OB-GYNE 2 Batch 2017 Ratio.pdf

OBSTETRICS AND GYNECOLOGY SECOND EVALUATION EXAMINATION Rationalization: Vea and Vash TOPIC: Bleeding in the First Half of Pregnancy - Dr. Soledad C. Crisostomo 1. Abortion is considered if the fetus is delivered less than: A. 20 weeks age of gestation B. 500 grams in weight C. 5 inches in length D. All of the above E. A and B

Abortion • early pregnancy loss/failure • premature birth before a live birth is possible, • pregnancy termination • prior to 20 weeks gestation • less than 500 grams

2. It is important to know if the abortion is early or late because most cases of early abortion is caused by: A. Maternal infection which needs to be prevented in the next pregnancy - late B. Chromosomal error which is maternal in origin C. Aneuploidy due to paternal sperm abnormality – should be maternal D. Maternal exposure to electromagnetic field Early Abortion = 12 wks = Maternal/Environmental 3. Heterotropic pregnancy is managed by: A. Observation B. Methotrexate administration –mgt. of cervical, interstitial, unruptured ovarian and cesarean scar pregnancy C. Salpingectomy with preservation of intrauterine pregnancy D. Intake of folic acid, calcium supplement and multivitamins –should be avoided 4. Which of the following laboratory examinations for diagnosing an incomplete abortion is the least invasive? A. Hysteroscopy B. Transvaginal ultrasound C. Serial serum HCG titers determination D. Serum progesterone titers determination 5. What is the most common location of an ectopic pregnancy? A. Isthmus B. Cornua C. Ampulla D. Infundibulum Ectopic Pregnancy definition: Most common site: ampulla of the fallopian tube 6. A patient who had 2 previous abortions and an ectopic pregnancy finally got pregnant after 5 years. She had irregular cycles after her salpingostomy. A transvaginal ultrasound should be requested in this patient primarily to determine: A. If indeed she is pregnant B. Fetal viability C. The age of gestation D. The location of the pregnancy The most common risk factor of ectopic pregnancy is previous ectopic pregnancy. 7. A patient had 2 consecutive late abortions which she attributed to stress with her work. Just like before, she presented with painless vaginal bleeding. She is now 12 weeks pregnant. Present management should include all of the following, EXCEPT: A. Cerclage – requirements before doing this: diagnosis of incompetent cervix, sonography to confirm a live fetus with no fetal anomalies, test and treat for gonorrhea and chlamydial infection B. CBC, urinalysis C. Antiphospholipid antibody syndrome work up D. Gram staining of cervical secretion for possible infection

8. CA, 8 weeks pregnant, came with a complaint of vaginal bleeding for almost 1 week accompanied by hypogastric heaviness. While defecating, she experienced severe abdominal pain with passage of meaty material and profuse vaginal bleeding. Thereafter, the abdominal pain and vaginal bleeding subsided. On internal examination, the uterus is small and the cervix is closed with very minimal blood per examining finger. The most appropriate management for her would be: A. Observation B. Prostaglandin intake C. Dilatation curettage – omit since both curettage. Suggest methotrexate D. Completion curettage This is a case of incomplete abortion. Management options of incomplete abortion include curettage, medical abortion, or expectant management in clinically stable women. 9. 38 y/o, 2 months amenorrheic, consulted because of vaginal spotting and hypogastric pain. Pregnancy test was requested only yesterday because she is used to have delayed menstruation. The test showed a positive result. Vital signs are all normal. There is slight hypogastric and right lower quadrant pain on deep palpation. On TVS, there is no intrauterine nor extrauterine pregnancy noted. A right complex mass is noted probably a corpus luteum cyst. What will be the next most appropriate step to do? A. Do laparoscopy B. Do culdocentesis C. Repeat the pregnancy test after 1 week D. Request for transvaginal ultrasound after 1 week – done to confirm pregnancy first and to know the correct age of gestation 10. ER, 35 y/o, G4P3, 6 weeks pregnant, consulted for vaginal spotting. She had her IUD removed just prior to this pregnancy because of complaint of purulent foul smelling vaginal discharge. On PE: BP 80/60mm Hg, PR 100 beats/min, afebrile. There is direct and rebound tenderness on the RLQ of the abdomen. IE: the cervix is closed, (+) cervical motion tenderness, (+) right adnexal tenderness. Uterus is slightly enlarged. (+) fullness in the cul-de-sac. What is the diagnosis? A. Septic abortion B. Missed abortion C. Ruptured ectopic pregnancy D. Unruptured ectopic pregnancy With tubal rupture, there is usually severe lower abdominal and pelvic pain that is frequently described as sharp, stabbing, or tearing. There is tenderness during abdominal palpation. Bimanual pelvic examination, especially cervical motion, causes exquisite pain. The posterior vaginal fornix may bulge from blood in the rectouterine cul-de-sac, or a tender, boggy mass may be felt to one side of the uterus. The uterus may also be slightly enlarged due to hormonal stimulation. 11. PM, 28 y/o, G4P1 (1021) came for prenatal check-up. Her first pregnancy was with her first partner which was a term, healthy live baby. Her succeeding pregnancies, including this pregnancy, are with her present living in partner. She came because of vaginal spotting and hypogastric heaviness. Her TVS showing an early fetal demise at 7 weeks AOG, similar to her previous pregnancies. What could be the most possible cause of this condition? A. Maternal infection - most are unlikely to cause recurrent miscarriage B. Incompetent cervix – causes abortion during the 2nd trimester C. Chromosomal aberration D. Antiphospholipid antibody syndrome 12. A 25 year old, G1P0, on her 12 weeks AOG came for consult because of vaginal spotting followed by passage of watery vaginal discharge and hypogastric heaviness. On speculum examination, there is amniotic fluid accumulation at the posterior fornix of the vagina. Fetal heart tones were appreciated but bradycardic. What is the diagnosis? A. Inevitable abortion – gross rupture of bag of water before bleeding B. Incomplete abortion – bleeding with passage of meaty material (placenta) out of an open cervix C. Threatened abortion D. Cervical ectopic pregnancy – amenorrhea with painless vaginal bleeding The clinical diagnosis of threatened abortion is presumed when bloody vaginal discharge or bleeding appears through a closed cervical os during the first 20 weeks.

13. Which of the following is/are possible if you get a negative culdocentesis? A. Unruptured ectopic pregnancy B. Unsatisfactory entry into the cul de sac C. The rupture of the ectopic pregnancy is just very recent D. All of the above E. A and C only Culdocentesis - Long, large bore needle (gauge 16-18) inserted through posterior vaginal fornix into pouch of Douglas or cul de sac and aspiration of non clotting blood - (+): presence of hemoperitoneum, 85% ectopic pregnancy - (-): does not exclude intact or unruptured ectopic pregnancy; unsatisfactory entry into the cul de sac - Aspiration of blood that subsequently clot- blood from blood vessel or recently ruptured ectopic pregnancy 14. Medical management of ectopic pregnancy with Methotrexate is done if all the following are present, EXCEPT: A. Viable fetus – should be nonviable B. Tubal mass less than 3.5 cm C. Pregnancy less than 6 weeks D. Serum B-hCg less than 15,000 mIU/ml 15. A G5P4 (4004), an IUD user, with a ruptured ectopic pregnancy of 8 weeks gestation is best managed with: A. Salpingotomy – for unruptured ectopic pregnancy B. Salpingostomy – for unruptured ectopic pregnancy C. Salpingectomy – for both ruptured and unruptured ectopic pregnancies to minimize the rare recurrence of pregnancy in the tubal stump 16. Which of the following is/are TRUE regarding the clinical presentation of an interstitial pregnancy? A. Diagnosis is made late because of late onset of symptoms. B. The uterus is irregularly shaped uterus with nodularity at the cornual area. C. When it ruptures, hemorrhage is increased because of increased vascularity in that area. D. All of the above E. A and C only Interstitial Pregnancy - Conceptus implanted in the interstitial segment of fallopian tube in the uterine cornu. - Accommodate grooving fetus with late onset of symptoms thus late diagnosis with increase risk of rupture and hemorrhage due to increased vascularity FOR QUESTIONS 17 TO 18: A 27 y/o, G2P1 (1001) with an amenorrhea of 7 weeks consults the Emergency Room for vaginal spotting. Vital signs are stable. Pregnancy test is positive. The cervix is closed, and there are no adnexal masses or tenderness. 17. The most probable clinical impression is ______________ abortion. A. Inevitable B. complete C. incomplete D. threatened (Refer to number 12) 18. A transvaginal ultrasound is requested in this patient primarily to determine fetal: A. aging B. viability C. location if intrauterine or extrauterine D. number if singleton or multiple pregnancy FOR QUESTIONS 19 TO 20: A 17 y/o, G2P1 (1001), 8 weeks AOG, consulted at the Emergency Room for bleeding and passage of meaty material per vagina a day prior to consult. BP was stable. Body temperature was 38.5°C. A history of mechanical manipulation of the cervix to induce vaginal bleeding was elicited. On pelvic examination, the cervix was open, the uterus was slightly enlarged, and there was no adnexal mass or tenderness. 19. What is the clinical impression? A. unruptured ectopic pregnancy B. threatened abortion C. inevitable abortion D. septic abortion - history of mechanical manipulation of the cervix to induce vaginal bleeding and the febrile state of patient can indicate infection

20. How should the patient be managed? A. antibiotics and curettage – prompt administration of broad-spectrum IV antibiotics should be done and curettage to remove retained products B. transabdominal ultrasound C. laparoscopy to rule out an ectopic pregnancy D. await for spontaneous expulsion for the remaining products of conception TOPIC: Gestational trophoblastic diseases, abnormalities of the placenta, fetal membranes and umbilical cord- Dr. Vincent Lohengrin Fortun 21. Which of the following conditions is a trophoblastic disease? A. chorangioma B. placental infarct C. hydatidiform mole D. placental hematoma Only Hydatidiform mole is the trophoblastic disease. Chorangioma is non neoplastic like growth in the placenta, Placental infarct is an interruption in the blood supply in the placenta while placental hematoma is pooling of blood in the placenta. 22. Which of the following conditions will require referral to a specialist in trophoblastic diseases? A. a patient with habitual abortion B. a post-curettage patient whose histopath result showed invasive mole C. a post-partum patient whose placenta was noted to have a succenturiate lobe D. a post-partum patient with persistent vaginal bleeding whose pelvic sonogram showed retained placental secundines Invasive mole must be handled by a specialist in trophoblastic diseases, the rest can be handled by an Obstetrician. 23. A complete h-mole is a trophoblastic disease with a ___________ karyotype. A. 23X B. 46 XY- should be 46xx C. triploid D. diploid Complete H- mole results from fertilization of an inactivated egg and a single 23x sperm which then duplicates to form the 46xx karyotype (diploid-85%). 24. A 26 y/o, G2P1 (1001), 10 weeks AOG patient consulted you for prenatal checkup. On internal examination, the uterus was 18 weeks size. Pelvic sonogram showed an intrauterine mass with “snowstorm pattern” with a fetus present. Your diagnosis is: A. molar pregnancy B. multifetal pregnancy C. pregnancy with chorangioma D. pregnancy with ovarian new growth Diagnosis of H-mole: Ultrasonography (snowstorm appearance) 25. This statement is characteristic of a complete H-mole: A. Trophoblastic proliferation is minimal. B. The chromosomes are paternally-derived. C. Fetal membranes may be seen on histology. D. There is no hydropic change of the placental villi. Chromosomal composition is usually diploid and of paternal origin. 26. A 34 y/o patient underwent a hysterectomy for a uterine mass. choriocarcinoma. What further advise can you give her? A. She should not worry. B. Chest x-rays every 4 months. C. hCG levels to be checked bi-annually. D. Consult a trophoblastic disease specialist. Treatment of GTN: Important: Referral to a trophoblastic disease expert.

Histopathology showed

27. A 320 y/o, G2P1 (1000) patient underwent curettage for vaginal bleeding. Histopathology of curettings showed a complete h-mole. What is the risk for malignancy? A. zero B. low C. medium D. high. All cases of H-mole should be considered potential cases of choriocarcinoma. 28. The tumor marker used to monitor response to therapy of placental site trophoblastic tumor is: A. beta-hCG B. alpha-fetoprotein C. human placental lactogen D. carcino-embryonic antigen PSTT secretes HPL which is a tumor marker. Serum beta hcg levels should be low. AFP and CEA are used as tumor markers in other organs of the body. 29. A 45 y/o, G6P5 (5005) patient was rushed to the Emergency Room due to profuse vaginal bleeding. Blood pressure was 60 palpatory. Stat hemoglobin was 60 gms%. There was passage of sago-like material per vagina. The surgical management is: A. hysterotomy B. hysterectomy C. suction curettage D. dilatation and curettage Sago like is the pathology of invasive mole. It has the propensity to spread to other parts of the body and so it must be surgically removed. 30. A 24 y/o patient underwent suction curettage for h-mole. What advice will you give her before you discharge her from the hospital? A. Chest x-rays need to be done monthly. B. Do not lift heavy objects for the next 2 weeks. C. Unprotected coitus may be resumed 4 weeks post-op. D. Serial serum hCG monitoring will have to be done for 18 months Serial serum hCG monitoring will have to be done for 18 months to see signs of persistence of the disease and degeneration to a malignancy. TOPIC: Bleeding in the Second Half of Pregnancy - Dr. Soledad C. Crisostomo 31. A 40 year old, G7P6 (6006) at 34 weeks AOG, noted to have vaginal bleeding while watching TV. She denies pain or uterine contractions. Examination of the uterus shows the fetus in transverse lie. Placenta previa is highly considered because of the painless vaginal bleeding and A. Grand multiparity B. Fetal transverse lie C. Advance maternal age D. All of the above E. A and B only Placenta Previa • Diagnosis: Presence of painless late trimester vaginal bleeding with transvaginal ultrasound showing placental implantation over the lower uterine segment • Risk Factors: Previous placenta previa, Advance maternal age, Multiparity, Prior Caesarean Section, Multiple gestation, Smoking 32. A 21 year old primigravida at 36 weeks AOG came because of vaginal bleeding. She noted the bleeding to occur after she noticed watery vaginal fluid coming out which she believes to be her bag of water. The electronic fetal monitor tracing showed fetal bradycardia at 70beats/min. The mother’s vital signs are stable with normal blood pressure and pulse. What is the diagnosis for this case? A. Vasa previa B. Placenta previa C. Inevitable abortion D. Abruption placenta Vasa Previa • Clinical Presentation: Classic triad of rupture of membranes and painless vaginal bleeding followed by fetal bradycardia

33. A G6P5 at 34 weeks AOG is brought to the emergency room because of profuse vaginal bleeding and loss of consciousness. All previous deliveries were by VSD at home except for the fifth which was delivered by Classical cesarean section. She attempted to deliver vaginally at home. However, when the head was almost crowning, she had profuse vaginal bleeding. She became hypotensive and tachycardic. No fetal heart tones were appreciated. On IE, the cervix is fully dilated and fetal head is floating. Basis for uterine rupture in this case include/s: A. Grand multiparity B. The previously almost crowning fetal head became floating C. Attempted VBAC with a previous classical caesarean section D. All of the above E. A and C only Uterine Rupture: • Clinical presentation: Non-reassuring fetal monitor tracing associated with vaginal bleeding, abdominal pain, alterations in uterine contractility • Risk factors: Previous classical uterine incision, Myomectomy, Excessive oxytocin stimulation, Grand multiparity, Marked uterine distention • From Williams (can explain choice B): If the rupture is of sufficient size, the uterine contents will usually escape into the peritoneal cavity. If the presenting fetal part is firmly engaged, however, then only a portion of the fetus may be extruded from the uterus. 34. A 35 year old multigravida, a chronic hypertensive with superimposed preeclampsia, on her 32 weeks AOG, complained of sudden onset of moderate vaginal bleeding for the past hour. She has intense, tetanic uterine contraction. Neither fetal movement nor fetal heart tone appreciated. What is the diagnosis for this case? A. Vasa previa B. Uterine rupture C. Placenta previa D. Abruptio placenta Abruptio Placenta: • Diagnosis: Based on the presence of painful late trimester bleeding with a normal (fundal or lateral wall) placental implantation not over the lower uterine segment • Clinical presentation: Most common cause of painful late trimester bleeding occurring in 1% of pregnancies at term, Bleeding and abdominal pain are the most common findings • Perinatal mortality and morbidity: Still births, Significant neurological defects • Risk Factors: Previous abruptio, Maternal trauma, Cocaine abuse, cigarette smoking, Premature rupture of membranes, Hypertension (pre-eclampsia, gestational or chronic hypertension) – No.1 predisposing factor • Implicated risks: uterine leiomyoma if located behind placental implantation, increasing maternal age and parity, thrombophilias 35. The most common cause of painful late trimester bleeding is: A. Vasa previa B. Placenta previa C. Inevitable abortion D. Abruptio placenta Refer to number 34 36. The most common predisposing factor for abruption placenta is: A. Hypertension B. Grand multiparity C. Abdominal trauma D. Premature rupture of membranes Refer to number 34

37. In the management of abruption placenta, which of the following statement/s is/are not true? A. Once diagnosed, all patients with abruptio placenta should be delivered by cesarean section B. Vaginal delivery is preferred if the fetus is dead unless hemorrhage cannot be managed even by vigorous blood replacement C. Conservative-in-hospital observation is done if the mother and fetus are stable and remote from term and the bleeding and contractions are subsiding D. All of the above Abruptio Placenta: • Management: Will vary depending upon gestational age and status of the mother and fetus o With massive external bleeding – intensive resuscitation with blood and crystalloid and prompt delivery to control the hemorrhage o If diagnosis is uncertain and the fetus is alive but without evidence of fetal compromise – very close observation, with facilities for immediate intervention o Emergency Caesarian Section - If maternal or fetal jeopardy is present as soon as the mother is stabilized o Vaginal Delivery – preferred if the fetus is dead unless hemorrhage cannot be managed even by vigorous blood replacement or there are other obstetrical complications that prevent vaginal delivery o Conservative in-hospital observation – performed if mother and fetus are stable and remote from term, bleeding is minimal or decreasing and contractions are subsiding; Confirm placental implantation with sonogram; Replace blood loss with crystalloids and blood products 38. Couvelaire uterus is usually associated with: A. Vasa previa B. Uterine rupture C. Placenta previa D. Abruptio placenta Couvelaire uterus/Uteroplacental apoplexy (From Williams, under Placental Abruption) • widespread extravasation of blood into the uterine musculature and beneath the serosa • Effusions of blood are also seen beneath the tubal serosa, between the leaves of the broad ligaments, in the substance of the ovaries, and free in the peritoneal cavity 39. A patient at 32 weeks AOG is diagnosed by color Doppler to have vasa previa. She is presently asymptomatic. How will you manage this patient? A. Cesarean section at term B. Immediate abdominal delivery C. Await labor and deliver vaginally D. Induce labor and deliver vaginally From Williams: Once vasa previa is identified, early scheduled cesarean delivery is planned. Bed rest apparently has no added advantage. 40. Digital pelvic examination under “double set-up” for cases of placenta previa would require available: A. Operating room for possible abdominal delivery B. Anesthesiologist for possible laparotomy C. Blood for possible blood transfusion D. All of the above E. A and B only Just discussed by Doc during the lecture, but to further explain, the definition of double set-up from a medical dictionary is a procedure in which an obstetric operating room is prepared for both vaginal delivery and cesarean section.

41. The following are findings in a typical case of severe abruptio placenta EXCEPT: A. Uterine tenderness B. Evidence of hypovolemia C. Loss of uterine contractility D. Absence of fetal heart sounds Placental Abruption Clinical Findings and Diagnosis • From Williams: sudden-onset abdominal pain, vaginal bleeding, and uterine tenderness, frequent contractions and persistent hypertonus • Mild Abruptio: o Vaginal bleeding is moderate with no fetal monitor abnormally o Localized uterine pain and tenderness with incomplete relaxation between contractions • Moderate Abruptio o 25-50% placental separation o Tachycardia, decreased variability or mild decelerations on fetal monitor • Severe Abruptio o Usually abrupt with continuous knife-like uterine pain o 50% placental separation o Severe late decelerations, bradycardia on fetal monitor or even death o Severe disseminated intravascular coagulation (DIC) may occur 42. Incomplete uterine rupture means: A. Complete separation of the wall of the pregnant uterus but without expulsion of the fetus B. Complete separation of the wall of the pregnant uterus not including the visceral peritoneum C. Incomplete separation of the wall of the pregnant uterus with partial expulsion of the fetus D. Incomplete separation of the wall of the pregnant uterus with separation of the visceral peritoneum Uterine Rupture Definition • Complete separation of the wall of the pregnant uterus with or without expulsion of the fetus that endangers the life of the mother or the fetus, or both • Rupture may be: o Incomplete – not including the visceral peritoneum o Complete – including the visceral peritoneum 43. A 29 y/o, G3P2 (2002) patient consulted you for vaginal spotting. She is 37 weeks pregnant. Pelvic ultrasound showed the edge of the placenta to be located 2 to 2.5 cms away from the internal cervical os. What kind of placenta previa does this patient have? A. total B. partial C. marginal D. low-lying Classification of Placenta Previa • Total, Complete, Central Previa o Placenta completely covers the internal cervical os o Most dangerous location because of its potential for hemorrhage • Partial Previa o Placenta partially covers the internal os • Marginal Previa o Edge of the placenta is at the margin of the internal os • Low Lying Previa o Placental edge is near but not over the internal os o There is a possibility for vaginal delivery if bleeding is minimal 44. A 35 weeks pregnant patient in labor is rushed to the emergency room due to hypertension. Fetal heart tones are absent. After 2 hours, she delivered to a fresh stillbirth. Examination of the placenta revealed a large retroplacental clot. What could have caused the death of the fetus? A. Vasa previa B. Uterine rupture C. Placenta previa D. Abruptio placenta Abruptio Placenta Etiopathogenesis (From Williams) • Placental abruption is initiated by hemorrhage into the decidua basalis. The decidua then splits, leaving a thin layer adhered to the myometrium. Consequently, the process begins as a decidual hematoma and expands to cause separation and compression of the adjacent placenta.

45. A 24 weeks pregnant came with vaginal spotting and mild uterine contractions. A pelvic ultrasound done showed a fetus appropriate for gestational age with good fetal heart tones and low lying placenta previa. Management for this patient would include the following EXCEPT: A. bed rest B. tocolysis C. Cesarean section at term D. Repeat ultrasound at 34 weeks Placenta previa management: • Emergency Caesarean Section o If maternal and fetal jeopardy is present as soon as the mother is stabilized • Vaginal delivery o May be attempted of the lower placental edge is more than 2cm from the internal cervical os (low lying previa) o This is possible if bleeding is minimal • Conservative in-hospital observation o Bed rest is performed in preterm gestations if mother and fetus are stable o Initial bleeding is rarely severe § Replace blood loss with crystalloids and blood products § Confirm placental implantation with sonogram • Scheduled Caesarian Section o If mother has been stable and after lung maturity of the fetus has been confirmed (by amniocentesis usually at 36 weeks of gestation) 46. The most common early warning sign of uterine rupture is: A. Cessation of uterine activity B. Fetal heart rate decelerations C. Recession of fetal presenting part D. Uterine atony after spontaneous rupture following a vaginal delivery Refer to number 33 (Clinical Presentation) 47. The following are classic triad of vasa previa, EXCEPT A. Fetal bradycardia B. Maternal hypovolemia C. Rupture of membranes D. Painless vaginal bleeding Refer to number 32 48. The severity of a placental abruption depends on: A. low parity B. high gravidity C. percentage of abruption D. age of gestation at onset of symptoms Refer to number 41 49. During labor, a primigravid experienced vaginal bleeding and severe abdominal pain. There is fetal bradycardia with maternal vital signs noted to be stable. Uterine rupture is highly considered. Management would be: A. Immediate cesarean delivery of the fetus B. Hysterectomy C. Uterine repair D. A and B Uterine Rupture Management: • Immediate Caesarean delivery of the fetus • Uterine repair in stable young women to conserve fertility • Hysterectomy in unstable patient or those who are not desirable of pregnancy 50. Which of the following is/are TRUE regarding the diagnosis of vasa previa? A. It is rarely confirmed before delivery. B. It is usually confirmed after delivery in examination of the placenta and fetal membranes C. It is suspected when antenatal ultrasound with color-flow Doppler reveals a vessel crossing the membranes over the internal cervical os D. All of the above Digest

TOPIC: Surgical and Gynecologic complications of pregnancy- Dr. Pearl Contemplacion 51. What is the most common cause of serious, life threatening or fatal blunt trauma during pregnancy? A. Intimate Partner Violence B. Automobile accidents C. Sexual Assault D. Falls Automobile accidents is the most common cause of serious, life threatening or fatal blunt trauma during pregnancy. It is the leading cause of death (82%). 52. Which of the following conditions are classified under penetrating trauma? A. Falls and Aggravated assaults B. Stab and Gunshot wounds C. Blast and Crush injuries D. Automobile accidents Stab and gunshot wounds are the only ones classified under penetrating trauma. The rest are classified under blunt trauma. 53. Which is NOT a complication of blunt trauma during pregnancy? A. Abruptio Placenta B. Placenta Previa C. Uterine rupture D. Placental Tear Complications of blunt trauma during pregnancy: Placental injury- Abruptio (separation) or tear, uterine rupture, fetal injury and death. 54. Decreased __________________may be a normal finding during pregnancy. A. white blood cell count B. alkaline phosphatase C. coagulation factors D. haemoglobin Laboratory changes during pregnancy: physiologic anemia, abnormal ECG findings, increased: WBC count, coagulation factors, alkaline phosphatise, circulating blood volume, cardiac output, decreased: calcium level 55. Which statement is CORRECT with regards thermal injury during pregnancy? A. Pregnancy alters maternal outcome. B. Severity is not correlated with fetal outcome. C. Treatment is the same as in the non-pregnant. D. A catabolic state will improve maternal/fetal outcome. Treatment of burned pregnant woman is the same with non pregnant: fluid replacement, antimicrobial coverage, managing symptoms and fetal surveillance. 56. Which of the following is CORRECT regarding acute appendicitis during pregnancy? A. The most reproducible sign is persistent nausea and vomiting. B. Pain in the right lower quadrant is specific to this disease. C. Rate of perforation decreases as pregnancy advances. D. Preterm Labor may mimic the abdominal pain. Digest 57. A 22 y/o female, married, amenorrheic for 6 weeks, with no previous checkup was diagnosed at the ER to have an Acute Abdomen probably secondary to a Ruptured Appendicitis. She was referred for OB clearance. Aside from pregnancy test and CBC, what other initial/immediate diagnostic test(s)/procedure(s) should be request for? A. Urinalysis, CT scan B. Whole Abdominal Ultrasound C. Urinalysis, Plain Abdominal X-ray D. Urinalysis, Transvaginal Ultrasound Appendicitis diagnostics: CBC (increased wbc and segmenters), Ultrasound, CT scan, MRI.

58. A 25 y/o G1PO on her 22nd week AOG, complained of sudden, severe, RUQ pain after eating a heavy meal in a fastfoodchain. She has been experiencing this type of pain, although mild, during the past 3 months but no consult was done. PE showed direct and rebound tenderness on the RUQ with muscle guarding. What will be the most appropriate management? A. Provide reassurance that there is nothing to worry about. B. Secure consent for a surgical exploration. C. Treat as a simple case of preterm labor. D. Give analgesics until the pain resolves. This seems to be a case of Chronic cholecystitis. Indications for surgery include symptomatic patients in the 2nd trimester and repeated attacks of biliary colic. 59. The following are the advantages of Laparoscopic Cholecystectomy EXCEPT: A. early ambulation B. more uterine manipulation C. faster GIT function recovery D. less frequency of abortion/preterm labor Advantages of Lap Chole: less uterine manipulation, early ambulation, shorter hospital stay, early resumption of normal activities, faster GIT function recovery, decreased: abortion, preterm labor and delivery. 60. What is the most common cause of intestinal obstruction in pregnancy? A. Volvulus- 25% B. Adhesions – 60% C. Colon Cancer- 5% D. Intussusception- 5% 61. What is the simplest diagnostic procedure to request for when you are considering intestinal obstruction in pregnancy? A. Whole Abdominal Ultrasound B. Plain Abdominal X-ray C. CT Scan D. MRI Plain abdominal x-ray (+) contrast: serial xrays at 4-8 intervals- thickened intestinal walls/ distended bowel loops/ distended cecum. 62. Maternal mortality with delayed management of intestinal obstruction during pregnancy is caused by the following EXCEPT: A. judicious use of antimicrobials B. cardiac arrest C. infection D. shock Maternal mortality (10-20%): cardiac arrest, infection, shock Fetal morbidity/ mortality: hypotension/ hypoxia 63. Where is the most common location of leiomyomas? A. Vagina B. Cervix C. Uterus D. Fallopian tube Leiomyomas are mostly found in the uterus (intramural, submucous, subserous) 64. What specific hormone has been linked to the development of leiomyomas? A. Progesterone B. Beta-HCG C. Prolactin D. Estrogen Digest 65. Which of the following statements is CORRECT regarding uterine leiomyoma in pregnancy? A. Myomas should be excised immediately after a vaginal delivery. B. Presence of a myoma is a general indication for a cesarian section. C. A myoma along the line of incision in a caesarean section may be excised. D. There is no need to repeat an ultrasound to monitor the myoma postpartum as all myomas will regress after delivery.

Indications for Myomectomy: cause pressure symptoms to other organs, along the incision site, large size may prevent the uterus to contract. 66. A 32 y/o G3P2 (2002) on her 8th week of pregnancy with a reliable LNMP, came in for her 1st prenatal checkup. On pelvic exam, you noted that her uterus was irregularly enlarged to 14 weeks size. What is the most appropriate diagnostic procedure to request for? A. Whole Abdominal Ultrasound B. Transvaginal Ultrasound C. Plain Abdominal X-ray D. CT Scan 67. A 25 y/o G1P0 on her 8th weeek AOG came for her 2nd PNCU with a TVS finding of a right ovarian cyst measuring 3 x 3 x 2.5 cm. What is the most probable diagnosis on the ovary? A. Ovarian malignancy B. Endometriotic cyst C. Corpus luteum D. Dermoid Cyst Ovarian masses: corpus luteum (most common), endometrioma, benign cystadenoma, mature cystic teratoma/dermoid 68. The following features characterize an ovarian malignancy on ultrasound, EXCEPT: A. Solid B. Cystic C. Thick capsule D. Papillary excrescences BENIGN: unilocular, cystic, thin capsule MALIGNANT: solid, bilateral, thick capsule, nodules, papillary excresenses 69. A 30 y/o G2P1 (1001) on her 15th week AOG consulted because of urinary frequency and pelvic heaviness. Urine studies ruled out UTI. Her first TVS at 8 weeks AOG revealed a 5-cm mass on the left ovary. Repeat ultrasound a week ago showed the mass to be 7 cms. What is the most appropriate plan of management? A. Give analgesics. B. Give antimicrobials. C. Surgical exploration D. Repeat ultrasound after a month. If there is suspected malignancy, timing of removal should be anytime. 70. A 40 y/o G4P3 (3003) on her 8th week AOG had an ultrasound done which revealed a solid right ovarian mass measuring 5 cms. After a month, repeat ultrasound showed the mass to have increased in size to 10 cms with thickened capsule and papillary excrescences. She is asymptomatic. What is the most appropriate plan of management? A. Monitor size of the mass by repeating the ultrasound after a month. B. Surgical exploration when she reaches at least 14 weeks AOG. C. Immediate surgical exploration. D. Wait until she reaches term then operate after delivery. If there is suspected malignancy, timing of removal should be anytime. TOPIC: Gestational trophoblastic diseases, abnormalities of the placenta, fetal membranes and umbilical cord- Dr. Vincent Lohengrin Fortun 71. In a retroplacental hematoma, where is the accumulation of blood located? A. between the chorion and the deciduas- Marginal hematoma B. between the placenta and the amnion- Subamniotic hematoma C. along the roof of the intervillous space- Subchorionic hematoma D. between the placenta and the deciduas- Retroplacental hematoma 72. A 37 y/o, G3P1 (1011), who had a previous Cesarean section, underwent a hysterectomy for placenta accreta. Which of the following would be present on histopathology of the implantation site in the uterus? A. chorangioma B. there is abundant calcification C. trophoblastic tissue invade the myometrium D. fibrinoid layer deposition on the placental basal plate Digest

73. Which of the following is NOT a complication of a chorangioma? A. fetal anemia B. fetal hydrops C. preterm delivery D. postpartum hemorrhage- should be antepartum hemorrhage 74. Which of the following abnormalities of the placenta is often associated with fetal growth restriction, abortion, and stillbirth? A. calcification B. placental tumors C. circulatory disturbances D. hypertrophic villous lesions Digest 75. Which of the following cord lengths is seen in a short umbilical cord? A. 30 cms B. 50 cms C. 75 cms D. 100 cms Normal length of umbilical cord: 50-60 cm 76. Which of the following cord abnormalities that are capable of impeding blood flow, is associated with cord prolapse? A. loops B. knots C. stricture D. funic presentation Funic presentation is often associated with fetal malpresentation, cord prolapsed and fetal heart rate abnormailities. 77. How does a Hyrtl Anastomosis improve placental perfusion during uterine contractions? A. shunts blood away from umbilical arteries B. prevents backflow of blood from umbilical arteries to the placenta C. acts as a pressure-equalizing system between the umbilical arteries D. provides a pathway for blood from umbilical arteries to enter the umbilical vein E. provides a pathway for blood from umbilical arteries to enter the umbilical vein Hrtyl anastomosis acts as a pressure-equalizing system between the umbilical arteries- improves placental perfusion during uterine contraction. 78. Which of the following abnormalities of cord insertion is present in a Battledore placenta? A. furcate B. marginal C. velamentous D. membranaceous Digest 79. Chorioamnionitis is caused primarily by: A. a systemic viral illness B. irritation to vaginal lubricants present in condoms C. entry of vaginal bacteria into the upper reproductive tract D. anaphylaxis to talcum powder present in examination gloves Chorioamnionitis is an infection fetal membrane. It begins with entry of vaginal bacteria into the upper reproductive tract- infection of chorion and adjacent deciduas overlying the internal cervical os- full thickness involvement of the membranes. 80. Which of the following is a setting for the passage of meconium? A. fetal asphyxia- initial insult B. 38 weeks gestation C. intercourse at 39 weeks AOG D. variable fetal heart rate decelerations