Gyne Flashcards
A 16-year-old girl came to a gynecologic OPD for the complaint of failure to see menses. She also complained a progressively worsening lower abdominal pain since a year back which has an associated abdominal swelling. However, her breast development and general body habitués is growing in a similar fashion to her peers. On physical examination, she has female pattern pubic hair distribution and a 16-week sized abdominopelvic mass. Since she has not stated to have any kind of sexual contact, pelvic examination has not been done. What is the most likely cause of her problem?
a.
Müllerian Dysgenesis
b. Longitudinal vaginal septum
• c. Imperforate hymen
d. Ovarian tumor
The most likely cause of this patient’s problem is:
c. Imperforate hymen
Explanation:
1. Key Features Supporting the Diagnosis:
• Primary amenorrhea: The patient has not started menstruation, which is a common presentation of imperforate hymen.
• Lower abdominal pain: Cyclic, progressively worsening pain indicates obstructed menstrual flow (hematometra).
• Abdominal swelling: Represents accumulated blood in the uterus and possibly the vagina (hematocolpos).
• Normal secondary sexual characteristics: Breast development and female pubic hair distribution confirm normal estrogen production, ruling out conditions affecting ovarian function or estrogen production.
2. Why Not Other Options?:
• a. Müllerian dysgenesis: Patients typically lack a uterus or upper vaginal structures, and they do not develop hematocolpos or hematometra. Secondary sexual development is normal, but there is no abdominal swelling due to blood accumulation.
• b. Longitudinal vaginal septum: While it may cause obstructive symptoms, it is less likely to lead to complete obstruction with hematometra. It usually presents with difficulty in tampon insertion or dyspareunia, which is not relevant here.
• d. Ovarian tumor: Ovarian tumors can cause an abdominal mass, but they do not explain primary amenorrhea, hematocolpos, or hematometra.
3. Diagnostic Confirmation:
• On physical examination, an imperforate hymen may appear as a bulging, bluish membrane at the vaginal introitus.
• Ultrasound will show fluid accumulation in the uterus and vagina (hematometra and hematocolpos).
Conclusion:
The patient’s symptoms are classic for imperforate hymen, a congenital anomaly that obstructs menstrual flow, leading to primary amenorrhea, cyclic abdominal pain, and abdominal swelling. Surgical intervention (hymenotomy) is the definitive treatment.
A 20-year-old primigravid lady at her 32nd week of gestation presented to an obstetrics triage complaining of right flank and back pain. She denies leakage of fluid or bleeding per vagina. Her antenatal history is unremarkable. On examination, her blood pressure is 100/60 mmHg, pulse rate is 104/min, temperature is 38.3°C, uterus is 32-week size, presentation is cephalic, uterine contractions are occurring every 3 to 5 minutes, and cervix is 3 cm dilated and 90percent effaced. Laboratory investigations reveal hemoglobin level is 13.5 g/di, WBC count is 14.1 x103/mm3 and urine analysis shows nitrate +2. What is the most likely cause for the lady’s condition?
a. Pyelonephritis
• b. Placental abruption
• c. Intra-amniotic infection
• d. Cervical insufficiency
The most likely cause of the lady’s condition is:
a. Pyelonephritis
Explanation:
1. Clinical Features Suggestive of Pyelonephritis:
• Right flank and back pain: Classic symptoms of pyelonephritis.
• Fever (38.3°C): Indicates an infectious process.
• Tachycardia (pulse rate 104/min): Common in systemic infections.
• Urine analysis showing nitrate +2: Highly suggestive of a urinary tract infection caused by nitrate-reducing bacteria (e.g., E. coli), which is the most common cause of pyelonephritis in pregnancy.
2. Preterm Labor:
• Pyelonephritis is a known cause of preterm labor due to the systemic inflammatory response. This patient has uterine contractions every 3 to 5 minutes, a dilated cervix (3 cm), and 90% effacement, indicating preterm labor.
3. Why Not Other Options?:
• b. Placental abruption: Typically presents with painful vaginal bleeding, uterine tenderness, and hypertonicity, none of which are noted here.
• c. Intra-amniotic infection (chorioamnionitis): Often associated with prolonged rupture of membranes and foul-smelling amniotic fluid, which this patient does not have.
• d. Cervical insufficiency: Causes painless cervical dilation in the second trimester, without uterine contractions or systemic infection.
Conclusion:
The most likely diagnosis is pyelonephritis, which has triggered preterm labor. Immediate management should include:
• Intravenous antibiotics (e.g., ceftriaxone).
• Hydration and monitoring for maternal and fetal well-being.
• Tocolytics to delay delivery if the infection is controlled and there is no contraindication.
A 21-year-old P-I mother was admitted with diagnosis of PID after she presented to an emergency OPD with the compliant of lower abdominal pain of five days duration Associated with frequent vomiting and offensive vaginal discharge. On Physical examination, her temperature is 39.9 degree centigrade, has adenexal tenderness and cervical motion tenderness but no adnexal mass. What is the most likely indication for admission of this patient?
• a. Pelvic abscess is suspected
• b. Her age
• c. Diagnosis is uncertain
• d. Severity of the illness
The most likely indication for admission of this patient is d. Severity of the illness.
Here are the key points supporting this:
High fever (39.9°C): Indicates a severe infection.
Frequent vomiting: Suggests the patient may not tolerate oral medications.
Adnexal and cervical motion tenderness: Signs of significant pelvic inflammatory disease (PID).
Offensive vaginal discharge: Indicates an ongoing infection.
Severe illness, including high fever and inability to tolerate oral medications, is a common reason for admitting patients with PID1.
If you have any more questions or need further clarification, feel free to ask!
A 25-year-old G-IlI, P-II Rh-negative woman presented to an ANC clinic at GA of 28 weeks with a positive indirect Coomb’s test result. Her previous pregnancies were uneventful. Obstetric ultrasonographic examination shows no abnormalities. What is the most appropriate next step in the evaluation of the mother?
• a. Determine maternal titer
b. Determine fetal antigen status
c. Determine fetal HCT level
d. Determine paternal zygosity
The most appropriate next step in the evaluation of this Rh-negative pregnant woman with a positive indirect Coomb’s test is a. Determine maternal titer.
Here’s why:
Determine maternal titer: This step is crucial to assess the level of antibodies in the mother’s blood. Monitoring the antibody titer helps in determining the risk of hemolytic disease of the fetus and newborn (HDFN) and guides further management1.
Determine fetal antigen status: While important, this is typically done if the maternal antibody titer is significant and there is a need to assess the risk to the fetus2.
Determine fetal HCT level: This is usually considered if there is evidence of fetal anemia, which is not indicated in this scenario3.
Determine paternal zygosity: This can help in understanding the likelihood of the fetus being Rh-positive, but it is not the immediate next step1.
If you have any more questions or need further clarification, feel free to ask!
A 26-year-old Para I woman came with a biopsy result which is suggestive of choriocarcinoma two months after evacuation is made for molar pregnancy. Further evaluation and metastatic work-up showed nothing except a slightly enlarged uterus and a bilateral adnexal cyst of 4 cm x 5 cm. Serum ß-hCG is 25,000 mlUmL (NR; 11,500-289,000 mlUmL) and renal function test is normal. What is the most appropriate management for this woman?
a. Etoposide
b. Actinomycin D
• c. Dactinomycin
• d. Methotrexate
D
Because it is the first line for low risk GTN
A 28-year-old G-Il, P-I woman, who was ammenhorric for two months, came to a hospital to start ANC follow-up. On ultrasound examination, an eight week intrauterine pregnancy with negative FHB was seen.
The result was disclosed to her and she preferred to go for medical method of termination. What is the most appropriate drug to be used for this woman?
• a. Oxytocine
• b. Methotrexate
• c. Misoprostole
• d. Hypertonoic saline
C
A 28-year-old Gravida II, Para I woman at her 38th week of gestation is admitted to a labour ward as active first stage of labor and on trial of labor after cesarean section. Her previous delivery was by cesarean section for mal-presentation. She has had adequate uterine contraction which has suddenly stopped and has developed minimal vagina bleeding after two hours of admission. Fetal heart rate was
checked and became negative. What is the most likely cause for this condition?
• a. Placental abruption
b. Uterine rupture
O c. Prolonged labor
• d. Vasa previa
B
Patient presentation
Antepartum and intrapartum — Signs of uterine rupture may include some or all of the following, listed from more common to less common [18]:
●Abnormal fetal heart rate (FHR) – Sudden development of a concerning category II or a category III FHR pattern is consistently reported in patients with uterine rupture, but no FHR pattern is pathognomonic of rupture. The most common FHR abnormality in rupture is fetal bradycardia [19,20], which may be sudden or preceded by significant variable or prolonged decelerations. Category III FHR tracings may occur in the hour preceding diagnosis of rupture [21]. Given these observations, continuous FHR monitoring is routinely recommended during a trial of labor after cesarean (TOLAC) [22].
●Abdominal pain – Rupture may be associated with the sudden onset of abdominal pain, but this pain may be partially masked by neuraxial analgesia administered for management of labor pain. Patients who attempt TOLAC with epidural anesthesia may ask for additional epidural doses and require frequent dosing because of pain from an unrecognized rupture [23]. Therefore, clinicians should be mindful that the acute onset of pain after previously effective neuraxial anesthesia may be a sign of uterine rupture [24].
●Vaginal bleeding – 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 – Loss of station can result from partial extrusion of the fetus through the rupture, or possibly from myometrial relaxation.
●Hematuria – A rupture that extends into the bladder may cause hematuria.
●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 have been described in association with uterine rupture [25]. Another external tocodynamometry finding that has been reported is a gradual decrease in the amplitude of consecutive contractions, the so-called “staircase sign” [26]. Nevertheless, a consistent change in uterine contraction patterns at the time of uterine rupture has not been identified, and an intrauterine pressure catheter, if utilized, may fail to show any abnormality [27].
A 29-year-old G-II, P-I mother, who is a known Graves’s disease patient on treatment, presented to the regular OPD at her 36thweeks of gestation with complaints of palpitation, nervousness, sweating, and diarrhea of one day duration. On physical examination, she is anxious and confused, her blood pressure is 150/90 mmHg, pulse rate is 130/min, respirations are 28/min, temperature is 38.3°C and there is systolic ejection murmur at the apex. CBC results were; hematocrit level of 39percent, WBC count of 18 x103/mm3, and platelet count of 260x103 /mm3. What is the most likely diagnosis of this patient?
• a. Myxedema coma
• b. Thyroid storm
• c. Eclampsia
• d. Adrenal crisis
B
A 32-year-old G-II, P-I woman was screened for diabetes at gestational age of 26 weeks with an indication of family history of diabetes and previous macrosomic infant. Her blood glucose level, one hour after ingestion of 50-g glucose load, was 145mg/dl.
Then a 3-hour oral glucose challenge test was done and the results were as follows; FBS of 90mg/dl, 1-hour RBS of 160mg/dl, 2-hour RBS of 140 mg/dI and
3-hour RBS of 125 mg/dl. What is the most appropriate management option for this woman?
• a. Expectant management
b. Metformin
• c. Glibenclamide
• d. Insulin
A
A 32-year-old G-II, P-I mother came for a routine antenatal care at 12th weeks of gestation. She has palpitation and fatigue. Her blood pressure is 110/70mmHg and pulse rate is 108/min. Laboratory findings are remarkable for hemoglobin level of 12.4g/di, WBC count of 6x103/mm3 and platelet count of 280 x103/mm3. What is the most likely explanation for these findings?
• a. Iron deficiency anemia
• b. Hypothyroidism
• c. Diabetes mellitus
• d. Hyperthyroidism
D
A 30-year-old G-II, P-I lady, who delivered her previous baby by cesarean section, came to an emergency OPD with a complaint of amenorrhea, vaginal spotting and mild back pain of two months duration. On physical examination, her vital signs were in the normal range, cervix is closed, uterus is about six-week sized, and cul-de-sac is not bulged and mass was not appreciated. Pelvic ultrasound showed empty uterus, no adenexal mass or free fluid seen. Her Serum HCG was 400IU. What is the most appropriate investigation in the diagnosis of the patient’s case?
• a. Culdocentesis
b. Serial hCG
• c. Serial HCT
• d. Laparotomy
This is for informational purposes only. For medical advice or diagnosis, consult a professional.
The most appropriate investigation in this case is:
b. Serial hCG
* Explanation:
* The patient presents with a complex picture: amenorrhea, spotting, and back pain, with a slightly enlarged uterus and an elevated but low hCG level.
* These findings raise concerns for an ectopic pregnancy, miscarriage, or even a rare gestational trophoblastic disease.
* Serial hCG levels are crucial in these situations.
* In a normal intrauterine pregnancy, hCG levels typically double every 48-72 hours in early pregnancy.
* Monitoring hCG levels can help determine:
* If the pregnancy is progressing normally: Rising hCG levels would suggest an ongoing intrauterine pregnancy.
* If it’s an ectopic pregnancy: hCG levels may plateau or even decline in ectopic pregnancies.
* If it’s a miscarriage: hCG levels may plateau or decline.
* Why other options are less suitable:
* Culdocentesis: This invasive procedure is generally not recommended as the first-line investigation in this scenario.
* Serial HCT (Hematocrit): Monitoring hematocrit is important to assess for blood loss in cases of suspected ectopic pregnancy or miscarriage, but it’s not the primary diagnostic tool.
* Laparotomy: Laparotomy is a major surgical procedure and should be reserved for cases where other investigations strongly suggest an ectopic pregnancy or when conservative management has failed.
Important Note: This is a complex case, and the management plan should be determined by the treating physician based on the patient’s individual circumstances and the results of serial hCG testing.
A 33-year-old G-III, P-II woman, at 40 weeks’ of gestation, presented with pushing down pain of four hours duration. She was admitted to labor and delivery unit and she was at 6cm of cervical dilatation. She was followed with partograph for labor progress. When she was re-evaluated after four hours, cervical dilation graph cross action line, with uterine contraction of 2/10/30-40”, FHB is 140/min, membrane ruptured and clear liquor. What is the most appropriate next step in the management of this patient’s care?
• a. Rehydrate her
• b. Augmentation
• c. Cesarean section
• d. Expectant management
In this case, the patient is at 40 weeks’ gestation, and after four hours of observation, her cervical dilation has not progressed as expected. According to the partograph, her cervical dilation is crossing the action line, indicating slow or inadequate progress in labor. Given the uterine contractions are weak (2/10/30-40 seconds), the most appropriate next step would be augmentation to help facilitate labor progression.
Correct answer: b. Augmentation
• Rehydrate her (a): This is important if there is suspicion of dehydration, but the primary issue here seems to be inadequate labor progression rather than dehydration.
• Cesarean section (c): This would be considered if there were signs of fetal distress, abnormal labor progress, or other complications, but here the FHR is reassuring (140/min) and there’s no indication of fetal compromise.
• Expectant management (d): This would not be appropriate because the labor has stalled, and waiting longer without intervention is unlikely to resolve the problem.
A 32-year-old Gravida IV Para Ill woman at her 34th week of gestation presented with complaints of abdominal pain and absent of fetal movement of 12 hours duration. Her prenatal course has been unremarkable. She denied vaginal bleeding or leakage of fluid per vagina. She has no history of trauma. All her previous deliveries were vaginally and uneventful. On physical examination, her blood pressure is 90/60 mmHg, pulse rate is 120/min, has pale conjunctiva, fundal height is 38 cm which is hypertonic with moderate tenderness, FHB is negative and cervix is closed. What is the most likely diagnosis?
• a. Uterine rupture
Placenta previa
Placental abruption
• d. Intra-amniotic infection
The clinical presentation described here — abdominal pain, absent fetal movement, hypotension, tachycardia, pale conjunctiva, hypertonic uterus with tenderness, and a negative fetal heart beat (FHB) — is most suggestive of placental abruption.
In placental abruption, the placenta prematurely separates from the uterine wall, which can cause severe abdominal pain, uterine tenderness, and hypertonicity. The loss of fetal heart tones and maternal signs of hypovolemia (low blood pressure, tachycardia, and pallor) suggest significant bleeding, which may be concealed or overt. The lack of vaginal bleeding or leakage of fluid does not rule out this diagnosis, as bleeding may be internal.
• Uterine rupture (a): Although uterine rupture can cause abdominal pain, it typically presents with severe pain, a loss of fetal heart tones, and possibly a palpable abdominal mass. It is a more dramatic, often acute, event and usually presents with abnormal fetal position or signs of shock that would have developed more suddenly.
• Placenta previa (b): Placenta previa typically presents with painless vaginal bleeding, not abdominal pain or uterine tenderness. The absence of vaginal bleeding in this case makes placenta previa less likely.
• Intra-amniotic infection (d): Intra-amniotic infection (e.g., chorioamnionitis) generally presents with fever, uterine tenderness, and sometimes foul-smelling vaginal discharge, but it doesn’t typically cause the severe abdominal pain or absent fetal heart tones described here.
Correct answer: c. Placental abruption
A 34-year-old pregnant woman at a gestational age of eight weeks has been presented to ANC for antenatal care. She has a history of pregnancy loss three times at the gestational age of 24 weeks, 22 weeks and 20 weeks. She had no pain during the expulsion process. She is worried about occurrence of similar condition in the current pregnancy. What is the most appropriate management for this patient?
Bed rest
Cerclage
Progesterone
• d. Indomethacin
The patient’s history of recurrent painless mid-trimester pregnancy losses strongly suggests cervical insufficiency (also known as incompetent cervix). This condition is characterized by painless cervical dilation leading to pregnancy loss in the second trimester. The most appropriate management in this case is cerclage, a surgical procedure in which the cervix is stitched closed to provide structural support.
Explanation of options:
• Bed rest (a): While bed rest was historically recommended, there is insufficient evidence to support its effectiveness in preventing pregnancy loss in cervical insufficiency.
• Cerclage (b): This is the standard treatment for cervical insufficiency, particularly in patients with a history of recurrent second-trimester losses. Cerclage is typically performed between 12–14 weeks of gestation in such cases.
• Progesterone (c): Progesterone supplementation can help prevent preterm labor in women with a short cervix but is not as effective as cerclage in cases of true cervical insufficiency with a history of recurrent pregnancy losses.
• Indomethacin (d): Indomethacin, a tocolytic, is used to manage preterm labor but is not indicated in the prevention of pregnancy loss due to cervical insufficiency.
Correct answer: b. Cerclage
A 35-year-old Gravida II, Abortion I woman at the 8th month of amenorrhea came for antenatal care. She has no ANC visit before and has no any compliant.
Her physical examination is non-revealing. Her laboratory result shows positive for HBsAg. She is counseled about the possibility of passing the infection to her baby and possible interventions.
What is the most appropriate preventive measure to reduce risk of vertical transmission?
a. HB vaccine series but avoid breast feeding
b. Hepatitis B hyperimmune globulin only at birth
c. Hepatitis B vaccine series and lamivudine
d. HB immune globulin and HB vaccine series
The most appropriate preventive measure to reduce the risk of vertical transmission of hepatitis B virus (HBV) in this case is:
d. HB immune globulin and HB vaccine series
Explanation:
1. Hepatitis B immune globulin (HBIG):
• HBIG provides immediate passive immunity and should be administered within 12 hours of birth to neutralize the virus.
2. Hepatitis B vaccine series:
• The vaccine stimulates the infant’s active immunity and is started at birth. The second dose is given at 1–2 months, and the third dose at 6 months.
Why not the other options?
• a. HB vaccine series but avoid breastfeeding:
Breastfeeding is not contraindicated if the infant has received HBIG and the HB vaccine. Thus, avoiding breastfeeding is unnecessary.
• b. Hepatitis B hyperimmune globulin only at birth:
While HBIG is essential, giving it alone without the HB vaccine series is insufficient for long-term protection.
• c. Hepatitis B vaccine series and lamivudine:
Lamivudine is an antiviral used to reduce maternal HBV DNA levels during pregnancy in cases of high viral load. It is not part of the neonatal prophylaxis.
Key Recommendations:
• If maternal HBV DNA levels are high (>200,000 IU/mL), maternal antiviral therapy (e.g., tenofovir) during the third trimester can further reduce vertical transmission risk.
• Infants receiving HBIG and HB vaccine have a >95% chance of avoiding chronic HBV infection.
