Pap smear d)Pelvic ultrasound e)Sigmoidoscopy

40 18- A 35 year old woman gravida 7, para 5,abortus 1, is in the active phase of labor with the vertex at -1 station.She complains of abdominal pain with the contractions. At the height of one contraction the pain becomes very intense. Following this intense pain, utrine contractions ceased. The maternal systolic blood pressure drops 15 mm Hg.You should: A)Immediately perform a pelvic examination B)Place the patient on her side & reassure her C)Manage expectantly D)Begin oxytocin E)Perform an U/S

41 19 -An inter-stitial ectopic pregnancy: A)Rarely exceeds 4 weeks of gestation. B)Is generally more dangerous than an ampullary ectopic pregnancy C) Requires hysterectomy D) Is extra uterine

42 20-Relative contra-indications to the use of vacuum extraction for delivery include A)Fetal coagulopathy B) Following fetal scalp sampling C)Fetal prematurity D)non-vertex presentation E) All of the above

43 MCQ DISCUSSION

44 1-A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy? a)Ampicillin b)Ampicillin-gentamicin c)Clindamycin-gentamicin d)Clindamycin-metronidazole e)Metronidazole

45 1) Explanation: The correct answer is C). This patient has signs and symptoms that are most consistent with endometritis. Postpartum endometritis is believed to result from organisms ascending from the vagina and causing a polymicrobial infection of the endometrium. Infection may also involve the myometrium and parametrial tissues. Patients with endometritis typically present with fever and chills, lower abdominal pain, a foul-smelling vaginal discharge, and malaise. Examination is significant for fever, abdominal tenderness, and uterine tenderness. Cesarean section is the major risk factor for postpartum endometritis. Patients undergoing cesarean section have a several-fold higher risk of developing endometritis compared with those having a vaginal delivery. The treatment of choice for endometritis following a cesarean section must include anaerobic coverage, along with gram-positive and gram-negative coverage. Therefore, the treatment of choice is clindamycin and gentamicin. Ampicillin (choice A) and ampicillin- gentamicin (choice B) fail to cover the anaerobic organisms that play an important role in the pathophysiology of post-cesarean section endometritis. Clindamycin-metronidazole (choice D) and metronidazole (choice E) have good activity against anaerobic organisms, but fail to cover gram-negative organisms.

46 2-. A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery? a) 0% b) 25% c)50% d)70% e) 100

47 2) Explanation: The correct answer is D. The cesarean delivery rate in the U.S. is roughly 25%. Much effort has been put into trying to lower this rate. One third of all cesarean births are a result of elective repeat cesarean delivery. Therefore, much attention has been focused on vaginal birth after cesarean (VBAC). A few decades ago, there was an obstetric dictum that "once a cesarean, always a cesarean." This is no longer the case. Some women are allowed to attempt vaginal birth after a prior cesarean delivery. And, in fact, the attempt is often successful. Estimates are that approximately 70% of all women that attempt VBAC will be successful. This patient has had one prior cesarean delivery, and it was through a low transverse uterine hysterotomy. Right now, she has no contraindications to VBA Therefore, a VBAC attempt may be tried. If the success rate of VBAC were 0% (choice A) or even 25% (choice B), the topic would be a non-issue. The fact that the success rate of VBAC is so high is what makes the choice between repeat cesarean and VBAC more complicated. 50% (choice C) is approximately the success rate in women who attempt VBAC who had a prior cesarean for dystocia. Women with a prior cesarean delivery for dystocia have a VBAC success rate of approximately 50% to 70%. Although this rate is still good, it is consistently lower than the rate for women with non-recurring indications, such as a non-reassuring fetal tracing. Attempts at vaginal delivery are not 100% (choice E) successful even in women who have never had a cesarean delivery. In fact, the success rate for vaginal delivery in women who have not undergone previous cesarean delivery is about 70%--the same success rate as women attempting VBAC with a non-recurring indication.

48 3-.A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response? a)There is no evidence that breast-feeding increases HCV transmission b)There is strong evidence that breast-feeding increases HCV transmission c)Complete isolation is not needed but breast-feeding is prohibited d)The patient should be completely isolated from the baby e)Casual contact with the baby is prohibited

49 3) Explanation : The correct answer is A. In the U.S., hepatitis C virus (HCV) is the most common blood-borne infection. HCV is a single-stranded RNA virus that is transmitted by blood-borne transmission or through sexual contact. With the disease being so prevalent-it affects 3.9 million Americans-it is not rare to find a pregnant patient with hepatitis C. In fact, it appears to infect as much as 0.6% of the pregnant population. Studies that have been performed so far show that the rate of infection of infants born to hepatitis C-positive, HIV-negative mothers is about 5%. Hepatitis C transmission through breast milk has not been clearly proven. Breast-fed and bottle-fed infants have a rate of infection that is approximately 4%. Therefore, the patient should be told that casual contact is permitted and that currently there is no evidence that breast-feeding increases HCV transmission to the baby. To state that there is strong evidence that breast-feeding increases HCV transmission to the baby (choice B) is incorrect. As explained above, the available studies do not demonstrate that breast-feeding increases HCV transmission. To state that complete isolation is not needed but breast-feeding is prohibited (choice C) is incorrect for the reasons detailed above. To state that the patient should be completely isolated from the baby (choice D), or that casual contact with the baby is prohibited (choice E) are both incorrect for the reasons detailed above. If patients with hepatitis C were not allowed contact with their infants, they would have to give them up, because hepatitis C is a chronic disease. Fifty percent of patients with HCV develop biochemical evidence of chronic liver disease. Hepatitis C is not like varicella-zoster (chickenpox), where a neonate can be isolated from the mother until she is no longer infectious.

50 4-.A 25-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management? a) No further treatment or diagnostic study is necessary b)Prophylactic antibiotics for the remainder of the pregnancy c)Intravenous antibiotics for the remainder of the pregnancy d)Intravenous pyelogram e)Abdominal CT Scan

51 4) Explanation: The correct answer is B). The most common medical complication of pregnancy is infection of the urinary tract. Because of the anatomic and physiologic changes that occur during pregnancy, asymptomatic bacteriuria is more likely to become symptomatic and there is also an increased progression to pyelonephritis during pregnancy. Escherichia coli is the causative organism in approximately 80% of cases of UTI while other gram-negative organisms (e.g., Klebsiella, Enterobacter, and Proteus species) and gram-positive cocci (e.g. enterococci and group B streptococci) are responsible for the remainder. UTI in pregnancy can be treated with a 3-day course of antibiotics including trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. It is essential to document successful treatment with a follow-up urine culture 10 days after treatment. All women who are treated for UTI during pregnancy should have periodic rescreening for infection with urine cultures or urine dipstick for nitrites or leukocyte esterase. If a woman develops a second infection, as this patient has, she should be retreated and then placed on chronic suppression with prophylactic antibiotics. The drug of choice for such prophylaxis is nitrofurantoin once a day or sulfisoxazole once a day. To state that no further treatment or diagnostic study is necessary (choice A) is incorrect. Women with bacteriuria during pregnancy are at increased risk of developing pyelonephritis and are at higher risk for low birth weight and preterm deliveries. Therefore, this patient should be placed on prophylactic antibiotics for the remainder of the pregnancy. To place the patient on intravenous antibiotics for the remainder of the pregnancy (choice C) would not be indicated. Once a day oral therapy is usually sufficient to prevent recurrence of the infection. Intravenous pyelogram (choice D) and abdominal CT scan (choice E) result in significant fetal exposure to radiation. They should only be performed when absolutely necessary. This patient has a second UTI, which does not require that either of these studies be performed.

52 5- A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nulliparity, and early age at menarche. She takes no other medications. Examination is within normal limits. Which of the following is this patient most likely to develop while taking tamoxifen? a) Breast cancer b)Elevated LDL cholesterol c)Endometrial changes d)Myocardial infarction e)Osteoporosis

53 5) Explanation : The correct answer is C. Tamoxifen is a nonsteroidal agent with both pro- and antiestrogenic properties. It was first approved in 1977 by the U.S. Food and Drug Administration for use in postmenopausal women with advanced breast cancer. Since that time, it has been approved for many other uses related to breast cancer: as adjuvant therapy in postmenopausal women with resected node-positive disease, in postmenopausal women with metastatic breast cancer, and as adjuvant therapy in women (pre- and postmenopausal) with resected node-negative disease. Recently, much attention has been focused on its use for breast cancer prevention. There is evidence that women at high risk for the development of breast cancer may reduce their risk by taking tamoxifen. However, although tamoxifen appears to be antiestrogenic at the level of the breast, it appears to act in a proestrogenic fashion at the level of the endometrium. Many women on tamoxifen will develop endometrial changes, including polyp formation, hyperplasia, and frank invasive carcinoma. Thus, women on tamoxifen need to be followed carefully, and prompt evaluation of abnormal vaginal bleeding should be conducted. Tamoxifen is used to prevent breast cancer (choice A). Tamoxifen, like estrogen, has been shown to lower blood levels of LDL cholesterol (choice B). Women on tamoxifen appear to be at no greater risk, and may be at a lower risk, for the development of myocardial infarction (choice D). Tamoxifen, like estrogen, has been shown to increase bone density and to reduce the likelihood of development of osteoporosis (choice E).

54 16 -.A patient who has been taking tamoxifen to prevent breast cancer for the past 6 months presents complaining of irregular vaginal bleeding. An endometrial biopsy is performed that demonstrates atypical hyperplasia. Which of the following is the most appropriate next step in management? a)Discontinue the tamoxifen b)Increase the tamoxifen dose c)Repeat the endometrial biopsy d)Schedule a pelvic ultrasound e)Switch the patient to estrogen

55 Its an example for using an information from a question to answer another one see Q 5 16) Explanation : The correct answer is A. Tamoxifen is known to act as an estrogen agonist at the level of the endometrium. Numerous studies have shown that women on tamoxifen develop changes in the endometrium including polyps, hyperplasia, and cancer. Hyperplasia runs a continuum from cystic glandular hyperplasia to atypical hyperplasia. Patients with atypical hyperplasia are at significantly increased risk for the eventual development of endometrial cancer. Thus, in a patient who is taking tamoxifen for breast cancer prevention and develops atypical endometrial hyperplasia, the tamoxifen should be stopped. If there is a need to continue the tamoxifen, then hysterectomy should be considered. To increase the tamoxifen dose (choice B) would be contraindicated. This patient has atypical hyperplasia, likely caused by the tamoxifen. Increasing the dose will only exacerbate the problem. To repeat the endometrial biopsy (choice C) would not be the most appropriate next step in management. The next step should be to discontinue the tamoxifen. The patient should then have a repeat endometrial biopsy in several months to ensure that there is no progression of the hyperplasia. To schedule a pelvic ultrasound (choice D) would not be the most appropriate next step in management. This patient has known atypical hyperplasia; thus, the tamoxifen should be stopped first. Pelvic ultrasound can be used to evaluate the endometrium; however, in this case, regardless of what the ultrasound shows, the pathology reveals atypical hyperplasia. To switch the patient to estrogen (choice E) would be absolutely contraindicated. Unopposed estrogen would worsen the endometrial changes.

56 6 -.A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient? a)Administer antibiotics to the mother after vaginal delivery b)Administer antibiotics to the mother now and allow vaginal delivery c)Perform cesarean delivery d) Perform cesarean delivery and then administer antibiotics to the mother e)Perform intra-amniotic injection of antibiotics

57 6- Explanation: The correct answer is B. Chorioamnionitis is an infection that can develop at any time before and during delivery. The most common findings in patients with chorioamnionitis are a fever and uterine tenderness. An elevated fetal heart rate is also often seen. This patient has a temperature elevation and uterine tenderness, which make the diagnosis of chorioamnionitis. It is essential that antibiotics be started immediately because prompt initiation of antibiotics, once the diagnosis of chorioamnionitis is made, results in better maternal and neonatal outcomes than if therapy is delayed. It is also essential that broad-spectrum antibiotic therapy be chosen because a mixture of organisms is usually involved including aerobes and anaerobes. The most frequently used regimen is ampicillin or penicillin with gentamicin. In terms of the mode of delivery, vaginal delivery is acceptable in patients with chorioamnionitis. While it is desirable to have an expeditious delivery, chorioamnionitis is not an indication for cesarean delivery. To wait to administer antibiotics to the mother after vaginal delivery (choice A) would not be correct, as the delay would deprive both the mother and the fetus of the beneficial effects of the antibiotics. To perform cesarean delivery (choice C) or to perform cesarean delivery and then administer antibiotics to the mother (choice D) would not be indicated. As explained above, when a woman has chorioamnionitis, it is desirable to expedite delivery, but cesarean delivery should be performed only for obstetric indications. To perform intra-amniotic injection of antibiotics (choice E) would not be indicated. Intra-amniotic injection of antibiotics during labor is not a therapy used to treat chorioamnionitis during labor.

58 7-. A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response? a) Gestational diabetes is associated with fetal anomalies b)Gestational diabetes is associated with intrauterine growth restriction c)Gestational diabetes is associated with macrosomia d)Gestational diabetes is not associated with future diabetes e)Gestational diabetes with normal fasting glucose is associated with stillbirth

59 7) Explanation: The correct answer is C. Gestational diabetes is defined as glucose intolerance that either has its onset or its first recognition during pregnancy. Gestational diabetes is usually diagnosed by means of oral glucose tolerance testing. Patients with gestational diabetes and normal fasting glucose levels have two major risks. The first is fetal macrosomia. Women with gestational diabetes are known to have larger babies, and this creates an increased risk of complications of delivery including shoulder dystocia and cesarean delivery. The second risk is of the eventual development of overt diabetes. Fifty percent of women with gestational diabetes will go on to develop overt diabetes within the next 20 years. Patients with gestational diabetes and abnormal fasting glucose levels do have an increased risk of stillbirth. To state that gestational diabetes is associated with fetal anomalies (choice A) is incorrect. However, patients with overt diabetes do have an increased risk of fetal anomalies. To state that gestational diabetes is associated with intrauterine growth restriction (choice B) is not correct. Gestational diabetes is associated with macrosomia. To state that gestational diabetes is not associated with future diabetes is incorrect (choice D), as explained above. To state that gestational diabetes with normal fasting glucose is associated with stillbirth (choice E) is incorrect. However, overt diabetes and gestational diabetes with abnormal fasting glucose levels (class A2) are associated with stillbirth.

60 8-. A 36-year-old primigravid woman at 36 weeks' gestation comes to the physician for a prenatal visit. She is experiencing good fetal movement and has had no loss of fluid, bleeding from the vagina, or contractions. She has no complaints. Her past medical history is significant for mitral stenosis, which she developed after an episode of rheumatic fever as a child. She also has asthma for which she uses an albuterol inhaler daily. She has herpes outbreaks approximately once a year. At her last visit she was found to be positive for Group B Streptococcus colonization. For which of the following disease processes would this patient benefit by having a forceps-assisted vaginal delivery at the time of delivery? a)Asthma b)Group B Streptococcus (GBS) colonization c)Herpes d)Mitral stenosis e)This patient would not benefit from a forceps-assisted vaginal delivery

61 8) Explanation : The correct answer is D. Mitral valve stenosis is one of the more common valvular lesions seen in pregnancy. The most common cause of mitral stenosis is rheumatic endocarditis. During normal pregnancy there is an increase in the cardiac output and an increase in preload and circulating volume. Patients with mitral stenosis have a fixed, decreased valve area, which places them at risk for the development of pulmonary hypertension and pulmonary edema. Control of arrhythmias is absolutely essential in these patients because they are at increased risk, given the left atrial enlargement that often goes along with their mitral stenosis. Labor and delivery can be a particularly dangerous time for these patients. Therefore, patients with significant mitral stenosis should be monitored invasively using a Swan-Ganz catheter. It is recommended that the second stage of labor be shortened using forceps or vacuum to prevent excess maternal Valsalva efforts and maternal tachycardia. Asthma (choice A) is not an indication for forceps-assisted vaginal delivery. In terms of mode of delivery, asthmatic patients may be managed like any other patient in the second stage of labor. Group B Streptococcus colonization (choice B) is an indication for intravenous penicillin or clindamycin (if the patient has an allergy to penicillin). These antibiotics are given to prevent GBS sepsis in the neonate. GBS colonization is not an indication for forceps- assisted vaginal delivery. Herpes (choice C) can be transmitted to the fetus at the time of delivery. Therefore, when lesions are present in the birth canal, most obstetricians recommend cesarean delivery. A history of herpes outbreaks, as this patient has, is not an indication for forceps. To state that this patient would not benefit from a forceps-assisted vaginal delivery (choice E) is incorrect. As explained above, given this patient's mitral stenosis, forceps-assisted vaginal delivery would be recommended.

62 9- A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management? a)Offer elective cesarean section after amniocentesis to determine lung maturity b)Offer elective cesarean section at 38 weeks c)Offer elective cesarean section at 34 weeks d)Recommend forceps-assisted vaginal delivery e) Recommend vaginal delivery

63 9) Explanation : The correct answer is B. A significant body of evidence has developed that transmission rates of HIV from mother to infant can be decreased through the use of medications and cesarean delivery. The Pediatric AIDS Clinical Trials Group (PACTG) 076 Zidovudine Regimen was shown to decrease the rate of transmission from 25% to 8%. This regimen consisted of ZDV being given antepartum and intrapartum to the mother and postpartum to the infant. More recent evidence is accumulating that the mode of delivery also affects transmission rates. The combination of ZDV therapy and cesarean delivery decreases the risk of transmission to approximately 2%. But, the decrease in transmission with cesarean delivery occurs regardless of whether the patient is receiving antiretroviral therapy. Thus, cesarean delivery should be offered to HIV-positive women to prevent transmission. Delivery at 38 weeks is recommended to reduce the chances that the patient will go into labor or rupture her membranes. Once these occur, the benefit of cesarean delivery is reduced. To offer elective c-section after amniocentesis to determine lung maturity (choice A) is incorrect. Amniocentesis should be avoided, if possible, in the HIV-positive woman. To offer elective c-section at 34 weeks (choice C) is incorrect. To perform a cesarean delivery at 34 weeks risks iatrogenic prematurity in the neonate. Cesarean delivery prior to the onset of labor or rupture of membranes is the preference, and this can be accomplished at 38 weeks with a lower risk of iatrogenic prematurity. To recommend forceps-assisted vaginal delivery (choice D) or vaginal delivery (choice E) is incorrect. The decision of which mode of delivery to choose ultimately belongs to the patient. But, vaginal delivery would not be recommended, as cesarean delivery has been shown to decrease transmission rates.

64 10. A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis? a) Constitutional delay b) Dysfunctional uterine bleeding c)Dysmenorrhea d)Primary amenorrhea e)Secondary amenorrhea

65 10) Explanation : The correct answer is A. Constitutional delay is normal pubertal progression at a delayed rate or onset. The average age at menarche is 12 1/2 years, but it may be delayed until 16 or may begin as early as age 10. Dysfunctional uterine bleeding (choice B) results when the endometrium has proliferated under estrogen stimulation, and then begins to slough and causes irregular painless bleeding. This is common in younger adolescents who have not been menstruating long. Dysmenorrhea (choice C) is pain associated with menstrual cycles, and this adolescent is not menstruating yet. Primary amenorrhea (choice D) is a delay in menarche with no menstrual cycles or secondary sex characteristics by 14 years of age or no menses with secondary sex characteristics by 16 years of age. This adolescent has secondary characteristics but is not yet 16 years of age. Secondary amenorrhea (choice E) is the absence of menses for at least three cycles after regular cycles have been present.

66 11.A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5 centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5 centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management? a)Expectant management b)Intravenous oxytocin c)Cesarean delivery d)Forceps-assisted vaginal delivery e)Vacuum-assisted vaginal delivery

67 11) Explanation : The correct answer is B. This patient is demonstrating an abnormal labor pattern with arrest of dilation. The normal pattern of labor is one of continued progression. Whether a patient is in the latent phase or the active phase, there should be a gradual progression with an increase in the amount of cervical dilation. This patient, however, has stopped dilating and has had her contractions space out considerably. An arrest of labor like this can be caused by several reasons: contractions may not be adequate; the fetus may have a malpresentation; or the maternal pelvis may not be able to accommodate the fetus. In this case it appears that the contractions are not adequate, so at this point, it would be reasonable to give intravenous oxytocin in an effort to re-establish a contraction pattern that can effect a vaginal delivery. Expectant management (choice A) would not be the most appropriate next step. The patient is clearly demonstrating a dysfunctional labor pattern at this point. To "watch and wait" in the face of insufficient uterine contractions is to place the patient at risk of an even longer labor and the correspondingly higher risk of infection. Cesarean delivery (choice C) would not be the most appropriate next step in management. This patient may very well need a cesarean delivery if she is truly unable to progress in labor. However, it is worth attempting a vaginal delivery in this multiparous patient who has already had two vaginal deliveries. To attempt a forceps-assisted vaginal delivery (choice D) or a vacuum-assisted vaginal delivery (choice E) would be contraindicated. This patient's cervix is only 5 centimeters dilated. Forceps and vacuum cannot be attempted in patients unless they are fully dilated and at +2 station or lower

68 12-.A 24-year-old woman comes to the physician because of right lower quadrant abdominal pain. She has had the pain off and on for the past month, but it is now increasing. She has no other symptoms and no medical problems. Examination reveals a mildly tender, right adnexal mass. Pelvic ultrasound shows a 7 cm right adnexal complex cyst. Urine hCG is negative. The patient is taken to the operating room for laparotomy and right ovarian cystectomy. Microscopically the cyst has cartilage, adipose tissue, intestinal glands, hair, and a calcification that appears to be a tooth. There is also a large amount of thyroid tissue. Which of the following is the most likely diagnosis? a)Corpus luteum b)Ectopic pregnancy c)Gastric carcinoma d)Struma ovarii e) Thyroid carcinoma

69 12)Explanation : The correct answer is D. Cystic teratomas, also known as dermoid cysts, are the most common benign ovarian neoplasm. They account for approximately 1/3 of all ovarian neoplasms. They may be composed of a variety of cell types and have a mixture of tissues, as this patient has. When thyroid tissue makes up more than 50% of the teratoma, the dermoid is then referred to as struma ovarii. Approximately 3% of ovarian teratomas fall into this category and there is an association of struma ovarii with carcinoid tumor. Struma ovarii is unilateral in approximately 90% of patients and most (80%) are benign. Rarely struma ovarii is a cause of hyperthyroidism and patients with this manifestation may have symptoms of hyperthyroidism, as well as elevated levels of thyroid hormones and decreased levels of thyroid stimulating hormone (TSH). Treatment of struma ovarii is by surgical removal of the tumor. A corpus luteum (choice A) is a common cause of complex cysts in young women. However, a corpus luteum does not contain thyroid tissue, hair, teeth, and other such tissues. Ectopic pregnancy (choice B) can cause an adnexal mass, and a live ectopic may have various tissues in it when examined microscopically. However, this patient has a negative hCG, which effectively rules out ectopic pregnancy unless there is a laboratory error. Also, this cyst has tissues that are found in struma ovarii. Gastric carcinoma (choice C) can metastasize to the ovary. In fact, 5% of all ovarian malignancies are metastases from other sites. The cancers that most frequently metastasize to the ovary are colon, breast, stomach, and pancreas. When a gastric carcinoma metastasizes to the ovary, it is termed a Krukenberg tumor and has the pathognomonic "signet-ring" cells. Thyroid carcinoma (choice E) rarely metastasizes to the ovary and rarely would be found in combination with the other tissue elements that this patient's cyst has.

70 13. A 62-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman in no apparent distress. Pelvic examination is unremarkable. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. Which of the following is the most appropriate next step in management? a) Chemotherapy b)Cone biopsy c)Dilation and curettage d)Hysteroscopy e)Hysterectomy

71 13) Explanation : The correct answer is E. Endometrial cancer is the most common gynecologic cancer in women ages 45 and older. The main factor that predisposes a woman to the development of endometrial cancer is exposure to unopposed estrogen, whether endogenous or exogenous. Endogenous factors include, early menarche, late menopause, chronic anovulation, estrogen-secreting ovarian tumors, and obesity. Exogenous factors include the ingestion of unopposed estrogen (as with estrogen replacement therapy). Hypertension and diabetes have also been associated with endometrial cancer, though this relationship may likely be related to obesity. This patient has endometrial cancer on the basis of her endometrial biopsy result. The correct management for this patient is with total abdominal hysterectomy, bilateral adnexectomy, and possible lymph node sampling. Chemotherapy (choice A) would not be the most appropriate next step in management. If the patient were not a surgical candidate, because of her obesity, for example, then radiation therapy could be administered. Cone biopsy (choice B) is used in the diagnosis and management of cervical cancer. It would not be used for this patient with an endometrial biopsy showing endometrial cancer. Dilation and curettage (choice C) or hysteroscopy (choice D) would not be the most appropriate next step in management. The diagnosis of endometrial cancer has been made on the basis of the endometrial biopsy. Therefore, the most appropriate next step in management is to treat the patient through hysterectomy or, if hysterectomy is not possible because of obesity or medical disease, radiation.

72 14 -.A 35-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward after a gush of clear fluid from the vagina. After the gush, she has had increasing contractions. Sterile speculum examination shows a pool of clear fluid in the vagina that is nitrazine positive. Cervical examination shows that the patient is 5 cm dilated, with the fetal face presenting in a mentum anterior position. External uterine monitoring shows that the patient is contracting every 2 minutes, and external fetal monitoring shows that the fetal heart rate is in the 140s and reactive. Which of the following is the most appropriate next step in management? a)Expectant management b)Oxytocin augmentation c)Forceps delivery d)Vacuum delivery e)Cesarean section

73 14) Explanation : The correct answer is A. This patient has a face presentation. Typically, a fetus in labor is as an occiput presentation. In certain rare instances (roughly 1 in 500 deliveries), however, the fetus is in a face presentation. Causes of face presentation include an anencephalic fetus, pelvic contraction, and high parity. A vaginal delivery is possible when the fetus is in a mentum anterior position (i.e., the fetal chin is oriented toward the maternal pubic symphysis.) The fetus can flex its head, thereby allowing delivery. This patient is in active labor with contractions every 2 minutes and 5 cm of cervical dilation. The fetus is in mentum anterior position. Therefore, expectant management is the most appropriate next step. Oxytocin augmentation (choice B) is not indicated. This patient is in active labor on her own and therefore does not need oxytocin to augment it. Forceps delivery (choice C) would not be indicated. Forceps are not used prior to full dilation of the cervix. Also, with a non-vertex presentation, forceps would be contraindicated. Vacuum delivery (choice D) is not indicated. As with forceps, vacuum delivery is not performed prior to full dilation of the cervix. With a face presentation, vacuum delivery would be contraindicated. Cesarean section (choice E) would not be indicated. Vaginal delivery is possible with face presentation.

74 15 -.A 36-year-old woman, gravida 3, para 2, at 33 weeks' gestation comes to the physician for a prenatal visit. She has some fatigue but no other complaints. Her current pregnancy has been complicated by a Group B Streptococcus urine infection at 16 weeks. Her past obstetric history is significant for a primary, classic cesarean delivery 5 years ago for a non-reassuring fetal tracing. Two years ago, she had a repeat cesarean delivery. Past surgical history is significant for an appendectomy 10 years ago. Which of the following is the major contraindication to a vaginal birth after cesarean (VBAC) in this patient? a) Classic uterine scar b)Group B Streptococcus urine infection c)Previous appendectomy d)Prior cesarean delivery for non-reassuring fetal tracing e)Two prior cesarean deliveries

75 15) Explanation: The correct answer is A. The presence of a classic uterine scar is an absolute contraindication to a vaginal birth after cesarean (VBAC). A classic uterine scar is a vertical incision into the uterus that extends from the lower uterine segment up into the active myometrial portion toward the fundus of the uterus. Patients with a previous classic cesarean delivery have roughly a 10% risk of uterine rupture. Therefore, these patients should have an elective repeat cesarean delivery when the fetus is mature. Group B Streptococcus (GBS) urine infection (choice B) is not a contraindication to vaginal delivery. Patients with GBS urine infection are allowed to have a vaginal delivery but must receive IV antibiotics during labor to prevent GBS invasive disease of the newborn. Previous appendectomy (choice C), or other intra-abdominal surgery, is not a contraindication to vaginal delivery. Prior cesarean delivery for non-reassuring fetal tracing (choice D) is not a contraindication to vaginal delivery. Patients with this indication for primary cesarean delivery have approximately a 70% rate of success with VBA C. Women with two prior cesarean deliveries (choice E) may undergo a trial of labor (VBAC). This is the case if the two prior cesarean deliveries were low-transverse hysterotomies. However, the patient should be cautioned that the risk of rupture does increase with the number of previous cesarean deliveries.

76 17-.A 18-year-old woman comes to the physician for an annual examination. She has no complaints. She has been sexually active for the past 2 years. She uses the oral contraceptive pill for contraception. She has depression for which she takes fluoxetine. She takes no other medications and has no allergies to medications. Her family history is negative for cancer and cardiac disease. Examination is unremarkable. Which of the following screening tests should this patient most likely have? a) Colonoscopy b)Mammogram c)Pap smear d)Pelvic ultrasound e)Sigmoidoscopy

77 17) Explanation: The correct answer is C. The Pap smear has been shown to be a highly effective screening test for cervical cancer. The Pap test was introduced in the U.S. roughly 50 years ago, and since that time the mortality rate from cervical cancer has decreased by 70%. The main drawbacks to Pap testing are that many women do not get a regular (or any) Pap smear and that the test has a high false-negative rate. That is, a given Pap smear may be read as negative when, in fact, the woman has abnormal cytology. The reason for this false negative rate is that there may be errors in sampling, preparation, screening, and interpretation, such that abnormal cells are missed. Yet, if a woman has a yearly Pap test, it is assumed that these abnormal cells will eventually be discovered. Because the natural history of most cervical cancers is believed to be a gradual progression over many years, then annual screening (even with a high false-negative rate) will lead to lesions eventually being discovered and appropriate treatment being given. Women should have an annual Pap test when they begin having sexual intercourse or at the age of 18, whichever comes first. Colonoscopy (choice A) is used to screen for colon cancer in some at-risk patients. This patient is not high-risk and therefore, at age 18, does not need to have a colonoscopy. The mammogram (choice B) is used to screen for breast cancer. Women should begin having regular mammograms at age 40. Pelvic ultrasound (choice D) is not used as a screening test. Certain studies have been done to evaluate whether pelvic ultrasound is a good screening test for ovarian cancer. On the basis of these studies, however, pelvic ultrasound is not recommended for this purpose. Sigmoidoscopy (choice E) is also used to screen for colon cancer. As explained above, this patient is not high-risk and therefore does not need a sigmoidoscopy

78 18- A 35 year old woman gravida 7, para 5,abortus 1, is in the active phase of labor with the vertex at -1 station.She complains of abdominal pain with the contractions. At the height of one contraction the pain becomes very intense. Following this intense pain, utrine contractions ceased. The maternal systolic blood pressure drops 15 mm Hg.You should: A)Immediately perform a pelvic examination B)Place the patient on her side & reassure her C)Manage expectantly D)Begin oxytocin E)Perform an U/S

79 18-Explanation: The correct answer is A.This is a classic example of utrine rupture. If rupture has occurred,fetal mortalityis very likelyand one should anticipate the possibility of rapid onset of sever maternal shock.Delivery and mechanical methods will stop the bleeding. Massive vascular support is often necessary to save the mother’s life.

80 19 -An inter-stitial ectopic pregnancy: A)Rarely exceeds 4 weeks of gestation. B)Is generally more dangerous than an ampullary ectopic pregnancy C) Requires hysterectomy D) Is extra uterine

81 19- Explanation: The correct answer; B. Interstitial pregnancies are rare. However, because of their placement and large blood supply, they can grow quiet big prior to rupture and then bleed massively. Because of the large uterine defect caused by rupture,hysterectomy may be ( but is not always ) necessary.

82 20-Relative contra-indications to the use of vacuum extraction for delivery include A)Fetal coagulopathy B) Following fetal scalp sampling C)Fetal prematurity D)non-vertex presentation E) All of the above

83 20-Explanation: The correct answer; E. The indications for vacuum extraction are the same as those for forceps delivery.Although forceps can be applied for face presentation mentum anterior vacuum should not be used on the face. If the fetus is very small it doesn’t fit well & there is increased risk of vascular rupture & bleeding, which is also a problem with fetal coagulopathies or after scalp sampling.

84 OSCE

85 CTG

86 Components of normal CTG  Baseline  Short term variability  Accelerations

87 SAMPLE OF NORMAL REACTIVE CTG

88 110 to 160 bpm at term Faster in early pregnancy Below 100 = baseline bradycardia Below 80 = severe bradycardia Tachycardia common with maternal fever Tachycardia with reduced STV = early hypoxia

89 Must be >15 bpm and >15 sec above baseline Should be >2 per 15 min period Always reassuring when present May not occur when fetus is “sleeping” Should occur in response to fetal movements or fetal stimulation Non reactive periods usually do not exceed 45 min (>90 min and no accelerations is worrying)

90 Beat to beat variation: Interval between 2 successive heart beats. Baseline variation: The minor fluctuations of baseline rate, observed over a minute. Reflects the activity of intact fetal sympathetic and parasympathetic systems (fetal HR is directly under the control of these 2 systems after 26th week of POA.)

91 Normal baseline variability: 5-15 (+/-) bpm from baseline Loss of baseline variability: variability <5 bpm ’’ ’’ Causes: Maternal drug use- Pethidine,Diazepam, Anti hypertensive ( Beta blockers) Fetal sleep status Fetal hypoxia Fetal asphyxia, Fetal acidosis

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93 Early: mirrors the contraction Typically occurs as the head enters the pelvis and is compressed, i.e. it is a vagal response Late: Follows every contraction and exhibits a slow return to baseline Is quite rare but is the response of a hypoxic myocardium Variable: Show no relationship to contractions o Mild o Moderate o Severe

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98 Baseline 100 or >160<180 STV 40 min but <90 min Early decelerations Variable decelerations A single prolonged deceleration up to 3 min

99 Baseline is 180 bpm STV is 90 min Late decelerations are repeated Atypical variable decelerations occur Two prolonged decelerations for >3 min occur Sinusoidal pattern >10 min

100 Reduced STV No accelerations Decelerations after most contractions with a slow return to baseline

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106 Instrumental delivery

107 Operative vaginal delivery refers to a delivery in which the operator uses forceps or a vacuum device to assist the mother in transitioning the fetus to extra uterine life. INSTRUMENTAL DELVRIES

108 Indications for Operative Vaginal Delivery (Evidence level III) - No indication is absolute and each case should be considered individually MATERNAL INDICATIONS Prolonged second stage of Labor Exhaustion Medical indications (cardiac disease, hypertensive crisis Neurological disorders where voluntary efforts are contraindicated or impossible FETAL INDICATIONS: - Foetal distress in second stage of labor Abnormal heart rate pattern Passage of meconium Abnormal scalp blood ph To control the After coming head of breech

109 Prerequisites for Operative Vaginal Delivery Safe operative vaginal delivery requires: Careful assessment of the clinical situation. Clear communication with the mother and healthcare personnel. And expertise in the chosen procedure

110 PREREQUISITES Fully dilated cervix. Bladder should be empty Ruptured membranes. Engaged head. Confirm Fetal presentation, position, lie,

111 Contraindications to operative delivery 1. Cephalopelvic disproportion 2. Borderline CPD or malposition with confirmed or good evidence of fetal compromise

112 Types of forceps There are three types of forceps Kielland's forceps are for rotation and extraction; Simpson's forceps are for mid cavity assisted delivery without the need for rotation when the maximum diameter of the fetal head is about 5­8 cm above the vulva. Short forceps (Wrigley's) are for low extraction when the maximum diameter is about 2.5 cm above the vulva. These were designed for use by general practitioner obstetricians, with the safety feature that they could not reach high into the pelvis

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115 Forceps Application Applying the left blade of the forceps

116 Applying the right blade of the forceps

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118 Vacuum extractor Vacuum extraction is fast becoming the method of choice for vaginal assisted delivery. vacuum causes less maternal trauma than forceps, but the incidence of scalp trauma in the baby is increased; they should not be used before 34 weeks' gestational age because of the softer fetal head. Vacuum extractors have a safety factor—they will come off if too much traction is applied, so they are not useful with even mild disproportion.

119 Types of vaccum Metal cups Soft cup Kiwi omni cup

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123 Possible Important Subjects To Review For OSCE * OGTT : values, interpretation, when to do,ect. *Pap Smear: indications,Interpretation, How to do it *Bishop score : For cervical scoring on P/V examination *Leopold's’ Maneuver: Obst abdominal examination *Basic Obstetric U/S

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125 PAP SMEAR

126 BISHOP SCORE

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128 Management OF Obstetrics Emergencies Post partum Hge Eclampsia & PET Cord Prolapse Shoulder dystocia & Erbs’ palsy(might bring a picture) Uterine Inversion

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