Obstetrics and Gynecology

Question 1

When would you offer an external cephalic version

Answer 1

If there is transerse lie or breech presentation at 37 weeks and vaginal delivery is not contraindicated

Question 2

Diagnosis and treatment of gonorrhea and chlamydia

Answer 2

Dx: nucleic acid amplification test (gold standard) on urine or cervical swab

Empiric: ceftriaxone and azithromycin
Confirmed chlamydia only: azithromycin or doxycycline
Confirmed gonorrhea only: ceftriaxone and azythromycin

Hospitalization and IV cefoxitin or cefotetan plus oral doxycycline if pregnancy, failed outpatient treatment, inability to tolerate oral medications, noncompliant with therapy, severe presentation (e.g. high fever, vomiting), complications (e.g. tubo-ovarian abscess, perihepatitis)

Question 3

Boggy, tender, globular uterus

Answer 3

Adenomyosis

Question 4

Gestational diabetes blood glucose targets and treatment

Answer 4

Fasting ? 95, 1-hr postprandial ? 140, 2-hr postprandial ? 120
Tx: dietary modifications (first line), insulin, metformin, glyburide (second line)

Question 5

Management of shoulder dystocia

Answer 5

BECALM
Breath, do not push, lower head of the bed
Elevate legs (McRoberts position)
Call for help
Apply suprapubic pressure
Enlarge vaginal opening with episiotomy
Maneuvers

Question 6

Treatment for spontaneous abortion

Answer 6

Expectant management
Medical induction (misoprostol)
Suction curettage if infection or hemodynamically unstable

Question 7

Indications for cerclage

Answer 7

History of second trimester delivery

Short cervical length (< 2.5 cm) via TVUS

Question 8

Evaluation for primary amenorrhea

Answer 8

Pelvic exam or ultrasound
If uterus, check serum FSH
If FSH increased –> karyotype
If FSH decreased –> cranial MRI
If no uterus, check testosterone and do karyotype
If 46XX and normal female testosterone, Mullerian agenesis
If 46XY and normal male testosterone, androgen insensitivity syndrome

Question 9

Diagnosis and management of pre-eclampsia

Answer 9

Risk factors: nulliparity, maternal age < 18

Dx: new-onset HTN > 20 weeks plus proteinuria and/or end-organ damage
Severe features: SBP > 160 or DBP > 110 (2 times > 4 hours apart), thrombocytopenia (< 100,000), increased creatinine (> 1.1), increased transaminases, pulmonary edema, visual or cerebral symptoms

Management: delivery > 37 (> 34 weeks if severe), magnesium sulfate (seizure prophylaxis), antihypertensives (IV labetalol, IV hydralazine, PO nifedipine)

Complications: fetal growth restriction/low birth weight, placental abruption, DIC, eclampsia

Question 10

Treatment for ectopic pregnancy

Answer 10

Stable: methotrexate
Unstable: surgery

Question 11

HELLP syndrome

Answer 11

Hemolysis, elevated liver enzymes, low platelets

Systemic inflammation and activation of complement and coagulation systems –> platelets rapidly consumed, microangiopathic hemolytic anemia causes hepatocellular necrosis and thrombi in the portal system causes elevated liver enzymes, liver swelling, and liver distension of hepatic capsule

Question 12

Types of fetal growth restriction

Answer 12

Definition: ultrasound-estimated fetal weight < 10th percentile
Symmetric: global growth lag caused by chromosomal abnormalities or congenital infection in the first trimester
Asymmetric: “head-sparing” growth lag caused by uteroplacental insufficiency or maternal malnutrition in the 2nd/3rd trimester

Question 13

Management and complications of intrauterine fetal demise

Answer 13

Management: dilation and evacuation or vagnial delivery is 20-23 weeks, vaginal delivery if ? 24 weeks
Complication: coagulopathy after several weeks of fetal retention

Question 14

Diagnosis and management of placenta previa

Answer 14

Dx: transabdominal followed by transvaginal ultrasound, placenta within 2 cm of internal cervical os
Tx: pelvic rest (no intercourse, digital exams), scheduled cesarian at 36-37 weeks

Question 15

Risk factors for cerebral palsy

Answer 15

PREMATURITY
Intrauterine growth restriction
Intrauterine infection
Antepartum hemorrhage
Placental pathology
Multiple gestation
Maternal alcohol consumption
Maternal tobacco use
Tx: physical, occupational, and speech therapies, baclofen and botulinum toxin for spasticity

Question 16

Vaccines contraindicated during pregnancy

Answer 16

HPV
MMR
Live attenuated influenza
Varicella

Question 17

When to administer Rhogam?

Answer 17

For Rh- mothers, administer at 28 weeks or if spontaneous abortion or trauma

If baby Rh+, administer within 72 hours after delivery

Question 18

Clinical features and treatment of magnesium toxicity

Answer 18

Magnesium sulfate is given to prevent eclamptic seizures and for fetal neuroprotection; renal insufficiency can cause hypermagnesemia
S&S: loss of deep tendon reflexes, somnolence, respiratory depression
Tx: IV calcium gluconate bolus

Question 19

Treatment for lactation suppression

Answer 19

Comfortable, supporting bra
Avoidance of nipple stimulation and manipulation
Application of ice packs to the breasts
NSAIDs to reduce inflammation and pain

Question 20

Management of hypothyroidism during pregnancy

Answer 20

Increase levothyroxine dose 30% at the time pregnancy is detected; adjust every 4 weeks based on TSH and total T4 using pregnancy-specific norms

The increasing need for thyroid hormone replacement is due to increased estrogen which induces increased levels of thyroxine-binding globulin decreasing the available T4/T3.

Question 21

Management of Erb-Duchenne palsy

Answer 21

Damage to C5, C6, C7; a/w shoulder dystocia

Tx: gentle massage and physical therapy to prevent contractures

Prognosis depends on whether damage resulted from mild nerve stretching or compression as opposed to severe rupture or avulsion

80% of patients have spontaneous recovery within 3 months; surgical intervention can be considered if no improvement by age 3-6 months

Question 22

Bartholin gland cysts

Answer 22

Soft, mobile, nontender masses located at the base of the labia majora (4 and 8 ‘oclock positions)

Tx: observation (if asymptomatic), I&D followed by Word catheter placement

Question 23

Management of preterm labor

Answer 23

Preterm labor = regular contractions that cause cervical change < 37 weeks

Management: betamethasone, penicillin if GBS+ or unknown, tocolytics if < 34 weeks, magnesium sulfate if < 32 weeks

Question 24

Types and causes of decelerations of fetal heart monitor

Answer 24

Early decelerations –> fetal head compression

Variable decelerations –> umbilical cord compression/prolapse, oligohydramnios

Late decerlations –> uteroplacental insufficiency

Question 25

Treatment of condyloma acuminata

Answer 25

Caused by HPV 6, 11

Chemical: podophyllin resin, trichloroacetic acid

Immunologic: imiquimod

Surgical: cryotherapy, laser therapy, excision

Question 26

Types of antepartum fetal surveillance

Answer 26

Nonstress test (reactive = > 2 accelerations)

Biophysical profile (normal = 8-10)

Contraction stress test (normal = no late or recurrent variable decelerations)

Doppler sonography of the umbilical artery to assess growth restriction (normal = high-velocity diastolic flow)

Question 27

Parts of the biophysical profile

Answer 27

Each of the following are graded as normal (2 points) or abnormal (0 points) for a total of 10 points

1. Nonstress test (normal = > 2 accelerations)
2. amniotic fluid volume (normal = single pocket > 2x1 cm or amniotic fluid index > 5)
3. Fetal movements (normal = > 3 general body movements)
4. fetal tone (normal > 1 episode of flexion/extension of fetal limbs or spine)
5. fetal breathing movements (normal = > 1 breathing episode for > 30 seconds)

Question 28

Side effect of epidural anesthesia

Answer 28

Hypotension

Anesthesia blocks sympathetic fibers –> decreased vascular tone –> vasodilation and venous pooling –> decreased venous return –> decreased cardiac output

Managment: prevention with IV fluids, positioning patient on left side to increase venous return, IV fluid bolus, vasopressors

Question 29

Management of Kumpke palsy

Answer 29

damage to C8 and T1; a/w shoulder dystocia; may manifest as ipsilateral Horner syndrome

Tx: gentle massage and physical therapy to prevent contractures

In most cases function returns within a few months; surgical intervention if no improvement by age 3-9 months