• It must include nearly all parts in the cutticulum

• Do not put 2 answers for the same question.• There are many different models.• Read the questions precisely , take care of

the words ( EXCPT, CORRECT, INCORRECT )• Sources ( Study guide, Lange case file, Obs. &

Gyne. Books , Text books )

Cases + Short questions

4 ( و 2حاالت حالة ( 2نساء كل و أسئلة = 5والدةسؤال 20

سؤال ) 5كل سؤال ممكن ألن تقريبا و 4درجاتسؤال لذا ( 6ممكن مثال درجة 5x20= 100درجات

10 سؤال أسئلة كل درجة 50درجات = 5قصيرة المجموع سؤال 30لذا ال من سؤال تقريبا 30كل سؤال

الى 3.5 الوقت مجموع يصل ق 105دقائق ق 15المراجعة

Cases + Short questions4 Cases ( 2 gynae, 2 Obs. )5 questions for every case, 5 marks for each

questions= 4x5x5 = 100 marks

10 short questions , 5 marks for each questionSo 10x5= 50 marks

MCQs

Benign cystic teratoma (dermoid cyst):All are INCORRECT EXCEPT

A. It is the commonest ovarian tumor during menopause.

B. It causes no harm to the patient when ruptures. C. Are germ cell tumors.

D. Never turn into malignant tumor.E. Conservative follow up is an option.

Risk factors of endometrial hyperplasia DO NOT include:

A. Anovulatory disorders.B. Chronic endometritis. C. ObesityD. Tamoxifen.E. Unopposed excessive estrogen.

Fibroid uterus may be associated with the following EXCEPT:

A. Precocious puberty B. MenorrhagiaC. MetrorrhagiaD. Postmenopausal bleedingE. Frequency of micturition

The following is the essential step in diagnosis and staging of pelvic endometriosis:

A. Laparoscopy B. CA-125 C. Biopsy form the suspicious nodules D. UltrasonographyE. Hysteroscopy

The INCORRECT statement regarding uretrovaginal fistula:

A. Might happen during complicated vaginal surgery in third degree uterine prolapse.

B. Might happen during surgery for broad ligament tumors.

C. Obstetric causes are the most common cause. D. Injury of the ureter may be at the level of the

pelvic brimE. Surgical treatment involves laparotomy.

Regarding tuberculosis of the genital tract all the following are correct EXCEPT:

A. The tubes are the commonest site. B. It is detected in 5% of infertile patients. C. Infection is usually sexually transmitted. D. The treatment is mainly medical. E. Menstrual disorders are common.

As regards follicle stimulating hormone, all the following are correct EXCEPT:

A. It stimulates spermatogenesis.B. Its plasma concentration is high in Klinefelter

syndrome. C. It stimulates ovarian estrogen production. D. It is secreted by basophilic cells of the

adenohypophysis. E. It prevents regression of the corpus luteum.

The following is characteristic of Sheehan syndrome:

– Profuse lactation– Amenorrhea – Hyperthyroidism– Renal insufficiency– Cushinoid faces

The following are contraindications to using combined oral contraceptives EXCEPT:

A. Pulmonary embolus B. Porphyria C. Sickle-cell disease D. DVTE. Depression

The following vessels are branches of the internal iliac artery EXCEPT:

A. Uterine artery. B. Obliterated umbilical artery. C. Pudendal artery. D. Superior rectal artery. E. Vaginal artery.

The following about Candidal infection are correct EXCEPT:

A. The infection is common with pregnancy B. Vaginal PH is usually alkaline. C. Vulval itching may occur. D. Vaginal isoconazole or miconazole are effective. E. The organism is yeast-like.

Symptoms of adenomyosis uteri include all the following except

A. MenorrhagiaB. DysmenorrheaC. Diurnal frequencyD. Abdominal swellingE. hot flushes

A 32-year-old woman complains of a vulval fishy odor and a vaginal discharge. The speculum examination reveals an erythematous vagina and punctuations of the cervix. Which is the MOST LIKELY diagnosis?

A. Candidal vaginitisB. Trichomonal vaginitis C. Bacterial vaginosisD. Human papilloma virusE. Herpes simplex virus

He correct statement about the decidua is:

A. It is modified endometrium of pregnancy.B. It is due to action of estrogen on the

endometrium.C. The decidua basalis is the part overlying the

embryo.D. Does not protect against the invasive power of

trophoblast.E. Is anatomically divided into four parts.

Sure signs of pregnancy include all of the following EXCEPT:

A. Palpation of fetal parts.B. Inspection & palpation of fetal movements.C. Auscultation of uterine soufflé.D. Detection of fetus by ultrasonography.

All of the following are causes of oversized uterus EXCEPT:

A. Incorrect dates.B. Transverse lie.C. Macrosomic fetus.D. Hydrocephalus.E. Polyhydramnios.

Warning symptoms during pregnancy DO NOT include:

A. Bleeding per vagina.B. Sudden loss of fluid per vagina.C. Abdominal pain.D. Leg cramps.E. Decreased fetal kicks.

Indications of amniocentesis include:

A. Diagnosis of chromosomal anomalies.B. Bilirubin estimation in Rh isoimmunization.C. Estimation of fetal lung maturity.D. All of the above.E. B & C only.

The following statements regarding obstetric ultrasound are correct EXCEPT:

A. It can be used with amniocentesis. B. It might induce a significant risk to the fetus. C. It can diagnose placental grading. D. It is a useful tool in the assessment of amniotic

fluid volume. E. It could estimate the approximate intrauterine

fetal weight.

The occipto frontal diameter:

A. Extends from occipital protuberance to center of bregma.

B. Measures 9.5 cm at term.C. Is the diameter of engagement in after coming

head of breech.D. Is the diameter of engagement in face

presentation with a fully extended head.

Caput succedaneum

A. is due to prolonged pressure on fetal head by maternal tissues.

B. is always few millimeters in thickness.C. does not cross suture lines.D. indicates that the fetus was dead during labor.

In management of multifetal pregnancy, the following is true:

A. Twin pregnancy is considered as a high risk pregnancy.

B. The lower the fetal weight, the safer the vaginal route of delivery.

C. The larger the fetal number, the more small the fetal weight and the safer vaginal route of delivery.

D. Mono-amniotic twins are associated have less perinatal mortality than diamniotic twins.

E. If the first twin is presenting by the breech internal podalic version is indicated.

Cord presentation is

A. Descent of the umbilical cord below the presenting part after ROM.

B. Descent of the umbilical cord below the presenting part before ROM.

C. Presence of the umbilical cord beside the presenting part.

D. Presence of the umbilical cord above the presenting part.

Regarding shoulder dystocia, which is CORRECT?

A. It is not related to maternal diabetes mellitus. B. Arrest occurs at pelvic inlet.C. Oligohydramnios is a predisposing condition. D. Most cases can be resolved by fundal pressure.E. Facial palsy is a possible complication.

The CORRECT statement regarding ruptured uterus:

A. More common in nulliparous than multiparous women.

B. More common with malpresentations. C. Is classified into mild, moderate and severe.D. Previous uterine scar must rupture in

consequence to vaginal delivery.E. Increases the fetal mortality but not the

maternal mortality.

The following IS NOT a risk factor for primary postpartum hemorrhage:

A. Maternal anemia. B. Intrauterine growth retardation. C. History of a previous postpartum hemorrhage. D. Uterine fibroids. E. Mismanagement of 3rdstage of labor.

As regards acute uterine inversion, the INCORRECT statement is:

A. It only occurs with a relaxed uterus. B. It is usually caused by applying fundal pressure. C. It is managed by immediate removal of placenta

before reposition of the uterus. D. It can be managed by increasing the hydrostatic

pressure in the vagina. E. Maintaining sufficient intravenous lines is

essential.

Coagulation failure IS NOT a major complication of the following:

A. Amniotic fluid embolus.B. Abruptio placenta.C. Placenta previa.D. Gram-negative septicemia.E. HELLP syndrome.

Causes of acute abdomen during pregnancy include the following EXCEPT:

A. Placenta abruption.B. Complicated fibroid.C. Ruptured tubal pregnancy.D. Complicated ovarian cyst.E. Placenta previa.

Maternal mortality refers to the number of maternal deaths that occur as the result of the reproductive process per:

A. 1000 births. B. 10.000 births. C. 100.000 births. D. 10.000 live births. E. 100.000 live births.

Which IS NOT a sign of hyaline membrane disease (RDS):

A. Increased respiratory rate.B. Grunting respiration.C. Chest wall retraction during inspiration.D. Retraction of the subsoctal area.E. Jaundice.

Uterine stimulants include all of the following EXCEPT:

A. Oxytocin.B. Ritodrine.C. Ergometrine.D. Prostaglandins.

A 30-year-old G1 P1 who underwent a cesarean section 3 days previously has a fever of 40˚ C. The wound is indurated and

erythematous. Which of the following is the best management?

A. Initiation of intravenous ampicillin.B. Initiation of intravenous heparin.C. Corticosteroids therapy.D. Placement of a warm compress on the wound.E. Wound drainage.

Cases + Short questions

Take care of the Language mistakes & the Fatal

mistakes

Case number 1

• A 22 year old Primigravida, pregnant at 35 weeks , BL.P 110/70 ,pulse 120 bpm, DROWZY, severe abd. Pain, tender rigid abdomen, FHS( Fetal heart sounds ) not heard , mild dark brown vag. Bleeding, Albuminuria +++, edema up to the knees

1. What is your provisional diagnosis ?2. Explain why there is apparantly normal Bl.P with tachycardia

?3. What is the cause of inability to hear FHS?4. Enumerate four important investigations required for this

case ?5. Enumerate lines of treatment

Answer

1. provisional diagnosis is PG, 35 weeks gestation, severe PET,complicated by accidental haemorrhage & IUFD

2. The pt was having severe PET ( severe HT is one of its criteria ) & The haemorrhage (which occurred due to premature separation of the placenta) made the high BL.P as this apparantly normal Bl.P now , this drop in BL.P was associated with tachycardia.

3. the cause of inability to hear FHS is accidental haemorrhage ( Mostly most if not all the placenta is separated ) this needs to be confirmed by US

4. four important investigations• A-U/S: To rule out placenta previa before vaginal

examination.• B-Blood tests , Coagulation profileBlood type & cross matching, Rh.CBC, PT, PTT, Fibrinogen, FDPs.A “poor man’s clot” or “bed side test” consists of placing

a specimen of whole blood in a closed tube, the blood should clot in less than 10min, longer clotting times suggest DIC and if the clot dissolves in less than 5 minute means fibrinolytic activity and increase FDPs.

• C-Kidney functions if needed.• D-Apt test to differentiate between fetal blood and

maternal blood

5-Lines of treatment• As the Bleeding is severe manifested by maternal

shock & fetal death Immediate Anti shock measures + immediate C.S. + ecbolics to treat uterine atony.

• Sometimes hysterectomy is needed in:• Severely lacerated uterus after failure of

ecbolic.• Failure of the uterus to contract.

• Correction of the PET + the use of MGSO4 to guard against eclamptic fits, better in the ICU + TTT of other complications if occur as DIC , ARF

Case number 2

• A 46-year-old gravida 3 para 3, presented with menorrhagia with dysmenorrhea for the last 5 months. The menstrual flow lasts for about 10 days with unusually heavy flow. She looked pale.

• Clinical examination did not reveal any pelvic pathology apart from symmetrically enlarged bulky uterus around 10 weeks pregnancy size.

1. Mention the commonest four possible causes?2. What laboratory investigations to be ordered?3. What imaging techniques are useful? 4. What is the possibility of malignant genital disease in such case?5. Mention the role of surgery in the management of this case?

Answer

1- Four possible causesDUB & Endometrial hyperplasiaUt. Leiomyomata ( Mostly Submucus )Adenomyosis uteri Iatrogenic ( IUD complications if it was there )General causes(As advanced liver D,

Hypothyroidism )Blood disorders ( rare ),V. rarely End. Carcinoma.

2-Laboratory investigationsInvestigations for general causes ( liver f.

tests, thyroid hormones, TSH )CBC Coagulation Profile as ----Vaginal and cervical smear for ---Hormonal assay as E2,Kid. F. tests ( preop prep.)

3-Imaging techniques Transabd. or better Transvaginal ultrasound:

Evaluate all pelvic organs & the endometrial, myometrial thickness , ? Doppler velocimetry on uterine vs.

CT scan or better MRI on the pelvic organs X-ray abdomen for calcified fibroid ??

4-Very rare possibility of endometrial carcinoma or Cervical cancer but must be excluded through previous lab. & imaging procedures.

5-The role of surgeryAccording to the cause– D&C biopsy better hysteroscopically guided.– Myomectomy ( Fibroid, ,,,, ) or Embolotherapy – Hysterectomy ( IF adenomyosis u., submucus F, DUB

with endomet. Hyperplasia with atypia , End. carcinoma ( rare )

– Endometrial ablation ( as Thermal balloon ) or hysteroscopic endometrial resection ( If DUB )

Case number 3

• A 19-year-old G1 P0 woman at 20 weeks’ gestation complains of the acute onset of pleuritic chest pain and severe dyspnea. She denies a history of obstructive airway disease or cough.

• On examination, her temperature is 36.6°C, heart rate 120 bpm, blood pressure 130/70 mm Hg, and respiratory rate (RR) 40 breaths per minute.

• The lung examination reveals clear lungs bilaterally. The heart examination shows tachycardia.

• The fetal heart tones are in the 140- to 150-bpm range.

• The oxygen saturation level is 82%. Supplemental oxygen is given.

1. What recent test would most likely lead to the diagnosis? What were the other tests ?

2. What is your concern? What supports your diagnosis?

3. Why is the pregnant woman predisposed to such disease ?

4. The lungs are clear on auscultation. What are the diseases excluded by this information?

5. What are the immediate treatments which should be given in this case ? What are their values ?

Answer

1. Test most likely to lead to the diagnosis: Spiral computed tomography or magnetic resonance angiography scan of the lungs.

Other tests are arterial blood gas, chest radiograph, electrocardiographPreviously ventilation-perfusion (V/Q) scans were recommended in pregnancy;

however, recent evidence indicates that V/Q scan exposes the fetus to slightly more radiation and is associated with a high rate of indeterminate cases.

2. Concern: Pulmonary embolism. Supported by Pleuritic chest pain and severe dyspnea are common presenting symptoms of

pulmonary embolism The physical examination confirms the respiratory distress due to the

tachycardia and tachypnea The patient has significant hypoxia with oxygen saturation of 85%.

3. The pregnant woman is predisposed to to such disease due to Pregnancy causes venous obstruction & DVT due to the mechanical effect of

the uterus on the vena cava. Additionally, the high estrogen level induces a hypercoagulable state due to

the increase in clotting factors, particularly fibrinogen.

4. The lungs are clear on auscultation, which rules out reactive airway disease or significant pneumonia or pulmonary edema.

5. If the imaging confirms pulmonary embolism, then the patient should receive anticoagulation to help stabilize the deep venous thrombosis and decrease the likelihood of further embolization.

Case number 4

• A 25-year-old ,P2 desires contraception for the next 4 years. She reports that she had a deep venous thrombosis when she took the combination oral contraceptive pill 2 years ago.

• She cannot remember to take the pill every day and wants contraception that will allow her to be spontaneous.

• She does not take any medications and has no known allergies to medications.

• Menstrual cycle is every 28 days, lasting for 10 days. She has blood clots in the first 3 days of her menstrual cycle.

• She denies any sexually transmitted infections. • She refused injectable contraception for personal factors.• Her blood pressure is 120/70 mm Hg, heart rate 80 beats per

minute (bpm), and temperature 37.2°C. Heart and lung examinations are normal.

• The abdomen is non tender and without masses.• P/V reveals a normal AVF uterus and no adnexal masses.

1. What would be the best contraceptive agent for this patient?

2. Why do you choose this method specifically ? 3. What is the mechanism of action of such method ?4. What would be contraindications to the proposed

contraceptive agent?5. Can this method be used as an emergency

contraception ? What is the time limits ?

Answer

1- Best contraceptive agent for this patient: The levonorgestrel releasing intrauterine device.

2- Because of the history of DVT, estrogen-containing contraception agents would be contraindicated.

The desire for spontaneity would make barrier methods less desirable.

Options for this patient would include (Depot provera) or the levonorgestrel IUD.

Because of the heavy menses, this 25 year old would most benefit from a levonorgestrel-releasing intrauterine device, since the progestin would cause the endometrial lining to be thinner and decrease the amount of menstrual bleeding. In addition , she refused intake of injectable contraception.

3. Mechanism of action(Neither ovulation nor steroidogenesis is affected)Local reaction in uterine cavity( Aseptic

endometritis ) hostile to sperm and possibly to the ovum.

Interference with ovum transportThe physical characters of the cervical mucus

changes impermeable to sperms (as well as to harmful microorganisms thus limiting ascending infection).

Partial suppression of ovulation.

4. Contraindications to the proposed contraceptive agent: Contraindications for an IUD include recent sexually transmitted infection, abnormal size and shape of the (Uterine distortion

that prevents correct IUD placement: e.g. subseptate uterus.

Unexplained vaginal bleeding ( this may be due to the presence of submucus myoma,

5- Yes ( for all IUDs), it can . But must be within 72 hours of unprotected intercourse. appears to be even more effective than estrogens or estrogen/progestin preparations.

Case number 5

• A 32-year-old G4P3 with no prenatal care presents to the hospital at 40 weeks stating that her membranes ruptured the day before and her contractions began about 8 hours prior to this admission.

• For the past 4 hours she has noted progressively severe pain and decreased fetal movements. She states that her first delivery was by cesarean section, second was a normal vaginal delivery, and third was by cesarean section.

• She denies diabetes, hypertension, or any chronic medical illnesses. She does not smoke. Both of her parents are obese with diabetes and hypertension.

• On physical examination she is in moderate distress with frequent contractions and complains that her right shoulder hurts.

• The maternal H.R. is 140 bpm. Her Bl.P is 80/40 mmHg. Her temperature is normal. She is having a BMI of 35 kg/m2.

• Her fundal height is difficult to measure, but appears near term. • Her abdomen is mildly tender in all quadrants. • The FHR by external Doppler is 140 bpm with absent variability and no

accelerations. • On P/V she is 8 cm dilated, 90% effaced, and the fetal vertex is floating

above the pelvic inlet.

1. What is the most likely diagnosis? What is the cause of these vital signs ? What is the cause of shoulder pain ?

2. What is the differential diagnosis?3. Mention three risk factors in this case which

lead to that condition.4. What is the significance of that the FHR is the

same as the mother’s HR, What is needed urgently to be done at such point?

5. What are your next steps in caring for this patient?

Answer

1- Most likely diagnosis: P3 ( First and third by c.s. ), NT, cephalic, in labour , Hypovelemic shock , Uterine rupture ( mostly ruptured scar ).

Internal haemorrhage and hypovolemic shock is the cause of these vital signs .

Referred pain to the shoulder from phrenic nerve irritation ( from internal Hage ) is the cause of shoulder pain .

2. Differential diagnosisA. Uterine ruptureB. Abruptio placentaC. Chorioamnionitis with sepsisD. PyelonephritisE. Appendicitis F. Cholecystitis or G. Other intra-abdominal acute processes

3. Three risk factors in this case which lead to that condition.

A. This is a patient with two prior cesareans, one prior vaginal delivery

B. Current risk factors for ? macrosomia ( Obese woman, F/H , increased Fundal height)

C. The patient was reaching near the end of the first stage of labour ( contracting uterus on previous two uterine scars of C.S.)

4. As the fetal heart rate is the same as the mother’s, the fetus may be alive and this is truly his heart rate & may be dead after the uterine rupture and what you are hearing is maternal and not fetal heart So a quick ultrasound to assess fetal viability should be obtained but should not delay the next steps.

5. Next steps: This is a life-threatening emergency for both, the mother and the fetus.

A. Quickly notify essential personnel such as anesthesia, operating room staff, blood bank, and laboratory services.

B. Immediately obtain large bore IV access.C. Simultaneously obtain blood for cross match and coagulation studies to

observe for clotting. D. Resuscitation with volume repletion is important while assessing the mother

and determining fetal status.

E. While continuing to resuscitate the mother, the patient should be immediately moved to the operating room as surgical management is imperative at this point even if the fetus is already dead.

F. Usually, a general anesthetic is indicated, as this clinical situation does not permit the time required for a regional anesthetic.

G. Surgical treatment will be through Mid line laparotomy, getting the fetus & the placenta out then mostly emergency ( supravaginal ) hysterectomy , rarely repair of the site of rupture.

Case number 6

• 46 years 0ld lady , Para 4 ( Last 2 were by C.S. ) was complaining of severe DUB, Vaginal Hysterectomy was performed with some difficulty during surgery.

• Postoperatively by 4 hours Bl.p was 80/40 Pulse 120/m , oliguria

• Laparotomy was done , Internal Haemorrhage was found ,some surgical maneuvres were performed to secure haemostasis & the pt received 4 units of Bl. Transfusion

• Post operative improvement of the general condition , but 4 days later she started to c/o severe lower abdomen Pain radiating to the back for which she received strong analgesics ,

• 20 days later ,she c/o leakage of watery vaginal discharge.

1. What is the most probable cause of this general condition 4hours post-operatively?

2. What is the surgical maneuvres done during the laparotomy?

3. What is the cause of lower abdominal pain and the leakage of watery vaginal discharge ?

4. What are the investigations required to prove your diagnosis?

5. What is the treatment of such condition at the end ? When can you perform this and why ?

Answer

1. Haemorrhagic shock due to blood loss from ? slipped ligature during vaginal hysterectomy on major blood vessels as uterine or ovarian arteries

2. Ensuring haemostasis by resuturing the pedicles especially those containing bleeding vessels as uterine arteries or ovarian arteries.

3. This injury to the ureter makes back pressure on the kidney of the affected side ( ? hydronehrosis ) leading to loin pain ( stormy post-operative course )

The leakage is mostly due to the occurance of uretero-vaginal fistula following urinoma formation at that side

4. The investigations required to prove the diagnosisA. Methylene blue test to exclude Vesico-vaginal fistulaB. IVP ( IVU ) will detect the affected ureter and even the site of injuryC. Cystoscopy to detect any bladder injury & to exclude Vesico-vaginal fistula +

performing ureteric catheterization as a diagnostic test for uretero-vaginal fistula and sometimes therapeutic for its treatment.

5. The treatment of such condition at the end is by exploratory laparotomy

Surgery for ureteric fistulas: The possibilities of the surgery D. Repair of the ureter + putting ureteric catheter. E. Transplantation of upper cut end into the bladder( uretero-vesical reimplantation) or

into a rolled flap of the bladder. F. Replacement of the defect by a loop of ileum. When We can perform this intervention• It is important to defer any reconstruction for 3-6 months after the initial injury to

allow all tissue reaction ( as edema ) to subside. It is important to treat any infection before the operation.