Obstetrics and Gynecology SMLE Past Paper 2023 PDF

Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Contraindications to Pregnancy (Medications and Vaccines) A 28-year-old female with history of recurrent pregnancy loss. She comes now want to improve her immunity bef...

Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Contraindications to Pregnancy (Medications and Vaccines) A 28-year-old female with history of recurrent pregnancy loss. She comes now want to improve her immunity before trying to conceive. What you will give her? A. Influenza vaccine B. Rubella vaccine C. Hepatitis D. Immunoglobulin Correct Answer: B Explanation: (According to UpToDate) Congenital rubella syndrome — Rubella infection can have catastrophic effects on the developing fetus, resulting in spontaneous abortion, fetal infection, stillbirth, or intrauterine growth restriction Female her previous pregnancy is stillbirth and now she want to pregnant and ask the doctor about all the vaccines that she is need before conception and reduce the stillbirth? A. Rubella B. Varicella C. Influenza Correct Answer: A Explanation: (According to UpToDate) Congenital rubella syndrome — Rubella infection can have catastrophic effects on the developing fetus, resulting in spontaneous abortion, fetal infection, stillbirth, or intrauterine growth restriction 4|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Married women came in winter to OB /gyn clinic she want to conceive later what vaccine you should give her before conceive? A. Rubella B. Influenza C. Varicella D. Tdap Correct Answer: B Explanation: (According to Williams Obstetrics and UpToDate) PRECONCEPTION IMMUNIZATION - Influenza o Vaccinate all women who will be pregnant during flu season. Vaccinate high-risk women prior to flu season. o Vaccination against influenza throughout the influenza season, but optimally in October or November, is recommended by the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists for all women who will be pregnant during the influenza season. - Measles, mumps, rubella (MMR) o Screen for rubella immunity. If nonimmune, vaccinate and counsel on the need for effective contraception during the subsequent month. - Varicella o Screen for varicella immunity. If nonimmune, vaccinate and counsel on the need for effective contraception during the subsequent month. - Tdap (tetanus, diphtheria, pertussis) o Update vaccination in all reproductive-aged women. 5|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Pregnant in 2nd trimester which vaccine to give her? A. H. influenza B. DTAP Correct Answer: A Explanation: (According to UpToDate) - Tdap Pregnant women should receive Tdap, ideally during the early part of the 27 to 36 week gestational age range (third trimester) - Inactivated Influenza Vaccine All women who are pregnant or might be pregnant during the influenza season should receive the inactivated influenza vaccine as soon as it becomes available and before onset of influenza activity in the community, regardless of their stage of pregnancy Pregnant lady, what vaccine should she get at first visit? A. Influenza B. Tdap Correct Answer: A Explanation: (According to UpToDate) - Tdap Pregnant women should receive Tdap, ideally during the early part of the 27 to 36 week gestational age range (third trimester) - Inactivated Influenza Vaccine All women who are pregnant or might be pregnant during the influenza season should receive the inactivated influenza vaccine as soon as it becomes available and before onset of influenza activity in the community, regardless of their stage of pregnancy Pregnant nullipara what vaccine should you give her? A. Influenza B. DTaP C. Rh immunoglobulin Correct Answer: Depends on the gestational age Explanation: - If 1st or second trimester à I would go with influenza - If third trimester à I would go with Tdap 6|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Female have regular cycle every 30 days her last period before 36, she received rubella vaccine before 3 weeks. She was asked not to get pregnant until 2 months of receiving rubella , But she got pregnant, what’s the most likely pregnancy outcome? A. Not affected B. Associated with congenital malformations. Correct Answer: A Explanation: (According to Williams Obstetrics and UpToDate) - Inadvertent administration of measles, mumps, rubella (MMR) or varicella vaccines during pregnancy should not generally be considered indications for pregnancy termination. - ACIP and American College of Obstetricians and Gynecologists (ACOG) recommendations to avoid pregnancy for one month following each dose of a live vaccine. Nevertheless, adverse outcomes in women who became pregnant soon after receiving these vaccines have not been established Pregnant women doesnt have rubella vaccine what should do? A. Take in second trimester. B. Postpartum Correct Answer: B Explanation: (According to UpToDate) POSTPARTUM IMMUNIZATION - MMR and varicella – The following vaccines should be given before discharge to protect a nonimmune mother and newborn: o MMR – The measles, mumps, rubella (MMR) vaccine should be administered to women nonimmune to rubella or measles o Varicella vaccination is recommended for women without evidence of immunity. The first dose is given while the patient is in the hospital and the second dose is given four to eight weeks later, which typically coincides with the routine postpartum visit. Breastfeeding is not a contraindication to administration. 7|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Pregnant her child school had an outbreak and she’s afraid to get to her child which vaccine she should get ? A. DtaP B. Influenza C. Rubella D. Varicella Correct Answer: B Explanation: (According to UpToDate) Inactivated Influenza Vaccine - All women who are pregnant or might be pregnant during the influenza season should receive the inactivated influenza vaccine as soon as it becomes available and before onset of influenza activity in the community, regardless of their stage of pregnancy A woman was taking highly androgenic progesterone without knowing she is pregnant. What complication will her daughter face? A. Nothing will change B. Hirsutism C. Masculinization D. Feminization Correct Answer: C Explanation: (According to UpToDate and Williams Obstetrics) Gestational hyperandrogenism — Virilization in an XX individual with normal female internal anatomy can result from exposure to maternal androgen or synthetic progestational agents. Because the placenta produces the aromatase enzyme, which converts androgens to estrogens, only very high levels of maternal androgens can overcome placental aromatase to cause virilization of the fetus. Causes include maternal luteoma or theca lutein cysts. These disorders are suggested by a history of maternal virilization during pregnancy and/or exogenous progestin or androgen exposure 8|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Cervical Incompetence G2P0 20 weeks of gestation, with cervical incompetence (cervix length 30mm), what’s the most appropriate management? A. Cervical cerclage B. Strict bed rest C. Progesterone supplementation Correct Answer: C Explanation: (According to ACOG and Uptodate) Indications for Cervical Cerclage in Women With Singleton Pregnancies - History Indicated Cerclage: A. History of one or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labor or abruptio placentae B. Prior cerclage due to painless cervical dilation in the second trimester C. Placed at approximately 13–14 weeks of gestation. - Physical Examination Indicated Cerclage: Painless cervical dilation in the second trimester (known as emergency or rescue cerclage) - Ultrasonographic Finding With a History of Prior Preterm Birth Indicated Cerclage: Current singleton pregnancy, prior spontaneous preterm birth at less than 34 weeks of gestation, and short cervical length (less than 25 mm) Before 24 weeks of gestation Candidates for progesterone supplementation: - Patients with singleton pregnancy and a short cervix (≤25 mm) - Twin pregnany with a short cervix (2 times the upper limit of the normal range or severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by an alternative diagnosis, or both Thrombocytopenia 1.1 mg/dL [97.2 micromol/L] or a doubling of the serum creatinine concentration in the absence of other renal disease) Pulmonary edema The symptom complex of dyspnea, chest pain, and/or decreased (≤93 percent) oxygen saturation Pregnant at 34 weeks of gestation, complaining of vaginal bleeding, open cervix 6cm, she has hypertension 160/90 and proteinuria, CTG shows fetal bradycardia, what is the management? A. MgSo4 and deliver B. Stabilize and MgSo wait until 37 week C. Stabilize give steroid then labour Correct Answer: A Explanation: Management of Preeclampsia with severe features o if rupture of membrane is mentioned in the question. To avoid infections, otherwise? NO INTERVENTION IN THE LATENT PHASE AT ALL. A primigravida patient presented in labor. O/E: the cervix is 5cm dilated and the fetus is in a station O with cephalic presenting part and this state for 4 hours even the oxytocin had been taken. CTG Picture as shown above. what is the management for this patient? A. Stop oxytocin B. Immediate C-section C. Wait for 2 hours D. Instrumental delivery Correct Answer: A Explanation: 82 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Her CTG is category 2 and is managed by in utero resuscitation measure e.g. lateral positioning of the mother, O2, IV fluid, stop oxytocin, administer toocolytic drugs. Let’s Exclude!! - Immediate CS -> if her CTG is category3 - Wait for 2 hours -> if her CTG is category1 - Instrumental Delivery -> If her cervix is fully dilated and the head is engaged +2 and beyond. CTG Categories: - Category 1 The fetal heart tracing shows All of the following Baseline FHR 110-160 BPM Moderate variability +- Accelerations +- Early decelerations Management: Routine surveillance - Category 2 Include all FHR tracing that are not included in. category1 or 3 Management: In utero resuscitation measure e.g. lateral positioning of the mother, O2, IV fluid, stop oxytocin, administer toocolytic drugs, and surveillance - Category 3 At least one of the following Absent variability with recurrent late decelerations Absent variability with recurrent variable decelerations Absent variability with bradycardia Sinusoidal pattern for at least 20 minutes Management: In utero fetal resuscitation measures and prepare of delivery 83 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Pregnant in labor was induced by oxytocin, CTG showing late deceleration (pic). what to do to reverse condition? A. Give epidural anesthesia. B. Give morphine. C. Let mother sleep supine. D. Stop oxytocin Correct Answer: D Explanation: Our patient has CTG category2, which is managed by in utero resuscitation measure e.g. lateral positioning of the mother, O2, IV fluid, stop oxytocin, administer toocolytic drugs. *Never choose supine position, the correct position is lateral, it was a trick question A 39-week pregnant patient, history of caesarean section, due to breech presentations, now she is in labor, with regular contractions 4 every 5 min, cervix fully dilated, full effacement, station +3, What is your management? A. Ventouse delivery B. Cesarean section C. Examine her after 2 hours. Correct Answer: A Explanation: According to ACOG: Similar standards should be used to evaluate the labor progress of women undergoing Vaginal delivery after cesarean and those who have not had a prior cesarean delivery. Let’s Exclude!! - Ventose Delivery -> because her cervix is fully dilated, and the head is engaged +2 and beyond. Although there is no strong indication for ventouse. Ventouse delivery indication examples are: CTG category 2, maternal exhaustion or prolonged 2nd stage of labor. But we answered this question by exclusion. - Immediate CS -> if her CTG is category3 - Examine her after 2 hours -> if she wasn’t fully dilated and station +3 Pregnant patient in labor. O/E: the cervix is fully dilated for 2 hrs, head in a station - 2, but the patient is got exhausted from pushing. What is your next step? A. Cesarean delivery B. Wait for another 2 hours C. Ventouse delivery D. Forceps delivery Correct Answer: A Explanation: Prolonged second stage of labor: - Definition: Greater than 3 hours in nulliparous women and greater than 2 hours in multiparous women (in patients who received an epidural add an extra hour) - Managed by: 84 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Instrumental Delivery (if the head is engaged at +2 station and beyond) (OUR PATIENT DOES NOT FULL FILL THE CRITERIA) Cesarean Section (if the instrumental delivery is contraindicated) (LIKE OUR PATIENT) 41 Weeks pregnant with non-reassuring CTG and she has fibroid, what is the most appropriate step in the management? A. Induce labor B. C-section C. CTG Daily Correct Answer: B Explanation: - Non-reassuring CTG means CTG Category 2 or 3. But, as long as he didn’t specify the category, then anticipate the worst and manage accordingly. Let’s Exclude!! - Induce labor à we cant induce labor (oxytocin) if her CTG is non-reassuring, as the management of non-reassuring CTG in to stop oxytocin - C-section à answered by exclusion and it’s the difintive management of CTG category3 - CTG daily à You cannot manage a non-reassuring CTG with CTG daily Pregnant 42 weeks, in labor 7 cm dilated, meconium staining liquor, regular and strong contractions, CTG showing fetal heart rate of 100? A. C-section B. Augment labor Correct Answer: A Explanation: (According to Uptodate) Management of Meconium stained amniotic fluid: - Induction of labor and continuous fetal monitoring. (expectant management in case of reassuring CTG is acceptable also) - Evaluation and interventions are implemented in cases with abnormal tracings indicative of fetal stress to reduce the likelihood of perinatal asphyxia. We agree that FHR monitoring identifies signs of hypoxemia and allows the caregivers to initiate prompt interventions in order to reduce the risk of MAS. Let’s Exclude!! - C-section à By exclusion, as our patient has CTG category2 (bradycardia), which is managed by in utero resuscitation measure e.g. lateral positioning of the mother, O2, IV fluid, stop oxytocin, administer toocolytic drugs. If in utero resuscitation measures are not in the choices, i would go with C-section - Augment labor à Management of CTG category 2 is to stop oxytocin as mentioned above. Also, she has regular and strong contractions no need to augment labor 85 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Pregnant, primigravida in labor for couple of hours, 6cm dilated, 80% effacement, 0 station, was managed with oxytocin and ruptured membrane for 20 hours. CTG showed late deceleration (see above pic) what is the appropriate mx? A. C-section B. Stop oxytocin C. Amnioinfusion D. Ampicillin Correct Answer: A Explanation: Prolonged Active Phase: - Definition: ≥ 6 cm cervical dilation and one of the following: No change in cervical dilation after 6 hours of inadequate contractions No change in cervical dilation after 4 hours of adequate contractions - Managed By: Augmentation with Oxytocin for hypotonic contractions (with cervical ripening for unfavorable cervix 6cm or less) Amniotomy (Rupture of membrane) Arrested Active Phase: - Definition: ≥ 6 cm cervical dilation with ruptured membranes and no cervical change after one of the following: ≥ 4 hours of adequate contractions > 6 hours of inadequate contractions despite oxytocin administration - Managed By: Cesarean Section! Let’s Exclude!! - C-section à The patient had prolonged active phase of labor-> she was managed by amniotomy and oxytoci. Now she is having arrested active phase, which is managed by C-section! - Stop oxytocin à I would do it as a next step (not the most appropriate) initiating in utero resuscitative measures while I’m waiting for the C-section (in utero resuscitative measures includes: change of maternal position is a reasonable first treatment option, followed by O2, IV fluid, stop oxytocin, administer toocolytic drugs.) 86 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics - Amnioinfusion à is the second line option after in utero resuscitative measures (so, i will not choose it as a next step or most appropriate) - Ampicillin à If he says next not most appropriate. 20-years-old primigravida, 42 weeks with closed cervix. Induction of labor with prostaglandins gel was started. Her CTG was “fetal HR 140-160” after 1 h fetal HR 80 and uterine contraction last 2 minutes, most important step in management? A. C-section B. Oxygen mask C. SC terbutaline D. Check for cord prolapse Correct Answer: C Explanation: Uterine Tachysystole - Definition >5 contractions in 10 minutes, averaged over a 30-minute window. Or uterine hypersystole/hypertonus (a contraction lasting at least 2 minutes). Uterine tachysystole is one of the causes of fetal bradycardia. - Managed by: Discontinue oxytocin or cervical ripening agents + administer tocolytics (e.g. terbutaline) Note: **Check cord prolapse-> if the membrane was ruptured (hint) was in the question Pregnant lady during labor, CTG show fetal persistent bradycardia, what is the cause of her condition? A. Placental insufficiency B. Congenital heart disease Correct Answer: A Explanation: (According to ACOG) - Rarely, bradycardia occur in fetuses with congenital heart abnormalities or myocardial conduction defects, such as those associated with maternal collagen vascular disease. 87 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics - Most often the onset of bradycardia associated with congenital heart block occurs in the second trimester; it is extremely unlikely that new onset intrapartum bradycardia would be due to this condition. Pregnant lady, 41 weeks GA in labor on epidural analgesia, mg sulfate for pre-eclampsia and oxytocin, CTG showed prolonged deceleration and the mother was hypotensive, most likely cause of the CTG finding: A. Mg Sulfate B. Oxytocin C. Epidural analgesia Correct Answer: C Explanation: (According to ACOG) Medications that can affect fetal heart rate: - Mg Sulfate: causes minimal or reduced variability - Epidural analgesia: causes maternal hypotension à uteroplacental insufficiency à late or prolonged decelerations - Oxytocin: late or prolonged decelerations + uterine hyperstimulation Pregnant 38 weeks. Diagnosed with preeclampsia and managed with magnesium sulfate. Shes in labor and epidural anesthesia was started. Oxytocin infusion is started as well. 88 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Normal regular contraction. CTG picture: as shown above, Whats the cause of this CTG finding? A. Oxytocin infusion B. Magnesium sulfate infusion C. Epidural analgesia D. Head position of the baby Correct Answer: B Explanation: CTG picture is showing, reduced variability. Medications that can affect fetal heart rate: - Mg Sulfate: causes minimal or reduced variability - Epidural analgesia: causes maternal hypotension à uteroplacental insufficiency à late or prolonged decelerations - Oxytocin: late or prolonged decelerations + uterine hyperstimulation Reduced variability is caused by? A. Magnesium sulfate B. Epidural analgesia Correct Answer: A Explanation: Medications that can affect fetal heart rate: - Mg Sulfate: causes minimal or reduced variability - Epidural analgesia: causes maternal hypotension à uteroplacental insufficiency à late or prolonged decelerations - Oxytocin: late or prolonged decelerations + uterine hyperstimulation Woman had C-section. What is the best way to prevent adhesions? A. Perform the C-section before onset of labor B. Add adhesion barrier consisting of oxidized regenerated cellulose before closing the wound C. Closure of the peritoneum D. Add a layer the incision site Correct Answer: B Normal vaginal delivery, Baby weight 4.2kg, Laceration reaching rectal mucosa, which degree: A. First B. Second 89 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics C. Third D. Fourth Correct Answer: D Explanation: Degrees of perineal tears - First degree: Skin - Second degree: Muscle - Third degree: Sphincter - Fourth degree: Rectal mucosa 35-Year-old pregnant lady with fetal death and DIC, her cervix is 4cm dilated, (her vitals are normal), what is the management? A. Induction of labor B. Urgent C-section Correct Answer: A Another recall 35-Year-old pregnant lady with fetal death and DIC, her cervix is 4cm dilated, (her vitals shows hypotension), what is the management? A. Induction of labor B. Urgent C-section Correct Answer: B Explanation: (According to Uptodate) DIC in Pregnancy - In Hemodynamically unstable mother OR fetal distress OR contraindication to vaginal delivery Cesarean delivery is indicated Why? if the mother is hemodynamically unstable, Vaginal delivery is not the safest maternal option if hemodynamic instability from ongoing brisk uterine bleeding persists despite vigorous transfusion of blood and blood products. In these cases, cesarean delivery is indicated to save the mother's life - In Hemodynamically stable mother with dead or nonviable fetus Induction of Labor is indicated Why? avoiding cesarean delivery because of the risk of uncontrollable hemorrhage from surgical incisions and lacerations. Delivery is initiated, as removal of the products of conception removes the trigger for DIC - In Hemodynamically stable mother with a viable fetus and reassuring fetal status In those rare cases in which the mother with acute disseminated intravascular coagulation (DIC) is responding appropriately to resuscitation with blood products and 90 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics the fetal heart rate (FHR) tracing is normal, there is no compelling need for immediate delivery (induction of labor, cesarean birth). Instead, the clinical focus is on reversing or eliminating the cause of DIC and reducing the risk of bleeding and thrombosis. After this has been achieved, decision-making regarding expectant management or delivery depends on the gestational age and expected course of the underlying cause of DIC. Pregnant with DIC and CTG normal no deceleration and good contract what to do? A. Augment labor B. C-section C. Reassure Correct Answer: C Explanation: (According to Uptodate) DIC in Pregnancy - In Hemodynamically stable mother with a viable fetus and reassuring fetal status In those rare cases in which the mother with acute disseminated intravascular coagulation (DIC) is responding appropriately to resuscitation with blood products and the fetal heart rate (FHR) tracing is normal, there is no compelling need for immediate delivery (induction of labor, cesarean birth). Instead, the clinical focus is on reversing or eliminating the cause of DIC and reducing the risk of bleeding and thrombosis. After this has been achieved, decision-making regarding expectant management or delivery depends on the gestational age and expected course of the underlying cause of DIC. Pregnant lady, diabetic, 38 weeks in active labor and having DKA profile and fetus in distress (CTG that is suggested of bradycardia) what to do? A. Change the mother’s position of labor B. Stop and do C-section Correct Answer: A Explanation: (According to Uptodate and ACOG) Diabetic KetoAcidosis in Pregnancy DKA - Clinical presentation Includes abdominal pain, nausea, vomiting, and altered sensorium. - Laboratory findings: Includes hyperglycemia (usually >250 mg/dL [13.9 mmol/L]), acidemia (arterial pH 12 mEq/L), ketonemia, low serum bicarbonate (4 mEq/L), and renal dysfunction - Continuous fetal heart rate monitoring Minimal or absent variability and absent accelerations, as well as repetitive decelerations. These abnormalities usually resolve with resolution of DKA - Management: Intravenous insulin, appropriate volume replacement, correction of electrolyte abnormalities (including potassium, phosphate, and magnesium), monitoring acidosis, and a search for precipitating causes. 91 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Emergency delivery before maternal stabilization should be avoided because it increases the risk of maternal morbidity and mortality and may result in delivery of a hypoxic, acidotic preterm infant. Note: - If IV insulin and hydration in the choices I would choose it. - If not? in utero resuscitation measure is also correct. Urine Dipstick pic with: +2 protein, very high glucose, +ve ketones in pregnant lady 39 weeks with effacement 90% and cervix dilation 2 cm, what is your most appropriate action? A. Induction of labor (IOL) B. C-section C. Expectant management Correct Answer: A Explanation: (According to ACOG ) When to deliver in case of Diabetes Mellitus? - At 39+0 to 39+6 weeks if well-controlled glucose levels and no vascular disease; - At 36+0 to 38+6 weeks if poorly controlled glucose levels or vascular disease (even earlier if severity of complications warrants earlier delivery) - Expectant management beyond 40+0 weeks is not recommended. Note: - Delivery before maternal stabilization should be avoided! - For this patient the correct answer is to manage the DKA (by insulin and hydration) and stabilize the mother! à Then induction of labor after correction of her status. - If IV insulin and hydration in the choices I would choose it. If not? IOL While the obstetrician closes the caesarean incision, patient developed bleeding. What is the cause? A. Liver haemangioma B. Spleen aneurysm C. Perforated peptic ulcer D. Mesenteric ischemia Correct Answer: B Explanation: Splenic artery aneurysms - Are the third most common true aneurysm occurring in the abdomen after aortic and iliac artery aneurysms. Splenic artery aneurysms are more common in women (female:male = 4:1) and are commonly associated with conditions of increased flow, such as pregnancy (particularly multiparity, because the risk increases with increasing parity) 92 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics - Approximately, 95% of SAA rupture occurs during pregnancy, most commonly during the third trimester. - If a woman has an existing SAA, the risk of rupture during pregnancy is 20–50%. - Though the rupture of a SAA during pregnancy is a rare event, it carries a high risk of maternal and fetal mortality. The mortality in the general population when a SAA ruptures is 25%. In pregnant women, this rate increases to a 75% maternal mortality rate and a 95% fetal mortality rate - Obstetricians and other emergency providers should consider a ruptured SAA in any pregnant woman who presents with an acute surgical abdomen. - In the rare minority of women of childbearing age who are discovered to have an asymptomatic SAA prior to rupture, a proactive approach to management should be undertaken due to the high risk of rupture in pregnancy. Liver hemangioma - May increase in size during pregnancy or with estrogen therapy. But, risk of lesion rupture is similar for pregnant and nonpregnant women Elective Cesarean section which week? A. 36 B. 37 C. 38 D. 39 Correct Answer: D Another recall Elective Cesarean section which week? A. 36-37 B. 38 C. 39 D. Full term Correct Answer: D Explanation: (According to Uptodate) - When a primary cesarean delivery is indicated for maternal or fetal reasons, but preterm birth is not indicated, there is consensus that planned term cesarean delivery should be scheduled in the 39th or 40th week of gestation - Full term = between 39 and 40 weeks Female pregnant, polyhydramnios had ruptured membrane, on CTG persistent fetal bradycardia? A. Rapid fetal descend B. Cord prolapse C. Anomaly 93 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Correct Answer: B Explanation: (According to Uptodate) Risk factors for cord prolapse - Malpresentation (breech, transverse, oblique, or unstable lie) - Preterm gestational age - Low birth weight - Second twin - Low lying placentation - Pelvic deformities - Uterine malformations/tumors - External fetal anomalies - Multiparity - Polyhydramnios - Long umbilical cord - Unengaged presenting part - Prolonged labor - Atypical placental cord insertions (velamentous and marginal) Obstetric interventions account for approximately 50 percent of cases of cord prolapse, include: - Iatrogenic rupture of membranes, especially with an unengaged presenting part - Cervical ripening with a balloon catheter - Induction of labor - Application of an internal scalp electrode - Insertion of an intrauterine pressure catheter - Manual rotation of the fetal head - Amnioinfusion - External cephalic version - Internal podalic version - Application of forceps or vacuum Note: Polyhydramnios + Ruptured membrane + Bradycardia = Cord prolapse! Signs of fetal distress in CTG: A. Less contractions B. Early deceleration C. Late deceleration Correct Answer: C Explanation: CTG Categories: - Category 1 The fetal heart tracing shows All of the following Baseline FHR 110-160 BPM Moderate variability +- Accelerations 94 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics +- Early decelerations Management: Routine surveillance - Category 2 Include all FHR tracing that are not included in. category1 or 3 Management: In utero resuscitation measure e.g. lateral positioning of the mother, O2, IV fluid, stop oxytocin, administer toocolytic drugs, and surveillance - Category 3 At least one of the following Absent variability with recurrent late decelerations Absent variability with recurrent variable decelerations Absent variability with bradycardia Sinusoidal pattern for at least 20 minutes Management: In utero fetal resuscitation measures and prepare of delivery Note - Fetal distress = non-reassuring CTG = CTG category 2 or 3 What's the best way to deliver placenta in C-section? A. Spontaneous separation B. Fundus pressure C. Manual removal Correct Answer: C Explanation: (According to NICE guidelines and ACOG) Method of placental removal Remove the placenta in caesarean birth using controlled cord traction and not manual removal to reduce the risk of endometritis. Two methods are frequently used to deliver the placenta at C-section: - Cord traction - Manual removal The best method to deliver the placenta during C/section is by cord traction followed by fundal message and pressure (active management of the 3rd stage to prevent PPH) Note: 95 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics If cord traction in the choices it’s the correct answer, if not I would go with manual removal Pregnant G3P2, 37 weeks with a history of C-section due to non-reassuring CTG. She is in labor with a 4 cm dilation. The presentation is breech. What is the absolute contraindication for ECV? A. History of C-section B. Active labor C. Variable decelerations Correct Answer: C Explanation: External Cephalic Version: Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery unless there are contraindications. Contraindications include: - Absolute: Prior classical cesarean delivery Prior uterine surgery that entered the endometrial cavity, such as myomectomy Placenta previa Non-reassuring fetal heart rate Unexplanied APH Multiple pregnancy Suspected macrosomia (typically 5000 grams in women without diabetes, 4500 grams in women with diabetes) Mechanical obstruction to vaginal birth (eg, large fibroid, severely displaced pelvic fracture, severe fetal hydrocephalus) Uterine rupture - Relative: Early labor Oligohydramnios or rupture of membranes Known nuchal cord Structural uterine abnormalities Fetal growth restriction IUGR Prior abruption or its risks e.g. preeclampsia Pregnant at 34 weeks, in labor, examination showed transverse presentation she want to know if she can do ECV Ultrasound shows bicornuate uterus with normal fetus What is the contraindication for ECV? A. Bicornuate uterus B. Breech presentation C. History of previous cesarean section Correct Answer: A Explanation: 96 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics External Cephalic Version: Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery unless there are contraindications. Contraindications include: - Absolute: Prior classical cesarean delivery Prior uterine surgery that entered the endometrial cavity, such as myomectomy Placenta previa Non-reassuring fetal heart rate Unexplanied APH Multiple pregnancy Suspected macrosomia (typically 5000 grams in women without diabetes, 4500 grams in women with diabetes) Mechanical obstruction to vaginal birth (eg, large fibroid, severely displaced pelvic fracture, severe fetal hydrocephalus) Uterine rupture - Relative: Early labor Oligohydramnios or rupture of membranes Known nuchal cord Structural uterine abnormalities Fetal growth restriction IUGR Prior abruption or its risks e.g. preeclampsia Note: - History of previous C-section is not a contraindication unless it’s a classical C-section 37 weeks pregnant came with breech presentation what is your next step? A. Cesarean section B. External cephalic version Correct Answer: B Explanation: External Cephalic Version: Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery unless there are contraindications. Lady at 34 weeks of gestation, had previous one C-section, on pelvic exam only the cervix was 3 cm dilated on US placenta was anterior and laying low. Why is ECV contraindicated in this case? A. Gestational age B. Vaginal exam findings C. US findings D. The previous history of C-section Correct Answer: C Explanation: 97 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics External Cephalic Version: Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery unless there are contraindications. Contraindications include: - Absolute: Prior classical cesarean delivery Prior uterine surgery that entered the endometrial cavity, such as myomectomy Placenta previa Non-reassuring fetal heart rate Unexplanied APH Multiple pregnancy Suspected macrosomia (typically 5000 grams in women without diabetes, 4500 grams in women with diabetes) Mechanical obstruction to vaginal birth (eg, large fibroid, severely displaced pelvic fracture, severe fetal hydrocephalus) Uterine rupture - Relative: Early labor Oligohydramnios or rupture of membranes Known nuchal cord Structural uterine abnormalities Fetal growth restriction IUGR Prior abruption or its risks e.g. preeclampsia Pregnant, twins one cephalic and another is breech presentation, how to deliver? A. Cesarean section B. Normal delivery Correct Answer: B Explanation: (According to ACOG) Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalic-presenting twins should be counseled to attempt vaginal delivery. Pregnant, twins both cephalic presentation with re-assuring CTG, how to deliver? A. Cesarean section B. Normal delivery C. Ventose D. Forceps Correct Answer: B Explanation: (According to ACOG) 98 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalic-presenting twins should be counseled to attempt vaginal delivery. A pregnant woman with twins, first twin is breech, second twin is cephalic, what is the management? A. Spontaneous vaginal delivery B. ECV then vaginal delivery C. C-section Correct Answer: C Explanation: (According to Uptodate) We suggest cesarean birth when the first twin is in a noncephalic presentation, which occurs in approximately 20 percent of twin gestations. Unbooked female came to the ED with labor, after investigation she has 100,000 colony bacteria of streptococcus and she has asthma with using salbutamol, what do you wanna give her now and after deliver? A. Ampicillin B. Oxytocin Correct Answer: A Explanation: (According to ACOG) - If GBS bacteriuria at any colony count is detected during pregnancy, the woman is at increased risk of GBS colonization during labor. A notation should be made in her medical record, she should be made aware of her GBS status, and antibiotic prophylaxis should be administered empirically during labor based on the risk factor of antepartum GBS bacteriuria - Intravenous penicillin remains the agent of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative. Pregnant at 39 weeks, now in labor during the delivery you noticed the amniotic fluid is mixed with dark black-green what is the cause of this color? A. Meconium aspiration syndrome B. Fetal distress C. Placenta abruptio D. Preterm labor Correct Answer: B Explanation: (According to Uptodate) 99 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics - Fetal stress may result in meconium passage, due to increased peristalsis and relaxation of the anal sphincter from increased vagal outflow associated with umbilical cord compression or increased sympathetic inflow during hypoxia - Fetal distress à causes meconium-stained amniotic fluid à which leads to meconium aspiration syndrome Female known to have DM, otherwise all normal, pregnant full term, during labor fetus had tachycardia, how to prevent this? Question A. Oxytocin B. Change mother position C. Mg gluconate Correct Answer: B Explanation: - Prompt relief of the compromising event, such as correction of maternal hypotension, can result in fetal recovery. CTG Categories: - Category 1 The fetal heart tracing shows All of the following Baseline FHR 110-160 BPM Moderate variability +- Accelerations +- Early decelerations Management: Routine surveillance - Category 2 Include all FHR tracing that are not included in. category1 or 3 Management: In utero resuscitation measure e.g. lateral positioning of the mother, O2, IV fluid, stop oxytocin, administer toocolytic drugs, and surveillance - Category 3 At least one of the following Absent variability with recurrent late decelerations Absent variability with recurrent variable decelerations Absent variability with bradycardia Sinusoidal pattern for at least 20 minutes 100 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Management: In utero fetal resuscitation measures and prepare of delivery Epidural anesthesia, what it’s sparring? A. Perineal B. Rectum Correct Answer: B Explanation: Epidural analgesia covers the pudendal nerve, which innervates: Sensory: The external genitalia of both sexes and the skin around the anus, anal canal and perineum Motor: Pelvic muscles, the external urethral sphincter and the external anal sphincter. After delivery of the placenta by manual extraction contracting, Retroverted uterus happened but was back in place. Where was the placenta in the uterus? A. Anterior B. Posterior C. Lateral D. Fundus Correct Answer: D Explanation: Retroverted uterus means the uterus is tipped backwards (fundus is aimed toward the rectum) For example, if there’s fibroids in the fundus of the uterus it will cause retroversion of the uterus. Pregnant women during vaginal delivery, what can make her has fourth degree perineal tear? A. Unrestrained legs and squatting position B. Unrestrained legs and sitting on chair C. Restrained legs and use of forceps and other metallic instrument Correct Answer: C Explanation: (According to ACOG) The strongest risk factors for OASIS (Obstetric Anal Sphincter Injuries) including forceps delivery, vacuum- assisted delivery, midline episiotomy, and increased fetal birth weight. Midline episiotomy combined with forceps delivery substantially increases the risk of third-degree laceration and fourth-degree laceration. The risk of anal sphincter trauma with operative delivery and episiotomy is increased in primigravid women and multigravid women. 101 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Which of the following positions of a patient in labor would most likely result in the development of a third or fourth-degree laceration? A. Unrestrained legs and squatting B. Unrestrained legs and semi setting C. Unrestrained legs and in chair D. Restrained legs and stirrups Correct Answer: C Explanation: (According to ACOG) Upright positions (including walking, sitting, standing, and kneeling), were associated with a possible increase in second-degree perineal tears Pregnant in labor and signs of meconium stain how to manage baby? A. Oropharynex suction before delivering the body B. NICU after delivery C. Tocolytics D. Intratracheal suctioning Correct Answer: B Explanation: (According to ACOG) - If the infant born through meconium-stained amniotic fluid presents with poor muscle tone and inadequate breathing efforts, the initial steps of resuscitation should be completed under the radiant warmer. - Appropriate intervention to support ventilation and oxygenation should be initiated as indicated for each infant. - Infants with meconium-stained amniotic fluid should no longer routinely receive intrapartum suctioning, whether they are vigorous or not. - In addition, meconium-stained amniotic fluid is a condition that requires the notification and availability of an appropriately credentialed team with full resuscitation skills, including endotracheal intubation. Pregegnant lady with dm in active labor ctg show abnormal fetal heart pattern. Which of the following is the most appropriate next step? A. Change maternal position B. Oxygen mask C. Stop oxytocin D. Give tocolytic Correct Answer: A Explanation: (According to ACOG) In utero resuscitative measures - Change of maternal position is a reasonable first treatment option - Followed by O2 102 | P a g e