Step 2 Obstetrics and Gynecology CF-2

25yo G2P1moderately obese delivering at 42 weeks, aprox 3700g. After 4 hrs of first stage of labor and 2 hrs second stage of labor, the fetal head delivers but is noted to be retracted back towards the patient's introitus. The fetal shoulders do not deliver, even with maternal pushing. NSM? Complication?

Risk factors for Shoulder Dystocia

CASE 12: 45yo underwent total abdominal hysterectomy for symptomatic endometriosis 2 days earlier. She complains of rt flank tenderness. BP 130/90 HR 100bpm and temp 102'F. Heart and lungs are normal, abdomen is slightly tender diffusely with normal bowel sounds. Incision appears within normal limits. Exquisite right costovertebral angle tenderness is noted. NSD? most likely Dx?

IVP shows possible obstruction, NSM?

55yo undergoes total abdominal hysterectomy and develops fever and flank tenderness.

33yo undergoes pelvic lymphectomy for cervical cancer. Rt ureter is meticulously and cleanly dissected free, and a penrose drain is placed around it to ensure its safety. She is asymptomatic until post op day 9, when she develops profuse nausea and vomiting and is noted to have ascites on ultrasound.

55yo who underwent vaginal hysterectomy for 3' vaginal prolapse 1 month ago, compains of constant leakage of fluid per vagina 7 days duration.

44yo undergoes right salpingo-oophorectomy laparoscopically. Bipolar cautery is used to ligate the infundibular pelvic ligament. The next day she complains of fever and flank tenderness.

66yo menopause at 55, complains of 2 week history of vaginal bleeding. Next step? Dx?

Risk factor for endometrial cancer

Approach to postmenopausal bleeding

Most common cause of postmenopausal bleeding?

48yo postmenopausal undergoes pap smear which reveals atypical glandular cells. Best next step?

57yo with HTN, DM, and PCOS complains of vaginal bleeding for 2 weeks. The endometrial sampling shows few fragments of atrophic endometrium. Estrogen replacement is begun. Patient continues bleeding 3 months later. Best next step?

Most important therapeutic measure in treatment of stage I endometrial cancer?

30yo G5 P4 at 32 weeks gestation complains of significant bright red vaginal bleeding. 4 weeks ago she experianced some vaginal spotting after engaging in sexual intercourse. BP 110/60 HR 80bpm Temp 99'F Heart and lung examinations are normal. Abdomen is soft and uterus nontender. Fetal heart tones range from 140 to 150bpm. Next Step? Dx? Long term management?

Risk factor for placenta previa?

Typical feature of placenta previa?

33yo at 37 weeks gestation, presents with moderately severe vaginal bleeding, sonogram shows placenta previa, best management for this patient?

22yo G1P0 at 34 weeks presents with moderate vaginal bleeding and no uterine contractions. Which of the following sequences of examination is most appropriate?

18yo marginal placenta previa on US at 22 weeks gestation. Most appropriate management?

CASE 15: 22yo 35 weeks gestation, admits to cocaine abuse, complains of abdominal pain, and moderate vaginal bleeding. BP 150/90 HR 110bpm. Fundus reveals tenderness, and moderate amount of dark vaginal blood in vaginal vault. US shows no placental abnormalities. Cervix is 1cm dilated. Fetal heart tones range from 160 to 170bpm. Dx? Complications? Management?

Risk factors for Abruptio Placentae

US evaluation of Abruptio Placentae

Concealed abruption

Fetomaternal hemorrhage

Courvelaire Uterus

Clot found adherent to placenta

Acid elution methodology

Maintain Hemoglobin above?

In which condition would consumptive coagulopathy most likely be seen?

In which of the following conditions is ultrasound an accurate and sensative method of diagnosis?

Which of the following is the most significant risk factor for abruptio placentae?

Which of the following statements regarding placental abruption is the most correct?

CASE 16: 50yo G5P5 complains of 6mth history of postcoital spotting and malodorous vaginal discharge. She had a prior infection with syphilis and she is a smoker. Speculum examination reveals a 3 cm exophilic lesion on the anterior lip of the cervix. Next step? Dx?

Mean age of presentation for Cervical Cancer?

“case” plus flank tenderness or leg swelling?

risk factors for cervical cancer

CIN

clinical approach to postcoital spotting or abnormal pap smear.

cervical cancer is diagnosed, whats next?

MCC of death due to cervical cancer?

Most common subtypes of HPV associated with cancer?

Gardasil vaccine covers?

Cervarix vaccine covers?

33yo Pap smear showing moderately severe cervical dysplasia (high grade Squamous intraepithelial neoplasia). Best next step?

40yo Pap smear, which shows HSIL. Most accurate statement?

When is HPV typing important?

CASE 17: 24yo G2P2 delivered vaginally 8mths earlier. Delivery was complicated by postpartum hemorrhage requiring curettage of the uterus and blood transfusion of two units of erythrocytes. Complains of amenorrhea since her delivery. She is not able to breast feed her baby and denies taking any medication or having headaches or visual abnormalities. Pregnancy test is negative. Most likely Dx? Complications?

postpartum hemorrage definition

Feature of intrauterine synchiae?

Consistent with Sheehan's syndrome?

25yo presents with 6mths of amenorrhea. Pregnancy test is negative. What would be consistent with PCOS?

22yo G3P2 at 40 weeks gestation complains of strong uterine contractions. She denies leakage of fluid per vagina. She denies medical illnesses. Antenatal history is unremarkable. Examination, her BP is 120/80 HR 85bpm. Cervix is 5cm dilated, vertex is at -3 station. Upon rupture of membranes, fetal hr drops to 70-80bpm for 4 min without recovery. Next step? Tx?

Predispose to umbilical cord prolapse?

Fetal Bradycardia?

Steps to take in fetal bradycardia?

Causes of fetal bradycardia?

18yo woman who had undergone a previous low-transverse cesarean delivery is admitted for active labor. During labor, an intrauterine pressure catheter displays normal uterine contractions every 3 min with intensity up to 60 mmHg. Fetal bradycardia ensues. Dx

Maneuver improves oxygenation to the placenta?

33yo G2P1 at 39 weeks gestation in active labor is noted to have a 1-min episode of bradycardia in the 100bpm range on external fetal heart rate tracing, which has not resolved. Her cervix is closed. Which is the best initial step in management of this patient?

30yo parous woman notes a watery breast discharge of 6mths duration. Her menses have been somewhat irregular. She denies a family history of breast cancer. The patient had been treated previously with radioactive iodine for Graves' disease. Currently, she is not taking any medications. On examination, she appears alert and in good health. Her blood pressure is 120/80 and HR 80bpm. The breast are symmetric and without masses. No skin retraction is noted. A white discharge can be expressed from both breast. No adenopathy is appreciated. The pregnancy test is negative. Dx? Next step? Mechanism for the disorder?

Causes of hyperprolactinemia?

Tx for low estrogen and hyperprolactinemia?

Microadenoma cure rate to surgery?

Which of the following clinical presentations is consistent with prolactin-secreting pituitary adenoma?

Hormones found in the posterior pituitary?

33yo with microadenoma of pituitary gland becomes pregnant. She reaches 28 weeks gestation, she complains of headaches and visual disturbances. Which of the following is the best therapy?

CASE 20: 24yo G1P0 at 28 weeks' gestation complains of a 2 week duration of generalized pruritus. She denies rashes, exposure to insects or allergies. Her medications include prenatal vitamines and iron suppliments. BP 100/60 HR 80bpm and weight 140lb. She is anicteric. The skin is without rashes. Fetal heart tones are in the 140bpm range. Dx?

Causes of puritus in pregnancy?

Cholestasis of pregnancy?

Cholestasis of pregnancy puts the patient at risk for?

Cholestasis of pregnancy tx?

Pruritic urticarial papules and plaques of pregnancy?

Herpes gestationalis?

Describe the pregnancy outcome of pruritic urticarial papules and plaques of pregnancy?

33 yo G1P0 at 39 weeks gestation is in labor. She has been diagnosed with herpes gestationalis and has the characteristic pruritus and vesicular lesions on the abdomen. What does the patient need to be advised of in the neonate?

23yo G0P0 complains of lower abdominal tenderness and subjective fever. She states that her last menstrual period started 5 days previous and was heavier than usual. She also complains of dyspareunia of recent onset. She denies vaginal discharge or prior sexually transmitted diseases. On examination, her BP 90/70, HR 90bpm and temperature 100.8'F. Heart and lung examination are normal. The cervix is somewhat hyperemic, and the uterus as well as adnexa are tender. Pregnancy test is negative. Dx? Long term complications?

Inpatient criteria for PID?

Treatment for PID?

Inpatient Tx?

Outpatient Tx?

Patient does not improve in 48 hrs next step?

Fitz Hugh Curtis syndrome

Tubo Ovarian Abscess

18yo undergoes laparoscopy for an acute abdomen. Erythematous fallopian tubes are noted. Culture of the purulent drainage most likely would reveal?

Most accurate method for diagnosing acute salpingitis?

33yo intrauterine contraceptive device develops symptoms of acute salpingitis. On laparoscopy, sulfer granules appear in the fimbria of the tubules. Most likely organism?