SMLE 2024 Obstetrics and Gynecology Past Paper PDF

Obstetrics and Gynecology SMLE Questions and Answers Ver.2  Table of Content Chapter 1: Obstetrics.....................................................................................................

Obstetrics and Gynecology SMLE Questions and Answers Ver.2  Table of Content Chapter 1: Obstetrics................................................................................................................... 4 Imunniazation During Pregnancy..................................................................................................................................................... 5 Cervical Incompetence..................................................................................................................................................................... 9 Prenatal care................................................................................................................................................................................... 15 Fetal Medicine................................................................................................................................................................................ 32 Hypertension in Pregnancy and Preeclampsia................................................................................................................................ 39 Diabetes Mellitus and Gestational Diabetes Mellitus..................................................................................................................... 65 Pregnancy Related Medical and Surgical Conditions..................................................................................................................... 75 Antepartum Hemorrhage (APH)..................................................................................................................................................... 79 Labor and Delivery......................................................................................................................................................................... 96 Preterm labor, Preterm Rupture of Membrane (PROM) and Premature Preterm Rupture of Membrane (PPROM)..................... 143 Postpartum Hemorrhage (PPH).................................................................................................................................................... 159 Postpartum.................................................................................................................................................................................... 179 Chapter 2: Gynecology............................................................................................................. 181 Puberty Disorders, Pediatrics, Adolescent and Young Gynecology............................................................................................. 182 Menstrual Cycle Abnormalities and Abnormal Uterine Bleeding (AUB).................................................................................... 184 Vaginal Infections......................................................................................................................................................................... 197 Pelvic Inflammatory Disease (PID).............................................................................................................................................. 208 Contraception and Hormonal Replacement Therapy (HRT)......................................................................................................... 215 Abortion, Pregnancy Loss, and Intrauterine Fetal Demise (IUFD)............................................................................................... 223 Ectopic Pregnancy........................................................................................................................................................................ 237 Gestational Trophoblastic Disease (Molar pregnancy and Choriocarcinoma).............................................................................. 261 Adnexal masses............................................................................................................................................................................ 270 Leiomyoma (Uterine Fibroids) and Leiomyosarcoma.................................................................................................................. 271 Endometriosis............................................................................................................................................................................... 280 Adenomyosis................................................................................................................................................................................ 289 Obstetrics and Gynecology: SMLE Questions and Answers TOC Asherman’s Syndrome.................................................................................................................................................................. 294 Cervical Cancer and Screening..................................................................................................................................................... 296 Endometrial Polyp, Hyperplasia and Carcinoma.......................................................................................................................... 315 Urogynecology............................................................................................................................................................................. 331 3|Page Chapter 1: Obstetrics 4|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Imunniazation During Pregnancy 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 get 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 Married women came in winter to OBGYN 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 5|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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. 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 6|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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 → I would go with influenza - If third trimester → I would go with Tdap Female have regular cycle every 30 days her last period before 36 days, 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 7|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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. Pregnant her child’s school had an outbreak and she’s afraid to get to her child which vaccine she should ge ? A. Tdap 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. 8|Page Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Cervical Incompetence G2P0 at 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 (35 is a risk factor. (our patient is 33) and still even if she was >35 years of age, smoking is a stronger risk factor than the age. Patient admitted to the labor room, she received prostaglandin, patient massively bleeding with stop in uterine contraction. What is the cause of her condition? A. Placenta previa B. Uterine rapture C. Placenta abruption D. Prostaglandin hypersensitivity Correct Answer: B Explanation: Typical scenario of uterine rupture→ Patient on oxytocin or prostaglandin then sudden pause of uterine contractions! - Managed by immediate laparotomy and emergency C-section. Pregnant in third trimester, with vaginal bleeding, abdominal exam shows a length less than the gestational age, CTG shows late decelerations, diagnosis? A. Placenta previa B. Vasa previa C. Placenta abrubtion Correct Answer: A Explanation: - Painless vaginal bleeding → Placenta previa - Painless vaginal bleeding upon rupture of membrane → Vasa previa - Painful vaginal bleeding → Placenta abruption. Another recall Pregnant in third trimester, with abdominal pain and vaginal bleeding, abdominal exam shows a length less than the gestational age, CTG shows late decelerations, diagnosis? A. Placenta previa B. Vasa previa C. Placenta abrubtion Correct Answer: C 82 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Explanation: - Painless vaginal bleeding → Placenta previa - Painless vaginal bleeding upon rupture of membrane → Vasa previa - Painful vaginal bleeding → Placenta abruption. Pregnant at 27 weeks of gestation, came with minimal vaginal bleeding, US showed placenta totalis. What is the most important step in management? A. Antibiotics B. Tocolytics C. Steroids Correct Answer: C Explanation: According to UpToDate In patients with placenta previa A course of antenatal corticosteroid therapy is administered to patients who experience bleeding. Pregnant at 38 weeks of gestation, had polyhydramnios and PROM recently. Presented with painful vaginal bleeding and uterine tenderness, CTG finding shows persistent fetal bradycardia, what would be the cause? A. Cord prolapse B. Abruptio placenta C. Vasa previa D. Placenta previa Correct Answer: B Explanation: Let’s Exclude! - Cord prolapse → will not present with bleeding and tenderness - Abruptio placenta → Usually presents with painful vaginal bleeding, abdominal tenderness. Also, polyhydramnios especially after rapid decompression is a risk factor for placenta abruption. - Vasa previa → Painless vaginal bleeding upon rupture of the membranes - Placenta previa → Painless vaginal bleeding. 83 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Painless mild painless vaginal bleeding at 34 weeks, next step? A. Admission B. C-section C. Steroid D. Antibiotic Correct Answer: A Explanation: Management of Placenta previa: Placenta previa when to do C-section? A. 36-37 weeks B. 38 weeks C. 39 weeks D. 40 weeks Correct Answer: A Explanation: Management of Placenta previa: 84 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics A 30 years-old woman G2 P1 at 34+2 weeks gestation presents to emergency room reporting painless vaginal bleeding. Immediately transvaginal ultrasound shows placenta completely overlying the cervical os. A fetus in cephalic presentation, and an amniotic fluid index of 14. The cervical appears long and closed on speculum examination. She has slow, continuous vaginal bleeding. Fetal heart is monitored. BP 110/78 HR 106 RR 14 Temperature 36.9C Which of the following is the most appropriate in management? A. Hospitalization B. Betamethasone C. Cesarean section D. Magnesium sulfate Correct Answer: A Explanation: Management of Placenta previa: 85 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Patient at 34 weeks of gestation, came after history of fall at home with abdominal tenderness and noticed reduced fetal movement, 4cm cervix and 80% effacement. Fetal heart rate 150, and moderate utrine contractions every 3 to 4 minutes. Whats diagnosis? A. Vasa previa B. Placenta abruption C. Placenta previa D. Latent phase of labor Correct Answer: B Explanation: According to UpToDate Concealed abruptio placentae: In ∼ 20% of cases, the hemorrhage is mainly retroplacental; vaginal bleeding does not occur and presents only with history of one of the risk factors for placenta abruption (e.g. HTN, trauma, smoking or cocaine use) and abdominal tenderness A primgravida at 28 weeks of gestation and a heavy smoker presented with severe vaginal bleeding and abdominal pain. What is the most likely cause? A. Rupture of fetal artery B. Uterine rupture C. Vasa previa D. Placental abruption Correct Answer: D Explanation: Smoking is a risk factor for abruptio placenta. Patient with abruptio will present with abdominal pain or tenderness with vaginal bleeding Pregnant unbooked present with painless vaginal bleeding, fundal high 34 weeks. She lives far away and has difficulty in trasport. What is the most appropriate thing to do? A. Corticosteroid induction B. Deliver by C-section C. US D. Admit to ward Correct Answer: D Explanation: According to UpToDate Any woman with placenta previa can’t be discharged from the hospital unless she is able to return to the hospital within 20 minutes 86 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Pregnant with history of placental abruption 2 times before came in 3rd pregnancy with same condition and severe bleeding, she's at 37 week, when to admit patient? A. Admit now B. Wait till next bleeding C. Wait until determination of labor day D. Discharge and reassure. Correct Answer: A Explanation: We deliver all pregnancies with suspected acute abruption at ≥36+0 weeks of gestation Most condition cause pregnancy DIC? A. Placenta abruption B. Retained product of conception C. Placenta previa D. Congenital hemorrhagic disorders Correct Answer: A Explanation: According to UpToDate The type and frequency of pregnancy-related conditions that triggered DIC - Placental abruption (37%) - Postpartum hemorrhage (PPH) (29%) - Preeclampsia/eclampsia/HELLP syndrome (14%) - Acute fatty liver (8%) - Amniotic fluid embolism(6%) Pregnancy-related sepsis (6%) Pregnant female at 30 weeks of gestation, present with abdominal pain and bleeding. What’s the next step? A. Send for US B. IV fluids Correct Answer: B Explanation: Initial management in case of Antepartum hemorrhage: - Initiate continuous fetal heart rate monitoring - Secure intravenous access. - Administer crystalloid 87 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 38 week pregnant came in labor, cervix was 10 cm dilated baby is in -3 station, CTG: bradycardia, poor variability with recurrent late deceleration, the mother developed abdominal pain and blood, what is the most appropriate next step? A. Immediate laparotomy B. Observation C. Send to home and give follow up appointment Correct Answer: A Explanation: Painful uterine bleeding is most probably due to placenta abruption or uterine rupture! - The most common fetal distress in uterine rupture is fetal bradycardia. - Management of uterine rupture→ Immediate laparotomy with emergency C-section Pregnant at 34 weeks of gestation, presenting with heavy bleeding and contraction. Ultrasound showing fundal posterior placental with retroplacental fluid and baby in transverse lie, 3cm cervical dilatation. What to do ? A. C-section B. Observation C. Tocolytics D. ECV Correct Answer: A Explanation: According to UpToDate Placenta abruption at 34 to 36 weeks of gestation — We deliver most patients with acute abruption at 34+0 to 36+6 weeks of gestation, since these patients remain at risk of maternal or fetal compromise. Pregnant with placenta previa what’s the common complication? A. Coagulation abnormalities B. Postcoital bleeding Correct Answer: B Explanation: According to UpToDate - The most common symptom of placenta previa is relatively painless vaginal bleeding - PATHOPHYSIOLOGY OF BLEEDING: Placental bleeding is the major adverse sequelae of placenta previa. It is thought to occur when uterine contractions or gradual changes in the cervix and lower uterine segment apply shearing forces to the inelastic placental attachment site, resulting in partial detachment. Vaginal examination or coitus can also disrupt this site and cause bleeding. Bleeding is primarily maternal blood from the intervillous space, but fetal bleeding can occur if fetal vessels in the terminal villi are disrupted. 88 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Patient known case of low laying placenta previa and stable on follow up, came to ER today on week 32 with minimal bleeding and stopped at home. What is the initial step? A. CTG B. US C. Bio physical profile D. Emergency delivery Correct Answer: A Explanation: The first thing to do in antepartum hemorrhage is US to exclude placenta previa. Then CTG. But she is already diagnosed with placenta previa, so I would go with CTG. Patient presented with painless vaginal bleeding and placenta covering the internal os , Which of the following is considerd a risk factor for her presentation? A. Hypertension B. Multiple gestation C. Smoking D. DM Correct Answer: B Explanation: According to UpToDate Risk factors for Placenta previa: - Major risk factors Previous placenta previa Previous cesarean birth Multiple gestation - Other risk factors Previous uterine surgical procedure Increasing parity Increasing maternal age Infertility treatment Maternal smoking Maternal cocaine use Male fetus Prior uterine artery embolization Endometriosis Abortion, either spontaneous or induced 89 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Female patient pregnant with history of previous x4 C-sections presented with mild bleeding and hypotension, what is the most likely cause of her presentation? A. Cord prolapse B. Uterine rupture C. Abruptio placentae D. Fetal vessel rupture Correct Answer: B Explanation: According to Williams Obstetrics and Uptodate Uterine rupture - Risk factors Surgery involving the myometrium: Cesarean delivery or hysterotomy Previously repaired uterine rupture Myomectomy incision through or to the endometrium Deep cornual resection of interstitial fallopian tube Metroplasty Coincidental uterine trauma: Abortion with instrumentation-sharp or suction curette, sounds Sharp or blunt trauma-assaults, vehicular accidents, bullets, knives Silent rupture in previous pregnancy Congenital Pregnancy in undeveloped uterine horn Defective connective tissue-Marfan or Ehlers-Danlos syndrome - Clinical presentation Abnormal fetal heart rate (FHR) –category II or a category III FHR pattern Abdominal pain Vaginal bleeding –may occur but is not a cardinal symptom as it may be modest or even absent despite major intraabdominal hemorrhage. Loss of station of the fetal presenting part Hematuria, if the rupture extends into the bladder. Hemodynamic instability – Intraabdominal hemorrhage from the site of rupture can lead to rapid maternal hemodynamic deterioration (hypotension and tachycardia). Changes in contraction patterns – Both increased uterine contractility and loss of uterine tone - Management Stabilize the patient and immediate laparotomy 90 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 35-year-old pregnant women, 32 weeks, was classified as low risk pregnancy during her antenatal care, came today with vaginal bleeding and abdominal pain of which she was diagnosed as placenta abruptio and bleeding was controlled with conservative management. What is the most appropriate next step? A. Continue as low risk pregnancy with f/u outpatient clinic B. Admit the patient C. Re-classify her as high risk pregnancy and do serial US to assess fetal growth D. Continue as low risk pregnancy and do serial US for bleeding Correct Answer: B Explanation: According to UpToDate and Williams Obstetrics Management of Placental Abruption in stable mother and reassuring fetus 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. 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. 128 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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! → 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) - 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 129 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics - 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 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 130 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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. 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. 131 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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 - 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 → causes meconium-stained amniotic fluid → which leads to meconium aspiration syndrome 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 Which of the following decreases the risk of PPH in a C-section? A. Curate uterus with sponge B. Fundal pressure C. Spontaneous separation of the placenta Correct Answer: C Explanation: According to Berghella Uterine massage - Uterine massage, associated with cord traction, is associated with less blood loss compared with no such interventions Placental removal - Gentle cord traction resulting in spontaneous expulsion should be utilized for delivery of the placenta, given the significant decrease in blood loss and endometritis as compared to manual placental removal. 132 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Another recall What's the accurate recommendation to deliver the placenta during cesarean section to reduce incedence of PPH? (2024) A. Spontaneous separation: expulsion B. Fundus pressure and message C. Manual removal extraction D. Using instrument Correct Answer: A Explanation: According to Berghella Placental removal Gentle cord traction resulting in spontaneous expulsion should be utilized for delivery of the placenta, given the significant decrease in blood loss and endometritis as compared to manual placental removal. 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 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. 133 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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. Elective Cesarean section to be done at which week? A. 36 B. 37 C. 38 D. 39 Correct Answer: D Another recall Elective Cesarean section to be done at 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 Pregnant in labor at term. OE (Head in funds and both hip and knees are flexed ) spine of baby parallel to spine of mother. What is the lie? A. Longitudinal B. Transverse C. Breech D. Cephalic Correct Answer: A 134 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Pregnant known case of Bicornute uterus, in leopold manouver you found globally soft structure in 1&2 grib. Fetal heart in the level of the umbilicus of the mother, Fetal kicking felt in lower abdomen. How you will deliver this baby? A. C-section B. Vaginal delivery C. Ventose D. Forceps Correct Answer: A Explanation: According to Uptodate and ACOG - Bicornuate uterus is risk factor for breech presentation. - Leopold Maneuver: The first maneuver assesses the uterine fundus. It permits identification of fetal lie and determination of which fetal pole occupies the fundus. The breech gives the sensation of a large, nodular mass, whereas the head feels hard and round and is more mobile. - External Cephalic Version: is relatively contraindicated in case of structural uterine abnormalities Pregnant lady in labor, vaginal examination revealed palpable orbital edge, nose, mouth and chin, what is the presentation? A. Occipital B. Brow C. Face Correct Answer: C Explanation: According to Uptodate and Williams Obstetrics Face presentation: - Diagnosis: Made by vaginal examination. Palpation of the orbital ridge and orbits, saddle of the nose, mouth, and chin Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. - Method of delivery: Mentum anterior Vaginal delivery. 135 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics - Labor progress should be closely monitored as arrest of descent may occur, although not inevitably as in persistent mentum posterior position. - Oxytocin augmentation and cesarean birth are performed for standard obstetric indications Mentum posterior or transverse Cesarean delivery - Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated - Unless spontaneous rotation to mentum anterior occurs, often late in the second stage of labor, or the fetus is very small, or the pelvis is very large. If the fetal status is reassuring and there is normal progress in labor, mentum posterior presentation can be managed expectantly to see if spontaneous rotation will occur Pregnant at 38 weeks of gestation came with labor. Cervix effaced 80% dilated 6 cm and there is uterine contraction. Vaginal examination revealed palpation of nose, mouth and lips. CTG was reactive no abnormality. Which of the following is the most appropriate next step? A. Order x-ray pelvimetry B. Augmentation of labor C. Cesarean section D. Monitoring of partograph Correct Answer: D Explanation: According to Uptodate and Williams Obstetrics Face presentation: - Diagnosis: Made by vaginal examination. Palpation of the orbital ridge and orbits, saddle of the nose, mouth, and chin Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. 136 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics - Method of delivery: Mentum anterior Vaginal delivery. - Labor progress should be closely monitored as arrest of descent may occur, although not inevitably as in persistent mentum posterior position. - Oxytocin augmentation and cesarean birth are performed for standard obstetric indications Mentum posterior or transverse Cesarean delivery - Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated - Unless spontaneous rotation to mentum anterior occurs, often late in the second stage of labor, or the fetus is very small, or the pelvis is very large. If the fetal status is reassuring and there is normal progress in labor, mentum posterior presentation can be managed expectantly to see if spontaneous rotation will occur Pregnant scheduled for labor induction, what to use for cervical ripening? A. Vaginal prostaglandin B. Vaginal progesterone C. Methyldopa D. Methergine Correct Answer: A Explanation: According to ACOG Effective methods for cervical ripening include the use of mechanical cervical dilators and administration of synthetic prostaglandin E1 (PGE1) and prostaglandin E2 (PGE2) 137 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Fetal spine parallel to mother and head at the fundus, the knee is extended and the hip is flexed, what is the presentation? A. Complete breech B. Incomplete breech C. Frank breech Correct Answer: C Explanation: According to Uptodate TYPES OF BREECH PRESENTATION - Frank breech – Both hips are flexed and both knees are extended so that the feet are adjacent to the head; accounts for 50 to 70 percent of breech fetuses at term. - Complete breech – Both hips and both knees are flexed; accounts for 5 to 10 percent of breech fetuses at term. - Incomplete breech – One or both hips are not completely flexed 41 weeks +5 days came for induction of labor. The patient had 2 previous uneventful vaginal delivery, Bishop score: - Position: anterior - Consistency: intermediate - Effacement: 50% - Dilation: 2 cm - Station: -2 Which method is the most appropriate? A. Artificial amniotomy B. Oxytocin infusion C. Prostaglandin ripening Correct Answer: C Explanation: According to ACOG 138 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics - If induction is indicated and the status of the cervix is unfavorable, agents for cervical ripening may be used. The status of the cervix can be determined by the Bishop pelvic scoring system. - An unfavorable cervix generally has been defined as a Bishop score of 6 or less in most randomized trials. - Primigravida in labor, when latent phase considered prolonged? A. 2 hours B. 4 hours C. 8 hours D. 18 hours Correct Answer: D Explanation: According to Uptodate Friedman considered the latent phase prolonged in nulliparas who had not entered the active phase by the 95th percentile for duration of the latent phase in pregnant people in spontaneous labor. - In nulliparas → 20 hours - In multiparas → 14 hours 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 139 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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: 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) 140 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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: 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 141 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics 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 142 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Preterm labor, Preterm Rupture of Membrane (PROM) and Premature Preterm Rupture of Membrane (PPROM) Pregnant at 38 weeks of gestation with ruptured membrane for 24hrs, no contractions and CTG Is reassuring, what is the management? A. C-section B. Induction of labor Correct Answer: B Explanation: Prelabor Rupture of Membrane (PROM) - Definition: Rupture of membranes before the onset of labor at term (≥37 weeks) - Investigations: Speculum Examination: Pooling of amniotic fluid in the posterior vaginal vault observed is the gold standard - Management: Induction of labor is recommended. Expectant management for up to 12–24 hours is reasonable in otherwise uncomplicated pregnancy and in the absence of infection. GBS Prophylaxis is indicated in case of Unknown GBS status PLUS rupture of membrane for ≥18hrs Woman G2 P1 at 32 weeks’ gestation presents to Emergency Department complaining of lower abdominal and back pain, which has increased in frequency and intensity over the last few hours Abdominal examination shows fundal height equals to 32 cm longitudinal lie fetus and cephalic presentation, Fetal heart was positive and cardiotocography is reactive with 2 uterine contractions per 10 minutes. Vaginal examination shows dilated cervix, 70 % effacement, -3 station and cephalic. Which of the following is the most appropriate step in management? A. Inform neonatologist, administer corticosteroids, and strict bed rest B. Inform neonatologist, administer corticosteroids, and hydrate the patient C. Inform neonatologist, administer tocolytics, and start intravenous antibiotics D. Inform neonatologist, administer intravenous antibiotics, and strict bed rest Correct Answer: B 143 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 1: Obstetrics Explanation: Management of Preterm labor: - ≥34 weeks of gestation Admitted for delivery! - 5000 milli-international units/mL. Ectopic pregnancy greater than 4 cm in size as imaged by transvaginal ultrasonography Refusal to accept blood transfusion Patient with ectopic pregnancy, her husband is in a military mission, she lives 80Km away fron hospital, brought by her neighbor, US showed unviable fetus, abscent heart rate, 4cm fetus, BHCG is 5000, Her vitals: BP 90/50, HR 110, T 35. What is the absolute contraindication for medical therapy in her condition? A. HCG B. Vital Signs C. Fetal size D. Far away from hospital or distance Correct Answer: B Explanation: According to ACOG and Williams Gynecology Ectopic pregnancy - Absolute Contraindications to Methotrexate MTX therapy (ACOG) Intrauterine pregnancy Evidence of immunodeficiency Moderate to severe anemia, leukopenia, or thrombocytopenia Sensitivity to methotrexate Active pulmonary disease Active peptic ulcer disease Clinically important hepatic dysfunction Clinically important renal dysfunction Breastfeeding Ruptured ectopic pregnancy Hemodynamically unstable patient Inability to participate in follow-up 245 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology - Relative Contraindications to Methotrexate MTX therapy (ACOG) Embryonic cardiac activity detected by transvaginal ultrasonography High initial hCG concentration >5000 milli-international units/mL. Ectopic pregnancy greater than 4 cm in size as imaged by transvaginal ultrasonography Refusal to accept blood transfusion Note: She is hemodynamically unstable which indicates ruptured ectopic. Which is indicates laparotomy. Patient diagnosed with ectopic pregnancy, BhCG 2500, 3cm, what is the contraindications for methotrexate treatment? A. BhCg and ultrasound findings B. Far away from hospital C. Her vital signs Correct Answer: B Explanation: According to ACOG and Williams Gynecology Ectopic pregnancy - Absolute Contraindications to Methotrexate MTX therapy (ACOG) Intrauterine pregnancy Evidence of immunodeficiency Moderate to severe anemia, leukopenia, or thrombocytopenia Sensitivity to methotrexate Active pulmonary disease Active peptic ulcer disease Clinically important hepatic dysfunction Clinically important renal dysfunction Breastfeeding Ruptured ectopic pregnancy Hemodynamically unstable patient Inability to participate in follow-up - Relative Contraindications to Methotrexate MTX therapy (ACOG) Embryonic cardiac activity detected by transvaginal ultrasonography High initial hCG concentration >5000 milli-international units/mL. Ectopic pregnancy greater than 4 cm in size as imaged by transvaginal ultrasonography Refusal to accept blood transfusion 246 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology A female patient diagnosed as ectopic pregnancy, where she lives far away from the hospital. Her B-HCG level is 6000 with an absent fetal heartbeat. What is the best management for her? A. Methotrexate B. Surgical intervention C. Expectant management Correct Answer: B Explanation: According to ACOG and Williams Gynecology Ectopic pregnancy - Absolute Contraindications to Methotrexate MTX therapy (ACOG) Intrauterine pregnancy Evidence of immunodeficiency Moderate to severe anemia, leukopenia, or thrombocytopenia Sensitivity to methotrexate Active pulmonary disease Active peptic ulcer disease Clinically important hepatic dysfunction Clinically important renal dysfunction Breastfeeding Ruptured ectopic pregnancy Hemodynamically unstable patient Inability to participate in follow-up - Relative Contraindications to Methotrexate MTX therapy (ACOG) Embryonic cardiac activity detected by transvaginal ultrasonography High initial hCG concentration >5000 milli-international units/mL. Ectopic pregnancy greater than 4 cm in size as imaged by transvaginal ultrasonography Refusal to accept blood transfusion Female patient present in the emergency with lower abdominal pain and bleeding, ultrasound done and a 3cm ectopic pregnancy found in the ovary. The B-HCG was 15000. from the above history what will make the medical treatment contraindicated? A. The size B. Abdominal pain C. BHCG level Correct Answer: C 247 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Explanation: According to ACOG and Williams Gynecology Ectopic pregnancy - Absolute Contraindications to Methotrexate MTX therapy (ACOG) Intrauterine pregnancy Evidence of immunodeficiency Moderate to severe anemia, leukopenia, or thrombocytopenia Sensitivity to methotrexate Active pulmonary disease Active peptic ulcer disease Clinically important hepatic dysfunction Clinically important renal dysfunction Breastfeeding Ruptured ectopic pregnancy Hemodynamically unstable patient Inability to participate in follow-up - Relative Contraindications to Methotrexate MTX therapy (ACOG) Embryonic cardiac activity detected by transvaginal ultrasonography High initial hCG concentration >5000 milli-international units/mL. Ectopic pregnancy greater than 4 cm in size as imaged by transvaginal ultrasonography. Refusal to accept blood transfusion. Ecopic pregnancy at 7 or 9 week, 4 cm mass. (BhCG not mentioned). What is the most appropriate management? A. Methotrexate B. Surgical management C. Observation Correct Answer: A Explanation: According to ACOG Ectopic pregnancy - Methotrexate MTX is the preferred treatment option when all of the following characteristics are present: Hemodynamic stability. Serum beta-human chorionic gonadotropin (hCG) concentration ≤5000 milli- international units/mL. No fetal cardiac activity detected on transvaginal ultrasound (TVUS). Ectopic mass size less than 4 cm Patients are willing and able to comply with post-treatment follow-up and have access to emergency medical services within a reasonable time frame in case of a ruptured fallopian tube. 248 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Patient diagnosed with ectopic pregnancy, the ectopic size is less than 3.5 cm, BhCG is 2500 how will you manage? A. Medical B. Surgical Correct Answer: A Explanation: According to ACOG Ectopic pregnancy - Methotrexate MTX is the preferred treatment option when all of the following characteristics are present: Hemodynamic stability. Serum beta-human chorionic gonadotropin (hCG) concentration ≤5000 milli- international units/mL. No fetal cardiac activity detected on transvaginal ultrasound (TVUS). Ectopic mass size less than 4 cm Patients are willing and able to comply with post-treatment follow-up and have access to emergency medical services within a reasonable time frame in case of a ruptured fallopian tube. Patient diagnosed with ectopic pregnancy Bhcg 3400, 3 cm. What is the most appropriate management? A. Medical treatment B. Surgical management Correct Answer: A Explanation: According to ACOG Ectopic pregnancy - Methotrexate MTX is the preferred treatment option when all of the following characteristics are present: Hemodynamic stability. Serum beta-human chorionic gonadotropin (hCG) concentration ≤5000 milli- international units/mL. No fetal cardiac activity detected on transvaginal ultrasound (TVUS). Ectopic mass size less than 4 cm Patients are willing and able to comply with post-treatment follow-up and have access to emergency medical services within a reasonable time frame in case of a ruptured fallopian tube. 249 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Patient diagnosed with ectopic pregnancy; B-HCG was 5000. What is the most appropriate management? A. Methotrexate B. Surgical management Correct Answer: A Explanation: According to ACOG Ectopic pregnancy - Methotrexate MTX is the preferred treatment option when all of the following characteristics are present: Hemodynamic stability. Serum beta-human chorionic gonadotropin (hCG) concentration ≤5000 milli- international units/mL. No fetal cardiac activity detected on transvaginal ultrasound (TVUS). Ectopic mass size less than 4 cm Patients are willing and able to comply with post-treatment follow-up and have access to emergency medical services within a reasonable time frame in case of a ruptured fallopian tube. A female patient her LMP was 6 weeks ago, presented with mild abdominal pain. Vitally stable, Closed OS. US shows no intrauterine pregnancy, but a 3 cm sac in the fornix area with no cardiac activity, BhCG was 3000. What is your management? A. Medical management B. Surgical management C. Medical and surgical management D. Medical management given that she has access to the hospital Correct Answer: D Explanation: According to ACOG Ectopic pregnancy - Methotrexate MTX is the preferred treatment option when all of the following characteristics are present: Hemodynamic stability. Serum beta-human chorionic gonadotropin (hCG) concentration ≤5000 milli- international units/mL. No fetal cardiac activity detected on transvaginal ultrasound (TVUS). Ectopic mass size less than 4 cm Patients are willing and able to comply with post-treatment follow-up and have access to emergency medical services within a reasonable time frame in case of a ruptured fallopian tube. Note: A and D are both correct. But D is more accurate. 250 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Patient diagnosed with ectopic pregnancy, her mother refusing OR. Her B-hCG 3500 size of sac 3cm, nonviable no signs of rupture. what will u do? A. Explain that failure is high B. Treat medically but sign consent C. Laparoscopy D. Laparotomy Correct Answer: B Explanation: According to ACOG Ectopic pregnancy - Methotrexate MTX is the preferred treatment option when all of the following characteristics are present: Hemodynamic stability. Serum beta-human chorionic gonadotropin (hCG) concentration ≤5000 milli- international units/mL. No fetal cardiac activity detected on transvaginal ultrasound (TVUS). Ectopic mass size less than 4 cm Patients are willing and able to comply with post-treatment follow-up and have access to emergency medical services within a reasonable time frame in case of a ruptured fallopian tube. A case of ectopic pregnancy, plateau of B-HCG for 3 weeks. What to do? A. Consider methotrexate. B. Reassure and follow up. C. Salpingostomy or Surgical management Correct Answer: A Explanation: According to ACOG If hCG levels plateau or increase during follow-up → consider administering methotrexate for treatment of a persistent ectopic pregnancy Case of ectopic pregnancy treated by Salpingostomy. On regular follow up her BHCG was decreasing until the last three visits the BHCG results plateaued. BHCG was 3200 on the last visit, How would you manage the case? A. Consider giving Methotrexate. B. Start OCP C. Surgical intervention D. Reassure Correct Answer: A 251 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Explanation: According to Williams Gynecology Persistent Trophoblast - After surgery, B-hCG levels usually fall quickly and approximate 10% of preoperative values by day 12. - Persistent trophoblast is rare following salpingectomy but complicates 5 to 15% of salpingostomies. - Bleeding caused by retained trophoblast is the most serious complication. - Incomplete removal of trophoblast can be identified by stable or rising B-hCG levels. - Monitoring approach: measure serum B-hCG levels weekly levels. - With stable or increasing B-hCG levels, additional surgical or medical therapy is necessary. o Without evidence for tubal rupture→ standard therapy for this is single-dose MTX, 50 mg/m 2 X body surface area (BSA). o With evidence of rupture and bleeding → require surgical intervention. Patient diagnosed with ectopic pregnancy, her initial BhCG 108,000 Treated and under observation. - 1st week 700 - 2 week 300 - 3 week 180 - 4 week 70 - 5 week 300 How to manage it? A. Give methotrexate. B. Continue observation. C. Treat surgically Correct Answer: A Explanation: (According to Williams Gynecology) Persistent Trophoblast - After surgery, B-hCG levels usually fall quickly and approximate 10 percent of preoperative values by day 12. - Persistent trophoblast is rare following salpingectomy but complicates 5 to 15 percent of salpingostomies. - Bleeding caused by retained trophoblast is the most serious complication. 252 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology - Incomplete removal of trophoblast can be identified by stable or rising B-hCG levels. - Monitoring approach: measure serum B-hCG levels weekly levels. - With stable or increasing B-hCG levels, additional surgical or medical therapy is necessary. o Without evidence for tubal rupture→ standard therapy for this is single-dose MTX, 50 mg/m 2 X body surface area (BSA). o With evidence of rupture and bleeding → require surgical intervention. Patient had a salpingostomy, she is following up with the BHCG every week, they noticed the BHCG plateaued for 3 weeks on 3442, what’s next? A. Laparotomy B. OCP C. Methotrexate D. Reassurance Correct Answer: C Explanation: According to Williams Gynecology Persistent Trophoblast - After surgery, B-hCG levels usually fall quickly and approximate 10 percent of preoperative values by day 12. - Persistent trophoblast is rare following salpingectomy but complicates 5 to 15 percent of salpingostomies. - Bleeding caused by retained trophoblast is the most serious complication. - Incomplete removal of trophoblast can be identified by stable or rising B-hCG levels. - Monitoring approach: measure serum B-hCG levels weekly levels. - With stable or increasing B-hCG levels, additional surgical or medical therapy is necessary. o Without evidence for tubal rupture→ standard therapy for this is single-dose MTX, 50 mg/m 2 X body surface area (BSA). o With evidence of rupture and bleeding → require surgical intervention. A 34-year-old lady pregnant, complaining of amenorrhea, bleeding, and abdominal pain. β- HCG done showed levels of 1600, she was given methotrexate. One week later she still has severe abdominal pain despite analgesia. β-HCG done showed 6000 units. What is the best management? A. Salpingostomy B. Salpingectomy C. Continue methotrexate. D. Exploratory laparotomy Correct Answer: B 253 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Explanation: Ectopic pregnancy Surgical management: - Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless a woman is hemodynamically unstable. - Ruptured tubal pregnancies with hemoperitoneum-can safely be managed laparoscopically. Salpingectomy o Standard procedure if the condition of the tube with the ectopic gestation is damaged (ruptured or otherwise disrupted), bleeding is uncontrolled, or the gestation appears too large to remove with salpingostomy. Note: The severe abdominal pain indicates rupture of ectopic pregnancy → which is an indication of laparoscopic salpingectomy, unless hemodynamically unstable → Laparotomy Ectopic pregnancy, BhCG 3500, she is hypotensive and tachypneic. What is the most appropriate management? A. Methotrexate B. Laparoscopy salpingectomy C. Laparotomy salpingectomy Correct Answer: C Explanation: According to ACOG and Williams Gynecology Ectopic pregnancy Surgical management: - Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless a woman is hemodynamically unstable. - Ruptured tubal pregnancies with hemoperitoneum-can safely be managed laparoscopically. Salpingectomy o Standard procedure if the condition of the tube with the ectopic gestation is damaged (ruptured or otherwise disrupted), bleeding is uncontrolled, or the gestation appears too large to remove with salpingostomy. A 25-Year-old female, presented to the ED with vague abdominal pain and amenorrhea for 2 months. She has a history of open appendectomy due to perforated appendix 14 year ago. Her B-hCG 1800. What’s the most appropriate management? A. Surgical intervention after stabilizing B. GS review for acute abdominal C. Strong analgesic D. Methotrexate Correct Answer: D 254 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Explanation: Ectopic pregnancy - Peritubal adhesions subsequent to salpingitis, appendicitis, or endometriosis are a risk factor for Ectopic Pregnancy - Methotrexate MTX is the preferred treatment option when all of the following characteristics are present: Hemodynamic stability. Serum beta-human chorionic gonadotropin (hCG) concentration ≤5000 milli- international units/mL. No fetal cardiac activity detected on transvaginal ultrasound (TVUS). Ectopic mass size less than 4 cm Patients are willing and able to comply with post-treatment follow-up and have access to emergency medical services within a reasonable time frame in case of a ruptured fallopian tube. Patient diagnosed with ectopic pregnancy on methotrexate and BhCG elevated in day 4 and 7 what to do? A. Recheck bhcg after 48 hours B. Recheck bhcg after one week C. Salpingectomy D. Discharge Correct Answer: C Explanation: According to Williams Gynecology and ACOG Ectopic pregnancy - Failure of Medical Treatment: When the B-hCG level plateaus or rises, fail to decrease adequately by 15% from days 4 to 7 postinjection or the tube ruptures. Managed by: o A repeat single dose of methotrexate (as indicated) o Surgical management (if maximum doses of methotrexate have reached or rupture of tubes) Ectopic pregnancy, her Initial BHCG 2900, given methotrexate, one-week later BHCG 6000, What to do? A. Repeated methotrexate B. Diagnostic laparoscopy Correct Answer: A 255 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Explanation: According to Williams Gynecology and ACOG Ectopic pregnancy - Failure of Medical Treatment: When the B-hCG level plateaus or rises, fail to decrease adequately by 15% from days 4 to 7 postinjection or the tube ruptures. Managed by: o A repeat single dose of methotrexate (as indicated) o Surgical management (if maximum doses of methotrexate have reached or rupture of tubes) Female had a previous ectopic pregnancy want to conceive, what to do? A. Close follow up for early detection of fetus location B. Folic acid therapy C. Should do IVF Correct Answer: A Explanation: According to Comprehensive Gynecology Ectopic pregnancy - Women with an ectopic pregnancy who become pregnant again should be monitored by ultrasound early in pregnancy. - Only about one of three nulliparous women who have had an ectopic pregnancy ever conceives again (35%), and about one third of these conceptions are an ectopic pregnancy. After salpingectomy how to follow? A. One BhCG to confirm decline B. Hysterosalpingogram C. Weekly BhCG D. Pelvic ultrasound after 6 days Correct Answer: A Explanation: Ectopic pregnancy Follow Up after treatment: - Serial beta-hCG measured weekly after treatment until the level is undetectable. - **Exception (According to UTD): o For patients who undergo salpingectomy→ if the pathology evaluation confirms a tubal gestation, many surgeons do not check a postoperative hCG, and others check a single postoperative hCG to confirm a large decline in the level. 256 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Ectopic pregnancy managed with salpingostomy. BHCG postoperative was 3500. how to follow up the BHCG? A. No need follow up B. Pelvic ultrasound C. Weekly measurements of B-HCG until undetectable Correct Answer: C Explanation: Ectopic pregnancy Follow Up after treatment: - Serial beta-hCG measured weekly after treatment until the level is undetectable. - **Exception (According to UTD): o For patients who undergo salpingectomy → if the pathology evaluation confirms a tubal gestation, many surgeons do not check a postoperative hCG, and others check a single postoperative hCG to confirm a large decline in the level. A pregnant lady at 7 weeks of gestation, she came to emergency room complaining of left iliac fossa pain and brownish vaginal discharge, what is your provisional diagnosis? A. Ectopic pregnancy B. Appendicitis C. Irritable bowel syndrome D. Threatened miscarriage Correct Answer: A Explanation: She has a localized pain → indicates ectopic more than threateend abortion A 30-year-old, pregnant women by in vitro fertilization (IVF) and diagnosed with ectopic pregnancy and scheduled of laproscopic removal of the prgnency. On US imaging: 4 cm tubal pregnancy on the right, and hydrosalpinx on the left. What is the management? A. Salpingotomy on the right only B. Salpingectomy on the right only C. Removal of both tubes (Bilateral salpingectomy) D. Hysterosalpingography with contrast Correct Answer: C Explanation: 257 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology According to Comprehensive Gynecology Textbook - If the hydrosalpinx is large and clearly visible on ultrasound, it is preferable to perform laparoscopic salpingectomy prior to IVF-ET because the pregnancy rate with IVF-ET may be decreased by as much as 40% - A significantly dilated tube (hydrosalpinx) on ultrasound is an indication for salpingectomy before carrying out IVF. According to Dewhurst’s Textbook of Obstetrics and Gynecology: - In women undergoing IVF, the presence of hydrosalpinx is associated with early pregnancy loss and poor implantation and pregnancy rates. - Hydrosalpinges large enough to be visible on ultrasound are associated with the poorest outcome, including increased miscarriage rates. Women with hydrosalpinges should therefore be offered treatment before IVF because this improves the chance of a live birth. - Various surgical treatments including salpingectomy, salpingostomy, proximal tubal ligation or clipping, and transvaginal aspiration have all been used to improve IVF outcome. Patient with a history of ruptured ectopic and previous management, came now with lower abdominal pain. Pregnancy test Lab’s show: 18000 BhCG, Hb low. How to mange? A. Consult surgery for possible acute abdomen. B. Misoprostol C. Surgical management after stabilization Correct Answer: C Explanation: According to ACOG and Williams gynecology Ectopic pregnancy - Absolute Contraindications to Methotrexate MTX therapy (ACOG) Intrauterine pregnancy Evidence of immunodeficiency Moderate to severe anemia, leukopenia, or thrombocytopenia Sensitivity to methotrexate Active pulmonary disease Active peptic ulcer disease Clinically important hepatic dysfunction Clinically important renal dysfunction Breastfeeding Ruptured ectopic pregnancy. Hemodynamically unstable patient Inability to participate in follow-up. - Relative Contraindications to Methotrexate MTX therapy (ACOG) Embryonic cardiac activity detected by transvaginal ultrasonography High initial hCG concentration >5000 milli-international units/mL. Ectopic pregnancy greater than 4 cm in size as imaged by transvaginal ultrasonography Refusal to accept blood transfusion 258 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Ectopic pregnancy received MTX and gradually result in BhCG decreased, what is the next step? A. Laparoscopy B. Give 2nd dose MTX C. Observe Correct Answer: C (Answered by exclusion) Ectopic pregnancy is a defect in which process? A. Implantation B. Fertilization Correct Answer: A Patient primigravida at 6 weeks of gestation, presents with moderate vaginal bleeding and severe lower abdominal pain and radiating to the shoulder. Upon examination: Abdominal guarding and rebound tenderness. US showed no Intrauterine pregnancy. What is the most appropriate next step? A. Laparoscopy B. Methotrexate C. Prostaglandin Correct Answer: A Explanation: According to Williams gynecology and ACOG Ectopic pregnancy Surgical management: - Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless a woman is hemodynamically unstable - Ruptured tubal pregnancies with hemoperitoneum-can safely be managed laparoscopically. Salpingectomy o Standard procedure if the condition of the tube with the ectopic gestation is damaged (ruptured or otherwise disrupted), bleeding is uncontrolled, or the gestation appears too large to remove with salpingostomy. 259 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology Patient presented to the ER with severe abdominal pain and hypotensive, diagnosis of ruptured ectopic pregnancy was made. What is the morality rate? (2024) A. 10 percent across four values during a three week period (eg, on days 1, 7, 14, and 21). o Increasing hCG levels — is defined as a level that progressively increases >10 percent across three values during at least a two week period (eg, on days 1, 7, and 14) o Plateaued hCG levels — is defined as four measurements that remain within ±10 percent over at least a three week period (eg, days 1, 7, 14, and 21) Note: B-hCG below 5 mIU/ml → negative result 265 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology A 42-Year-Old lady with a history of molar pregnancy 2 years ago, she wants to conceive. What to do regarding her history? A. Early follow up in pregnancy B. Contraception as she shouldn’t get pregnant. Correct Answer: A Explanation: According to Williams Gynecology - Women with prior hydatidiform mole sonographic evaluation is recommended in early pregnancy - For women with molar pregnancy after these 6 months of surveillance and undetectable B- hCG level, monitoring is discontinued, and pregnancy allowed. Patient at 12 weeks of gestation with fundal hight at 19 weeks and BhCG 270000, what is the most likely diagnosis? A. Partial mole B. Complete mole C. Ectopic pregnancy Correct Answer: B Explanation: According to Williams Gynecology and UpToDate Hydatidiform mole - Clinical presentation o Common features ▪ Vaginal bleeding ▪ Pelvic pressure or pain ▪ Enlarged uterus (greater than normal) ▪ Hyperemesis gravidarum o Less common or late features ▪ Hyperthyroidism — Due to elevation of hCG >100,000 mIU/mL for several weeks. These patients may present with tachycardia, warm skin, and tremor. Laboratory evidence of hyperthyroidism is commonly detected in asymptomatic patients with HM ▪ Ovarian theca lutein cysts — Are a form of ovarian hyperstimulation resulting from high circulating levels of hCG and prolactin ▪ Preeclampsia 100,000 mIU/mL for several weeks. These patients may present with tachycardia, warm skin, and tremor. Laboratory evidence of hyperthyroidism is commonly detected in asymptomatic patients with HM ▪ Ovarian theca lutein cysts — Are a form of ovarian hyperstimulation resulting from high circulating levels of hCG and prolactin ▪ Preeclampsia 100,000 mIU/mL), a transvaginal ultrasound should be performed and will likely demonstrate molar disease if present. - If the hCG level is high and the ultrasound shows an apparently normal singleton gestation, the ultrasound and hCG should be repeated in one week to exclude the possible presence of a twin conception with normal fetus and coexistent molar pregnancy. Post partumthree months, came with history of something that protruded from the cervix bleeding on touch, what is the management? A. Immediate D&C B. Measure B-hCG after 1 week C. Biopsy D. Tests for metastasis Correct Answer: D Explanation: According to UpToDate This is a case of Choriocarcinoma following a normal gestation DIAGNOSIS AND STAGING GTN is a clinical diagnosis made based upon elevation of serum human chorionic gonadotropin (hCG), after a nonmolar pregnancy and after other etiologies of an elevated hCG have been excluded. Imaging findings of uterine enlargement or pathology consistent with GTN, bilateral ovarian theca lutein cysts, or metastatic disease support the diagnosis Unlike other solid tumors, a tissue diagnosis is not required prior to treatment, biopsy is not required and may cause significant bleeding. Laboratory evaluation hCG — An elevated human chorionic gonadotropin (hCG) is often the first evidence of possible GTN. A serum quantitative hCG should be drawn in all patients with suspected GTN. 268 | P a g e Obstetrics and Gynecology: SMLE Questions and Answers Chapter 2: Gynecology - For women with a prior molar pregnancy, serial measurement of hCG is part of posttreatment surveillance, and an elevation, plateau, or persistence of hCG suggests the development of GTN. - For women wi