Ob/Gyn (UWorld)

Question 1

31yo patient presents with burning on urination, tender inguinal lymph nodes, and multiple painful ulcers with erythematous base grouped on vulva. Labs reveal pyuria, and she complains of dysuria. Diagnosis? Differential?

Answer 1

Herpes simplex. Key is the painful, grouped ulcers with erythematous base. Note the UA findings can indicate inflammation of genital tract, not really a UTI.
DDx: syphilis ulcers are painless w/o erythematous base and nontender lymph nodes

Question 2

Patient presents at 31 weeks with painful contractions occurring every 7 minutes and is found to be dilated to 3cm with 80% effacement. Fetal heart monitoring shows a reassuring pattern. Next steps? General approach here?

Answer 2

Preterm labor. Rx: tocolytics (e.g. terbutaline), betamethasone, magnesium (neuroprotection)
General: Tocolytics for labor before 34 weeks to allow for betamethasone, magnesium for neuroprotection before 32 weeks. After 34 weeks or in the setting of preeclampsia, abruption, etc. proceed as otherwise indicated

Question 3

22yo patient presents complaining of not being able to have intercourse. She feels a spasm & tightness in her pelvic region whenever penetration is attempted. Speculum exam isn’t possible due to tense perineal musculature. Diagnosis? Rx?

Answer 3

Dx: Vaginissmus
Rx: Kegel exercises and gradual dilation with increasing diameter “probes.” Kegels are super counterintuitive here…

Question 4

Patient at 35 weeks gestation presents with BP 190/110, elevated BUN, urinalysis showing 4+ protein. Dx? Rx? She afterward is found to have hyporeflexia in DTR. Dx? Rx?

Answer 4

Severe preeclampsia. Rx: lower BP with hydralazine or labetalol, also give magnesium.
Hyporeflexia indicates Mg toxicity. Rx: d/c Mg, add calcium gluconate

Question 5

Patient presents at 36weeks gestation completely healthy. Palpation reveals the vertex palpable at the fundus. Next steps?

Answer 5

Expectant management before 37weeks! Babies will often resolve from breech presentation.
If 37 weeks breech, external cephalic version should be attempted if no abnormal placenta or fetopelvic disproportion

Question 6

Guidelines for streptococcus agalactiae screening during pregnancy?

Answer 6

Universal screening for Group B strep via recto-vaginal culture within 5 weeks of expected due date. (Usually week 35)
Rx: Penicillin prophylaxis starting at 4hrs prior to delivery

Question 7

14yo girl presents for not having started her period yet. She is in 6th percentile for height with a webbed neck. BP is elevated in upper extremities and low in lower extremities. Diagnosis? What hormone along the HPGonadal axis will be elevated?

Answer 7

Dx: Turner syndrome with elevated FSH!

Note that inhibin and estrogen levels will be low.

Question 8

17yo female complains of excessive vaginal discharge. On exam is it copious, white, mucoid discharge without odor. Microscopic analysis reveals a predominance of squamous cells and occasional polymorphonuclear leukocytes (PMNs). Diagnosis? Rx?

Answer 8

Dx: physiologic leukorrhea (normal variant). No Rx needed.
Don’t be fooled by PMNs! Concern for pathologic discharge comes with erythema, pain, malodorous discharge, pruiritis, or curd-like discharge

Question 9

You suspect bacterial vaginosis. What pH would you expect from vaginal secretions? What is the whiff test?

Answer 9

pH > 4.5 (Amsel criteria). Remember vaginal secretions are usually acidic
Whiff test is foul odor (“fishy” “amine-like) of discharge upon addition of KOH on a slide

Question 10

28yo woman at 36weeks gestation complains she does not feel her baby move. Fetal doppler confirms heart tones at 135/min. Non-stress test at 40minutes is completely non-reactive. Next step (two options)?

Answer 10

Biophysical profile (4 components: amniotic fluid, gross movement, fetal breathing, fetal tone)
Contraction stress test (CST): administer oxytocin and look for late decels. Only abnormal if late decels present after >50% of contractions
Note that BPP and CST are equivalent in predicting fetus is safe for 7 days

Question 11

Two 55yo patients present with incontinence. Patient A it occurs after sneezing, coughing, and laughing. Cotton swab in the urethral orifice demonstrates an angle >30degrees. Patient B it occurs randomly with the sudden feeling of needing to pee. Dx? Rx?

Answer 11

A: stress incontinence from ineffective closure of urethral sphincter (pay attention to the cotton swab bit) Rx:urethropexy
B: urge incontinence from overactive detrusor muscle. Rx: Oxybutynin

Question 12

A patient diagnosed with gestational diabetes initially managed with diet modification should have what blood glucose goals (fasting, 1hr, 2hr post-prandial)? Rx options if not well controlled?

Answer 12

Patients being monitored for gestational diabetes should have:
Fasting glucose

Question 13

What is the utility of a mid-luteal phase progesterone level? Explain physiology

Answer 13

Tests for ovulation. After ovulation (during the luteal phase) the corpus luteum is maintained for 14 days and is the main source of progesterone. If ovulation is successful, elevated serum progesterone levels will be evident.

Question 14

46yo G3P3 presents due to pelvic pain. Pelvic exam shows a symetrically enlarged uterus consistent with ~10weeks. The uterus is soft, boggy, globular, and freely mobile. bHCG is negative. Diagnosis?

Answer 14

Dx: adenomyosis (pay attention to physical exam description)

More common in multiparous women

Question 15

Important risk factors for endometritis? How far from delivery would you expect to see it? Rx?

Answer 15

Risk factors: instrumentation of uterus (e.g. fetal scalp electrodes, intrauterine pressure cateters), prolonged rupture of membranes, C-section delivery
Occurs >24hrs after delivery with first manifestation often a fever
Rx: Clindamycin + gentamycin. Endometritis is a polymicrobial infection!

Question 16

Pap smear/cervical cancer screening guidelines for a) Age < 21 b) age 21-29 c) age 30-65 d) age > 65.

Answer 16

a) No screening for women under 21! (Unless immunocompromised e.g. HIV, SLE, organ transplant)
b) Cytology every 3years
c) Cytology q3yrs or cytology + HPV q5yrs
d) No screening for 65+ as long as prior scans negative and not at increased risk

Question 17

Timing of oral glucose tolerance screening test in an otherwise healthy pregnant patient?

Answer 17

24-28weeks gestation. At start of 3rd trimester (as long as patient doesn’t have other risk factors for gestational diabetes)

Question 18

26yo patient presents with new onset severe pelvic pain during sex. She also complains of pelvic pain while defecating, and intense pain with menses. Diagnosis? Rx?

Answer 18

Endometriosis. Remember the 3 D’s of endometriosis: Dysmenorrhea (menses), dyspareunia (sex), dyschezia (defecation)
Rx: NSAIDs and OCPs

Question 19

Difference between nuchal translucency + PAPP-A vs. AFP, estriol, HCG, inhibin tests?

Answer 19

Both are for trisomy 21 screening, but nuchal translucency + PAPP-A can be performed in first trimester (~11 weeks) but the quad screen is a 2nd trimester screen

Question 20

Quad screen results expected in trisomy 21 fetus (2nd trimester screen)? Biggest difference with trisomy 18?

Answer 20

Remeber H+I is high, E&A fall away (low)
HCG, inhibin A are high | Estriol, AFP are low
Trisomy 18: Everything is low except inhibin which is usually normal

Question 21

60yo postmenopausal woman is being evaluated for a 8cm adnexal mass. The mass is unilocular (cystic) with a regular border and no signs of ascites in the abdomen. Next step?

Answer 21

CA-125 is a good choice in post-menopausal women. If it’s low → watchful waiting.
If CA125 high, mass > 10cm, +ascites, surgical exploration necessary

Question 22

28yo female presents after having sudden onset R adnexal pain during sexual intercourse. She is in exquisite pain on physical exam and u/s reveals a cystic ovarian mass with moderate amount of free fluid. Doppler velocimetry to that ovary is normal? Dx? What other pathology is common in R adnexa

Answer 22

Ruptured ovarian cyst.

Note that ovarian torsion is more common R than left, but doppler will show decreased blood flow to that ovary

Question 23

25yo woman at 38 weeks gestation and history of preeclampsia presents with painful uterine contractions and vaginal bleeding. Physical exam revelas a hyperactive uterus with increased tone and moderate vaginal bleeding. Dx? Next step?

Answer 23

Placental abruption. Uterine tone is crucial to this diagnosis.
Delivery by C-section if fetal tracing non-reassuring, trial of delivery if reassuring fetal tracing and >34weeks gestation

Question 24

Woman at 38 weeks gestation with history of prior c-section currently in labor reports suddenly feeling intense lower abdominal and back pain. She is restless and vaginal bleeding is noted as well. On exam the fetus presenting part is at -2 station after just previously being at 0 station. Diagnosis? Next step?

Answer 24

Uterine rupture. Loss of fetal station (from 0 to -2) is a red flag for uterine rupture as baby now can retreat into abdomen. Prior C-section is risk factor
Rx: emergency C-section STAT! Woman can easily exsanguinate from uterine rupture

Question 25

Patients with hypothyroidism usually require increasing doses of levothyroxine during their pregnancy. This usually occurs during the first semester. Physiologic explanation for this? (Excluding hemodynamic phenomenon of pregnancy)

Answer 25

Pregnancy increases blood levels of thyroid binding globulin.

Question 26

Selective estrogen receptor modulator (SERM) used in prevention of osteoporosis. What effect does it have on breast, bone, and vaginal tissue? Important contraindication?

Answer 26

Raloxifene. Estrogen agonist on bone tissue (prevent osteoporosis), otherwise and antagonist in breast and vaginal tissue (decreases risk for breast cancer)
Contraindicated in patients with history of thrombosis
NTBCw/ tamoxifen which can increase risk of endometrial cancer!!

Question 27

Patient presents for regular prenatal visit at 12 weeks gestation. She has no concerning symptoms and a clean-catch urine culture reveals >100k colony-forming units/mL of E. Coli. She denies any symptoms of dysuria, frequency change, CVA tenderness, etc. Dx? Rx?

Answer 27

Asymptomatic bacteriuria (>100k CFU/mL).  Rx: amoxicillin (or augmentin), nitrofurantoin, or cephalexin
Avoid bactrim in 1st & 3rd trimesters!

Question 28

30yo woman develops severe post-partum bleeding requiring 5 units of blood to stabalize. By day 7 postpartum, she reports still not being able to breast feed, feels lethargic, and labs reveal mild hyponatremia. Dx?

Answer 28

Prolactin deficiency from Sheehan syndrome. Remember association with postpartum bleeding (hypotension induced pituitary infarction)
No real treatment for this condition.