OB-GYN MODULE

35 yr old multigravid. First 5 pregnancies delivered normally at home. Next

pregnancy were twins delivered at 8 mos aog. Spontaneous abortion last year,
no d and c. Woke up with bleeding without contractions. Normal PE and vital
signs. Leopolds = breech. Fundic height=34 and fht=134
1. OB index:
A. G8P6 (5117)
B. G7P5 (5216)
C. G7P5 (5116)
D. G8P6 (5217)
Answer: A; pregnant for 5 times + 1 twin+ 1 aborted+ currently pregnant= G8; 5
children + 1 twin= P6; 5 terms; 1 preterm; 1 aborted; 7 living children

2. Fetal presentation:
A. Cephalic
B. Shoulder
C. Breech
D. Transverse
Answer: C. Breech

3. What is highly suspected that the patient may have?

a. Ectopic Pregnancy
b. Placenta Previa
c. Abruptio Placenta
d. H-mole
Answer: B. Since the bleeding wasn't accompanied w/ lumbosacral and hypogastric
pains.

4. The ff would be the initial step in assessing the px, Except?

a. Abdominal Exam
b. Speculum Exam
c. Internal Exam
d. Pelvic Ultrasound
Answer: C
Useful indirect information may be obtained by careful abdominal examination. In
placenta previa, the uterus is usually soft, easily palpable, nontender and
noncontractile. Internal examination is withheld in women whom delay in delivery is
advisable. The only remaining indication for double setup is in the patient who
presents with minimal bleeding and in active labor. Placental localization by
transabdominal sonography has become a standard feature in the diagnosisof
placenta previa. To rule out pathologic lesions in the vagina and cervix, a speculum
examination is advocated. (Panlilio)

5. The most accurate method to confirm the diagnosis is

a. Abdominopelvic ultrasound
b. Transvaginal ultrasound
c. Doppler sonography
d. Double set-up examination
Answer: D
The double set-up examination has been considered as the final diagnostic step in
the management of placenta previa.

6. Upon admissiom, the following must be ordered, except

a. CBC with blood-typing and cross-matching
b. Bed rest
c. Expectant management
d. Corticosteroid
Answer: D
Those in whom the fetus is preterm but there is no pressing need for delivery.
Expectant management isrecommended with a target date for delivery at the end of
the 37th week. It includes hospitalization, replacement of blood loss, keeping cross
matched blood available for emergency and bed rest under close observation.
(Panlilio)
7. The fetus is endangered from except
A. Anemia
b. Infection
c. Rds
d. Nota
Answer: D
Based on Panlilio, IUGR and congenital abnormalities are the fetal complications for
placenta previa.

8. At the ward, bleeding is scanty. Best mgt is

a. Intelligent expectancy
b. Tocolytic
C. Deliver
D. Corticosteroids
Answer: A: Those in whom the fetus is preterm but there is no pressing need for
delivery, expectant managementt is recommended with a target date of delivery at
he end of the 37 week..Panlillio page 314

9. After delivery of the baby, the placenta was noted to be markedly adherent
to the uterine wall. This is most probably due to:
A. Placenta accreta
B. Abruptio placenta
C. Uterine atony
D. Uterine inversion
Answer: A
panlilio p.468; Placenta accreta is any placental implantation in which there is
abnormally firm adherence to the uterine wall as a result of partial or total absence of
the decidua basalis and imperfect development of Nitabuch's layer.

10. The markedly adherent placenta in this case would be best managed by
A. Total abdominal hysterectomy
B. Subtotal abdominal hysterectomy
C. Total abdominal hysterectomy with bilateral salpingo-oophorectomy
D. Dilatation & Curettage
Answer: A.In general, the safest way to manage morbidly adherent placentation is
to deliver the baby by cesarean delivery that leaves the placenta untouched, and
then to remove the uterus and cervix (total abdominal hysterectomy). The patient's
ovaries are both left in place unless one or both need to be removed for safety
(which only occurs about 10% of the time).
Accdg to ACOG (2015): "The recommended mngt of placenta accreta is
hysterectomy with the placenta left in situ because removal of the placenta is
associated with significant hemorrhagic morbidity....A subtotal hysterectomy can be
safely performed but persistent bleeding from the cervix may preclude this approach
and make total hysterectomy necessary."

A 24 year old G2P0 came in for hypogastric and lumbosacral pain (I think naa
ni for 7hours just check sa exam) Lmp - dec 2006 Pmp - nov 2006 VS: 37 C
120/80 78 bpm
Abdominal exam: globularly enlarged, cephalic presentation, FH - 29cm, FHT -
130/min IE: cervix 1 cm dilated, beginning of effacement, intact bag of water,
cephalic floating
11. What is the main problem of the patient?
A. Station of presenting part
B. Cervical condition
C. Fetal prognosis
D. Fetal condition
Since libog man ang LMP ani kay December pa (and naa pud possibility na
JULY ni nga exam since wala pay calendar shift ato na time) so we rely on the
FUNDIC HEIGHT which is 29 cm = 29 weeks....
SO
AOG is 28-32 weeks --> our concern is the CERVICAL CONDITION which is letter B
since preterm pa ang fetus and nag start na ug dilate and efface ang cervix
(Panlilio, Pathologic Obstetrics: page 368 DIAGNOSIS na paragraph)

The question is vague and misleading esp that the LMP was given and without
knowledge of what day is today to compute for the AOG. And engaged at the same
time floating. How was that?
Now, if we try to disregard the LMP computation and resorted on the AOG via fundic
height which is 29, we get 29 weeks AOG. It is unusual to have a cervix at 29 weeks
with starting effacement..
Nevertheless, take note that engagement is expected to occur by the 37 th week
(Panlilio 427)

12. Which of the following is part of your management?

A. Corticosteroids
B. Tocolytics
C. Prompt delivery
D. A & B

Corticosteroids are not needed since the LMP was December 2006 (ga assume ko
na dapat december 2015 ni) thus the AOG will approximately be 9 months, and
corticosteroids are given to preterm fetuses to hasten lung maturity.
Tocolytics should also not be given since the SSx are of true labor and not false
labor.
By virtue of elimination I think the correct answer would be C (I agree with this if 9
months na gyud ang AOG since we are considering IUGR here if relating to the
Fundic Height and according to Panlilio, Pathologic Obstetrics: page 369:
Management na paragraph – IF PREGNANCY IS UNDOUBTEDLY OVER 37
WEEKS, IT SHOULD BE TERMINATED)
S0 if atoa siyang iconnect sa #11, the answer would be D, since the fundic height is
29 cm --> the fetus is preterm so we give Corticosteroids and Tocolytics (stated on
Panlilio, Pathologic Obstetrics page 355: Pharmacologic Treatment of Preterm
Delivery AND Williams Obstetrics, 23rd edition page 820: paragraph on
Corticosteroids)

13. 3 hrs after admission, there was watery vaginal discharge which was
accompanied by hypogastric and lumbosacral pain. Which of the following will
least likely happen?
A. Cord prolapse
B. Chorioamnionitis
C. Inevitable delivery
D. Uterine rupture
ANSWER: D

Rupture of the membranes is significant for three reasons. First, if the presenting
part is not fixed in the pelvis, the possibility of umbilical cord prolapse and
compression is greatly increased. Second, labor is likely to begin soon if the
pregnancy is at or near term. Third, if delivery is delayed after membrane rupture,
intrauterine infection is more likely as the time interval increases. (William’s, 23 rd
ed, p 392)
14. What is the most reliable indicator for ruptured membranes?
A. Fluid observed per os (?)
B. (+) nitrazine test
C. (+) ferning
D. (+) oncofetal fibronectin

ANSWER: C

Upon sterile speculum examination, ruptured membranes are diagnosed when

amnionic fluid is seen pooling in the posterior fornix or clear fluid is flowing from
the cervical canal.

The use of the indicator nitrazine to identify ruptured membranes is a simple and
fairly reliable method.
Other tests include arborization or ferning of vaginal fluid, which suggests
amnionic rather than cervical fluid. Amnionic fluid crystallizes to form a fernlike
pattern due to its relative concentrations of sodium chloride, proteins, and
carbohydrates. Detection of alpha-fetoprotein in the vaginal vault has been used to
identify amnionic fluid. (William’s, 23rd ed, p 392)
-----
Fetal fibronectin is detected in cervicovaginal secretions in women who have
normal pregnancies with intact membranes at term. It appears to reflect stromal
remodeling of the cervix prior to labor. Lockwood and co-workers (1991) reported
that fibronectin detection in cervicovaginal secretions prior to membrane rupture was
a possible marker for impending preterm labor. (William’s, 23 rd ed, p 816)

15. The ff could give a false positive result on nitrazine test except:
A. Vaginal bleeding
B. Candida
C. Bacterial vaginosis
D. Cervical mucus
Answer: B
False Positive Results affected by: Soap, Blood, Semen, Cervical Mucus, Infections
(Bacterial Vaginosis/Trichomoniasis)
Nitrazine test can produce false positives. If blood gets in the sample or if there is an
infection present, the PH of the vaginal fluid may be higher than normal. Semen also
has higher pH, so a recent vaginal intercourse can produce false reading.
pH in Candida is within normal vaginal pH so it will roduce negative results on your
nitrazine
Source: healthline.com

Case: 38yo G2P1 diabetic asthmatic on her early third trimester came in with
early onset of fever (t-38), chills, nausea and backache. No vaginal
bleeding/discharge. No contractions noted.
16. What is the initial lab test necessary for diagnosis?
A. CBC with platelet
B. Urinalysis
C. Pelvic ultrasound
D. Cxray
Answer: B
The diagnosis of acute pyelonephritis is based on the presence of abrupt onset of
fever, shaking chills and costovertebral angle ache or tenderness with assoc.
anorexia, nausea and vomiting. Laboratory findings include pyuria and bacteriuria.

17. What is the most likely diagnosis?

A. Acute appendicitis
B. Bronchial asthma in acute exacerbation
C. Pyelonephritis
D. (Nakalimot ko huhu.. Palihug nlng supply sa makahinumdom)

Answer: C. The patient presents the signs and symptoms of acute pyelonephritis.
The diagnosis of acute pyelonephritis is based on the presence of the following signs
and symptoms: abrupt onset of fever, shaking chills and costovertebral angle ache or
tenderness, with associated anorexia, nausea and/or vomiting (Panlilio, p. 548).

18. Pregnant asthmatics are at most risk for:

A. Macrosomia
B. Perinatal mortality
C. All of the above
D. None of the above
Answer: D (not sure). Long term studies have not shown consistently any significant
correlation between asthma and the incidence of premature delivery and abortion or
that increased perinatal morbidity, mortality and neurologic problems at age one year
are demonstrable among babies of asthmatic women (Panlilio, p. 497).

19. If her diabetes would not be controlled, the baby would characteristically
exhibit:
a. Absent of the islets of Langerhans
b. Atrophy of the islets of Langerhans
c. Hypertrophy of the islets of Langerhans
d. Normal islets of Langerhans

Answer: C
Rationale: Autopsy of infants of diabetic mothers commonly reveal hypertrophy and
hyperplasia of the Islet of Langerhans. (Panlilio page 503)

20. true about the use of oral hypoglycemics:

a. it is the drug of choice
b. may be teratogenic
c. neonatal hyperglycemia
d. all of the above

Answer: B
Rationale: Oral hypoglycemic agents – such as Tolbutamide are not used during
pregnany because of possible fetal teratogenesis and prolonged neonatal
hypoglycemia. (Panlilio page 506)

A 21 yo primigravida @ 37 weeks AOG was seen for the first time complaining
of laborpains since early morning. No vaginal discharge, BP = 150/110, edema
+2, FH- 27 cm, FHT= 134/min.

21. You will:

a. perform internal exam
b. request rush urinalysis
c. both A and B
d. none of the above

Answer: C ?
Rationale: Perform IE to assess if there is a positive cervical dilatation. Presence of
cervical dilatation is one of the characteristic that could differentiate the presence of
a true labor from a false labor. (Williams Table 17-4 Page 390)

Request Rush Urinalysis: Since the patient has a BP of 150/110 and an edema of
+2, Request for urinalysis to see if there is proteinuria in the patient would be of great
help for the management of the patient if pre-eclampsia is suspected.

Question: Since the patient is already on the 37th week of gestation and possibly is
on active labor, would we still assess if the patient have pre-eclampsia?? -yes, we
are physicians and we need to find explanation for our patient's condition so that we
will be able to provide the most appropriate care.lol
22. You expect to find:
a. cervix dilated
b. BOW(bag of water) intact
c. both A and B
d. none of the above

Answer: C ?

23. If patient's cervix is 2 cm dilated and 80% effaced, you would conclude that
she is:
A. In latent phase
B. Active phase
C. 2nd stage of labor
D. Not in labor

Answer: A
Rationale: The latent phase commences with maternal perception of regular
contractions, and in the presence of progressive although slow cervical dilatation,
ends at between 3 and 5 cms dilatation which is the threshold for active phase
transition.

24. After several hours of observation, you note that the uterus does not relax
completely between the patient's complaints of severe pain. You conclude
that:

A. She is suffering from hypertonic uterine dysfunction

B. She is suffering from hypotonic uterine dysfunction
C. Precipitate labor
D. None of the above

Answer: A
OB williams 23rd ed p 467
"From these observations, it is possible to define two types of
uterine dysfunction. In the more common hypotonic uterine dysfunction,there is no
basal hypertonus and uterine contractions have a normal gradient pattern
(synchronous), but pressure during a contraction is insufficient to dilate the cervix. In
the second type, hypertonic uterine dysfunction or incoordinate uterine dysfunction,
either basal tone is elevated appreciably or the pressure gradient is distorted.
Gradient distortion may result from contraction of the uterine midsegment with more
force than the fundus or from complete asynchronism of the impulses originating in
each cornu or a combination of these two."
Pridominantly a disorder of primigravida (Jones,169)
25. If this will not be promptly recognized and treated, the patient can have the
following complications, except:

A. Placenta previa
B. Abruptio placenta
C. Uterine rupture
D. None of the above
Answer: A. Placenta Previa
The risk factors for placenta previa includes the following: multiparity, multiple
induced abortions, previous cesarean delivery, puerperal endometritis, large
placenta and advanced age, which are all absent in the patient. Symptoms present
in the patient include: painful contractions and the absence of vaginal bleeding,
which is the opposite presentation for previa (Panlilio, 313).
Considering hypertonic uterine dysfunction, the complications include: colicky uterus
and constriction ring dystocia (Jones, 170). For Williams, 22ed pp 519: Intrapartum
infection, uterine rupture, fistula formation, pelvic floor and lower extremity nerve
injury. Can't find complication in Panlilio.
Constriction rings develop in prolonged labors, and signifies impending rupture of the
lower uterine segment (Williams, 22ed pp 519).
For abruptio placenta, the risk factors present in the patient include: preeclampsia or
chronic HPN based on the BP (Panlilio, 317).

26. You will give the following:

A. Sedation
B. Oxytocin drip
C. Both A & B
D. Neither

Answer: A. Sedation
Hypertonic uterine contraction will usually respond to sedation (Panlilio, 408).
Hypertonic dysfunction occurs in the latent phase of delivery causing failure in
cervical dilatation. This is also part of the preparatory phase which is the time that
sedation and analgesia are routinely given since it is the phase that is responsive to
these agents (Williams, 22ed, 422).

27. Lab result showed ++ proteinuria. what diagnosis?

a. chronic HPN in pregnancy
b. preeclampsia, mild
c. preeclampsia, severe
d. eclampsia

Answer: B
(DBP is 110, mild jud ni?) -severe pre ec na man ata ni ky 2+ ang dipstick :)
Severe pod akoang answer ani
Mild ni: 140-160 SBP, 90-110 DBP, dipstick +1/+2, no systemic disturbances
How about presence of edema? According to Williams OB, edema is part of severe
preeclampsia.

28. pathophysiology of preeclampsia

a. vasodilation
b. vasospasm
c. hemodilution
d. hypervolemic

Answer: B. endothelial cell dysfunction leading to abnormal vasospasm and

persistent vasoconstriction
29. You give d5w. Why?
a. Promote diuresis
b. Safeguard fetus
c. Provide calories to mother
d. Aota.

Answer: D

30. Contraindicated antihypertensive in pregnancy

a. Hydralazine
b. Furosemide
c. Metoprolol
d. Methyldopa

Answer: B
Contraindicated Drugs are ACEI, ARBS, Diuretics

31. Possible fetal outcome that is already present in the fetus

a. Erythroblastosis fetalis
b. intrauterine growth retardation
c. macrosomia
d. abruptio placenta

Answer: b. Intrauterine growth retardation (37 wks. AOG but FH is only 27cm).
Panlilio page 367 kay "placental conditions associated with diminished fetal weight
include placental abruption, abnormal imolantation site, cirvumvallate placenta,
specific vascular or inflammatory lesions and transfusion syndromes as in multiple
pregnancy."

32. abruptio placenta features except

a.
b. pregnancy-induced hypertension
c. consumptive coagulopathy
d. painless vaginal bleeding

Answer: D painless vaginal bleeding (in Abruptio placentae, there is painful vaginal
bleeding)

33. 8 hrs post admission, cervical dilation is now 6cm and almost fully effaced.
a. normal
b. too fast
c. too slow
d. NOTA

Answer: C
Normal rate of dilatation for nulliparas is 1.2cm/hr
34. Contraction is now every 5 mins lasting 30 secs. you consider.
a. hypotonic contraction
b. give IV oxytocin
c. both a & b
d. neither

Answer: A
Question: With hypotonic contraction, will you not give oxytocin?, because
hypotonus favorably responds with oxytocin

35. What is the most common cause of dystocia

a. Uterine dysfunction
b. pelvic contraction
c. malpresentation
d. a and b

Answer: D.
Pelvic contraction is often accompanied by uterine dysfunction and the two together
constitute the most common cause of dystocia. (Panlillio, Chapter 43, p. 405)

36. What is the most common indication of primarcy CS

a. malpresentation
b. placental abruption
c. prematurity
d. dystocia
Answer: D.
Dystocia is the most common contemporary indication for CS. (Panlilio, Chap.43,
p.405)
Cephalopelvic disproportion or failre ot progress (= dystocia), the most common
indication for primary CS, which constituted 40 percent of primary CS. (Panlilio,
Chap.48, p.455)

Case 4: 21y/o primigravid 37wks AOG, 1st consult, complaints of labor pains
since early morning, no vaginal discharge, BP 150/110, Edema +2, contractions
5min interval 1min duration, FH 27cm, FHR 137/min

37) The cesarean section in this patient should be:

A. Low transverse
B. Infraumbilical
C. Either
D. Neither

ANSWER: A. Low transverse

RATIONALE: since the patient is a primigravid, low transverse should be done so
that naa pa siya chance mag normal delivery in subsequent pregnancies

38) The abdominal incision should be:

 A. Midline infraumbilical
B. Pfannenstiel
C. Either
D. Neither

ANSWER: A. Midline infraumbilical

RATIONALE: the maternal BP is severely increased and the mother is in danger of
eclamsia. Prompt termination of pregnancy is needed and a midline infraumbilical
incision would render a quicker delivery compared to a Pfannenstiel incision.

39) The following is/are good reason for CS in the case:

A. No progress of labor
B. Maternal exhaustion
C. Unstabilized BP
D. AOTA

ANSWER: D. All of the Above

RATIONALE: (The question is asking for good reason, not absolute or relative.)
All of them are good reason.
Maternal Exhaustion – she has been in labor for more than 8hrs with hypertonic
uterine contraction, logically exhausted na sya.
Unstabilized BP – she has BP that suggests severe pre-eclampsia. The best
treatment for this is termination of pregnancy since 37wks naman pud ang AOG and
the patient is already in labor. (Pregnancies >34 weeks of gestation complicated
by severe preeclampsia is best managed by delivery after maternal
stabilization. (Level I, Grade A, CPG on HPN in pregnancy 2010)
No progress of labor – (not really sure with this if she really has no progress in labor
since primigravid man sya, but w/ hypertonic uterine contractions and for more than
8hrs 6cm lng dilatation nya and almost fully effaced) Failure to progress in labor is
a relative indication for CS. – DC Dutta Obstetrics

40) Emergency CS is seldom indicated in which of the following:

A. Prolapsed cord
B. Pre-eclampsia
C. Transverse lie
D. Placenta previa

ANSWER: B or C?
RATIONALE:

ANSWER: I don’t know whether C. Transverse lie or B. Pre-eclampsia

RATIONALE:
Pre-eclampsia –
When is the woman with severe preeclampsia delivered? - Pregnancies >34
weeks of gestation complicated by severe preeclampsia is best managed by delivery
after maternal stabilization. If the fetus is less than 34 weeks of gestation and
delivery can be deferred, corticosteroids should be given, although after 24 hours,
the benefits of conservative management should be reassessed.
If the gestation is greater than 34 weeks and complicated by severe preeclampsia,
delivery after stabilization is recommended. As the gestational age approaches 34
weeks, short and long term neonatal outcomes are excellent, fetal survival is already
similar to that of term gestations, and the potential benefits of expectant
management becomes less compelling.
Prolonging the pregnancy at very early gestation may improve the outcome for
the premature infant but can only be considered if the mother remains stable.68,69
Two small randomized controlled trials73,74 have reported a reduction in neonatal
complications with an expectant approach to management of severe early-onset
preeclampsia with no increase in maternal complications. Several case series have
also reported similar outcomes in different settings with gestations as early as 24
weeks.

What is the mode of delivery? - The mode of delivery should be determined

after considering the presentation of the fetus and the fetal condition, together
with the likelihood of success of induction of labor after assessment of the
cervix.
In all situations, a carefully planned delivery is appropriate. Vaginal delivery is
generally preferable but, if gestation is below 32 weeks, caesarean section is more
likely as the success of induction is reduced. After 34 weeks with cephalic
presentation, vaginal delivery should be considered. The obstetrician should discuss
the mode of delivery with the mother. Vaginal prostaglandins will increase the
chance of success. Anti-hypertensive treatment should be continued throughout
assessment and labor.
(CPG on Hypertension in Pregnancy 2010)

Transverse lie: Active labor in a woman with a transverse lie is usually an indication
for cesarean delivery. Before labor or early in labor, with the membranes intact,
attempts at external version are worthwhile in the absence of other
complications. If the fetal head can be maneuvered by abdominal manipulation into
the pelvis, it should be held there during the next several contractions in an attempt
to fix the head in the pelvis. (William’s Obstetrics 23 rd ed p.478) – Meaning, this is
not an emergency unless the woman is in active labor, external version can be
attempted.

Others:
Prolapsed cord - The gold standard for treatment of umbilical cord prolapse in the
setting of a viable pregnancy typically involves immediate delivery by the quickest
and safest route possible. This usually requires cesarean section, especially if the
woman is in early labor. Occasionally, vaginal delivery will be attempted if clinical
judgment determines that is a safer or quicker method. – (heheh Wikipedia, can’t find
an exact wording in William’s 23rd )

Placenta Previa – Cesarean delivery is necessary in practically all women with

placenta
previa. (William's OB 23rd ed p. 773)
Indications for cesarean delivery: Cesarean delivery is done when labor is
contraindicated (central placenta previa) and/or vaginal delivery is found unsafe for
the fetus and/or mother.
Emergency CS —When the operation is performed due to unforeseen or acute
obstetric emergencies. An arbitrary time limit of 30 minutes is thought to be
reasonable from the time of decision to the start of the procedure.

ABSOLUTE INDICATIONS
Vaginal delivery is not possible. Cesarean is needed even with a dead fetus
Indications are few:
1. Central placenta previa
2. Contracted pelvis or cephalopelvic disproportion (absolute)
3. Pelvic mass causing obstruction (cervical or broad ligament fibroid)
4. Advanced carcinoma cervix
5. Vaginal obstruction (atresia, stenosis)
RELATIVE INDICATIONS
Vaginal delivery may be possible but risks to the mother and/ or to the baby are high
More often multiple factors may be responsible
1. Cephalopelvic disproportion (relative)
2. Previous cesarean delivery —
(a) when primary CS was due to recurrent indication (contracted pelvis).
(b) Previous two CS
(c) Features of scar dehiscence.
(d) Previous classical CS
3. Non-reassuring FHR (fetal distress)
4. Dystocia may be due to (three Ps) relatively large fetus (passenger), small pelvis
(passage) or inefficient uterine contractions (Power)
5. Antepartum hemorrhage (a) Placenta previa and (b) Abruptio placenta
6. Malpresentation—Breech, shoulder (transverse lie), brow
7. Failed surgical induction of labor, Failure to progress in labor
8. Bad obstetric history—with recurrent fetal wastage
9. Hypertensive disorders—
(a) Severe pre-eclampsia,
(b) Eclampsia—uncontrolled fits even with antiseizure therapy
10. Medical-gynecological disorders—
(a) Diabetes (uncontrolled), heart disease (coarctation of aorta, Marfan’s
syndrome.
(b) Mechanical obstruction (due to benign or malignant pelvic tumors
(carcinoma cervix), or following repair of vesicovaginal fistula
(AYY GRABEE SYA OOH) THUMBS UP!

Case 5: A 35 y/o multigravida came with a bloody mucoid discharge that

started yesterday. There's no abdominal pain and watery discharge.
LMP: Dec 26; FH: 34; FHT: 130
The IE revealed: 1cm dilated cervix, soft, posterior, uneffaced. station -3.

41) The following could be a possible problem, EXCEPT:

A. Fetal Macrosomia
B. Fetal Prematurity
C. Postterm Pregnancy
D. Oligohydramnios
ANSWER: C
RATIONALE: AOG is 37 weeks and post term pregnancy starts at 42 weeks

42) The following is included in the planning of the management, EXCEPT:

A. Contraction Stress Test

B. Biophysical Profile
C. Bishop Scoring
D. Amniocentesis

ANSWER: D?
RATIONALE: Amniocentesis detects chromosomal abnormalities, neural tube defects
and genetic abnormalities. It is a procedure done during the early part of the second
trimester of pregnancy (usually between 16 and 18 weeks).

43. A positive contraction stress test is

a. occasional fetal heart rate deceleration with accelaeration

b. Uniform late fetal heart rate deceleration
c. Uniform variable fetal heart rate acceleration
d. At least 2 early fetal heart rate deceleration

ANSWER: B
RATIONALE: (william's page 337- The criterion for a positive (abnormal) test was
uniform repetitive late fetal heart rate decelerations

44. Which is not a component of Manning BPS?

a. Placental grading
b. Fetal breathing
c. Fetal movement
d. Fetal tone

ANSWER: A
RATIONALE: william's page 341- biophysical components include: (1) fetal heart rate
acceleration, (2) fetal breathing, (3) fetal movements, (4) fetal tone, and (5) amnionic
fluid volume.)

45. If the BPS of this patient is 6, it would mean:

A. Normal nonasphyxiated fetus

B. Possible fetal asphyxia
C. Probable fetal asphyxia
D. Almost certain fetal asphyxia

ANSWER: B
RATIONALE: Table 15-3 Williams 23rd Edition Page 342
46. The Bishop Score of this patient would mean:

A. Favorable cervix for induction of labor

B. Ripe cervix
C. Unfavorable cervix for induction of labor
D. Both a and b

ANSWER: C
RATIONALE: A Bishop Score of 4 or less identifies an unfavorable cervix and may
be an indication for cervical ripening.

47) Single best test for fetal well-being

A. CST
B. BPS
C. Doppler velocimetry
D. There is no single best test

ANSWER: B.
RATIONALE:
Manning and colleagues (1980) proposed the combined use of five fetal
biophysical variables as a more accurate means of assessing fetal health than a single
element. (William’s Obstetrics, 24th ed, Chapter 17, p. 341)
Manning, in his study of the different fetal activities, developed a scoring system
(BPS) which has revolutionized, and has become the “Golden Standard” in the
evaluation of intrauterine fetal health. (Textbook of Obstetrics by Panlilio, 1st ed,
Chapter 12, p. 146)
[Nag-assume na ko ani. Hehehe]

48) L1 freely moveable and ballotable round mass, L2 hard, resistant surface
on the left, L3-large, nodular mass

a. vertex
b. breech
c. shoulder
d. NOTA

ANSWER: B.
RATIONALE:
The first maneuver permits identification of which fetal pole-that is, cephalic or
podalic-occupies the uterine fundus. The breech gives the sensation of a large,
nodular mass, whereas the head feels hard and round and is more mobile and
ballotable.
Performed after determination of fetal lie, the second maneuver is accomplished
as the palms are placed on either side of the maternal abdomen, and gentle but deep
pressure is exerted. On one side, a hard, resistant structure is felt --- the back. On the
other, numerous small, irregular, mobile parts are felt --- the fetal extremities. By noting
whether the back is directed anteriorly, transversely, or posteriorly, fetal orientation
can be determined.
 The third maneuver is performed by grasping with the thumb and fingers of one
hand the lower portion of the maternal abdomen just above the symphysis pubis. If the
presenting part is not engaged, a movable mass will be felt, usually the head. The
differentiation between head and breech is made as in the first maneuver. If the
presenting part is deeply engaged, however, the findings from this maneuver are
simply indicative that the lower fetal pole is in the pelvis, and details are then defined
by the fourth maneuver.
(William’s Obstetrics, 24th ed, Chapter 22, p. 437)

49) When ultrasound is done, there was oligoydramnios noted, what is the
recommended management to the pt based from the latest clinical practice
guidelines in this case?

a. External cephalic version

b. Induction of labor by oxytocin
c. Immediate CS
d. Both A and B

ANSWER: C
RATIONALE: Both A and B promotes further or possible compression of the fetus

Case 6 : A 38 yr old G10P10 female sought consult due to postcoital bleeding

50) The most common cause of this is

a. Vaginal hyperplasia
b Endometrial Hyperplasia
c. Cervical neoplasms
d. Ovarian neoplasms

ANSWER: C.
RATIONALE: Postcoital bleeding develops 20-40 y/o, multiparas, causes are cervical
eversion, endocervical polyps, cervicitis, and less commonly endometrial polyps. In
some women, postcoital bleeding may be from cervical neoplasia. Epithelium
associated with cervical intraepithelial neoplasia (CIN) and invasive cancer is thin and
friable and readily detaches from the cervix. CIN- 7-10%, invasive cancer 5%, vaginal
and endometrial is less than 1%. (Williams, 23rd)

51) Of physical examinations, the one most useful for your diagnosis would
be:

a. Speculum Examination
b. Internal Examination
c. Abdominal Examination
d. Both a & b

ANSWER: Answer: A.
Rationale: Bleeding following intercourse most commonly develops in women aged
20-40 years and in those who are multiparous. Generally, the pathologies usually
involved are endocervical polyps, cervicitis and less commonly endometrial polyps.
In some women it may be d/t cervical and other genital tract neoplasia. So
considering these pathologies, the site of bleeding must first be confirmed by PE and
that entails visualizing the cervix. So the best answer is speculum examination

52) The diagnostic test to confirm the dx are the ff EXCEPT:

a. Pelvic ultrasound guided biopsy

b. Cervial Punch biopsy
c. Colposcopically guided biopsy
d. Conization biopsy

ANSWER: Answer: A
All the rest are used for Dx of Cervical neoplasias. Pelvic ultrasound guided biopsy is
more useful in upper genital tract neoplasias such as in the endometrium or the
adnexae.
Conization biopsy - Conization of the cervix is defined as excision of a cone-shaped
or cylindrical wedge from the cervix uteri that includes the transformation zone and
all or a portion of the endocervical canal. It is used for the definitive diagnosis of
squamous or glandular intraepithelial lesions, for excluding microinvasive
carcinomas, and for conservative treatment of cervical intraepithelial neoplasia
(CIN).
Colposcopically guided biopsy ug cervical punch kay sa cervix gihapon

53) Histopathological report sent showed squamous cell carcinoma, the

important prognosis would be:

a.clinical staging
b.surgical staging
c.both
d.neither

ANSWER: C Both
RATIONALE: Clinical staging protocols can fail to demonstrate pelvic and aortic lymph
node involvement in 20-50% and 6-30% of patients, respectively. For that reason,
surgical staging sometimes is recommended.

54 ) Management of the patient include the following except:

a.chemotherapy
b.surgery
c.radiotherapy
d.brachytherapy

ANSWER: D Brachytherapy
RATIONALE: The treatment of cervical cancer varies with the stage of the disease
(see Cervical Cancer Staging). For early invasive cancer, surgery is the treatment of
choice. In more advanced cases, radiation combined with chemotherapy is the current
standard of care. In patients with disseminated disease, chemotherapy or radiation
provides symptom palliation.

55. Her condition would have been diagnosed early if she had
a. Annual mammogram
b. Annual pap smear
c. Annual chest xray
d. Annual cervical punch biopsy
Answer & Ratio: Answer is C - cervical precancerous lesions are associated with
abnormalities in cytological preparations (Pap smears) that can be detected long
before any abnormality is visible on gross inspection. -robbins 9th ed p. 678 56.

56. Her condition is associated with the following except:

a. HPV
b. CMV
c. HSV
d. MTV
Answer & Ratio is D - no mention of viruses other than hpv in novaks, robbins and
katz while williams additionally mentions HSV.. Journals associate HPV, CMV and
HSV to cervical cancer..

57. The hormone responsible is:

A. Estrogen
B. Progesterone
C. Both
D. Neither
Answer:

58.HPV types associated with her disease, except

A. 10
B. 16
C. 18
D. None

Answer: A. Doc van's lecture

59. Based on bethesda classification with pap smear, the following is related to
HPV infection;
a. HSIL
b. LSIL
c. carcinoma-in-situ
d. normal finding of infection

Answer: B
Low-grade squamous intraepithelial lesion (LSIL)—LSIL means that the cervical cells
show changes that are mildly abnormal. LSIL usually is caused by an HPV

60. Which of the following are risk factors for the patient for cervical carcinoma?
a. Multiple sex partner
b. HPV infection
c. gonorrhea
d. HIV infection

61.) Highly associated to this disease, except:

a.) Obesity
b.) Diabetes Mellitus
c.) Hypertension
d.) Multiparity

62.) Aggressive form of the disease..

a.) Large cell, nonkeratnizing
b.) Adenosquamous
c.) Basaloid
d.) Glassy Cell
Answer: D.
Glassy cell carcinoma of the uterine cervix is a rare form of cervical cancer that is
characterized by aggressiveness and poor prognosis

A 53 yr old nulligravida obese. Admitted due to uterine bleeding for 10 days.

Known hypertensive, diabetic, asthmatic. LMP = 2 years ago. Not enlarged
uterus on pelvic exam.
63. Upon transvaginal ultrasonography, the endometrial thickness would be:
a. <1 cm
b. > 4 cm
c. Atrophic
d. Cannot be visualized
TVS: Endometrial thickness or stripe relates to the risk of hyperplasia and cancer in
postmenopausal women. Thickness of ≤ 4mm is required for the exclusion of cancer. If >4mm
requires additional evaluation with Saline infusion, hysteroscopy, or biopsy.In
postmenopausal women, atrophic endometrium 3.4, hyperplasia 9.7 and cancer 18.2 mm
(Williams, 227).

64. The LEAST likely diagnosis of this patient is:

a. Endometrial CA
b. Simple Hyperplasia
c. Complex Hyperplasia
d. Ovarian CA
Abnormal uterine bleeding in postmenopausal women typically originates from atrophy of
endometrium or vagina, endometrial polyp, and endometrial carcinoma. Less commonly are
estrogen producing ovarian carcinoma which may cause hyperolasia, and serosanguinous
discharge from Fallopian tube cancer (Williams, 222).

65. The nxt best thing to do is:

A. Hysterectomy
B. Endometrial biopsy
C. Pap smear
D. Colposcopic biopsy
Endometrial thickness of >4mm require additional evaluation with saline infusion
sonography, hysteroscopy or endometrial biopsy (Williams, 227).
66. If d&c yielded reddish brown tissue fragments, and the histo exam showed:
disclosed large, varisized glands, side by side with small glands, abundant and
hypercellular stroma. The dx is most likely:
A. Simple hyperplasia
B. Complex hyperplasia
C. Adenocarcinoma
D. choriocarcinoma
Answer: A. Simple Hyperplasia
Simple hyperplasia is characterized by glands of various sizes (can be small and can
be large) with mild increase in gland to stroma ratio, while Complex hyperplasia shows
an increase in number and size of glands. As a result the glands may appear crowded
back-to-back with little intervening stroma. (Robbins and Cotran Pathologic Basis of
Disease, 8th ed)

67. Malignant potential of Endomentrial Hyperplasia:

a. 0%
b. 3%
c. 25%
d. Over 50%
Answer: B. (Williams Gynecology 2nd Ed. Page 819)

68. Predisposing factors of Endometrial Adenocarcinoma except:

a. Obesity
b. Diabetes
c. Hypertension
d. Asthma
Answer: D. (Williams Gynecology 2nd Ed. Page 818)
(Pero ang question ata dri kay katong other histologic feature, katong naay
"intraluminal tufts thingy" :D. #69 mn pud gud ni so double na ni na question.)
 Lagi nangita pod ko ato na question! Ang answer ato kay complex hyperplasia

69. The following predisposes to endometrial adenocarcinoma except:

a. Obesity
b. Diabetes Mellituis
c. Hypertension
d. Asthma
Answer: D. (Williams Gynecology 2nd Ed. Page 818)

70. Endometrial carcinoma is a common malignancy of the female genital tract. In the
Philippines, what rank is endometrial carcinoma?
a. First
b. Second
c. Third
d. Fourth
ANSWER: D.
RATIONALE: "Uterine cancer – also known as endometrial cancer – is actually the
most common gynecologic malignancy and the fourth most common cancer in
women." (http://endometrialcancerphilippines.blogspot.com/2012/10/how-you-can-
 prevent-uterine-cancer.html)

71. What is the best managment in this pt. with a histopathologic finding of endometrial
carcinoma?
a. Endometrial ablation
b. Total vaginal hysterectomy
c. Total abdominal hysterectomy
d. TAHBSO
Answer:D. TAHBSO ? Since patient is already on her postmenopausal period
60 year old woman came in for routine gynecologic exam. Aside from a normal
pelvic exam, you discovered a 3 cm left ovarian cyst

72. The best thing to do is:

a. Ask to come back next year/or something like yearly check up
b. Monitor for the next 2-3 months
c. Have CT Scan or MRI
d. Schedule laparoscopy
For asyptomatic ovarian masses in postmenopausal women:
<1cm Normal histologic finding.
<5cm CA125, if normal then TVS q 2-3 months, if persistent yearly TVS.
>7cm MRI/Surgical evaluation
10 cm is the threshold for simple cyst
(Williams, 264)

Case: A 26 year old women nulliparous presented with an ovarian cyst

73. If it manifests as menstrual-like symptom, what would likely be the

diagnosis?
a. granulosa theca cell tumor
b. krukenberg tumor
c. sertoli leydig cell tumor
d. teratoma
Answer: A.
Estrogens are produced by functioning tumours, and the clinical presentation
depends on the patient's age and sex.
o If the patient is postmenopausal, she usually presents with abnormal uterine
bleeding.
o If the patient is of reproductive age, she would present with menometrorrhagia.
However, in some cases she may stop ovulating altogether.
o If the patient has not undergone puberty, early onset of puberty may be seen

74. Ovarian cysts can become enormously large but what is the largest?
a. serous cystadenoma
b. mucinous cystadenoma
c. dermoid cyst
d. follicular cyst
Answer: B
Mucinous tumors tend to produce larger cystic masses; some have been recorded
with weights of more than 25kg. (Robbins and Cotran Pathologic Basis of Disease,
8th ed)

75. If the ovarian mass has a masculinizing effect, what would be the possible
cause?
A. Granulosa-theca lutein cell tumor
B. Sertoli-Leydig cell tumor
C. Krukenberg tumor
D. Dermoid Cyst

Answer: B
Women with Androblastomas (sertoli-leydig cell tumor) produce masculinization or at
least defeminization, but a few have estrogen effects.(Robbins and Cotran
Pathologic Basis of Disease, 8th ed)

76. Best Surgical approach for the patient to undergo?

A. TAHBSO
B. Unilateral oopherectomy
C. Bilateral oopherectomy
D. Oopherecystectomy
Answer: D. (baka mali lang ug spelling) Oophorocystectomy- by definition is the
excision of an ovarian cyst. Stedman's Medical dictionary

Case: 21 year old came in the clinic with vaginal itching and a burning
sensation

77. On physical exam the vaginal pH was 5.5, which of the ff is LEAST likely to
be your diagnosis?
A. Gonoccocal vaginitis
B.trichomonas vaginitis
C.bacterial vaginosis
D.Vaginal candidiasis

Answer: D. Vaginal Candidiasis is < or equal to the vaginal pH . Other gives an

increase in the vaginal pH
Vaginal pH is around 4.5

78. Microscopic analysis of the sample found clue cells and mobile
trichomonas, what is the treatment?
a.fluconazole orally
b.metronidazole orally
c.clotrimazole vaginally
d. Metronidazole vaginally

Answer: B.
Metronidazole is the drug of choice for treatment of Vaginal Trichomoniasis (both a
single dose 2g orally and a multidose 500mg tid for 7 days. Metronidazole gel
(intravaginal), although highly effective for the treatment of BV, should not be used
for the treatment of vaginal trichomoniasis. (Novaks 14th ed, p.544-555)

79. A clue cell is

A. white blood cells with phagocytized bacteria
B. Squamous epithelial cells covered with bacteria
C. White blood cells containing Diplococci bacteria
D. Squamous epithelial cells with macrophages

Answer: B. Based on Doc Van's lecture

80. If incidental vulvar warts are seen while examination, the best treatment is
A. Laser therapy
B. Podofilox
C. Excision
D. Cryotherapy
Answer: D.
Cryotherapy involves freezing the wart using liquid nitrogen and is usually
recommended to treat multiple small warts, particularly those that develop on the
shaft of the penis or on, or near, the vulva.

81. This px does not have PID because the most common symptom of PID is
A. Vaginal discharge
B. Vaginal bleeding
C. Nausea and vomiting
D. Lower abdominal pain

Answer: D. PID dx is based on triad of symtoms including pelvic pain, cervical

motion tenderness and adnexal tenderness. Novak's Gyne 14 ed,p550

Case. 35y.o. healthy couple came for infertility evaluation.

82. Which of the following results of semen analysis is abnormal.

A. Volume 2.5ml
B. Ph 7.5
C. Sperm count 15million/ml
D. Motility 75%: good to excellent motility

Answer: C
Williams Gyne: Normal sperm count >20 Million/ml

83. Clomiphene citrate can be used to treat infertile couples. what kind of drug
is it?
A. natural Estrogen
B. natural Progesterone
C. synthetic Estrogen
D. synthetic Progesterone
Answer: C
Rationale: Clomiphene citrate is the usual first-line pharmacologic agent for treating
women with oligomenorrhea as well as those with amenorrhea who have sufficient
ovarian E2 production. This synthetic, weak estrogen acts by competing with
endogenous circulating estrogens for estrogen-binding sites on the hypothalamus,
thereby blocking the negative feedback of endogenous estrogen. GnRH is then
released in a normal manner, stimulating FSH and LH, which in turn cause oocyte
maturation with increased E2 production. The drug is usually given daily for 5 days
beginning 3 to 5 days after the onset of spontaneous menses or withdrawal bleeding
induced with progesterone in oil or an oral progestin. Source: Compre Gyne,
Infertility, MANAGEMENT OF THE CAUSES OF INFERTILITY

84. Clomiphene citrate can be of use to

A.
B.
C.
D. an ovulatory women
Rationale: Clomiphene citrate is the usual first-line pharmacologic agent for treating
women with oligomenorrhea as well as those with amenorrhea who have sufficient
ovarian E2 production. This synthetic, weak estrogen acts by competing with
endogenous circulating estrogens for estrogen-binding sites on the hypothalamus,
thereby blocking the negative feedback of endogenous estrogen. GnRH is then
released in a normal manner, stimulating FSH and LH, which in turn cause oocyte
maturation with increased E2 production. The drug is usually given daily for 5 days
beginning 3 to 5 days after the onset of spontaneous menses or withdrawal bleeding
induced with progesterone in oil or an oral progestin. Source: Compre Gyne,
Infertility, MANAGEMENT OF THE CAUSES OF INFERTILITY

85. Clomiphene Citrate is:

a. Natural estrogen
b. natural progesterone
c. synthetic progesterone
d. synthetic estrogen

Answer: D
Rationale: Clomiphene citrate is the usual first-line pharmacologic agent for treating
women with oligomenorrhea as well as those with amenorrhea who have sufficient
ovarian E2 production. This synthetic, weak estrogen acts by competing with
endogenous circulating estrogens for estrogen-binding sites on the hypothalamus,
thereby blocking the negative feedback of endogenous estrogen. GnRH is then
released in a normal manner, stimulating FSH and LH, which in turn cause oocyte
maturation with increased E2 production. The drug is usually given daily for 5 days
beginning 3 to 5 days after the onset of spontaneous menses or withdrawal bleeding
induced with progesterone in oil or an oral progestin.
Source: Compre Gyne, Infertility, MANAGEMENT OF THE CAUSES OF
INFERTILITY

86. Treatment for hyperprolactinemia is beneficial in:

a. 35 y/o and above
b. male with low sperm count
c. anovulatory
d. AOTA

Answer: C
Rationale: In addition, as discussed in Chapter 39 (Hyperprolactinemia,
Galactorrhea, and Pituitary Adenomas), if anovulation is due to hyperprolactinemia,
dopamine agonists are an effective means of inducing ovulation.
Source: Compre Gyne, MANAGEMENT OF THE CAUSES OF INFERTILITY

49 y/o multigravid px comlaints of severe hot flushes and insomnia for 3

weeks. LMP was 18 months ago
87. You would expect to find the following EXCEPT:
a. Decreased basal body temerature
B. Decreased estrone
C. Decreased FSH
D. AOTA
Answer: C. FSH is increased in menopause
Following menopause, the predominant estrogen is estrone and to a lesser extent
estradiol. Serum level of estrone (30-70 pg/ml) is higher than that of estradiol (10-20
pg/ml). Major source of estrone is peripheral conversion of androgens from adrenals
and ovaries.
The decrease in serum estradiol decreases the negative feedback effect on
hypothalamopituitary axis resulting in increase in FSH. The increasein FSH is also
due to diminished inhibin. Rise in FSH is about 10-20 fold whereas that of LH is
about 3-fold. (DC Dutta Textbook of Gynecology)

88. She will likely tell you that the hot flushes:
A. Are occasionally followed by profuse sweating
B. Comes gradually over 15 minutes
C. Occurs not more than once per 24 hrs
D. Lasts from 30 mins to 1 hour
Answer: A, An individual hot flash generally lasts 1 to 5 minutes, and skin
temperatures rise because of peripheral vasodilation. This change is particularly
marked in the fingers and toes, where skin temperature can increase 10 to 15°C.
Most women sense a sudden wave of heat that spreads over the body, particularly
on the upper body and face. Sweating begins primarily on the upper body, and it
corresponds closely in time with an increase in skin conductance. (Williams
Gynecology 2nd ed page 560)

49 y/0, multigravid, with Severe Hot flashes and insomnia for 3 weeks. LmP 18
months ago
89. To alleviate the symptoms:
A. Give Progesterone
B. Give Estrogen
C. Give Calcium
D. Advise to gain weight
Answer: B. Common early symptoms of menopause are those caused by
vasomotor instability and include hot flashes, insomnia, irritability, and mood
disorders. Systemic ET is the most effective treatment for vasomotor symptoms and
is the only therapy currently approved by the FDA for this indication. (williams gyne.
2nd ed. Page 585)

90. % bone decrease after menopause

A. 0.25 to .50%
B. 1 to 2 %
C. 5-6%
D. 10-20%
Answer is B. During menopause, the rate increases to 2 to 5 percent per year for
the first 5 to 10 years and then slows to 1 percent per year. (Williams Gyne. 2nd ed.
Page 565)
Following menopause, there is loss of bone mass by about 3-5% per year. This is
due to the deficiency of estrogen. Osteoporosis is a condition where there is a
reduction in bone mass but bone mineral to matrix ratio is normal. (DC Dutta
Textbook of Gynecology)

49 years old multigravid complained of severe hot flushes and insomnia for
the last 3 weeks. Her LMP was 18 mos ago.

91. Factors known to increase risk of osteoporosis except:

A. Sedentary lifestyle
B. Surgical menopause
C. Cigarrete smoking
D. Obesity
Answer: D Katz: risk factors mentioned were thinness, immobilization, nutritional
deficiencies, family history, etc.) Also, in katz, obese postmenopausal women have
higher levels of estrone than thin women and are less likely to have hot flushes or
OSTEOPOROSIS and more likely to develop endometrial CA

18 year old female. Never had menstruation. P.E reveals breast tanner 1.
92. Of the ff., most likely diagnosis is
A. Imperforate hymen
B. Gonadal dysgenesis
C. Androgen insensitivity
D. Rokitansky-kuster-Hauser syndrome
Answer: B.
The px, considering that there is no breast dev't (taner stage 1/prepubertal), but with
a uterus present, the most likely cause is gonadal failure/dysgenesis.
Please refer to the katz, chapter 38, page 818, box 38-1.
For androgen insensitivity and rokitansky syndrome, they are most likely associated
with breast development but absent uterus. :)
For imperforate hymen, it is more likely on distal outflow tract obstruction, and thus
breast dev't is also not affected.

93. The diagnostic test for the above case is?

A. FSH determination
B. Karyotyping
C. Serum Estrogen determination
D. Progesterone test
 Answer: B? - Individuals may present with a variety of clinical features and can be
divided into two broad groups based on whether the patient's KARYOTYPE is
normal or abnormal.
Source: Williams Gyne, p. 369
See also Figure 16-7 p. 376

94. The most common cause of primary amenorrhea in nonpregnant women

is?
A. Imperforate hymen
B. Gonadal dysgenesis
C. Androgen insensitivity
D. Rokitansky Hauser

Answer: B - Failure of gonadal development is the most common cause of primary

amenorrhea, occuring in almost 50%.
Source: Katz Gyne, p. 818
Gonadal dysgenesis is the most frequent cause of POF
Source: Williams Gyne, p. 369

40 yr old, G5P5, profusely bleeding after placental separation.

95. Cause of early postpartum bleeding
A. Retained placenta
B. Uterine atony
C. Peritoneal laceration
D. Cervical laceration
Answer: B
Rationale: Failure of the uterus to contract properly FOLLOWING delivery isthe
most common cause of obstetrical hemorrhage. The overdistended uterus is prone
to be hypotonic after delivery. Thus, women with a large fetus, multiple fetuses, or
hydramnios are prone to uterine atony. The woman whose labor is characterized by
uterine activity that is either remarkably vigorous or
barely effective is also likely to bleed excessively from postpartumatony.
(williams 23rd ed. Pg. 774)

96. 1st line management

A. Bimanual uterine compression
B. Oxytocin
C. Maleate
D. Sedation
Answer: A.
Rationale: with the hand still inside the uterus in manual exploration, bimanual
massage is done to promote. Contraction. If bleeding continues, bimanual uterine
compression is employed. Rapid IV bolus of oxytocin is not recommended because it
may cause hypotension or cardiac arrest (panlilio pg. 466)

97. Late bleeding postpartum is most often caused by

a. Retained Placental fragment
b. Uterine atony
c. Uterine rupture
d. Laceration

Answer: A; immediate postpartum hemorrhage is seldom caused by retained

placental fragments, but a remaining piece of placenta is a common cause of
bleeding late in the puerperium. -pp 775 Williams OB 23rd Ed

98. Others are more apt to having uterine atony and hemorrhage after delivery.
Circumstances that allow to happen postpartum hemorrhage are the ff except
a. Multigravid
b. Primigravid
c. Distended uterus
d. Prolonged labor

Answer: B; others are mentioned in Table 35.3 predisposing factors and causes of
immediate postpartum hemorrhage from Williams OB 23rd Ed pp 760 except
primigravid.

99. 25 year old female consulted you why all her 5 previous pregnancies did
not reach term. The possible diagnosis could be EXCEPT:
a. Uterine didelphys
b. Imperforate hymen
c. Rudimentary uterine horn
d. Complete uterine septum

Answer: B. Imperforate hymen

RATIONALE: Primary amenorrhea is the major symptom of imperforate hymen
which is usually during puberty. In imperforate hymen, there is no connection
between the vaginal lumen and the uterus thus pregnancy is not possible. William’s
Gynecology Third Edition Page 415
Why not A (Uterine didelphy)? In didelphic uterus, pregnancies develop in one or the
two horns, and of the major uterine malformations, the didelphic uterus has a good
reproductive prognosis.William’s Gynecology Third Edition Page 421
Why not C (Rudimentary uterine horn)?Rudimentary uterine horn is a type of
unicornuate uterus. Women with unicornuateuterus have impaired pregnancy
outcomes. A review of studies reveals a spontaneous abortion rate of 36 percent, a
preterm delivery rate of 16 percent, and a live birth rate of 54 percent. William’s
Gynecology Third Edition Page 421
Why not D (Complete uterine septum)? Although this defect does not predispose to
increase rates of preterm labor or cesarean delivery, septate uterus is associated with
a marked increase in spontaneous abortion rates. William’s Gynecology Third Edition
Page 422

100. Didelphys:
Answer: C
RATIONALE:
A is a septate uterus
B is a unicornuate uterus
D is a bicornuate uterus
Comprehensive Gynecology 6th edition Page 195