Вы находитесь на странице: 1из 87

DEPARTEMEN OBSTETRIK DAN GINEKOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN


Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

USULAN SOAL UJIAN NASIONAL MARET 2017

1. A 30-year-old P1A0 presents with pelvic pain persisting for several months. The pain does
not change with her menstrual cycles. She mentions that she has been feeling fatigued and
occasionally dizzy recently. On examination, she is afebrile, her pulse is 90 beats/min, and
her blood pressure (BP) is 110/65 mmHg. She is pale-appearing, and her uterus is nontender
and palpated midway between her pelvic symphysis and umbilicus. A pregnancy test is
negative, a complete blood count (CBC) reveals microcytic anemia, and transvaginal
ultrasound shows a thickened junctional zone. Which of the following is the most likely
diagnosis?
(A) Adenomyosis
(B) Endometriosis
(C) Pelvic inflammatory disease
(D) Ectopic pregnancy
(E) Endometrial carcinoma

2. A 26 -year-old presents with a 2-week history of right lower quadrant sharp abdominal pain.
She has noticed intermittent spotting, but has not had her normal menstruation in 8 weeks.
She is currently sexually active with two partners. She only uses condoms for contraception,
but mentions she occasionally forgets . On examination, she is afebrile, and her abdomen is
mildly tender to palpation in the right lower quadrant. What is the next most appropriate step
in the evaluation?
(A) Computed tomography (CT) of the abdomen and pelvis
(B) Urinalysis + chlamydia/gonorrhea testing
(C) Quantitative beta-human chorionic gonadotropin (-hCG)
(D) Transvaginal ultrasound
(E) Pap smear

3. A 40-year-old P3A0 presents to the emergency department (ED) with a 2-hour history of
severe left lower quadrant (LLQ) pain. The pain began suddenly and has stayed constant
since. On examination, her pulse is 85 beats/min, her BP is 145/80 mmHg, and her abdomen
is diffusely tender without rebound or guarding. On ultrasound, the left ovary is larger than
the right, and blood flow is diminished. What is the next best step in the management of this
patient?
(A) Emergent surgery
(B) Left ovary biopsy
(C) Obtain CA- 125 , -fetoprotein, and -hCG levels
(D) CT of the abdomen and pelvis
(E) Intravenous (IV) antibiotics

4. A 32 -year-old presents for an infertility workup. She and her partner have been trying to
conceive for 2 years without success. She has regular menstruation, though she mentions she
has severe cramping during her cycles. She also notes she experiences pelvic pain during
sex. On examination, she is a thin, well-developed woman. She is afebrile, and she
experiences a great deal of pain during the pelvic examination. You do not note discharge on
examination. Which of the following tests is required for diagnosis of the patient's
infertility?
(A) Ultrasound
1
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(B) -hCG level


(C) Pap smear
(D) Laparoscopy
(E) Hysterosalpingogram

5. A 39-year-old P3A0 presents to the clinic complaining of a fever of 40C and reports pelvic
pain. She is post-op day 3 from a total abdominal hysterectomy and was discharged on post-
op day 2 without any concerns after a normal early post-op course. She denies nausea,
vomiting, diarrhea, constipation, chest pain, or shortness of breath. The patient has no
allergies and has no other medical conditions. What is the next step in the management of
this patient?
(A) Reassure the patient
(B) Begin antibiotics
(C) Perform a urinalysis
(D) Order a CT angiogram
(E) Order a chest X-ray

6. A 45 -year-old patient post-op day 6 from total abdominal hysterectomy presents to the
emergency room (ER) complaining of serous fluid that is oozing from her incision. The
patient's BMI is 33 . She has diabetes and required an open laparotomy for her surgery. On
her examination, the skin incision is separated, and a Q-tip can be placed past the fascial
layer. What is the most likely cause of this patient's condition?
(A) Fascial dehiscence
(B) Hematoma formation
(C) Normal healing
(D) Infection development
(E) Seroma formation

7. A 32-year-old P0A0 presents to the clinic with worsening pelvic pain for the last several
years. Physical examination is grossly benign with the exception of some mild diffuse lower
abdomen tenderness on deep palpation. Which of the following is the most common
gynecologic diagnosis associated with chronic pelvic pain (CPP)?
(A) Pelvic inflammatory disease (PID)
(B) Adhesions
(C) Gynecologic malignancy
(D) Dysmenorrhea
(E) Endometriosis

8. A 29-year-old P2A0 complains of pelvic pain since the delivery of her second child 8 months
ago. She notices it most when sitting, though it is relieved when she sits on the toilet. She
also reports leaking urine more often since the delivery. As a part of the evaluation, her
practitioner evaluates her pelvic floor musculature and notices tenderness at the
sacrospinous ligament. What nerve is most likely responsible for the patient's symptoms?
(A) Genitofemoral
(B) Pudendal
(C) Iliohypogastric
(D) Lateral femoral
(E) Ilioinguinal nerve
2
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

9. A 62-year-old presents to the clinic complaining of intermittent resting pelvic pain after
eating certain foods and pain with urination. She states that it has persisted for several
months and denies overt urine leakage but does admit to urgency, frequency, and nocturia.
She went through menopause when 48 years old. She has six children that were delivered
vaginally without complication. A urine culture is negative. Which therapy would be of least
therapeutic benefit to this patient?
(A) Nonsteroidal anti-inflammatory drugs (NSAIDs)
(B) Dietary restrictions
(C) Antibiotics
(D) Tricyclic antidepressants
(E) Sacral neuromodulation

10. A 37 -year-old waitress, P3A0, is seen for increasing pelvic pain over the last 2 years. She
describes the pain as a dull, constant ache and finds that it is worse after a long day waiting
tables. It is also worse right before her periods. She has tried ibuprofen and acupuncture with
little relief. On physical examination, you notice varicose veins along her thighs. The
remainder of her examination is benign. You order a transvaginal ultrasound and find a
slightly enlarged uterus and thickened endometrium. Ovaries are normal. What is the most
accurate test to identify this patient's problem?
(A) MRI
(B) CT scan
(C) -hCG
(D) Venogram
(E) CA-125

11. A 70-year-old woman presents with complaints of leaking of urine with a cough, sneeze, or
while walking daily. It is significantly impacting her life. Medical history is complicated by
hypertension controlled on hydrochlorothiazide. Vital signs are BP 149/90 mmHg and pulse
87 beats/min. Physical examination is remarkable for loss ofher mid-urethral angle and
minimal cystocele. There is no uterine prolapse or rectocele. The patient undergoes
urodynamic testing confirming your suspected diagnosis of her urinary incontinence. What
is the next best step in therapy for this patient?
(A) Oxybutynin
(B) Mid-urethral sling
(C) Trimethoprim/sulfamethoxazole
(D) Tolterodine
(E) Anterior colporraphy

12. An 80-year-old woman presents to the office with complaints o f leaking large amounts of
urine when she hears running water. Her symptoms began about 1 month ago and have
gotten progressively worse. She denies any abdominal or pelvic pain. Medical history is

complicated by hypertension treated with hydrochlorothiazide and lisinopril. BP today is


150/99 mmHg with a pulse of 65 beats/min. What is the next best step in her workup?
(A) Urinalysis
(B) Urine cytology
3
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(C) Urine culture


(D) Basic metabolic panel
(E) Pap smear

13. A 64-year-old woman presents with complaints of leaking a large amount of urine after a
cough or sneeze. She has no significant past medical history. During examination, you
have the patient stand or cough. The patient begins to leak a large amount of urine a few
seconds after a deep cough. From this examination, what is the most likely type of
incontinence this patient suffers from?
(A) Stress urinary incontinence
(B) Detrusor overactivity
(C) Mixed urinary incontinence
(D) Neurogenic bladder
(E) Urinary tract infection

14. A 65 -year- old woman presents with complaints of leaking of a large amount of urine along
with a sudden urge to urinate several times a week. She has no significant past medical
history. Your clinical diagnosis based on the history is confirmed by cystometrics. What is
the first step in therapy for this patient?
(A) Oxybutynin
(B) Mid-urethral sling
(C) Trimethoprim/sulfamethoxazole
(D) Prazosin
(E) Fosfomycin

15. A 70-year-old woman presents with complaints of leaking a small amount of urine multiple
times per day. She states over the last several weeks she has had worsening difficulty
voiding along with a small amount of leaking throughout the day. Her past medical history
is significant for type 2 diabetes mellitus, chronic obstructive pulmonary disease,
congestive heart failure, hypertension, and hyperlipidemia. Medications include
hydrochlorothiazide, lisinopril, metformin, ipratropium, lasix, and pravastatin. Of the
patient's medications, which one is likely to cause the patient's complaint?
(A) Hydrochlorothiazide
(B) Lisinopril
(C) Metformin
(D) Ipratropium
(E) Furosemide

16. An 85 -year-old woman presents to the emergency department (ED) with new-onset pelvic
pain and leaking of urine. Her medical history is complicated by congestive heart failure,
hypertension, diabetes mellitus, and osteoarthritis. On evaluation, her BP is 161/105
mmHg, pulse 102 beats/min, T 36,8C, and RR 18 breaths/min. Blood count shows a white

blood cell (WBC) count of 12.500/mm3 and a red blood cell count of 10.200/mm3.
Urinalysis shows negative leukocytes, negative nitrites, and moderate blood. What is the
next best step in her workup?
(A) Basic metabolic panel
(B) Urodynamics
4
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(C) Urine culture


(D) Urine cytology
(E) Ultrasound

17. A 59 -year-old woman presents to the office with complaints of leaking urine whenever she
coughs. Symptoms began recently and have been getting progressively worse. She does not
complain of any significant suprapubic pain since onset. The patient smokes one half pack
per day and drinks three b eers nightly. She has no significant past medical history.
Urinalysis shows moderate leukocytes with positive nitrites and trace blood. Urodynamics
reveal stress urinary incontinence. What is the next best step in the treatment for this
patient?
(A) Oxybutynin
(B) Mid-urethral sling
(C) Trimethoprim/sulfamethoxazole
(D) Tolterodine
(E) Retropubic urethropexy

18. A 31-year-old P0A0 woman complains of pelvic pain that increases with menstrual cycles.
She also admits to dyspareunia. What would be the most probable findings of a diagnostic
laparoscopy?
(A) Black pinpoint lesions on the appendix
(B) Erythema in the posterior cul-de-sac
(C) Red, white, or blue lesions on the ovaries
(D) Abscess adjacent to the uterosacral ligaments
(E) Blue lesions in the posterior cul-de-sac

19. A 23-year-old P0A0 presents for her annual well-woman examination complaining that she
is unable to get pregnant after trying for more than 1 year. She notes severe pain with her
menses and heavy vaginal bleeding. A clinical diagnosis of endometriosis is made. What
are the expected pathologic findings if tissue biopsies were collected during a diagnostic
laparoscopy?
(A) Ectopic endometrial glands, neutrophil invasion of glandular tissue, rete pegs
(B) Ectopic endometrial glands, hemorrhage, and ectopic endometrial stroma
(C) Ectopic endometrial stroma, neutrophil invasion of glandular tissue, and hemorrhage
(D) Hemorrhage, neutrophil invasion, and rete pegs
(E) Ectopic endometrial glands, hemorrhage, and rete pegs

20. A 45-year-old P1A2 complains of worsening pelvic pain that coincides with menses. What
is the mechanism of action of the empirical drug of choice for endometriosis?
(A) Activates androgen and progesterone receptors
(B) Acts as a gonadotropin- releasing hormone (GnRH) antagonist

(C) Decreases sex hormone binding globulin


(D) Acts as a GnRH agonist
(E) Deactivate estrogen receptors

21. A 37-year-old woman, P1A0, presents to your office complaining of gradually worsening
dysmenorrhea and menorrhagia, though her cycles remain regular. Bimanual examination
5
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

reveals a mildly tender, 14-week -sized globular uterus. Abdominal ultrasound reveals a
globally enlarged uterus without evidence of discrete masses. What is the most likely
diagnosis?
(A) Adenomyosis
(B) Leiomyomata
(C) Endometriosis
(D) Endometrial hyperplasia
(E) Leiomyosarcomata

22. A 26-year-old woman complains of a golf ball-sized mass at the entrance of her vagina. She
says that this area is "sore all the time" and began hurting "about 3 days ago:' On
examination, the patient has a tender 4-cm mass on the lateral aspect of the labia minora at
the 5 o'clock position. There is erythema and edema, and the area is very tender and
fluctuant. No cellulitis is noted. What is the most appropriate treatment for this condition?
(A) Trimethoprim/ sulfamethoxazole
(B) Azithromycin for the patient and any sexual partner
(C) Incision and drainage of the mass followed by a course of trimethoprim/
sulfamethoxazole
(D) Incision and drainage of the mass
(E) Incision and drainage of the mass with placement of a Word catheter

23. A 39-year-old P0A0 woman undergoing infertility workup is diagnosed with a small
intracavitary lesion on saline-infused sonography. She elects to undergo operative
hysteroscopy with dilation and curettage (D &C) and polypectomy using monopolar
cautery. She has a history of chlamydia 5 months ago that was treated in your office. What
is the most serious risk to this patient associated with this procedure?
(A) Uterine perforation with the uterine sound
(B) Hyponatremia caused by absorption of distension media
(C) Seeding the upper genital tract with organisms likely to cause pelvic inflammatory
disease
(D) Risk of anesthesia causing uterine atony and subsequent hemorrhage
(E) Asherman syndrome

24. A 21-year-old woman presents to the emergency room (ER) complaining of gradually
worsening left lower quadrant (LLQ) pain and vaginal spotting. Her quantitative -hCG is
3761. On examination, her abdomen is tender to palpation in the LLQ but is without
rebound or guarding. No intrauterine pregnancy is seen on transvaginal ultrasound, but a
fetus with positive cardiac activity is noted in the patient's left adnexa. The patient is
frightened of anesthesia and declines surgery. What is the best course of management?

(A) Urge the patient to reconsider surgery, as she is not a candidate for expectant or
medical management for a presumed ectopic pregnancy
(B) Recommend expectant management with precautions and in-office follow-up for a
quantitative -hCG in 3 and 6 days
(C) Admit the patient for a 3 - day course of intravenous (IV) cyclophosphamide
(D) Administer intramuscular methotrexate and follow up for a quantitative -hCG
in 3 and 6 days
6
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(E) Consult psychiatrist to determine the patient's mental competency to make decisions
regarding her health

25. A 49-year-old P5A0 woman comes to see you because of intermittent pelvic pain and
constipation. The patient saw her primary care physician 1 month ago for the same
complaints. A colonoscopy performed at that time showed no abnormalities. Today, the
patient also confides that she has experienced increasing postcoital spotting over the past
year. The patient is afebrile with a BP of 125/85 mmHg and an HR of 90 beats/min.
Cardiac, pulmonary, and abdominal examinations are unremarkable. Bimanual pelvic
examination reveals a nontender, 15 weeksized uterus with several dense cobblestone-like
protrusions. Pelvic ultrasound shows at least seven 2 to 5 cm areas of hypogenicity. What
is the next best step in the care of this patient?
(A) Saline infusion sonogram
(B) Endometrial biopsy
(C) Medroxyprogesterone
(D) Hysterectomy
(E) MRI-guided thermoablation

26. A 68-year-old woman presents to clinic complaining of lower abdominal heaviness, which
worsens and localizes to the vagina when she lifts her 5-year- old grandson. She also
admits to some stress urinary incontinence, as well as the need to urinate two to three times
during the night. She has not been sexually active since the death of her husband 2 years
ago. Pelvic examination reveals poorly estrogenized vaginal mucosa with a herniation of
the anterior vaginal wall; when the patient is asked to bear down, this herniation extends to
the level of the introitus. What is the likely diagnosis?
(A) Grade 2 enterocele
(B) Grade 3 enterocele
(C) Grade 2 cystocele
(D) Grade 3 cystocele
(E) Grade 2 rectocele

27. A 58-year-old postmenopausal woman is seen in clinic for a routine examination. At the end
of the visit, she sheepishly admits to mild urinary incontinence over the past several years .
She is P4A0; all her children were normal spontaneous vaginal deliveries, and the largest
weighed 4000 g. She has hypertension treated with metoprolol and has been using a topical
estrogen cream for vaginal dryness since menopause at age 54. Further questioning reveals
that she occasionally leaks small amounts of urine, particularly with laughing, sneezing, or
coughing. She denies large volume loss, increased urinary frequency, or

nocturia. Based upon this history, which of the following is a good initial treatment option
for this woman's urinary incontinence?
(A) Pelvic floor strengthening exercises
(B) Urethral bulking injections
(C) Imipramine
(D) Discontinue topical estrogen cream
(E) Urethral sling procedure

7
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

28. A 72-year-old nursing home resident with mild cognitive impairment is brought to clinic
with complaints of constant "dribbling" of urine during the day and increased urinary
urgency, both during the day and at night. When she does urinate, her stream is weak and
hesitant, occasionally stopping and starting several times. In addition, she has occasional
episodes of large-volume urinary incontinence. A postvoid residual in the clinic shows
urinary retention of 225 mL. What is the likely diagnosis?
(A) Stress incontinence
(B) Urge incontinence
(C) Mixed incontinence
(D) Functional incontinence
(E) Overflow incontinence

29. A 74-year-old woman with Alzheimer dementia is brought to clinic for a medical
examination prior to admission to a nursing facility. She is healthy and has had little
medical care since the birth of her last child 46 years ago. Menopause occurred at age 53 .
Speculum and bimanual examination reveal uterine prolapse to the level of the introitus.
Surgery to correct this patient's condition involves plication of which of the following
structures?
(A) Uterosacral ligaments
(B) Rectal fascia
(C) Endopelvic fascia
(D) Rectovaginal fascia
(E) Rectovaginal fascia and posterior abdominal wall

30. A 37-year-old P0A0 with a history of irregular periods comes to see you to discuss her
bleeding pattern. The patient reports that she menstruates 9 to 10 times per year and she
has felt that her bleeding has gotten heavier over the years . She also has occasional
spotting between periods. The patient's pulse is 80 beats/min, respiratory rate is 18
breaths/min, BP 126/88 mmHg, weight 80 kgs, and height 152 cm. The most important
next step in the management of this patient is:
(A) Prescribe oral contraceptive pills (OCPs) to regulate bleeding
(B) Perform an endometrial biopsy
(C) Measure complete blood count (CBC), prothrombin time/partial thromboplastin time,
factor VIII, and von Willebrand factor antigen and activity
(D) Perform a pelvic ultrasound
(E) Administer intravenous (IV) estrogen 25 mg every 4 hours for 24 hours

31. An 18 -year-old GO presents to her gynecologist complaining of painful periods. She


reports that she experiences severe cramping pain beginning 1 week prior to menses, which
peaks 1 to 2 days into menses. Her pain is relieved when she gets her period, however, and
she reports that she feels normal for the rest of the month. She has had this pattern of pain
since she started menstruating at age 15, but it has been getting progressively worse. If
initial empiric medical treatment of her condition fails, which of the following will provide
definitive diagnosis of this patient's likely condition?
(A) Pap smear with human papillomavirus (HPV) testing
(B) Bimanual examination
8
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(C) Transabdominal ultrasound


(D) Direct visualization via laparoscopy
(E) Serum -hCG

32. A 24-year-old woman complains of headache, irritability, low mood, restlessness, and
fatigue that occur mostly in the 2 weeks preceding menstruation. She reports regular 5 -day
periods every 30 days and says that she feels relatively symptom-free for the week
following her period. Which of the following treatments is most likely to be helpful in this
patient?
(A) Naproxen
(B) Nortriptyline
(C) Quetiapine
(D) Lorazepam
(E) Fluoxetine

33. A 17-year-old girl complains of painful periods. She says that she began menstruating at 14
years of age and has had significant pain and cramping associated with menstruation since
then. Her pain is worst on the first and second days of menstruation and is often associated
with nausea, vomiting, and headache. Her pain is so severe that she often has to miss
school on the first day of her period. She has tried heating pads and baths, which provide
some minor relief. Physical examination reveals no abnormalities. Which of the following
interventions is considered first-line therapy for this patient's condition?
(A) Acetaminophen
(B) Nonsteroidal anti-infl ammatory drugs (NSAIDs)
(C) Opiate analgesics
(D) Oral contraceptive pills (O CPs)
(E) Gonadotropin antagonists

34. A 26-year-old G2P1A0 at 39 weeks 3 days by last menstrual period (LMP) consistent with
a 6-week ultrasound undergoes a scheduled repeat low transverse Cesarean section. Her
medical history is complicated by type 1 diabetes mellitus, well controlled on insulin.
Visual inspection of the exteriorized uterus reveals two well-circumscribed, firm nodules
of approximately 2 to 3 cm in diameter beneath the serosa of the uterus. She has no history
of menorrhagia or urinary frequency and was taking oral contraceptive pills (OCPs) prior
to pregnancy. What is the most likely diagnosis for these masses?
(A) Fibrous cysts
(B) Leiomyomata

(C) Uterine sarcomas


(D) Endometrial polyp
(E) Endometrial carcinoma

35. Which of the following is the best management in this patient?


(A) Expectant management
(B) Nonhormonal medical therapy
(C) Hormonal therapy
(D) Removal of the masses during the Cesarean section
(E) Ultrasound series
9
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

36. A 36-year-old G l P l presents to her gynecologist with progressively heavier menstrual flow
and pelvic pressure. She strongly desires future fertility. Bimanual examination reveals a 1
6-week-sized uterus, and urine -hCG testing is negative. Ultrasonography reveals multiple
uterine leiomyomas, but cannot comment on the specific location of each fibroid. The
patient is considering surgical treatment. What is the next best step in identifying the
locations of the uterine fibroids?
(A) Hysterosalpingography (HSG)
(B) Sonohysterography
(C) MRI
(D) CT
(E) Positron emission tomography (PET)

37. A 34-year-old woman presents to her physician with feelings of depression, abdominal
bloating, and breast tenderness 5 days prior to her onset of menses last month. She states
that symptoms resolved with the onset of her menses and she felt back to herself. She
reports that this happened once before, she thinks about 6 months ago. Her periods have
always been regular since her onset of menses at the age of 13 . What is the next step in the
management of this patient?
(A) Instruct her to begin documenting a menstrual diary
(B) Begin treatment with an selective serotonin reuptake inhibitor (SSRI) such as
fluoxetine or sertraline
(C) B6 supplementation
(D) Order follicle- stimulating hormone (FSH) level
(E) Administer depression screen

38. A 34-year-old woman presents to her physician with a 4-day history of fevers, chills,
nausea, and vomiting. She also notes pain radiating to her back. A urinalysis detects
leukocyte esterase in the urine. What is the next step in the management of this patient?
(A) Obtain a urine culture
(B) Start empiric treatment with trimethoprim/sulfamethoxazole
(C) Give intravenous (IV) fluids and discharge home
(D) Abdominal CT
(E) Urine cytology

39. A 22 -year- old sexually active woman pres ents to her physician with a 3 - day history of
pain with urination as well as frequent awakening at night with the urge to void. Sh e
denies fevers, chills, flank, or suprapubic pain. Upon microscopic examination, 14
leukocytes/mL are noted. What is the next step in the management of this patient?
(A) Reassurance
(B) Obtain urine culture results prior to initiating treatment
(C) Trimethoprim/sulfamethoxazole
(D) Ampicillin and gentamicin
(E) Urine cytology

10
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

40. A 29-year-old woman presents with signs and symptoms consistent with an uncomplicated,
lower urinary tract infection (UTI). It is decided to begin treating her with antibiotic
therapy. What is the recommended duration of oral antibiotic treatment for an
uncomplicated UTI?
(A) 1 day
(B) 3 days
(C) 5 days
(D) 7 days
(E) 10 to 14 days

41. A 24-year-old P0A1 presents for a preconception consultation. She wishes to conceive in
the next year. Three years ago, she has a termination of pregnancy at 10 weeks via suction
curettage. Until 18 months ago, she used depot medroxyprogesterone acetate (DMPA) but
has used no contraception since. She resumed having very regular menses 5 months after
her last DMPA injection, but they are very scant and associated with severe cramping. She
regularly checks an ovulation predictor kit that reveals a luteinizing hormone (LH) surge
consistently on day 16 of her cycle. She has remained sexually active. Her general medical
examination is unremarkable. Her thyroid is of normal size. Gender specific examination
reveals normal internal and external genitalia. Uterus is small and is at mid-position.
Ovaries are palpable bilaterally about 2 cm each. Pregnancy test is negative. Which of the
following will be the most beneficial in evaluating this patient's differential diagnosis?
(A) Diagnostic laparoscopy
(B) Hysteroscopy
(C) Progesterone challenge
(D) Thyroid function testing
(E) Ultrasound

42. A 55 -year- old P0A0 presents with a 2 -month history of intermittent bright red vaginal
bleeding. She went through menopause at the age of 51 and has not had a period since until
recently. She presents for a second opinion about the management of postmenopausal
bleeding through a hysterectomy. Other than a preoperative complete blood count (CBC),
she has had no workup. You recommend an endometrial biopsy but she is concerned that
she may have endometrial cancer, and an outpatient endometrial biopsy will not be
accurate enough to diagnose endometrial cancer. You explain to her that the diagnostic
accuracy of office endometrial sampling techniques is:
(A) 90% to 98%

(B) 80% to 89%


(C) 70% to 79%
(D) 60% to 69%
(E) 50% to 59%

43. A 43-year-old woman presents with a 4-month history of abnormal menses. Some months
she has periods that last for 12 days; she may then skip 2 weeks and have another really long
period. The periods are irregular and heavy. Until 4 months ago, she had been having regular
menses with cycles of 28 -day length, periods lasting 5 days with moderate bleeding. She
has been having occasional hot flashes at night, not sleeping well, and feeling very fatigued.
She gives no history of unusual bleeding with procedures. She is currently on no
11
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

medications, and she denies taking any herbal or over-the-counter remedies. Physical
examination reveals a pleasant, mildly obese woman with a slightly enlarged thyroid gland.
Vital signs are BP 146/89 mmHg, P 82 beats/min, T 37C, and R 20 breaths/min in no acute
distress. Her pelvic examination is significant for an enlarged uterus approximately the size
of a 3-month pregnancy. She tells you she has had fibroids for 8 years, but they have been
asymptomatic. All other pelvic structures appear normal. Thyroid-stimulating hormone is
normal at 4,5. A pregnancy test is negative. A transvaginal ultrasound confirms the presence
of three intramural fibroids ranging from 1 to 2 cm in diameter. A saline-infused ultrasound
reveals no evidence of endometrial polyps or masses. You see her back in 3 weeks of follow-
up. The endometrial biopsy performed 3 days before her period revealed proliferative
endometrium. She had a withdrawal bleed after you gave her progesterone therapy for 10
days. Since that time, she has had no other vaginal bleeding. The most likely diagnosis for
this patient is:
(A) Anovulatory bleeding
(B) Hypothyroidism
(C) Polycystic ovary syndrome
(D) Menopause
(E) Endometrial hyperplasia

44. A 19-year- old college student presents with amenorrhea for the past 6 months. Her menses
began at age 1 2 and were regular until then. She denies sexual activity, and a pregnancy
test is negative. Her physical examination is unremarkable except for the milky white
discharge she expresses from her nipples. What is the next step?
(A) Transvaginal ultrasound
(B) Measure serum prolactin
(C) Order brain MRI
(D) Get thyroid ultrasound
(E) Prescribe bromocriptine

45. Refer to the patient in Question 44. The prolactin comes back as 175 g/L. What is the next
step ?
(A) Coned down view of the sella turcica
(B) Cranial radiography
(C) Dual-energy X-ray absorptiometry scanning
(D) Helical CT

(E) MRI

46. A 29 -year-old P0A0, woman with regular menses (every 28 days lasting 5 days) is
currently trying to conceive. She has not used contraception for 6 months. Her ovulation
predictor kit revealed an luteinizing hormone (LH) surge 7 days ago. She presents with
acute abdominal/ pelvic pain . This clinical picture is most consistent with :
(A) Cystic teratoma
(B) Ectopic pregnancy
(C) Follicular cyst
(D) Hemorrhagic corpus luteum cyst
(E) Serous cystadenoma

12
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

47. A 34-year-old woman, P2A0, presents to the emergency room (ER) with sudden onset pain
that was severe in nature. The pain has occurred before, and in fact, she has been present to
the ER four times in the past 6 months for similar pain. Each time, the pain has resolved
within a few hours. The pain does not occur in any pattern with relation to her menstrual
cycle. It is always on her left side. Today, the pain is the worst it has ever been and has
lasted far longer than on previous occasions. She has been having some anorexia and
nausea currently. In physical examination, she is afebrile and normotensive. You note
guarding and rebound in the left lower quadran. Bowel sounds are absent. Pelvic
examination reveals a normal sized uterus, extreme tenderness in the left adnexal area
when you move the cervix, but no obvious mass in the pelvis . As you review her records,
you view an abdominal X-ray from 6 months ago. After reviewing the X-ray, you are able
to make the diagnosis of ovarian torsion and prepare the patient for immediate surgery.
What finding on the X-ray would support this diagnosis and plan?
(A) Air-fluid levels
(B) Fluid in the pelvic cul-de -sac
(C) Large simple cystic structure
(D) Subdiaphragmatic gas collection
(E) Teeth with roots

48. You are called to the emergency room (ER) to evaluate a 25-year-old patient P1A0 with
moderate left lower quadrant (LLQ) pain. The pain woke her from sleep and is described
as throbbing but constant 4/10 . Her last menstrual period (LMP) was 6 weeks ago. She has
regular monthly periods and uses condoms inconsistently. She became sexually active at
age 16 and has had five lifetime male partners, the present one for almost a year. She has a
history of chlamydia treated at age 18. She has not had any regular gynecologic care since
then. She appears to be in no distress and her vital signs are as follows: BP 120/72 mmHg,
P 88 beats/min, R 1 8 breaths/min, and BMI 27. Her abdomen is non tender, but her pelvic
examination reveals mild tenderness in the left adnexal area. What is your next step ?
(A) Qualitative hCG
(B) Quantitative hCG
(C) Vaginal ultrasound
(D) Abdominal ultrasound
(E) Laparoscopy

49. Refer to the patient in Question 48. The quantitative hCG is 900 mIU/mL. The patient is
stable with an hemoglobin/hematocrit of 12/ 35 . What is your next step?
(A) Admit the patient and repeat quantitative hCG in 48 hours
(B) Admit the patient and schedule laparoscopy
(C) Admit the patient and get a serum progesterone level
(D) Admit the patient and administer methotrexate
(E) Hemoglobin count series

50. Refer to Questions 48 and 49 to answer the question. About 36 hours after admission for
observation, the patient complains of worsening left lower quadrant (LLQ) pain that is now
8/10. Her BP is now 100/60 mmHg and pulse is 120 beats/min. Her abdomen is tense and
she now has marked LLQ tenderness and rebound. A quick bedside vaginal ultrasound
reveals fluid in the cul-de-sac. What is the next step?
13
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(A) Repeat quantitative hCG STAT


(B) Watch patient until 48-hour quantitative hCG can be performed
(C) Call the operating room (OR) to add patient to the OR schedule tomorrow
(D) Take patient to the OR for emergency diagnostic scope
(E) Perform bedside culdocentesis

51. Refer to Questions 48-50 to answer the question. During the course of the laparoscopy, you
find dense adhesion in the pelvis as well as between the liver and the right diaphragm. A
ruptured ectopic is noted in the left distal tube, and a salpingectomy is performed after lysis
of adhesions. What do these laparoscopic findings describe?
(A) Normal findings with ectopic
(B) Fitz-Hugh- Curtis syndrome
(C) Asherman syndrome
(D) Kallmann syndrome
(E) Meigs syndrome

52. A 17 -year-old girl presents to your office for follow-up 2 weeks after an appendectomy.
She was told that in addition to appendicitis the CT scan revealed a left-sided ovarian cyst
measuring 4 cm. The radiology report describes a unilocular, homogenous simple cyst with
no septations. The operative report does not describe any pelvic findings. She reports
menarche at age 13 and has regular periods every 28 to 35 days with mild menstrual
cramps. Her last period was 1 week ago. What is the most appropriate next step in
managing this patient's ovarian cyst?
(A) Repeat CT scan
(B) Follow-up visit in clinic in 4 to 6 weeks
(C) Abdominal ultrasound
(D) Transvaginal ultrasound
(E) Laparoscopic cystectomy

53. A 49 -year-old woman comes into your office due to concerns of changes in her menses for
the past year and a half. Although unpredictable, her cycles have been farther apart and
lighter. She had no period the last 7 months but bled for 3 days last month. Her last Pap
smear was 9 months ago and was normal. She has no history of abnormal Pap smears or

sexually transmitted infection (STI) . Her mother had breast cancer at the age of 65. The
patient reports taking levothyroxine and hydrochlorothiazide. When should the patient
receive an endometrial biopsy?
(A) In the office today, her absence of menses greater than 6 months classifies her bleeding
as postmenopausal
(B) In the office today, irregular bleeding at her age indicates the need for endometrial
biopsy
(C) If she continues to have irregular bleeding for greater than 5 months, once she passes 12
months of irregular bleeding a biopsy is indicated
(D) She should never have an endometrial biopsy if there is no family history of endometrial
cancer
(E) She should not have an endometrial biopsy unless she is amenorrheic for 12
months, and then begins to have irregular bleeding

14
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

54. A 55-year-old P3A0 presents to your office for irregular bleeding. She has not had a period
in over 3 years and is concerned that she is beginning to have menses again. The patient
reports two episodes of vaginal bleeding over the past 2 months, both times with
inconsistent flow and length. She has had regular Paps, her last one being 2 years ago. She
uses vaginal estrogen cream three times a week for vaginal atrophy and is well controlled on
Risperidone for schizoaffective disorder. Which of the following examinations would rule
out the most concerning diagnosis of her bleeding?
(A) Pap with HPV cotesting
(B) Endometrial biopsy
(C) CA- 125 serum levels
(D) Speculum examination and bimanual examination
(E) Transvaginal ultrasound

55. A 28-year-old P0A0 presents to your office for an infertility workup. She and her partner
have been having regular unprotected intercourse for 14 months with no resultant
pregnancies. She achieved menarche at the age of 15, with her menses occurring every 2 to
3 months for irregular durations of time. She admits to excessive hair on her face, chest,
and lower abdomen. She has no health conditions other than obesity and has never had
surgery. Her mother had uterine cancer at the age of 41, and her grandmother had breast
cancer at 55 years old. You suspect polycystic ovarian syndrome (PCOS). Which of the
following is indicated in her workup for PCOS?
(A) Endometrial biopsy
(B) LH:FSH ratio levels > 1
(C) Testosterone levels
(D) Pelvic ultrasound
(E) No further workup is needed

56. A 42-year-old woman P3A0 status posttubal presents to your clinic with a recurrent
complaint of intermenstrual bleeding. She has been having irregular, heavy periods for the
past 2 years and has been tried on multiple medical treatments. Her hemoglobin is 8.9 g/dL
from labs performed on day 6 of her cycle. Pelvic examination reveals a smooth, mobile 8-

week-sized uterus. She wants to pursue a hysterectomy. Which of the following must be
performed before she is an eligible candidate for hysterectomy?
(A) Repeat hemoglobin before menses occurs
(B) Endometrial biopsy
(C) Pelvic ultrasound
(D) Follicle- stimulating hormone (FSH) levels
(E) CA 125 levels

57. A 48-year-old P2A0 presents to your clinic for irregular bleeding. She states she reached
menarche at 13 and has regular monthly menses lasting 6 days each month until 18 months
ago when she began having irregular periods that are heavier than usual. The patient also
reportsa large amount of yellow, foul-smelling discharge for the past 2 weeks. She is
sexually active and has had three partners in the last 6 months with whom she usually uses
condoms. You perform a pelvic examination and a gonorrhea and chlamydia culture. The

15
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

results of the culture show that the patient is positive for gonorrhea and negative for
chlamydia. What is your next step ?
(A) Pelvic ultrasound to evaluate the thickness of her endometrium
(B) Treat her with ceftriaxone and azithromycin, then perform endometrial biopsy
(C) Treat her with ceftriaxone, then perform pelvic ultrasound
(D) Perform endometrial biopsy, then treat with ceftriaxone and azithromycin
(E) Pelvic ultrasound followed by endometrial biopsy

58. While following up on lab reports you had ordered earlier in the week, you come across a
report on a new obstetric patient that found an Escherichia coli count of 100,000 + colonies
on urine culture. You review her chart and no mention is made of her having dysuria. The
nurse calls her to find out whether she is having any complaints and reports to you that she
is not. Which of the following is the most appropriate next plan of action?
(A) Call in the appropriate antibiotic for her bacteriuria
(B) Reassure the patient that her test was not abnormal since she is asymptomatic
(C) Tell the patient to present for a renal ultrasound
(D) Admit the patient for possible asymptomatic pyelonephritis
(E) Repeat the urine culture

59. The gold standard test for antenatal surveillance of the pregnancy at-risk for an adverse
pregnancy outcome with the lowest false negative rate is:
a) Biophysical Profile
b) CTG only
c) CTG and an estimation of the amniotic fluid volume
d) Contractions stress test

60. A pregnant woman presents at 10 weeks' with a high temperature (38C) and ongoing
asthenia for 2 weeks. CMV serology is performed; which of the following is true regarding
this serology?
a) IgG and IgM are both negative: the diagnosis of recent CMV primary infection is unlikely
b) IgG are positive and IgM are negative: the diagnosis of recent CMV primary infection is
unlikely
c) IgG and IgM are both positive: it might be a recent CMV primary infection
d) The presence of positive CMV IgM ascertains the diagnosis of a recent primary
infection
e) In case of positive IgM, an IgG avidity test must be performed to confirm or to exclude
recent primary infection

61. A pregnant woman has a primary CMV infection diagnosed based on clinical symptoms at
17 weeks of gestation. Although, there are no abnormal features on prenatal ultrasound the
patient wishes an amniocentesis for prenatal diagnosis.
a) The amniocentesis could be done at 21 weeks
b) The amniocentesis should be done after 23 weeks
c) CMV PCR in the amniotic fluid is the gold-standard diagnosis
d) The women should be warned of the possibility of a 5% to 10% false negative rate of the
amniocentesis at diagnosing fetal infection at birth.
e) If CMV-PCR is negative in the amniotic fluid, the amniocentesis should be repeated 3
weeks later
16
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

62. Prenatal ultrasound performed at 26 weeks' shows: hyperechogenic bowel grade 2,


hepatosplenomegly and unilateral ventriculo-megaly measured at 12 mm. Which of the
following is are true?
a) CMV- PCR in amniotic fluid should not be performed because CMV serology shows
negative IgG and negative IgM
b) CMV-PCR in amniotic fluid should be done because CMV serology shows positive IgG
and negative IgM
c) CMV-PCR in amniotic fluid should not be done because CMV serology showed positive
IgG and negative IgM two years ago
d) A negative CMV PCR in amniotic fluid excludes fetal congenital CMV infection
e) A positive CMV PCR in amniotic fluid confirms CMV fetal infection

63. When diagnosing a twin pregnancy at 11 weeks' gestation as calculated from the last
menstrual period (LMP), the sonographer should do which of the following?
a) Take the smallest Crown-Rump Length (CRL) to recalculate gestational age
b) Look for the T-sign to determine chorionicity
c) Reassure the pregnant woman that twin-twin transfusion syndrome is unlikely to occur
when the embryos have identical nuchal translucencies (NT)

d) Distinguish between an empty and a full lambda sign


e) Perform color Doppler examination of direction of blood flow in the aorta to exclude
TRAPS

64. When detecting a monochorionic twin with discordant estimated fetal weight of more than
25% at 23 weeks' gestation, the obstetric caregiver should do which of the following?
a) Perform Doppler examination of the umbilical artery and ductus venosus to determine the
prognosis
b) Refer the patient to a fetal therapy centre for laser coagulation of the vascular
anastomoses
c) Look for the presence of a large arterio-arterial anastomosis to estimate the risk of acute
demise of both twins
d) Perform an MRI to exclude brain damage in the larger twin
e) Refer the patient to a fetal medicine center for counselling on prognosis and options for
intervention.

65. The current best practice in managing monoamniotic twin pregnancies includes:
a) Detailed ultrasound examination for structural anomalies
b) Ultrasound examination at least every two weeks including measurement of the deepest
pocket of amniotic fluid and evaluation of bladder filling of both twins
c) Induction of labour after a course of corticosteroids at 36 weeks gestation when the first
twin is in cephalic position
d) Immediate version and extraction of the second twin after vaginal birth of the first twin
e) Admission to hospital from 24 weeks onwards and daily Doppler to look for notching in
the umbilical arteries

66. A small fetus (estimated fetal weight on 2nd centile) presents with the following results on
ultrasound and Doppler at 37 weeks: normal cerebro-placental ratio (thus normal umbilical
17
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

artery and middle cerebral artery Dopplers), normal uterine artery Doppler, normal ductus
venosus Doppler, and normal amniotic fluid index. Cardiotocography and biophysical
profile are normal. What would be your recommendation for clinical management?
a) Follow-up in 2 weeks.
b) Follow-up in 1 week.
c) Elective delivery within the next few days.
d) Elective Caesarean section
e) No further follow up as Dopplers are normal

67. Biochemical or clinical hyperandrogenism is one of the most clinical characteristics of


women with PCOS and is associated with the elevated risk of metabolic disturbance and
liver disorder. The following statement is true about hyperandrogenism and anti-androgen
treatment in relationship to hepatic steatosis in women with PCOS:
a) Statins, a lipid lowering agent, are effective in reducing hyperandrogenemia in women
with PCOS
b) Statins are effective in reducing biopsy-proved liver-related morbidity and mortality in
women with PCOS.
c) Both elevated adrenal and ovarian androgen levels in women with PCOS are associated
with an increased risk of NAFLD.
d) Flutamide, a potent anti-androgen, used for treating acne and hirsutism in women with
PCOS, should be used with caution due to the concern of hepatotoxicity.
e) Oral contraceptives and spironolactone could be beneficial in treating menstrual
irregularity, hyperandrogenism and NAFLD (Non-alcoholic fatty liver disease) in
women with PCO

68. The following is true regarding the ultrasound assessment of ovarian morphology for
women in making the diagnosis of PCOS?
a) The threshold value for measurement of ovarian volume to diagnose PCOS in Asian
women is more than 7 cm3
b) Ovarian follicles numerically more than 12, measuring 2 to 9 mm, is a prerequisite of the
NIH 1990 criteria to diagnose PCOS
c) Higher prevalence of the polycystic ovarian morphology has been reported in Caucasian
PCOS populations compared to East Asian PCOS subjects
d) The ovary reaches its maximum volume before puberty
e) Age-related decline in antral follicle count (AFC) among women with PCOS is
slower than in those without PCOS

69. Insulin resistance leading to compensatory hyperinsulinaemia in PCOS results in increased


endogenous androgen levels via which of the following mechanisms?
a) Excess insulin binds to the insulin-like growth factor (IGF)-1 receptors
b) Excess insulin increases the synthesis of sex hormone binding globulin (SHBG) by the
liver
c) Excess insulin stimulates the hepatic secretion of insulin-like growth factor binding
protein (IGFBP)-1
d) Excess insulin acts synergistically with FSH
e) Excess insulin decreases cytochrome P450c17a enzyme activity

70. The following statements about the hypothalamic-pituitary ovarian axis is true:
18
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

a) Throughout the normal menstrual cycle, the GnRH pulse frequency and amplitude
remains consistent
b) The kiss 1 system located in the arcuate nucleus of the hypothalamus acts as the
GnRH pulse generator
c) Serum LH concentrations are universally elevated in women with PCOS
d) In women with PCOS, high levels of androgens directly affect LH pulsatility
e) Increased opioid and dopaminergic tone results in tonic hypersecretion of LH

71. In healthy women estrogen receptors are which of the following?


a) Absent in the secretory phase of the menstrual cycle
b) Expressed the highest levels in the secretory phase of the menstrual cycle
c) Downregulated by progesterone
d) Upregulated by progesterone
e) May have synergistic activation with insulin

72. The following is further true regarding women with PCOS:


a) Have been suggested to have an impaired endometrial steroid hormone response
and shallow placentation that may lead to pregnancy complications
b) Have a lower risk for pre-eclampsia and preterm delivery compared with controls
c) Have increased HOXA10 expression in secretory phase endometrium
d) May have decreased IGFBP-1 response to progesterone during decidualization
e) Present with an altered inflammatory endometrial profile

73. Which of the following is true regarding screening for markers related to altered
endometrial function?
a) There are several clinically validated specific markers related to impaired implantation
process or endometrial cancer in women with PCOS
b) In clinical practice women with PCOS should be regularly screened for endometrial
markers related to impaired endometrial function
c) More studies should be conducted to identify endometrial markers that have clinical
relevance in order to establish recommendations for clinical practice
d) Women with PCOS should be screened for endometrial cancer if they present with
several risk factors
e) Women with PCOS should be informed about their risk for endometrial and ovarian
cancer

74. Treating women with PCOS for endometrial abnormalities includes which of the following?
a) The factors impairing the peri-conceptual environment should be discussed with women
with PCOS prior to conception
b) Women with PCOS and with amenorrhea/oligomenorrhea should be treated with
progestins to protect the endometrium
c) Metformin has no evidence to have beneficial effects on endometrial health
d) Women should be encouraged to make life style changes to increase weight
e) Progestins may not be enough to rescue normal endometrial health in PCOS

75. Which of the following strategies has not been shown to arrest uterine fibroid growth?
a) Oestrogen antagonist action
b) Progesterone antagonist action
19
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

c) Ovarian removal
d) The combined oral contraceptive pill
e) Gonadotropin-releasing hormone analogues

76. Factors identified in the literature to date as potentially contributing to AUB in the context
of fibroids include which of the following?
a) Decreased vascular flow
b) Increased plasminogen-activator inhibitor-1 (PAI-1)
c) Increased transforming growth factor-beta (TGF-b)
d) Intramural fibroids
e) Decreased anti-thrombin III

77. Which of the following is/are true regarding medical treatments for uterine leiomyomas?
a) They have proliferative effects
b) They have fibrotic effects
c) They increase extracellular matrix production
d) They target growth factors and their signaling
e) They regulate angiogenesis

78. Which parameters is considered fundamental in the evaluation of submucous myomas?


a) Grading
b) Minimal free myometrial margin
c) Percentage of intra-cavity growth
d) The presence of a spiral feeding vessel
e) The presence of acoustic shadowing

79. Which features would be suspicious of a leiomyosarcoma?


a) Large solid myometrial mass
b) Rapid interval growth
c) Anechoic areas without shadowing
d) Myometrial lesion with radial stripes and vascular spaces
e) Rich vascularization

80. Prior to laparoscopic myomectomy, gonadotropin releasing hormone (GnRH) can be


administrated 3 to 4 months before for which of the following reasons?
a) To reduce surgical difficulty
b) To reduce fibroid volume
c) To improve pre and post-operative haemoglobin
d) To change the initially predicted surgical route
e) To shorten operative time

81. Regarding hysteroscopic myomectomy procedures, which of the following is true?


a) Cervical preparation with Misoprostol is associated with less operative complications
b) GnRH use is associated with a higher rate of complete resection of submucous myomas
c) The use of monopolar energy is associated with a higher rate of adverse events than
bipolar energy

20
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

d) The use of anti-adhesion barriers following procedures is associated with a higher


pregnancy rate
e) Resection of myomas over 6 cm in diameter is associated with more two-step
resections

82. Regarding lifestyle intervention in PCOS which of the following is true?


a) Weight loss of >20% total body weight is required to improve both metabolic and
reproductive outcomes
b) Exercise can improve metabolic parameters in the absence of weight loss
c) Modification of macronutrient content can augment weight loss
d) Combined exercise and dietary advice should be limited to overweight/obese women
e) The metabolic benefits of exercise between PCOS women and non-PCOS controls are
comparable

83. Regarding other therapies in PCOS which of the following is true?


a) Bariatric surgery should be avoided in women who plan to fall pregnant in the future
b) Metformin has been associated with reductions in BMI and adiposity in meta-
analysis data
c) Metformin increases the risk of OHSS with assisted reproductive technologies
d) Metformin is recommended as second-line therapy in overweight/obese PCOS women
with persistent menstrual irregularity despite lifestyle intervention
e) Thiazolidinediones such as rosiglitazone are recommended in PCOS women who cannot
tolerate metformin due gastrointestinal upset

84. The following is true in relation to serum AMH?


a) The correlation between AMH and the current diagnostic PCOS criteria is robust
b) There is a significant correlation between serum AMH and the antral follicle count
(AFC)
c) There is lack of international standardisation of the AMH assay
d) Each AMH result needs to interpreted depending upon the specific assay
e) It has been suggested that AMH could be used interchangeably with the AFC as a
diagnostic criterion for PCOS

85. Which of the following statements is false regarding AMH?


a) AMH is expressed by the granulosa cells in the ovarian antral follicles.
b) Serum AMH is significantly higher in women with PCOS than those with normal
ovaries.
c) High serum AMH values in PCOS are due to an increased concentration of antral
follicles.
d) High serum AMH values in PCOS are due to an increased production of AMH per antral
follicle.
e) Serum AMH values are significantly higher in the ovulatory phenotypes of PCOS
as compared to those with anovulation.

86. Which of the following serum levels are considered to be the single most sensitive test for
biochemical hyperandrogenism?
a) Total T
b) Free T
21
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

c) DHEAS
d) DHEA
e) A4

87.Which of the following should be included in the differential diagnosis of


hyperandrogenism?
a) 21-hydroxylase deficient non-classic congenital adrenal hyperplasia
b) Hypogonadotropic hypogonadism
c) Androgen-secreting neoplasms
d) Cushing's disease
e) 5a-reductase deficiency

88. Which of the following should be considered as first line treatment for hirsutism?
a) Hormonal contraceptives
b) Insulin sensitizers
c) 5-reductase agonists
d) Spironolactone
e) Glucocorticoids

89. The following statement is true about polycystic ovarian morphology (PCOM):
a) There is an increased number of primordial follicles in polycystic ovaries compared with
normal ovaries
b) Growth differentiation factor (GDF)-9 is under-expressed in polycystic ovaries
compared with normal ovaries

c) Anti-mllerian hormone (AMH) expression is greater in the primordial and primary


follicles from polycystic ovaries compared with the same stage follicles from normal
ovaries
d) AMH expression is greater in the antral follicles from polycystic ovaries compared
with the same stage follicles from normal ovaries
e) Vascular endothelial growth factor (VEGF) is over-expressed in the stroma of polycystic
ovaries compared with the stroma of normal ovaries

90. The following is true regarding the occurrence of adnexal masses in pregnancy
a) The incidence of adnexal masses in pregnancy is 1%
b) The incidence of ovarian cancers in pregnancy is between 1:1000
c) The most common type of benign ovarian cyst in pregnancy is a mature teratoma
d) The most common histopathological subtype for malignant ovarian tumor in
pregnancy is epithelial ovarian tumor
e) The resolution rate of adnexal masses in the second trimester of pregnancy is 60-70%

91. The following is true regarding the presentation and imaging of an ovarian cyst during
pregnancy.
a) The most common mode of presentation of an adnexal mass is pain
b) The sensitivity of detection of ovarian cysts on clinical examination alone is less than 5%.
c) The size of ovarian cyst that should prompt investigation for malignancy is 10 cm

22
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

d) The validated sensitivity and specificity of IOTA rules on USS evaluation of an


ovarian cyst is sensitivity: 78%, specificity: 87%
e) The sensitivity and specificity of MRI in the diagnosis of a malignancy is 100 and 94%
respectively

92. The following is pertinent to surgery in patients with persisting adnexal masses?
a) If required, surgery should ideally be scheduled beyond 24 weeks
b) A laparoscopic surgical approach should be adopted in patients with a persisting adnexal
mass in pregnancy
c) Poor fetal outcome with surgery is seen beyond 36 weeks
d) Hypertension is a common adverse effect noted with the use of laparoscopy in
pregnancy
e) For micro-papillary histopathological subtype of borderline ovarian tumors a
completion staging should be considered

93. The following points is true regarding patients receiving chemotherapy for ovarian cancer
during pregnancy.
a) In a patient with ovarian cancer in pregnancy receiving chemotherapy the delivery
should be planned at completion of chemotherapy
b) Chemotherapy use in pregnancy is generally considered safe beyond 20 weeks of
gestation
c) CNS and neural tube complications occur during the week 8-12 weeks in pregnancy
d) This percentage of patients receiving chemotherapy in pregnancy who develop major
congenital malformations is 30-40%

e) Cardiovascular defects are common congenital malformations in platin based


chemotherapy regimens

94. The following statement is true regarding diagnostic imaging performed during pregnancy:
a) For any imaging modality, the principle of using it only when clinically indicated,
for the shortest amount of time, and with the lowest level of energy compatible
with an accurate diagnosis should be employed.
b) Ionizing radiation can result in three harmful fetal effects: cell death (and related
teratogenic consequences), carcinogenesis, and genetic effects or mutations in germ
cells.
c) The generally accepted safe range of ionizing radiation during pregnancy is less than 20
rad.
d) The use of MRI with or without gadolinium is a safe imaging modality in pregnancy
because it utilizes magnets rather than ionizing radiation and gadolinium has not been
associated with adverse fetal effects.
e) The fetal thyroid does not concentrate iodine until the third trimester, therefore
radiopaque contrast agents can be safely used until that time.

95. The following statement is true regarding chemotherapy during pregnancy?


a) The all or none in fetal development refers to the third trimester just prior to delivery
at which point chemotherapy should not be used.

23
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

b) Combination chemotherapy is not associated with an increased risk of congenital


anomalies when compared to single-agent chemotherapy.
c) Exposure to chemotherapy in the second and third trimesters is associated with
fetal growth restriction, preterm delivery, and intrauterine fetal demise, however,
long-term complications have not been seen.
d) Biologic agents such as monoclonal antibodies are small molecules that can cross the
placenta at any point during pregnancy.
e) Tyrosine kinase inhibitors are small molecule agents that can cross the placenta at any
point during pregnancy and therefore can be administered in the first trimester.

96. The following statement regarding specific malignancies during pregnancy is true?
a) Breast cancer in pregnancy is most often axillary lymph node-positive and presents
with a larger primary tumor size than outside of pregnancy
b) With a finding of CIN2-3, colposcopy should be performed monthly to evaluate for
progression of disease
c) The diagnosis of adnexal masses during pregnancy is a common occurrence and
approximately 10% are found to be malignant
d) Acute leukemia adversely impacts a concurrent pregnancy
e) Melanoma is known to metastasize to both the placenta and the fetus

97. Problems encountered during delivery and postpartum period in patients with malignant
disease complicating pregnancy include which of the following?
a) Psychological distress
b) Increased postpartum haemorrhage
c) The need for more assistance to cope up with raising the child

d) Thromboembolism is more common


e) Malignancy is an indication for Caesarean section

98. In the management of vulval cancer in pregnancy which of the following is true?
a) Vulval cancer should be managed after delivery
b) Diagnostic biopsy is safe in pregnancy
c) CT scan is the preferred imaging for staging
d) Chemotherapy is not safe in pregnancy
e) Caesarean section is the preferred mode of delivery

99. Regarding lower genital tract cancers in pregnancy.


a) Adenocarcinoma is more common in pregnancy
b) The incidence of vulva cancer in younger women is decreasing
c) Vaginal clear cell cancer is common in pregnancy
d) Squamous carcinoma is the commonest lower genital tract cancer overall in
pregnancy
e) Vulval melanoma is more common in pregnancy

100. Regarding surgical management of lower genital tract cancers which of the following is
true?
a) There is evidence to NOT perform sentinel node sampling in pregnancy

24
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

b) It is better to perform inguinal or pelvic lymphadenectomy in the post-partum


period
c) Pelvic lymphadenectomy is recommended in lesions in the lower 1/3 of the vagina
d) Wide local excision of vulval lesions is contraindicated in pregnancy
e) Vulvectomy is most commonly performed in the post-partum period

101. The following is true regarding chemotherapy for breast cancer during pregnancy
a) It is generally only recommended after delivery
b) It must exclude all Taxanes
c) It is contraindicated only below 14 weeks of gestation
d) It must be given with an increased dose because of changes to maternal
pharmacokinetics
e) Altered maternal pharmacodynamics reduce the drug effect for many chemotherapeutic
agents

102. The following is true regarding termination of pregnancy:


a) It can improve maternal outcome when performed during the 1st trimester for
concurrent breast cancer
b) Overall it has no effect on oncologic survival
c) It is indicated for all patients receiving chemotherapy
d) It actually worsens maternal prognosis as shown in prospective trials
e) The reduction in oestrogen levels following TOP reduce the need for adjuvant anti-
oestrogen therapy

103. A 35yo lady G3P2A0, 18 weeks pregnant, is found to have a large cancer on the cervix
replacing the substance of the cervix and infiltrating the left parametrium. Rectovaginal
examination shows parametrial involvement which has not reached the pelvic side wall.
Pelvic MRI did not detect any suspicious nodes. The chest X-ray was negative. Which of
the following is true?
a) Laparoscopic pelvic lymph node dissection is contraindicated because at that
gestational age there is a low chance of harvesting a good number of lymph nodes
b) Careful discussion on pros/cons on pregnancy preserving management should be taken
in the presence of CNS nurse
c) Trachelectomy followed by cervical cerclage should be advised as a treatment option
in pregnancy preserving treatment
d) Chemotherapy should not be offered because lymph nodes are not suspicious on MRI
e) TOP followed by chemo/radiotherapy should be offered in pregnancy non-
preserving treatment

104. With regard to cervical cancer in pregnancy:


a) Cervical cancer is the most common malignancy detected in pregnancy
b) TOP and radical hysterectomy followed by PLND is mandatory in stage 1B1 disease
diagnosed during the second trimester
c) Cervical cancer is an indication for a classical caesarean section

25
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

d) In micro invasive tumors (Stages 1A1/1A2) diagnosed during the early second
trimester, pregnancy preserving management is not indicated and TOP should be
performed asap
e) Fetal viability is one of the most important aspects to be considered in the
management of cervical cancer in pregnancy

105. A 40 yo G4P3A0, 18 weeks pregnant, has had post coital bleeding for the last month.
Speculum examination showed a vaginal discharge and a 1 cm exophytic lesion on the
anterior cervical lip. She does not remember when she last time had a smear test. Which
of the following statements is true regarding her further management?
a) She should have a pap smear test performed
b) Punch biopsy of the lesion is indicated
c) Prescribe a dose of antibiotics and reassess the cervix when the vaginal discharge has
settled down
d) In view of the findings and the gestational age a cone biopsy should be offered as
treatment of the lesion
e) Assuming that the lesion has been biopsied and histology results showed cancer cells,
MRI without contrast should be considered as next step

106. Regarding chemotherapy in pregnancy:


a) The most important risk of using chemotherapy in the first trimester of pregnancy is
the occurrence of intrauterine growth restriction and low birth weight
b) The most important risk of using chemotherapy in second trimester of pregnancy, is
the occurrence of teratogenesis
c) Chemotherapeutic drugs cross freely into the fetal circulation
d) Cisplatin is the most commonly used drug in pregnancy
e) Neoadjuvant chemotherapy makes it possible for fertility preservation in selected
patients

107. The following statement is true regarding pre-malignant disease of the lower genital tract
in pregnancy:
a) CIN complicates 1% of pregnancies.
b) CIN progresses due to the relative immune-suppression of pregnancy.
c) CIN3 should be treated during pregnancy to prevent progression to cancer.
d) It is ideal to use pregnancy care as an opportunity to perform cervical cytology.
e) Suspicious vulval lesions noted during pregnancy, should be biopsied.

108. The following statement is true regarding colposcopy in pregnancy:


a) It increases the risk of preterm delivery and should ideally be avoided in pregnancy
b) It increases the risk of early miscarriage
c) An abnormal cytology result in pregnancy requires referral for colposcopy
d) It is only indicated if the woman previously had treatment for CGIN or treatment for
CIN2/3 with involved or uncertain margin
e) It can be undertaken by any colposcopist

109. The following statement is false regarding pregnancy-related outcomes:


a) HPV vaccination in pregnancy is not associated with an increase in stillbirth or
spontaneous miscarriage
26
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

b) Cold-knife and laser conisation are associated with an increased risk of preterm
delivery
c) Ablative treatments are associated with an increased risk of serious adverse
pregnancy outcomes
d) The risk of preterm delivery increases after multiple conisations
e) Most of the studies on adverse pregnancy outcomes after treatment for CIN are large
prospective studies

110. The following statement is true regarding the management of CIN in pregnancy:
a) Colposcopic directed biopsies are mandatory in the management of CIN in pregnancy
b) Punch biopsies are adequate to safely confirm or exclude invasive disease
c) Standard practice in the UK involves deferring definitive treatment until 3-4 months
postpartum if invasive cancer has been excluded
d) Colposcopy should be repeated at 3-monthly intervals during pregnancy if
CIN2/3 is suspected
e) Haemorrhage is more likely to occur if biopsies are taken in pregnancy

111. The following is false regarding radiotherapy in pregnancy:


a) Deterministic effects have a cause and effect relationship
b) Deterministic effects are radiation effects that occur by chance, for example,
induction of cancer
c) Deterministic effects mean that once a threshold dose has been exceeded the severity
of the effect will increase in a linear fashion with increasing dose
d) Stochastic effects have shown that risk increases in a linear quadratic relationship with
dose
e) The threshold dose a fetus can be exposed to is 0.1Gy

112. Which of the following tumour markers is increased by pregnancy itself and are therefore
less accurate in diagnosis and follow-up of pregnant cancer patients?
a) Squamous cell carcinoma antigen (SCC)
b) Human epididymis protein 4 (HE4)
c) Cancer antigen 125 (CA 125)
d) Carbohydrate antigen 15-3 (CA 15-3)
e) Anti-Mullerian hormone (AMH)

113. Regarding fetal oxygenation which of the following is true?


a) The fetus requires oxygen only to maintain cellular aerobic metabolism
b) Both glucose and oxygen can be stored allowing later mobilisation if required
c) Maternal respiratory complications alone can result in a downstream reduced
fetal oxygen supply
d) For there to be a significant reduction in the oxygen supply to the baby it usually
requires a combined materno-placento-fetal complication
e) In the event of utilisation of the anaerobic metabolism pathway, it yields 19 times the
production of lactic acid compared to aerobic.

114. Regarding fetal blood supply which of the following is true?


a) In the inter-villous space, de-oxygenated blood from the mothers spiral arteries flows
around the fetal chorionic villi, which contain oxygenated blood
27
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

b) The two umbilical veins transport deoxygenated blood and waste products from the
fetus to the placenta, while the umbilical artery provides the fetus with oxygenated
blood and nutrients from the mother.
c) The neonatal acidebase status is best reflected by the umbilical arterial blood
d) The venous umbilical blood contents depend on the maternal acidebase status and
placental function
e) Blood from the placenta passes via the umbilical vein almost unhindered through the
ductus venosus

115. Further regarding fetal blood supply which of the following is false?
a) The fetal cardiovascular system is designed such that the most highly oxygenated
blood is delivered to the myocardium and brain
b) Fetal circulatory adaptations are achieved by the presence of intra-cardiac shunts
c) Fetal circulatory adaptations are achieved by the presence of extra-cardiac shunts
d) The fetal carotid bodies contain baro-receptors for the detection of pressure
changes in the fetus
e) The fetal heart is equipped with baro and volume receptors which sense changes in the
pressure and volume of blood in the heart.

116. Regarding fetal metabolism which of the following is true?


a) Glycolysis results firstly in the conversion of glucose into pyruvate
b) Two ATP molecules are generated after the initial first step of glycolysis
c) Citric acid in the presence of oxaloacetate enters the Acetyl coenzyme A cycle.
d) The reaction CO2 H2O H2CO3 H HCO3 only occurs uni-directionally in
the placenta to facilitate CO2 elimination
e) The bicarbonate buffer is the main buffer system in plasma accounting for 35% of the
fetal buffering capacity in blood

117. Regarding fetal asphyxia which of the following is true?


a) Fetal asphyxia almost always occurs as a result of a gradual insufficiency in the
umbilical blood flow or insufficient uterine blood flow
b) Occlusion of one or more of the vessels in the umbilical cord impedes the circulation
to and from the fetus and during these events both the oxygen content of the fetal
blood may decrease and the CO2 content may increase
c) Excess fetal CO2 is initially removed by a large increase in fetal respiratory rate
d) Prolonged hypoxia leads to a further increase in CO2 content and further respiratory
acidosis
e) The accumulation of CO2 can deplete the buffer system causing failure of the ATP-
dependent sodiume potassium pump initiating a cascade that leads to cell injury and
death

118. Regarding the causes of intrapartum fetal hypoxia/acidosis, the following statement is
true?
a) Uterine contractions may decrease placental perfusion and reduce umbilical cord
circulation.
b) Aorto-caval compression by the pregnant uterus may cause sudden maternal
hypotension.
c) Maternal cardio-respiratory arrest is an irreversible cause of fetal hypoxia/acidosis.
28
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

d) Shoulder dystocia may cause umbilical cord compression.


e) Asking the mother not to push during contractions in the second stage of labour may
contribute to reducing fetal hypoxia/acidosis.

119. In relation to specific CTG patterns which of the following is true?


a) The sinusoidal pattern occurs secondary to subacute hypoxia
b) The saltatory pattern in combination with atypical or late decelerations reflects fetal
movements and should be considered as a reassuring feature.
c) In the presence of an atypical sinusoidal pattern, delivery should be expedited and
fetal hemoglobin tested immediately after birth as this pattern is suggestive of
feto-maternal hemorrhage
d) The saltatory pattern can also be called cycling
e) The typical sinusoidal pattern is suggestive of fetal thumb sucking.

120. A 25-year-old patient, P0A0, and her husband are planning to start a family. The patient
has started prenatal vitamins and neither she nor her husband are smokers. What are the
chances that she will become pregnant in the first 3 months?
(A) 1 0% to 1 5%
(B) 20% to 25%
(C) 3 5 % to 45%
(D) 45% to 55%

121. A 26-year-old woman, P0A0, presents to the office with the inability to conceive after 12
months of unprotected intercourse. She has regular periods and her husband has one child
from a previous relationship. Her medical history is positive for asthma and history of
Chlamydia when she was 19 . Surgical history is positive for tonsillectomy. What is the
most likely cause of her infertility?
(A) Male factor
(B) Premature ovarian failure
(C) Tubal factor
(D) Polycystic ovarian syndrome (PCOS)
(E) Diethylstilbestrol (DES) exposure in utero

122. A 24-year-old, P0A0 with a body mass index (BMI) of 34, presents to the office. She has
had only three periods in the last year, and she complains of moderate facial hair that she
has had treated with laser. She has no recent weight gain or fatigue. She desires pregnancy
in the next year. What is the next step in her workup?
(A) Refer her for assisted reproductive technology
(B) Order transvaginal ultrasound to assess ovaries
(C) Order a semen analysis
(D) Obtain hemoglobin/hematocrit
(E) Order testosterone and dehydroepiandrosterone sulfate (DHEAS)

123. A 38-year-old, P2A0, presents with her new husband and is interested in trying to
conceive. She is in good health, has no history of sexually transmitted infections (STis) ,
and does not smoke. Her husband has fathered a child in the past. What single test will
assess her chances of getting pregnant?
(A) Thyroid- stimulating hormone (TSH)
29
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(B) Prolactin
(C) Hemoglobin
(D) Follicle-stimulating hormone (FSH)
(E) Progesterone level

124. Your patient is a 30-year-old GO with a long history of irregular cycles, hirsutism, and an
ultrasound appearance consistent with Polycystic ovarian syndrome (PCOS) who presents
for preconception counseling. She is a nonsmoker and is already taking prenatal vitamins.
Her husband has fathered a child with a previous partner. She understands the
pathophysiology of PCOS and her ovaries. You discuss the use of medication to help her
conceive. What is mechanism of action of this medication?
(A) It is an antiestrogen that results in increased production of Follicle stimulating
hormone (FSH) and luteinizing hormone (LH)
(B) It decreases the conversion of androgens into estrogens which reduces the negative
feedback loop on the hypothalamus which increases FSH
(C) It inhibits gluconeogenesis and therefore allows the ovary to respond to normal
gonadotropin signals
(D) It interferes with the pulsatile release of FSH and LH from the anterior pituitary
(E) It binds GnRH receptors

125. A 29-year-old, P0A1, presents to your clinic desiring pregnancy. She had one ectopic
healthy and has normal menstrual cycles. What is the next step in her workup?
(A) Magnetic resonance imaging
(B) Clomid citrate challenge
(C) Hysterosalpingogram
(D) Saline infuse sonography
(D) In vitro fertilization

126. A 31-year- old, P0A0, with a long history of endometriosis presents to discuss future
childbearing. She has no genetic family history complicating her prenatal counseling. Her
husband is a nonsmoker with no medical problems. She has used birth control pills in the
past to control her menses and pain. She would like to proceed with the best option for her
to obtain pregnancy quickly. What would you recommend for this patient?
(A) Use depot leuprolide for 6 months and then attempt pregnancy
(B) Restart birth control pills for 3 months and then attempt pregnancy
(C) Perform laparoscopy with fulguration of endometrial implants and then attempt
pregnancy
(D) Start clomiphene therapy cycle with next cycle on days 5 to 9
(E) Offer intrauterine insemination

127. A 30-year-old, P1A0 , presents to clinic with intermittent thin milky discharge from both
nipples. The symptoms have been present for the past 6 months. The discharge is non-
bloody and is not associated with increased breast tenderness. The patient has also had
irregular menses lately. The patient says that up until recently her periods were always very
regular. The patient is currently not taking any medications. The pregnancy test in the
office is negative. The patient says the discharge occurs spontaneously without manual
stimulation and denies any recent changes in bras. In the office, the patient's blood pressure
(BP) is 120/75 mmHg, heart rate (HR) 82 beats/min, temperature (T) 36,5C, height 150
30
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

cm, and weight 70 kgs which is 10 kgs heavier than when you saw her last year. On
physical examination, the breasts are symmetric and no breast lesions or masses are
appreciated. A thin white discharge can be manually expressed bilaterally. What is the most
likely mechanism leading to these findings?
(A) Microadenoma of the pituitary gland leading to hyperprolactinemia
(B) Excessive stimulation of the nipple
(C) Renal failure leading to a decreased clearance of prolactin
(D) Hypothyroidism leading to an increased thyrotropin-releasing hormone (TRH)
which causes increased prolactin release
(E) Cushing disease leading to increased growth hormone causing hyperprolactinemia

128. A 32-year-old woman comes for her annual examination. The patient states that she has
been under a great deal of stress lately due to work. The patient also reports hair loss,
weight gain, and unusually light periods for the past 4 months. The patient attributes most
of these symptoms to stress and wonders if there is anything you can do to help. The
patient's only current medication is an oral contraceptive pill. The patient is currently not
sexually active and her last period ended 2 days ago. The pelvic and breast examinations
are normal. What is the next best step in the care of this patient?
(A) Refer the patient to a psychiatrist
(B) Prescribe alprazolam 0.25 mg PO TID with follow-up in 1 month
(C) Perform a pregnancy test
(D) Tell the patient to keep a daily basal body temperature log and return in 1 month
(E) Obtain a Thyroid- stimulating hormone (TSH) test

129. A 19-year-old girl presents to clinic with concern about amenorrhea for 2 months. She is
sexually active with one partner and uses the levonorgestrel intrauterine system for
contraception. Past history is relevant for a broken humerus when she was 7 and
Chlamydia found on routine sexually transmitted infection (STI) screening 1 year ago
which was treated as an outpatient. She subsequently had a negative test of cure. She has
recently started training for a half marathon and has lost 5 kgs over the past 3 months; she
is 155 cm and currently weighs 50 kgs. What is the appropriate next step?
(A) Serum Follicle- stimulating hormone (FSH)/ luteinizing hormone (LH) to evaluate for
hypothalamic anovulation secondary to weight loss
(B) Beta-human chorionic gonadotropin to rule out pregnancy as a result of
levonorgestrel intrauterine system failure
(C) Inform the patient that her amenorrhea is due to tubal scarring from pelvic
inflammatory disease (PID)
(D) No action required because anovulatory cycles are common in young women. Tell the
patient to return if she misses two more periods

130. 24-year-old, P0A0, presents to her obstetrician/gynecologist complaining of amenorrhea.


She states that her menses have always been irregular, but have become increasingly rare
over the past year and have now been entirely absent for 3 months. She is sexually active
with her husband for 2 years; they used to use condoms for contraception, but since she has
not been menstruating they have ceased using them. A urinary pregnancy test in the office
is negative. She has no history of sexually transmitted infections (STis). She is 160 cm and
weighs 90 kgs. Terminal hairs are evident on her jaw and upper lip, she has moderate acne,
and the skin of her axillae and the nape of her neck are darkly pigmented. Aside from
31
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

infertility, what is the major morbidity associated with the condition this woman likely
has?
(A) Diabetes mellitus type 2 (DM type 2)
(B) Ovarian carcinoma
(C) Congenital adrenal hyperplasia
(D) Coronary artery disease
(E) Endometrial cancer

131. A 22-year-old woman comes to see you for her annual examination. The patient expresses
frustration at not being able to lose weight despite regular exercise and a balanced diet. The
patient reports increased feelings of depression and thinks that the extra weight is causing
her to have acne. The patient has also noticed stiff dark hairs on her upper lip and chin
which is further decreasing her self- esteem. On examination, the patient's BP is 112/85
mmHg, HR 69 beats/min, height 150 cm, and weight 80 kgs. The thyroid, cardiac,
pulmonary, breast, and pelvic examinations are all normal. What is the most likely cause of
this patient's symptoms?
(A) Steroid abuse
(B) Idiopathic hirsutism
(C) Stein-Leventhal syndrome
(D) 2 1 -a - Hydroxylase deficiency
(E) von Hipple- Lindau disease

132. A 29-year-old, P0A0, comes to see you for an infertility evaluation. The patient has been
trying to conceive for the past 2 years. The patient's husband recently had a semen
analysis, and sperm count and motility were normal. Today, the patient's BP is 122/79
mmHg, pulse (P) 76 beats/min, and T 36.6C. The patient's current BMI is 33 . Initial labs
show an luteinizing hormone (LH) of 36 miU/mL, Follicle-stimulating hormone (FSH) of
8 miU/mL, Thyroid- stimulating hormone (TSH) of 1,6, normal dehydroepiandrosterone
(DHEA) , and mildly elevated androstenedione and testosterone. What is the best next step
in addressing the patient's infertility?
(A) Hysterosalpingography
(B) Combined estrogen and progesterone challenge
(C) Magnetic resonance imaging of the brain
(D) Ovulation induction with clomid
(E) Pelvic ultrasound

133. A 36-year-old, P2A0, presents to her primary care physician complaining of several
months' poor sleep, heat intolerance, newly irregular menses, and decreased libido. She
denies recent changes in weight, diet, or activity, and does not use alcohol or illicit drugs.
Her obstetric history includes two uncomplicated, full-term vaginal deliveries and one
firsttrimester spontaneous abortion. On examination, she is thin and tired appearing,
without exophthalmos or thyromegaly. Vital signs show the following: T 36.8C,
respiratory rate of 17 breaths/min, P 77 beats/min, and BP 142/88 mmHg. Her breasts are
nontender, without masses or nipple discharge. Pelvic examination reveals moderately
well-estrogenized vaginal mucosa and a small, nontender uterus with regular contours and
no palpable adnexal masses. A urinary pregnancy test is negative. What laboratory values
are appropriate to check at this time?

32
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(A) Follicle-stimulating hormone (FSH)/ luteinizing hormone (LH), prolactin,


Thyroid-stimulating hormone (TSH), complete blood count (CBC), basic
metabolic panel (BMP)
(B) CBC, BMP, serum ferritin/total iron-binding capacity (TIBC)
(C) Endometrial biopsy and CT abdomen/pelvis
(D) Adrenocorticotropic hormone (ACTH), dehydroepiandrosterone (DHEA) , 24-hour
cortisol, and memantine challenge
(E) -hCG serum

134. A 37-year-old, P1A0 , presents to clinic with 3 months of amenorrhea. Her history is
significant for obesity (BMI 30.6), occasional headaches, and moderate hypertension well
controlled with lisinopril/hydrochlorothiazide. Her one pregnancy was uncomplicated,
and the infant was born at term by normal spontaneous vaginal delivery. She and her
husband are sexually active and use condoms for contraception. A urinary pregnancy test
is negative. Serum Follicle-stimulating hormone (FSH)/luteinizing hormone (LH) are
both low. What is the most likely diagnosis?
(A) Polycystic ovarian syndrome (PCOS)
(B) Early menopause
(C) Prolactinoma
(D) Missed abortion
(E) Premature ovarian failure

135. A 16-year-old is brought into her primary care physician's office because her mother is
concerned that her daughter has not starting menstruating yet. In conversation with the
teenager, her doctor learns that she has been having low pelvic pain for the past few
months. On speculum examination, a dark bulging mass is identified 5 cm from the
vaginal introitus, and the hymenal ring is identified distal to the bulging mass. What is the
most likely etiology of this patient's condition?
(A) Failure of fusion of the paramesonephric duct and the urogenital sinus
(B) Failure of fusion of the mesonephric duct and the urogenital sinus
(C) Failure of fusion of the paramesonephric duct and the vitelline duct
(D) Failure of fusion of the mesonephric duct and the vitelline duct
(E) Failure of fusion of the urogenital sinus and the vitelline duct

136. A 19-year-old sexually active college student presents requesting oral contraception to
help clear up acne. Gender-specific history reveals she uses condoms inconsistently and
has had no menstrual period for 7 months. Three pregnancy tests at home have been
negative. Menarche began at 14. Periods occurred irregularly three to four times a year,
never heavy. Coitarche was at 17. Vital signs are as follows: P 88 beats/min, R 18
breaths/min, BP 110/68 mmHg, BMI 25, and height 140 cm. General physical
examination reveals a short-statured, well-proportioned woman with a moderate case of
acne. Gender-specific examination reveals the presence of both axillary and pubic hairs in
the appropriate distribution. Breast examination is Tanner stage 2. External genitalia
appear normal as does a speculum examination that reveals a normal vagina with a single
cervix. After Gonococcal/ Chlamydia trachomatis specimens are obtained, a bimanual
examination reveals a normal-sized uterus. Adnexa were nonpalpable bilaterally. Both
estrogen and testosterone levels are low. Follicle-stimulating hormone (FSH) is 35.

33
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

Pregnancy test is negative. Gonococcal/ Chlamydia trachomatis is negative. What is the


most likely diagnosis for this patient?
(A) Androgen insensitivity syndrome (AIS)
(B) Congenital adrenal hyperplasia
(C) Hypothalamic hypogonadism
(D) Swyer syndrome
(E) Turner syndrome

137. A 15 -year-old sexually active adolescent girl presents with primary amenorrhea. Vital
signs are as follows: BP 110/68 mmHg, P 88 beats/min, R 16 breaths/min, BMI 24, and
height 150 cm. An examination reveals normal external genitalia. A three-dimensional
(3D) ultrasound reveals the presence of uterus, tubes, and ovaries bilaterally. On
speculum examination, she has an unobstructed vagina and a patent cervical os. Breasts
are Tanner stage 2. She has scant axillary hair, Tanner stage 2, which has developed over
the past 6 months. Follicle- stimulating hormone (FSH) and luteinizing hormone (LH) are
low; Thyroid-stimulating hormone (TSH), estrogen, and testosterone levels are all within
normal limits. She relates that she has grown 2 cm in the last 3 months. What is the most
likely diagnosis?
(A) Androgen insensitivity syndrome (AIS)
(B) Anorexia nervosa
(C) Constitutional delay
(D) Turner syndrome
(E) Congenital adrenal hyperplasia

138. A 14-year-old adolescent presents with a history of primary amenorrhea. Her past medical
history is unremarkable as is her family history. Her vital signs are as follow: P 90
beats/min, respiratory rate 14 breaths/min, BP 124/76 mmHg, and BMI 21. General
physical examination reveals no evidence of acne. She has no axillary or pubic hair.
External genitalia are of normal female. Breasts are Tanner stage 4. She is not sexually
active so a three-dimensional (3D) pelvic ultrasound was performed revealing no evidence
of a uterus. What is the next step in evaluation?
(A) Chromosomal analysis
(B) Estrogen level
(C) Follicle- stimulating hormone (FSH) level
(D) Speculum and bimanual examination
(E) Testosterone level

139. Refer to the vignette in Question 138 to answer the question. In this case, the
chromosomal analysis reveals XY. What hormone is implicated in this case of
amenorrhea?
(A) Estrogen
(B) Testosterone
(C) dehydroepiandrosterone/sulfate (DHEA/S)
(D) Follicle- stimulating hormone (FSH)
(E) Thyrotropin- releasing hormone (TRH)

140. A 15 -year-old adolescent presents with a complaint of a vaginal discharge. Further history
reveals she had attempted to have intercourse with her 16-year- old boyfriend for the first
34
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

time a week earlier. The attempt was painful and her boyfriend commented that he could
not "enter" her. They presumed it was due to her hymen. A second attempt was equally
uncomfortable and the boyfriend became frustrated because he still could not enter her
vagina. Past medical history is positive for asthma that does not require medication.
Gender-specific history reveals she has never had a menstrual period, but her family
medicine doctor had told her 9 months ago that everything seemed normal and she should
just wait a bit longer since she had normal breast and axillary hair development. General
physical examination reveals vital signs as follows: P 78 beats/min, R 16 breaths/min, BP
126/82 mmHg, and BMI 28. Lungs clear to auscultation . A 10 cm solid, nontender mid-
abdominal mass is noted on deep palpation. No skeletal or hearing abnormalities noted.
Gender-specific examination: Tanner stage 4, breasts and external genitalia normal. Patient
could not tolerate a speculum examination and it was impossible to perform a satisfactory
bimanual examination partly due to the patient experiencing vaginismus. What is the most
likely diagnosis?
(A) Androgen insensitivity syndrome (AIS)
(B) Imperforate hymen
(C) Swyer syndrome
(D) Turner syndrome
(E) Vaginal agenesis

141. A 14-year-old girl presents to the resident clinic with complaint of no periods for the past 6
months. Menarche was at age 11 with regular periods for the last 2 years. Five months ago
she noted facial hair that has increased to the point of requiring shaving almost daily. She
is very embarrassed about this situation since it is impacting her social life. On physical
examination, breasts are Tanner stage 3 . Hirsutism is not noted due to the patient shaving.
Examination of the external genitalia reveals an enlarged clitoris, approximately 1 cm in
diameter.What is the most likely cause of her symptoms?
(A) Exogenous testosterone administration
(B) Brenner tumor
(C) Hyperthyroidism
(D) Polycystic ovarian disorder
(E) Sertoli-Leydig tumor

142. A 21-year-old presents to the local teen clinic concerned about several days of new frothy,
yellowish-green discharge with a foul odor. She endorses sexual intercourse with one male
partner in her lifetime. Her last encounter was 1 week ago. She uses combined oral
contraceptives for pregnancy prevention. She reports no history of cervical cytology
screening. Testing today includes a pregnancy test, wet prep, and nucleic acid amplification
tests of cervical samples. What should the clinic recommend for this patient regarding
cervical cytology screening?
(A) Immediate cervical cytology
(B) Cervical cytology in 1 year
(C) Cervical cytology in 2 years
(D) Cervical cytology in 3 years
(E) Cervical cytology in 4 years

143. A 67-year-old woman with a new diagnosis of cervical squamous cell carcinoma based on
cold-knife cone biopsy is undergoing an examination under anesthesia for clinical staging
35
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

of her cervical cancer. She does not have any urinary symptoms. In the operating room, a
soft mass is palpable in the posterior and lateral vaginal fornices extending into the
surrounding tissues, but it does not extend into the lower vagina. On rectovaginal
examination, the mass does not extend into the pelvic wall. What is the clinical staging for
this patient based on International Federation of Gynecology and Obstetrics (FIGO)
criteria?
(A) Stage I
(B) Stage II
(C) Stage III
(D) Stage IV

144. A 31-year-old G1P0A0 at 24 weeks 2 days by last menstrual period (LMP) dating with no
prenatal care presents to the emergency department for vaginal bleeding after intercourse.
She denies any loss of fluid and reports normal fetal movements. On examination, fundal
height is 25 cm, and fetal heart tones by Doppler are 140 bpm. Sterile speculum
examination reveals scant dark blood in the posterior vaginal vault and a friable appearing
cervix. Combined cervical cytology with human papillomavirus (HPV) DNA is done, and
the results show high-grade squamous intraepithelial lesion (HGSIL) . What is the next
step in the management for this patient?
(A) Repeat combined cervical cytology in 4 to 6 months
(B) Repeat combined cervical cytology in 12 months
(C) Immediate colposcopic examination
(D) Colposcopic examination at 6-week postpartum visit
(E) Immediate endocervical curettage

145. A 22-year- old, G1P0A0, presents to the emergency room with 5 days of worsening nausea
and vaginal bleeding. Last menstrual period (LMP) was 10 weeks ago. Pelvic examination
is significant for a 14-weeksized uterus. Quantitative human chorionic gonadotropin (hCG)
level is 120,000 units/mL, and ultrasound imaging reveals material within the endometrial
canal that has a "snowstorm" appearance. There are no fetal parts seen. The patient
undergoes an uncomplicated dilation and evacuation in the operating room, and the tissue
is sent for genetic testing. What is the most likely genetic constitution of the specimen?
(A) 69, XXX
(B) 69, XXY
(C) 46, XX
(D) 46, XY

146. A 28 -year-old, G3P2A0, presents to clinic for routine obstetric care. Last menstrual period
(LMP) was 12 weeks ago. A 10-week-sized uterus is found on pelvic examination, and a
subsequent ultrasound reveals a grossly abnormal fetus without cardiac activity. The
patient opts for uterine evacuation. Pathology inspection notes the presence of fetal parts,
focal villous edema, and focal trophoblastic proliferation. What is the most likely genetic
constitution of the specimen?
(A) 46, XX
(B) 46, XY
(C) Triploidy
(D) Aneuploidy

36
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

147. An otherwise healthy 24-year-old woman presents to her gynecologist because of


irregular, heavy vaginal bleeding for the past few days. She also complains of worsening
nausea, vomiting, headache, and dizziness over the past few weeks. She reports that her
last regular menstrual period before her current bleeding started was 6 weeks ago. On
examination, she has a slight tremor in both hands, an enlarged 10-weeksized uterus, and
blood coming from the cervical os. Urine -hCG is positive. Vital signs are temperature
36.8C, heart rate 100 beats/min, blood pressure 160/100 mmHg, and respiratory rate 16
breaths/min. What is the most likely diagnosis?
(A) Missed abortion
(B) Incomplete abortion
(C) Gestational hypertension
(D) Molar pregnancy
(E) Ectopic pregnancy

148. A 48-year-old perimenopausal woman presents with a chief complaint of perineal and
perianal burning. Vulvar colposcopy reveals multiple acetowhite lesions; biopsy of these
lesions reveals vulvar intraepithelial neoplasia (VIN). What is the expected course of this
patient's condition?
(A) Spontaneous regression without treatment is very common in this age group
(B) Progression of untreated disease in this patient's age group may be as high as
100%
(C) Treatment with topical 5 - fluorouracil (5 -FU) and Imiquimod is as effective as
surgical resection
(D) Post-treatment recurrence rates are as high as 60%
(E) Surgical resection is the best option

149. A 54-year- old P2A1 presents to your office for the first time with a chief complaint of
"feminine itching:' She has not had a gynecologic examination since the birth of her last
child 25 years ago and underwent menopause 3 years ago. She says that she has had
significant pruritus "for years;' occasionally accompanied by cracking and bleeding of the
affected area. She is clearly nervous, saying she has not sought treatment for this issue
sooner because she is afraid that something is "really wrong:' On examination, a single 3 -
cm lobular mass is noted on the right labia majora. Careful examination also reveals an
enlarged, painless right inguinal lymph node. The patient denies any recent weight loss,
pain, or changes in bowel or bladder habits. Surgical staging confirms that this mass is
squamous cell carcinoma with unilateral nodal involvement. What is the recommended
course of treatment?
(A) Wide radical local excision with ipsilateral inguinal lymph node dissection
(B) Modified radical vulvectomy with bilateral inguinal lymph node dissection
(C) Radical vulvectomy, bilateral inguinal lymph node dissection, and pelvic
exenteration
(D) Modified radical vulvectomy, bilateral inguinal lymph node dissection, and pelvic
exenteration
(E) Modified radical vulvectomy, ipilateral inguinal lymph node dissection, and pelvic
exenteration

150. A 28 -year-old woman presents to the emergency department with hemoptysis. She reports
that she has had increasing cough and shortness of breath over the past 8 weeks and that
37
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

she coughed up a dime- sized blood clot this morning. On review of systems, the patient
endorses heavy and irregular vaginal bleeding. She says that she had a spontaneous
abortion 6 months ago and that she started having increasingly irregular and heavy periods
about 4 months ago. On examination, her uterus is enlarged to 12-week size. Serum -hCG
is elevated, hemoglobin is 10 mg/dL, and chest X-ray reveals two dense areas in her lungs,
one in the right upper lobe and one in the left lower lobe. Which of the following is the
most likely diagnosis?
(A) Missed abortion
(B) Incomplete abortion
(C) Choriocarcinoma
(D) Molar pregnancy
(E) Ectopic pregnancy

151. A 69-year-old woman presents to her gynecologist complaining of vulvar itching for the
past 3 months . She was prescribed a topical antifungal cream by her primary care
provider 1 month ago, but did not experience any relief. Examination reveals a 6 - cm
red, raised lesion with sharp borders and small pale eczematous islands over the vulva
and inner thigh. What is the next step in the management of this patient?
(A) Prescribe single-dose oral fluconazole
(B) Prescribe oral valacyclovir
(C) Prescribe oral doxycycline and administer intramuscular ceftriaxone
(D) Prescribe hydrocortisone cream
(E) Perform a biopsy of the lesion

152. A 46-year-old asymptomatic patient with known human papillomavirus (HPV) 18


infection has had three Pap smears in the past year that revealed high-grade squamous
intraepithelial lesions (HGSIL). However, multiple cervical biopsies have failed to show
any evidence of neoplasia. Which of the following conditions is most likely to account
for these findings?
(A) Ovarian neoplasm
(B) Endometrial neoplasm
(C) Vaginal neoplasm
(D) Occult cervical neoplasm
(E) Chronic HPV infection

153. A 58-year-old woman with the history of polycystic ovary syndrome presents to her family
physician for heavy postmenopausal bleeding for the last week. Speculum examination
reveals dark blood in the vaginal vault with a normal-appearing cervix. Bimanual
examination reveals a 9-week-sized uterus with no adnexal masses. Rectovaginal
examination reveals no masses in the rectovaginal cul-de-sac. An in-office endometrial
biopsy is performed and sent for pathology. After histologic grade, what is the second
most important prognostic factor for endometrial carcinoma?
(A) Extent of uterine tube involvement
(B) Depth of myometrial invasion
(C) Location of lymph node metastases
(D) Involvement of bladder or bowel
(E) Vaginal metastases
38
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

154. A 67-year-old P0A0, obese woman with a 40-pack-year history presents to her
gynecologist for daily postmenopausal bleeding for the last 5 months. She reports menses
onset at age 11 and menopause at age 54. She has had no abnormal Pap smears and
reports negative human papillomavirus (HPV) testing. Which of the following is thought
to be protective against endometrial cancer?
(A) Nulliparity
(B) Obesity
(C) Smoking
(D) Early menarche
(E) Late menopause

155. A 2-year-old P2A1 who underwent a postpartum tubal ligation 6 weeks ago has a Pap
smear reported as an high-grade squamous intraepithelial lesion (HGSIL). At the time of
her postpartum examination, no visible lesions were noted on the cervix. The next step in
her management should be :
(A) Cold-knife cone biopsy
(B) Colposcopically directed biopsies
(C) Hysterectomy
(D) Laser therapy
(E) Local chemotherapy

156. A 35-year-old G2P1A0 presents with scant first-trimester bleeding. An ultrasound report
describes an empty gestational sac. Which of the following statements is correct regarding
this presentation?
(A) It is caused by an abnormality of the placenta
(B) It is the result of a genetic error
(C) The quantitative -hCG is likely to be unusually low
(D) It is most often due to paternal causes
(E) The risk of severe hemorrhage is increased

157. A 24-year-old woman presents to clinic with an atypical squamous cells of undetermined
significance (ASCUS) Pap. She had a Pap about 2 to 3 years ago, and it was normal. She
became sexually active at age 17 and has had two lifetime partners. She and her male
partner have been together for over a year. She started having periods at age 13 and has
regular cycles on her own. Her last period was 1 week ago on oral contraceptives. She has
a history of herpes simplex virus well controlled with daily acyclovir. Her physical
examination is normal. What is the next step?
(A) Repeat the Pap
(B) Get high-risk human papillomavirus (HPV) typing
(C) Get low-risk HPV typing
(D) Perform colposcopy
(E) Perform a conization

158. You are seeing a patient who is a 24-year-old woman P1A0 on Depo-Provera. Her Pap
showed low-grade squamous intraepithelial lesion (LGSIL). The patient had a normal
Pap 2 years ago when she was pregnant and has never had an STD. She became sexually
39
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

active at age 19 and has had one lifetime partner. She has not had Gardasil. She smoked a
pack of cigarettes per day until her pregnancy. What would you recommend?
(A) Repeat Pap immediately
(B) Gardasil and repeat Pap in 1 year
(C) Repeat Pap in 1 year
(D) Gardasil and repeat Pap in 6 weeks
(E) Colposcopy immediately

159. You are in the resident clinic seeing a patient for follow-up of an abnormal Pap showing
high-grade squamous intraepithelial lesion (HGSIL). The patient is a 25-year-old woman
P2A0 last menstrual period (LMP) 2 week's ago on oral contraceptive pills (OCPs). She
became sexually active at 20. She has recurrent genital herpes that she controls with
acyclovir. What is the next step in the evaluation of this patient?
(A) Repeat Pap now
(B) Repeat Pap in 1 year
(C) Colposcopy and biopsies
(D) High-risk human papillomavirus (HPV) typing
(E) Hysterectomy

160. A 7-year-old girl presents to her pediatrician with her parents who are concerned about her
early sexual development. She is developing breasts, axillary hair, and pubic hair, and
they are noticing body odor. A thorough clinical workup reveals the child has an irregular,
echogenic, thickly septated ovarian mass on her left ovary. What type of tumor is
responsible for this child's clinical presentation?
(A) Dysgerminoma
(B) Embryonal carcinoma
(C) Sertoli-Leydig cell tumor
(D) Endodermal sinus tumor
(E) Granulosa-theca cell tumor

161. A 9-year-old prepubertal girl presents to her pediatrician complaining of worsening


abdominal pain over the past 3 months. Physical examination demonstrates Tanner stage I
development and right lower quadrant tenderness. CT scan demonstrates a complex right
-sided ovarian mass, and she undergoes an exploratory laparoscopy to remove the mass.
The resulting pathology reveals chaotically arranged cartilaginous, dermal, and neural
tissue. This is consistent with which of the following tumor types?
(A) Dysgerminoma
(B) Mature teratoma
(C) Immature teratoma
(D) Embryonal carcinoma
(E) Endodermal sinus tumor

162. A 67-year-old woman presents with abdominal discomfort and bloating, 10 kgs weight
loss, decreased appetite, and fatigue. Vital signs are stable. Physical examination
demonstrates a menopausal woman witha large left adnexal mass detected on bimanual
examination. You perform a transvaginal ultrasound that shows an 8 - cm complex mass
with solid and cystic components, thick irregular septations, and an irregular surface.

40
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

Based on your clinical assumptions, what is the most likely course of management for
this patient?
(A) Chemotherapy
(B) Abdominal exploration with surgical resection
(C) Neoadjuvant chemotherapy, abdominal exploration, and surgical resection
(D) Abdominal exploration with surgical resection followed by chemotherapy
(E) Abdominal exploration with surgical resection followed by radiation

163. A 77-year-old woman with a history of cancer 10 years ago presents to your clinic
complaining of abdominal discomfort, bloating, and weight loss. Symptoms have been
increasing in severity for about 3 months. On physical examination, her abdomen is soft
with mild lower abdominal tenderness. On pelvic examination, you palpate masses
bilaterally. Assuming the masses are cancer, what is the most likely primary source of the
tumors?
(A) Bone
(B) Liver
(C) Breast
(D) Gastrointestinal tract
(E) Lymph nodes

164. A 26-year-old P2A0 presents for her annual gynecologic examination and would like to
discuss her risk of ovarian cancer. Menarche occurred at age 14. She used oral
contraceptive pills (OCPs) for 3 years prior to the birth of her first child when she was 23.
She breastfed both of her children for 1 year each. Her mother is 46 and currently is
undergoing chemotherapy for ovarian cancer, and she had a maternal aunt who passed
away in her 50 from breast cancer. What is this woman's greatest potential risk factor for
developing ovarian cancer?
(A) BRCA (breast cancer gene) mutation
(B) Hereditary nonpolyposis colorectal cancer (HNPCC) mutation
(C) Family history
(D) Early menarche
(E) Late childbearing

165. A 36-year-old woman presents to your clinic complaining of abnormal periods, acne,
thinning hair on her scalp, and increased coarse hair on her face, abdomen, and thighs.
She has no significant past medical history. She denies any history of abnormal pelvic
examinations or Pap smears. She has taken oral contraceptive pills (OCPs) for 10 years.
In addition to her complaints, on physical examination, you note vaginal atrophy and you
palpate a mass in the right adnexa. What is the most likely cause of her complaints?
(A) Adrenal tumor
(B) Dysgerminoma
(C) Granulosa cell tumor
(D) Serous cystadenocarcinoma
(E) Sertoli-Leydig cell tumor

166. A 28-year-old G2P1A0 at 15 week's gestation returns to your clinic to discuss her lab
results from her new obstetric visit. You inform her that all of her laboratory results were
within normal limits with the exception that her Pap smear cytology was reported at low-
41
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

grade squamous intraepithelial lesion (LGSIL). After further discussion, she tells you she
has had previous abnormal Pap smears in the past but has never had further workup done.
According to the current standard of care, what is the preferred approach in monitoring
her cervical dysplasia?
(A) No further workup until postpartum period
(B) Repeat Pap smear at 32 week's gestation
(C) Monitor for changes in pelvic examination or symptoms of irregular spotting at
monthly obstetric exams
(D) Colposcopy during this pregnancy
(E) HPV-DNA testing

167. A 27-year-old P3A1 returns to your clinic to follow up on the results of her annual Pap
smear. She has had a full annual examination including Pap smear since the age of 21 and
has never had abnormal cervical cytology. Her STD screening at her last examination was
normal. The cytology of her Pap smear showed high-grade squamous intraepithelial lesion
(HGSIL). You discuss the management options to the patient, and she decides to have a
colposcopy. The biopsy results of the colposcopy you perform are insufficient to give a
histology report. Which of the following options is the next best step in management for
this patient?
(A) Repeat Pap smear at 6-month intervals for a year
(B) Repeat colposcopy to obtain better sample
(C) Perform diagnostic excisional procedure such as Loop electrical excision
procedure (LEEP)
(D) Request that the lab repeats their tests on the biopsy samples given
(E) Conization

168. A 26-year-old presents to your clinic for follow-up on her Pap smear results. Her menses
occur at 34-day intervals and last approximately 4 days. She denies any irregular spotting
or dyspareunia. The cytology results from the Pap smear show low-grade squamous
intraepithelial lesion (LGSIL). She previously had not had any abnormal Pap smears and
has no history of STDs. What is the next best step in management?
(A) Repeat Pap smear in 6 months, biopsy if abnormal at that time
(B) Repeat Pap in 12 months
(C) Colposcopy with biopsy
(D) Loop electrical excision procedure (LEEP)
(E) Cold-knife cone

169. A 27-year- old returns to your clinic to follow up on the results of her annual Pap smear.
She has had a regular annual examinations including Pap smear since the age of 21 and has
never had abnormal cervical cytology. The patient reports having had chlamydia twice in
her life and was treated both times. Her STD screening at her last examination was normal.
The cytology of her Pap smear showed atypical squamous cells of undetermined
significance (ASCUS) . What are the treatment options for this patient?
(A) Repeat Pap smear at 6 months, if negative return to annual screening
(B) Repeat Pap smear at 6 and 12 months, if both negatives return to annual screening
(C) Proceed with colposcopy
(D) High-risk human papillomavirus (HPV) testing
(E) Colposcopy with biopsy
42
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

170. A 25 -year-old P2A0 woman presents to discuss birth control options. She denies any past
medical history and does not smoke tobacco. She is interested in taking a daily birth
control pill. You review the risks and benefits with her. You report one of the
noncontraceptive benefits to combined oral contraceptive pills (OCPs) is:
(A) Decreased risk of deep vein thrombosis
(B) Decreased risk of ovarian cancer
(C) Decreased incidence of migraine headaches
(D) Decreased risk of high blood pressure
(E) Decreased risk of breast cancer

171. A 21-year-old P0A0 patient calls your office requesting information on emergency
contraception. She had unprotected intercourse the previous night and wants to know if
Plan B (progesterone only) would still be an efficacious option, as well as any other risks
or benefits she should know about before taking the medication. Which of the following
statements should be included in her counseling?
(A) Plan B is most effective if taken within 72 hours of unprotected intercourse
(B) Plan B would disrupt a current pregnancy
(C) She can only take it if she is in the last 2 weeks of her cycle
(D) She must take two doses for it to be effective
(E) She should take Plan B and also use another contraceptive method

172. A 39-year-old P2A0 would like to discuss birth control at her postpartum visit. She is
breastfeeding exclusively and plans to attempt pregnancy again in the next year due to
her age and desire for at least one more child. She asks about lactational amenorrhea as a
form of birth control. Which of the following statements while counseling her on the
benefits and risks of this method you should include?
(A) She may ovulate before she has her first period
(B) She may have increased risk of postpartum depression
(C) This method should only be used for the first 12 months postpartum
(D) She should discontinue her prenatal vitamins
(E) she should breastfeed her baby at least every 4 hours/day

173. A 36-year-old P3A0 patient presents for discussion of contraception. She smokes tobacco
and has chronic hypertension. She is considering another pregnancy in the next year. You
review with her all of the progesterone-only options due to her smoking. She states that she
is interested in the depo-provera shot. What are you concerned about for this patient?
(A) An increase in irregular bleeding
(B) Return of regular ovulation after use of depo-provera can be 6 to 18 months
(C) An increased risk of endometrial cancer
(D) A high rate of failure with the depo-provera shot
(E) An increased risk of thromboembolic disease

174. A healthy 16-year-old girl presents to the emergency room for the third time this year due
to painful ovarian cysts. Examination is significant for a 5 cm mass in the right adnexa.
Ultrasonography confirms the presence of a simple ovarian cyst. Which of the following is
the most appropriate treatment to prevent further ovarian cyst formation in the future?
(A) Progestin-only oral contraceptives
43
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(B) Continuous low-dose oral estrogen


(C) Combination oral contraceptives
(D) Levonorgestrel intrauterine system (IUS)
(E) Mini pil

175. A 34-year-old woman has recently become sexually active. She often experiences
mittelschmerz (midcycle ovulatory pain) and hopes to find a method of birth control that
will decrease this occurrence. Which of the following contraceptive methods would be
inappropriate to offer the patient?
(A) Contraceptive vaginal ring
(B) Subdermal contraceptive implant
(C) Depot medroxyprogesterone acetate (DMPA)
(D) Progestin- only oral contraception
(E) Low dose estrogen

176. A 29-year-old woman with endometriosis has been on depot medroxyprogesterone acetate
(DMPA) for 4 years. She is very satisfied with this method of contraception, her resulting
amenorrhea, and with the decrease in her endometriosis associated pain. She wishes to
continue using DMPA; however, she is concerned about the U.S. Food and Drug
Administration warning that use beyond 2 years should be carefully considered due to the
adverse effects on bone mineral density. Which of the following is the most appropriate
next step in management?
(A) Advise her that she should immediately change contraceptive methods since she has
been on DMPA for over 2 years
(B) Refer her for bone densitometry and recommend that she continue to use D MPA if her
results are normal
(C) Place an etonogestrel contraceptive implant because this will have the same side effect
profile as DMPA without affecting bone mineral density
(D) Explain that decreases in bone mineral density appear to be substantially
reversible after discontinuation of DMPA and weigh her individual risks and
benefits
(E) Place DMPA with GnRH analogue

177. A 25-year-old, P2A0, presents for her routine annual gynecologic examination. She had an
Intrauterine device (IUD) placed for contraception 2 years ago and is very satisfied with
this method. The patient has no complaints and her physical examination is within normal
limits. Routine sexually transmitted infection screening was performed and she was found
to be positive for chlamydia. You inform the patient she will be treated with antibiotics.
What is the most appropriate next step in management?
(A) Immediately remove the IUD and inform her that she should no longer use IUDs for
contraception.
(B) Leave the IUD in place unless treatment fails and infection spreads.
(C) Leave the IUD in place unless she remains with her current sexual partner.
(D) Immediately remove the IUD and consider reinsertion 3 months after successful
treatment.
(E) Place the IUD with the new one

44
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

178. An 28 -year-old, G2P1A0 , presents to the emergency room due to a positive pregnancy
test with a copper Intrauterine device (IUD) in place. She does not have any pain or
bleeding. A pelvic ultrasound shows an intrauterine pregnancy consistent with 6 week's
gestation. On examination, the IUD strings are visualized protruding approximately 2 cm
from the cervical os. Although unplanned, the patient would like to continue the
pregnancy. Which of the following is the most appropriate course of action?
(A) Perform diagnostic laparoscopy to rule out heterotopic pregnancy
(B) Offer termination of pregnancy due to the risk of congenital anomalies
(C) No intervention at this time
(D) Remove the IUD in the emergency room
(E) Follow up in 4-6 weeks later

179. A 27-year-old, P1A0, and her husband desire to use natural family planning for
contraception. They decide to use the calendar method. Based on her regular 28-day cycle,
which of the following represents her fertile period?
(A) Days 14 through 21
(B) Days 10 through 17
(C) Days 7 through 14
(D) Days 12 through 19
(E) Days 16 through 25

180. A 29-year-old Caucasian primigravid patient is 20 weeks pregnant with twins. She found
out today on her routine ultrasound for fetal anatomy that she is carrying two boys. In this
patients case, which of the following statements about twinning is true?
a. The twins must be monozygotic since they are both males.
b. If division of these twins occurred after formation of the embryonic disk, the twins
will be conjoined.
c. She has a higher incidence of having monozygotic twins since she is Caucasian.
d. If the ultrasound showed two separate placentas, the twins must be dizygotic.
e. Twinning causes no appreciable increase in maternal morbidity and mortality over
singleton pregnancies.

181. A 24-year-old primigravida with twins presents for routine ultrasonography at 20 weeks
gestation. Based on the ultrasound findings, the patient is diagnosed with dizygotic twins.
Which of the following is true regarding the membranes and placentas of dizygotic twins?
a. They are dichorionic and monoamniotic only if the fetuses are of the same sex.
b. They are dichorionic and monoamniotic regardless of the sex of the fetuses.
c. They are monochorionic and monoamniotic if they are conjoined twins.
d. They are dichorionic and diamniotic regardless of the sex of the twins.
e. They are monochorionic and diamniotic if they are of the same sex.

182. After delivery of a term infant with Apgar scores of 2 at 1 minute and 7 at 5 minutes, you
ask that umbilical cord blood be collected for pH. The umbilical arteries carry which of the
following?
a. Oxygenated blood to the placenta
b. Oxygenated blood from the placenta
c. Deoxygenated blood to the placenta
d. Deoxygenated blood from the placenta
45
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

183. During the routine examination of the umbilical cord and placenta after a spontaneous
vaginal delivery, you notice that the baby had only one umbilical artery. Which of the
following is true regarding the finding of a single umbilical artery?
a. It is a very common finding and is insignificant.
b. It is a rare finding in singleton pregnancies and is therefore not significant.
c. It is an indicator of an increased incidence of congenital anomalies of the fetus.
d. It is equally common in newborns of diabetic and nondiabetic mothers.
e. It is present in 5% of all births.

184. A 22-year-old G1P0A0 at 28 weeks gestation by LMP presents to labor and delivery
complaining of decreased fetal movement. She has had no prenatal care. On the fetal
monitor there are no contractions. The fetal heart rate is 150 beats per minute and reactive.
There are no decelerations in the fetal heart tracing. An ultrasound is performed in the
radiology department and shows a 28-week fetus with normal-appearing anatomy and size
consistent with dates. The placenta is implanted on the posterior uterine wall and its margin
is well away from the cervix. A succenturiate lobe of the placenta is seen implanted low on
the anterior wall of the uterus. Doppler flow studies indicate a blood vessel is traversing
the cervix connecting the two lobes. This patient is most at risk for which of the following?
a. Premature rupture of the membranes
b. Fetal exsanguination after rupture of the membranes
c. Torsion of the umbilical cord caused by velamentous insertion of the umbilical cord
d. Amniotic fluid embolism
e. Placenta accreta

185. A healthy 34-year-old G1P0A0 patient comes to see you in your office for a routine OB
visit at 12 weeks gestational age. She tells you that she has stopped taking her prenatal
vitamins with iron supplements because they make her sick and she has trouble
remembering to take a pill every day. A review of her prenatal labs reveals that her
hematocrit is 39%. Which of the following statements is the best way to counsel this
patient?
a. Tell the patient that she does not need to take her iron supplements because her prenatal
labs indicate that she is not anemic and therefore she will not absorb the iron supplied in
prenatal vitamins
b. Tell the patient that if she consumes a diet rich in iron, she does not need to take any iron
supplements
c. Tell the patient that if she fails to take her iron supplements, her fetus will be anemic
d. Tell the patient that she needs to take the iron supplements even though she is not
anemic in order to meet the demands of pregnancy
e. Tell the patient that she needs to start retaking her iron supplements when her
hemoglobin falls below 11 g/dL

186. During a routine return OB visit, an 28-year-old G1P0A0 patient at 23 weeks gestational
age undergoes a urinalysis. The dipstick done by the nurse indicates the presence of trace
glucosuria. All other parameters of the urine test are normal. Which of the following is the
most likely etiology of the increased sugar detected in the urine?
a. The patient has diabetes.
b. The patient has a urine infection.
46
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

c. The patients urinalysis is consistent with normal pregnancy.


d. The patients urine sample is contaminated.
e. The patient has kidney disease.

187. A 29-year-old G1P0A0 patient at 24 weeks gestational age presents to your office
complaining of some shortness of breath that is more intense with exertion. She has no
significant past medical history and is not on any medication. The patient denies any chest
pain. She is concerned because she has always been very athletic and cannot maintain the
same degree of exercise that she was accustomed to prior to becoming pregnant. On
physical examination, her pulse is 72 beats per minute. Her blood pressure is 90/50 mm
Hg. Cardiac examination is normal. The lungs are clear to auscultation and percussion.
Which of the following is the most appropriate next step to pursue in the workup of this
patient?
a. Refer the patient for a ventilation-perfusion scan to rule out a pulmonary embolism
b. Perform an arterial blood gas
c. Refer the patient to a cardiologist
d. Reassure the patient
e. Order an ECG

188. A patient presents in labor at term. Clinical pelvimetry is performed. She has an oval-
shaped pelvis with the anteroposterior diameter at the pelvic inlet greater than the
transverse diameter. The baby is occiput posterior. The patient most likely has what kind of
pelvis?
a. A gynecoid pelvis
b. An android pelvis
c. An anthropoid pelvis
d. A platypelloid pelvis
e. An androgenous pelvis

189. The labor nurse calls you in your office regarding your patient who is 30 weeks pregnant
and complaining of decreased fetal movement. The fetus is known to have a ventricular
septal defect of the heart. The nurse has performed a nonstress test on the fetus. No
contractions are seen. She thinks the tracing shows either a sinusoidal or saltatory fetal
heart rate (FHR) pattern. Without actually reviewing the FHR tracing what can you tell the
nurse?
a. The FHR tracing is probably not a sinusoidal FHR pattern because this pattern can be
diagnosed only if the patient is in labor.
b. The FHR tracing is probably not a saltatory FHR pattern because this pattern is
almost always seen during rather than before labor.
c. The FHR tracing of the premature fetus should be analyzed by different criteria than
tracings obtained at term.
d. Fetuses with congenital anomalies of the heart will invariably exhibit abnormal FHR
patterns.
e. Neither sinusoidal nor saltatory fetal heart rate patterns are seen in premature
fetuses because of the immaturity of their autonomic nervous systems.

190. A 32-year-old poorly controlled diabetic G2P1A0 is undergoing amniocentesis at 38


weeks for fetal lung maturity prior to having a repeat cesarean section. Which of the
47
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

following laboratory tests results on the amniotic fluid would best indicate that the fetal
lungs are mature?
a. Phosphatidylglycerol is absent
b. Lecithin/sphingomyelin ratio of 1:1
c. Lecithin/sphingomyelin ratio of 1.5:1
d. Lecithin/sphingomyelin ratio of 2.0:1
e. Lecithin/sphingomyelin ratio of 2.0:1and phosphatidylglycerol is present

191. A 26-year-old G1P0A0 patient at 34 weeks gestation is being evaluated with Doppler
ultrasound studies of the fetal umbilical arteries. The patient is a healthy smoker. Her fetus
has shown evidence of intrauterine growth restriction (IUGR) on previous ultrasound
examinations. The Doppler studies currently show that the systolic to diastolic ratio (S/D)
in the umbilical arteries is much higher than it was on her last ultrasound 3 weeks ago and
there is now reverse diastolic flow. Which of the following is correct information to share
with the patient?
a. The Doppler studies indicate that the fetus is doing well.
b. With advancing gestational age the S/D ratio is supposed to rise.
c. These Doppler findings are normal in someone who smokes.
d. Reverse diastolic flow is normal as a patient approaches full term.
e. The Doppler studies are worrisome and indicate that the fetal status is
deteriorating.

192. A 17-year-old primipara at 41 weeks wants an immediate cesarean section. She is being
followed with biophysical profile (BPP) testing. Which of the following is correct
information to share with the patient?
a. BPP testing includes amniotic fluid volume, fetal breathing, fetal body movements, fetal
body tone, and contraction stress testing.
b. The false-negative rate of the BPP is 10%.
c. False-positive results on BPP are rare.
d. Spontaneous decelerations during BPP testing are associated with significant fetal
morbidity.
e. A normal BPP should be repeated in 1 week to 10 days in a post-term pregnancy.

193. A healthy 20-year-old G1P0A0 presents for her first OB visit at 10 weeks gestational age.
She denies any significant medical history both personally and in her family. Which of the
following tests is not part of the recommended first trimester blood testing for this patient?
a. Complete blood count (CBC)
b. Screening for human immunodeficiency virus (HIV)
c. Hepatitis B surface antigen
d. Blood type and screen
e. One-hour glucose challenge testing

194. A healthy 31-year-old G3P2A0 patient presents to the obstetricians office at 34 weeks
gestational age for a routine return visit. She has had an uneventful pregnancy to date. Her
baseline blood pressures were 100 to 110/60 to70, and she has gained a total of 15 kgs so
far. During the visit, the patient complains of bilateral pedal edema that sometimes causes
her feet to ache at the end of the day. Her urine dip indicates trace protein, and her blood
pressure in the office is currently 115/75. She denies any other symptoms or complaints.
48
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

On physical examination, there is pitting edema of both legs without any calf tenderness.
Which of the following is the most appropriate response to the patients concern?
a. Prescribe Lasix to relieve the painful swelling.
b. Immediately send the patient to the radiology department to have venous. Doppler
studies done to rule out deep vein thromboses.
c. Admit the patient to rule out preeclampsia.
d. Reassure the patient that this is a normal finding of pregnancy and no treatment is
needed.
e. Tell the patient that her leg swelling is caused by too much salt intake and instruct her to
go on a low-sodium diet.

195. A 28-year-old G1P0A0 presents to your office at 18 weeks gestational age for an
unscheduled visit secondary to right-sided groin pain. She describes the pain as sharp and
occurring with movement and exercise. She denies any change in urinary or bowel habits.
She also denies any fever or chills. The application of a heating pad helps alleviate the
discomfort. As her obstetrician, what should you tell this patient is the most likely
etiology of this pain?
a. Round ligament pain
b. Appendicitis
c. Preterm labor
d. Kidney stone
e. Urinary tract infection

196. A 29-year-old G1P0A0 presents to her obstetricians office for a routine OB visit at 32
weeks gestation. Her pregnancy has been complicated by gestational diabetes requiring
insulin for control. She has been noncompliant with diet and insulin therapy. She has had
two prior normal ultrasounds at 20 and 28 weeks gestation. She has no other significant
past medical or surgical history. During the visit, her fundal height measures 38 cm. Which
of the following is the most likely explanation for the discrepancy between the fundal
height and the gestational age?
a. Fetal hydrocephaly
b. Uterine fibroids
c. Polyhydramnios
d. Breech presentation
e. Undiagnosed twin gestation

197. A 43-year-old G1P0A0 who conceived via in vitro fertilization comes into the office for
her routine OB visit at 38 weeks. She denies any problems since she was seen the week
before. She reports good fetal movement and denies any leakage of fluid per vagina,
vaginal bleeding, or regular uterine contractions. She reports that sometimes she feels
crampy at the end of the day when she gets home from work, but this discomfort is
alleviated with getting off her feet. The fundal height measurement is 36 cm; it measured
37 cm the week before. Her cervical examination is 2 cm dilated. Which of the following is
the most appropriate next step in the management of this patient?
a. Instruct the patient to return to the office in 1 week for her next routine visit.
b. Admit the patient for induction caused by a diagnosis of fetal growth lag.
c. Send the patient for a sonogram to determine the amniotic fluid index.
d. Order the patient to undergo a nonstress test.
49
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

e. Do a fern test in the office.


198. A pregnant woman who is 7 weeks from her LMP comes in to the office for her first
prenatal visit. Her previous pregnancy ended in a missed abortion in the first trimester. The
patient therefore is very anxious about the well-being of this pregnancy. Which of the
following modalities will allow you to best document fetal heart action?
a. Regular stethoscope
b. Fetoscope
c. Special fetal Doppler equipment
d. Transvaginal sonogram
e. Transabdominal pelvic sonogram

199. A 30-year-old G2P1A0 patient comes to see you in the office at 37 weeks gestational age
for her routine OB visit. Her first pregnancy resulted in a vaginal delivery of a 3500 g baby
boy after 30 minutes of pushing. On doing Leopold maneuvers during this office visit, you
determine that the fetus is breech. Vaginal examination demonstrates that the cervix is 50%
effaced and 1 to 2 cm dilated. The presenting breech is high out of the pelvis. The
estimated fetal weight is about 2800 g. The patient denies having any contractions. You
send the patient for a sonogram, which confirms a fetus with a double footling breech
presentation. There is a normal amount of amniotic fluid present and the head is
hyperextended in the stargazer position. Which of the following is the best next step in
the management of this patient?
a. Allow the patient to undergo a vaginal breech delivery whenever she goes into labor.
b. Send the patient to labor and delivery immediately for an emergent cesarean section.
c. Schedule a cesarean section at or after 41 weeks gestational age.
d. Schedule an external cephalic version in the next few days.
e. Allow the patient to go into labor and do an external cephalic version at that time if the
fetus is still in the double footling breech presentation.

200. A healthy 23-year-old G1P0A0 has had an uncomplicated pregnancy to date. She is
disappointed because she is 40 weeks gestational age by good dates and a first-trimester
ultrasound. She feels like she has been pregnant forever, and wants to have her baby now.
The patient reports good fetal movement; she has been doing kick counts for the past
several days and reports that the baby moves about eight times an hour on average. On
physical examination, her cervix is firm, posterior, 50% effaced, and 1 cm dilated, and the
vertex is at a-1 station. As her obstetrician, which of the following should you recommend
to the patient?
a. She should be admitted for an immediate cesarean section.
b. She should be admitted for Pitocin induction.
c. You will schedule a cesarean section in 1 week if she has not undergone spontaneous
labor in the meantime.
d. She should continue to monitor kick counts and to return to your office in 1 week
to reassess the situation.
e. She should be admitted for cervical ripening.

201. A 29-year-old G1P0A0 presents to the obstetricians office at 41 weeks gestation. On


physical examination, her cervix is 1 centimeter dilated, 0% effaced, firm, and posterior in
position. The vertex is presenting at 3 station. Which of the following is the best next step
in the management of this patient?
50
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

a. Send the patient to the hospital for induction of labor since she has a favorable Bishop
score.
b. Teach the patient to measure fetal kick counts and deliver her if at any time there are less
than 20 perceived fetal movements in 3 hours.
c. Order BPP testing for the same or next day.
d. Schedule the patient for induction of labor at 43 weeks gestation.
e. Schedule cesarean delivery for the following day since it is unlikely that the patient will
go into labor.

202. Your patient had an ultrasound examination today at 39 weeks gestation for size less than
dates. The ultrasound showed oligohydramnios with an amniotic fluid index of 1.5
centimeters. The patients cervix is unfavorable. Which of the following is the best next
step in the management of this patient?
a. Admit her to the hospital for cesarean delivery.
b. Admit her to the hospital for cervical ripening then induction of labor.
c. Write her a prescription for misoprostol to take at home orally every 4 hours until she
goes into labor.
d. Perform stripping of the fetal membranes and perform a BPP in 2 days.
e. Administer a cervical ripening agent in your office and have the patient present to the
hospital in the morning for induction with oxytocin.

203. A healthy 30-year-old G1P0A0 at 41 weeks gestational age presents to labor and delivery
at 11:00 PM because she is concerned that her baby has not been moving as much as
normal for the past 24 hours. She denies any complications during the pregnancy. She
denies any rupture of membranes, regular uterine contractions, or vaginal bleeding. On
arrival to labor and delivery, her blood pressure is initially 140/90 but decreases with rest
to 120/75. Her prenatal chart indicates that her baseline blood pressures are 100 to 120/60
to 70 mm Hg. The patient is placed on an external fetal monitor. The fetal heart rate
baseline is 180 beats per minute with absent variability. There are uterine contractions
every 3 minutes accompanied by late fetal heart rate decelerations. Physical examination
indicates that the cervix is long/closed/2. Which of the following is the appropriate plan
of management for this patient?
a. Proceed with emergent cesarean section.
b. Administer intravenous MgSO4 and induce labor with Pitocin.
c. Ripen cervix overnight with prostaglandin E1 and proceed with oxytocin induction in
the morning.
d. Admit the patient and schedule a cesarean section in the morning, after the
patient has been NPO for 12 hours.
e. Induce labor with prostaglandin E1.

204. A 27-year-old G3P2A0, who is 34 weeks gestational age, calls the oncall obstetrician on a
Saturday night at 10:00 PM complaining of decreased fetal movement. She says that
yesterday her baby has moved only once per hour. For the past 6 hours she has felt no
movement. She is healthy, has had regular prenatal care, and denies any complications so
far during the pregnancy. Which of the following is the best advice for the on-call
physician to give the patient?
a. Instruct the patient to go to labor and delivery for a contraction stress test.

51
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

b. Reassure the patient that one fetal movement per hour is within normal limits and she
does not need to worry.
c. Recommend the patient be admitted to the hospital for delivery.
d. Counsel the patient that the baby is probably sleeping and that she should continue to
monitor fetal kicks. If she continues to experience less than five kicks per hour by
morning, she should call you back for further instructions.
e. Instruct the patient to go to labor and delivery for a nonstress test.

205. Your patient complains of decreased fetal movement at term. You recommend a modified
BPP test. Nonstress testing (NST) in your office was reactive. The next part of the
modified BPP is which of the following?
a. Contraction stress testing
b. Amniotic fluid index evaluation
c. Ultrasound assessment of fetal movement
d. Ultrasound assessment of fetal breathing movements
e. Ultrasound assessment of fetal tone

206. You are seeing a patient in the hospital for decreased fetal movement at 36 weeks
gestation. She is healthy and has had no prenatal complications. You order a BPP. The
patient receives a score of 8 on the test. Two points were deducted for lack of fetal
breathing movements. How should you counsel the patient regarding the results of the
BPP?
a. The results are equivocal, and she should have a repeat BPP within 24 hours.
b. The results are abnormal, and she should be induced.
c. The results are normal, and she can go home.
d. The results are abnormal, and she should undergo emergent cesarean section.
e. The results are abnormal, and she should undergo umbilical artery Doppler
velocimetry.

207. A healthy 30-year-old G2P1A0 presents to the obstetricians office at 34 weeks for a
routine prenatal visit. She has a history of a cesarean section (low transverse) performed
secondary to fetal malpresentation (footling breech). This pregnancy, the patient has had an
uncomplicated prenatal course. She tells her physician that she would like to undergo a
trial of labor during this pregnancy. However, the patient is interested in permanent
sterilization and wonders if it would be better to undergo another scheduled cesarean
section so she can have a bilateral tubal ligation performed at the same time. Which of the
following statements is true and should be relayed to the patient?
a. A history of a previous low transverse cesarean section is a contraindication to vaginal
birth after cesarean section (VBAC).
b. Her risk of uterine rupture with attempted VBAC after one prior low transverse cesarean
section is 4% to 9%.
c. Her chance of having a successful VBAC is less than 60%.
d. The patient should schedule an elective induction if not delivered by 40 weeks.
e. If the patient desires a bilateral tubal ligation, it is safer for her to undergo a
vaginal delivery followed by a postpartum tubal ligation rather than an elective
repeat cesarean section with intrapartum bilateral tubal ligation.

52
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

208. A 21-year-old primigravida presents to your office at 35 weeks gestation. Her blood
pressure is 170/110 mm Hg and she has 4+ proteinuria on a clean catch specimen of urine.
She has significant swelling of her face and extremities. She denies having contractions.
Her cervix is closed and uneffaced. The baby is breech by bedside ultrasonography. She
says the babys movements have decreased in the past 24 hours. Which of the following is
the best next step in the management of this patient?
a. Send her to labor and delivery for a BPP.
b. Send her home with instructions to stay on strict bed rest until her swelling and blood
pressure improve.
c. Admit her to the hospital for enforced bed rest and diuretic therapy to improve her
swelling and blood pressure.
d. Admit her to the hospital for induction of labor.
e. Admit her to the hospital for cesarean delivery.

209. While you are on call at the hospital covering labor and delivery, a 32-year-old G3P2A0,
who is 35 weeks of gestation, presents complaining of lower back pain. The patient
informs you that she had been lifting some heavy boxes while fixing up the babys nursery.
The patients pregnancy has been complicated by diet-controlled gestational diabetes. The
patient denies any regular uterine contractions, rupture of membranes, vaginal bleeding, or
dysuria. She denies any fever, chills, nausea, or emesis. She reports that the baby has been
moving normally. She is afebrile and her blood pressure is normal. On physical
examination, you note that the patient is obese. Her abdomen is soft and nontender with no
palpable uterine contractions. No costovertebral angle tenderness can be elicited. On pelvic
examination her cervix is long and closed. The external fetal monitor indicates a reactive
fetal heart rate strip; there are rare irregular uterine contractions demonstrated on the
tocometer. The patients urinalysis comes back with trace glucose, but is otherwise
negative. The patients most likely diagnosis is which of the following?
a. Labor
b. Musculoskeletal pain
c. Urinary tract infection
d. Chorioamnionitis
e. Round ligament pain

210. A 29-year-old G3P2A0 presents to the emergency center with complaints of abdominal
discomfort for 2 weeks. Her vital signs are: blood pressure 120/70 mm Hg, pulse 90 beats
per minute, temperature 36.9C, respiratory rate 18 breaths per minute. A pregnancy test is
positive and an ultrasound of the abdomen and pelvis reveals a viable 16-week gestation
located behind a normal-appearing 10 6 5.5 cm uterus. Both ovaries appear normal. No
free fluid is noted. Which of the following is the most likely cause of these findings?
a. Ectopic ovarian tissue
b. Fistula between the peritoneum and uterine cavity
c. Primary peritoneal implantation of the fertilized ovum
d. Tubal abortion
e. Uterine rupture of prior cesarean section scar

211. A 24-year-old presents at 30 weeks with a fundal height of 50 cm. Which of the following
statements concerning polyhydramnios is true?
a. Acute polyhydramnios rarely leads to labor prior to 28 weeks.
53
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

b. The incidence of associated malformations is approximately 3%.


c. Maternal edema, especially of the lower extremities and vulva, is rare.
d. Esophageal atresia is accompanied by polyhydramnios in nearly 10% of cases.
e. Complications include placental abruption, uterine dysfunction, and postpartum
hemorrhage.

212. A 20-year-old G1P0A0 at 32 weeks presents for her routine obstetric (OB) visit. She has
no medical problems. She is noted to have a blood pressure of 150/96 mm Hg, and her
urine dip shows 1+ protein. She complains of a constant headache and vision changes that
are not relieved with rest or a pain reliever. The patient is sent to the hospital for further
management. At the hospital, her blood pressure is 158/98 mm Hg and she is noted to have
tonic-clonic seizure. Which of the following is indicated in the management of this patient?
a. Low-dose aspirin
b. Dilantin (phenytoin)
c. Antihypertensive therapy
d. Magnesium sulfate
e. Cesarean delivery

213. During routine ultrasound surveillance of a twin pregnancy, twin A weighs 1200 g and
twin B weighs 750 g. Hydramnios is noted around twin A, while twin B has
oligohydramnios. Which statement concerning the ultrasound findings in this twin
pregnancy is true?
a. The donor twin develops hydramnios more often than does the recipient twin.
b. Gross differences may be observed between donor and recipient placentas.
c. The donor twin usually suffers from a hemolytic anemia.
d. The donor twin is more likely to develop widespread thromboses.
e. The donor twin often develops polycythemia.

214. A 32-year-old G5P1A3 presents for her first prenatal visit. A complete obstetrical,
gynecological, and medical history and physical examination is done. Which of the
following would be an indication for elective cerclage placement?
a. Three spontaneous first-trimester abortions
b. Twin pregnancy
c. Three second-trimester pregnancy losses without evidence of labor or abruption
d. History of loop electrosurgical excision procedure for cervical dysplasia
e. Cervical length of 35 mm by ultrasound at 18 weeks

215. A 32-year-old G2P1A0 presents to labor and delivery at 34 weeks of gestation,


complaining of regular uterine contractions about every 5 minutes for the past several
hours. She has also noticed the passage of a clear fluid per vagina. A nurse places the
patient on an external fetal monitor and calls you to evaluate her status. The external fetal
monitor demonstrates a reactive fetal heart rate tracing, with regular uterine contractions
occurring about every 3 to 4 minutes. On sterile speculum examination, the cervix is
visually closed. A sample of pooled amniotic fluid seen in the vaginal vault is fern and
nitrazine-positive. The patient has a temperature of 38.8C, pulse 102 beats per minute,
blood pressure 100/60 mm Hg, and her fundus is tender to deep palpation. Her admission
blood work comes back indicating a WBC of 19.000/mm 3. The patient is very concerned
because she had previously delivered a baby at 35 weeks who suffered from respiratory
54
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

distress syndrome (RDS). You perform a bedside sonogram, which indicates


oligohydramnios and a fetus whose size is appropriate for gestational age and with a
cephalic presentation. Which of the following is the most appropriate next step in the
management of this patient?
a. Administer betamethasone
b. Administer tocolytics
c. Place a cervical cerclage
d. Administer antibiotics
e. Perform emergent cesarean section

216. A 30-year-old G1P0A0 with a twin gestation at 25 weeks presents to labor and delivery
complaining of irregular uterine contractions and back pain. She reports an increase in the
amount of her vaginal discharge, but denies any rupture of membranes. She reports that
earlier in the day she had some very light vaginal bleeding, which has now resolved. On
arrival to labor and delivery, she is placed on an external fetal monitor, which indicates
uterine contractions every 2 to 4 minutes. She is afebrile and her vital signs are all normal.
Her gravid uterus is nontender. The nurses call you to evaluate the patient. Which of the
following is the most appropriate first step in the evaluation of vaginal bleeding in this
patient?
a. Vaginal examination to determine cervical dilation
b. Ultrasound to check placental location
c. Urine culture to check for urinary tract infection
d. Labs to evaluate for disseminated intravascular coagulopathy
e. Apt test to determine if blood is from the fetus

217. A 30-year-old G1P0A0 with twin gestation at 28 weeks is being evaluated for vaginal
bleeding and uterine contractions. A bedside ultrasound examination rules out the presence
of a placenta previa. Fetal heart rate tracing is reactive on both twins, and the uterine
contractions are every 2 to 3 minutes and last 60 seconds. A sterile speculum examination
is negative for rupture membranes. A digital examination indicates that the cervix is 2 to 3
cm dilated and 50% effaced, and the presenting part is at 3 station. Tocolysis with
magnesium sulfate is initiated and intravenous antibiotics are started for group B
streptococcus prophylaxis. Betamethasone, a corticosteroid, is also administered. Which of
the following statements regarding the use of betamethasone in the treatment of preterm
labor is true?
a. Betamethasone enhances the tocolytic effect of magnesium sulfate and decreases the risk
of preterm delivery.
b. Betamethasone has been shown to decrease intraamniotic infections.
c. Betamethasone promotes fetal lung maturity and decreases the risk of respiratory
distress syndrome.
d. The anti-inflammatory effect of betamethasone decreases the risk of GBS sepsis in the
newborn.
e. Betamethasone is the only corticosteroid proven to cross the placenta.

218. A maternal fetal medicine specialist is consulted and performs an in-depth sonogram on a
30-year-old G1P0A0 at 28 weeks with a twin gestation. The sonogram indicates that the
fetuses are both male, and the placenta appears to be diamniotic and monochorionic. Twin
55
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

B is noted to have oligohydramnios and to be much smaller than twin A. Which of the
following would be a finding most likely associated with twin A?
a. Congestive heart failure
b. Anemia
c. Hypovolemia
d. Hypotension
e. Low amniotic fluid level

219. A 30-year-old G1P0A0 at 28 weeks gestation with a twin pregnancy is admitted to the
hospital for preterm labor with regular painful contractions every 2 minutes. She is 3 cm
dilated with membranes intact and a small amount of bloody show. Ultrasound reveals
growth restriction of twin A and oligohydramnios, otherwise normal anatomy. Twin B has
normal anatomy and has appropriate-for-gestational-age weight. Which of the following is
a contraindication to the use of indomethacin as a tocolytic in this patient?
a. Twin gestation
b. Gestational age greater than 26 weeks
c. Vaginal bleeding
d. Oligohydramnios
e. Fetal growth restriction

220. A 34-year-old G2P1A0 at 31 weeks gestation with a known placenta previa is admitted to
the hospital for vaginal bleeding. The patient continues to bleed heavily and you observe
persistent late decelerations on the fetal heart monitor with loss of variability in the
baseline. Her blood pressure and pulse are normal. You explain to the patient that she needs
to be delivered. The patient is delivered by cesarean section under general anesthesia. The
baby and placenta are easily delivered, but the uterus is noted to be boggy and atonic
despite intravenous infusion of oxytocin. Which of the following is contraindicated in this
patient for the treatment of uterine atony?
a. Methylergonovine (Methergine) administered intramuscularly
b. Prostaglandin F2 (Hemabate) suppositories
c. Misoprostol (Cytotec) suppositories
d. Terbutaline administered intravenously
e. Prostaglandin E2 suppositories

221. A 38-year-old G4P3A0 at 33 weeks gestation is noted to have a fundal height of 29 cm on


routine obstetrical visit. An ultrasound is performed by the maternal-fetal medicine
specialist. The estimated fetal weight is determined to be in the fifth percentile for the
estimated gestational age. The biparietal diameter and abdominal circumference are
concordant in size. Which of the following is associated with symmetric growth
restriction?
a. Nutritional deficiencies
b. Chromosome abnormalities
c. Hypertension
d. Uteroplacental insufficiency
e. Gestational diabetes

222. A 38-year-old G2P1A0 comes to see you for her first prenatal visit at 10 weeks gestational
age. She had a previous term vaginal delivery without any complications. You detect fetal
56
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

heart tones at this visit, and her uterine size is consistent with dates. You also draw her
prenatal labs at this visit and tell her to follow up in 4 weeks for a return OB visit. Two
weeks later, theresults of the patients prenatal labs come back. Her blood type is A, with
an anti-D antibody titer of 1:4. Which of the following is the most appropriate next step in
the management of this patient?
a. Schedule an amniocentesis for amniotic fluid bilirubin at 16 weeks
b. Repeat the titer in 4 weeks
c. Repeat the titer at 28 weeks
d. Schedule Percutaneous Umbilical Blood Sampling (PUBS) to determine fetal hematocrit
at 20 weeks
e. Schedule PUBS as soon as possible to determine fetal blood type

223. A 23-year-old G3P1A1 at 6 weeks presents for routine prenatal care. She had a cesarean
delivery 3 years ago for breech presentation after a failed external cephalic version. Her
daughter is Rh-negative. She also had an elective termination of pregnancy 1 year ago. She
is Rh-negative and is found to have a positive anti-D titer of 1:8 on routine prenatal labs.
Failure to administer RhoGAM at which time is the most likely cause of her sensitization?
a. After elective termination
b. At the time of cesarean delivery
c. At the time of external cephalic version
d. Within 3 days of delivering an Rh-negative fetus
e. At 28 weeks in the pregnancy for which she had a cesarean delivery

224. An 18 -year-old G1P0A0 with inadequate prenatal care presents to labor and delivery in
active labor at approximately 38 weeks by last menstrual period (LMP). Her admission
history and physical examination are unremarkable and labor progresses with no
complications. However, upon delivery the infant is in respiratory distress, has a protruding
abdomen, and is covered in a bullous rash. Which of the following tests performed on the
mother might further clarify her infant's condition?
(A) Herpes simplex virus serum antibody screen
(B) Gonorrhea and chlamydia urine polymerase chain reaction
(C) Serologic testing for Treponema pallidum
(D) Serologic testing for Toxoplasmosis
(E) HIV serum antibody screen

225. A 27-year-old, G1P0A0, is now at 1 8 week's gestation. Her first trimester was
complicated by a false-positive result on first-trimester screening for trisomy 21. She had
chorionic villus sampling (CVS) that revealed a fetal karyotype of 46, XY. What additional
screening test does she need at this time?
(A) No additional screening
(B) Quadruple screen
(C) Integrated screen
(D) Maternal serum a-fetoprotein (MSAFP)
(E) Cordocentesis

226. A 55-year-old man and his 30-year-old wife present for preconception genetic counseling.
A thorough family history shows no significant genetic disorders on either side. The couple

57
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

is informed that advanced paternal age predisposes the fetus to an increased risk of the
following:
(A) Autosomal recessive disorders
(B) X-linked recessive disorders
(C) Mitochondrial mutations
(D) X-linked dominant disorders
(E) Y chromosome disorders

227. A 25-year-old, G2P0A1, and her husband present for a routine second trimester ultrasound
at 20 week's gestation. She had previously declined both first- and second-trimester genetic
screening. On US, a structural defect is discovered and an amniocentesis is offered to the
patient. Which of the following defects is most likely to be associated with aneuploidy?
(A) Gastroschisis
(B) Single umbilical artery
(C) Facial cleft
(D) Cystic hygroma
(E) Club foot

228. A 40-year-old, G4P3A0, presents with an unintended pregnancy at 10 week's gestation.


She is concerned about her risk of Down syndrome and wishes to pursue the most effective
genetic screening modality. What screening test will have the highest detection rate for
Down syndrome?
(A) First-trimester screening
(B) Second-trimester quadruple screening
(C) Stepwise sequential screening
(D) Serum integrated screening

229. A 29-year-old G2P0A1 woman comes to see you at 6 weeks for her first prenatal visit. The
patient had one previous pregnancy that ended in spontaneous abortion. The fetus had
multiple congenital anomalies consistent with trisomy 18. The patient is now concerned
that she could lose the current pregnancy and would like early prenatal testing. The patient
read about chorionic villus sampling (CVS) and would like the procedure performed as
soon as possible. What is the mechanism of limb reduction in CVS before 9 weeks?
(A) Destruction of large areas of the chorionic villus
(B) Direct trauma to the growing fetus
(C) Vascular interruption to the growing fetus
(D) Leakage of amniotic fluid leading to oligohydramnios
(E) Lung hypoplasia

230. A 37-year-old G3P1A1 at 12-week gestational age (GA) presents to the high-risk
maternity clinic for counseling after routine blood testing showed elevated levels of
amniotic -fetoprotein (AFP), estriol, and -hCG. Ultrasound shows increased nuchal
translucency and echogenic intracardiac focus. Based on this history and these findings, the
fetus is at greatest risk for which of the following?
(A) Duodenal atresia
(B) Omphalocele
58
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(C) Micrognathia
(D) Absent thymus
(E) Hypogonadism

231. Your patient is a 34-year-old G1P0A0 coming to see you for her first prenatal visit. Based
on her last menstrual period (LMP) , the patient is at 21 week's gestation. The patient is
very excited about her pregnancy and wants to make sure she does everything to ensure a
healthy baby. The patient's past medical history includes recurrent sinus infections and
hypothyroidism. The patient's surgical history includes an appendectomy performed 3
years ago. The patient currently takes a prenatal vitamin and levothyroxine. The patient's
blood pressure (BP) is 110/70 mmHg, HR 80 beats/min, respiratory rate (RR) 15
breaths/min, T 36C, height 148cm, and weight 55 kgs. Physical examination is normal
with a fundal height of 20 cm and fetal heart tones (FHTs) of 150 to 160. Her thyroid-
stimulating hormone (TSH) is slightly elevated. In addition to standard prenatal care, this
patient should also :
(A) Increase levothyroxine by 25 % at this appointment and again at 30 and 37 weeks
(B) Increase the levothyroxine until TSH is maintained below 2.5 miU/L with frequent
measurements of TSH and free thyroxine (T4)
(C) Increase the levothyroxine until the TSH is kept just below the normal range to prevent
hyperthyroidism in the fetus
(D) Lower the levothyroxine dosage by 25% now with frequent measurements of TSH and
free T4 to ensure therapeutic levels
(E) Consult to Internist for another drug combining

232. A 25-year-old G1P0A0 epileptic comes to see you for her first prenatal visit at 10 weeks.
At the appointment, the patient informs you that she stopped taking her epileptic
medication 2 months ago because she heard it could damage the fetus. The patient was first
prescribed valproic acid 10 years ago and has not had a seizure in 5 years. The patient
denies any complications since stopping the medication on her own. You inform your
patient that there is an increased risk of fetal anomalies associated with epilepsy, even
without medication. What is the next best step in the management of this patient?
(A) Restart the patient on valproate but increase dosing to four times per day from two
times per day, as the teratogenic risk is associated with high peak plasma levels
(B) Restart valproate only if the patient has a seizure and plan to use for management of
any seizures during active labor
(C) Start the patient on lamotrigine for seizure prophylaxis, as the newer antiepileptic
medications have not demonstrated the same increase in congenital anomalies as the
older medications
(D) Restart the patient on valproate as the risk to the mother outweighs the risk to the fetus
(E) Allow the patient to continue without medication and perform an Maternal serum
a-fetoprotein (MSAFP) at 16 weeks, level 2 fetal survey at 20 weeks, and use
phenytoin at delivery if needed

233. A 39-year-old P1A0 is 7 days post-Cesarean section after a failed induction at term. She
was diagnosed with endometritis on post -op day 2 and has remained febrile with elevated
white blood cells (WBCs). Her antibiotic regimen initially was IV gentamicin and
clindamycin. When she remained febrile on day 4, ampicillin was added to the regimen.
She spiked a fever to 39.6C this morning. A complete blood count (CBC) revealed a WBC
59
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

count of 15.300/mm3, hemoglobin of 11.4g/dl, and platelets at 252.000/mm3. What is the


next step?
(A) Administration of fever-reducing drugs and rest
(B) Empiric treatment with heparin
(C) Placement of an inferior vena cava
(D) Switch from double- to triple- antibiotic therapy
(E) Blood serum culture

234. A 34-year-old woman, G1P0A0, presents for her second prenatal visit at 9 week's
gestation. A review of prenatal laboratory results reveals she is rubella nonimmune. The
risk to the fetus should she contract rubella includes which constellation of findings:
(A) Blindness, deafness, and microcephaly
(B) Cerebral palsy, sensorineural hearing loss, and musculoskeletal deformity
(C) Chorioretinitis, hydrocephalus, and intracranial calcifications
(D) Ergogenic liver foci, microcephaly, ventriculomegaly, and deafness
(E) Nonimmune hydrops, placentamegaly, and anemia

235. A 42 -year-old woman, G2P1A0 , is currently at 35 week's gestation. Her BP have


remained 160/110 on two separate occasions over the past 6 hours. Labetalol successfully
normalizes the BP. She complains of a severe headache that improves slightly with
acetaminophen. A CBC reveals a WBC count of 6.8, hemoglobin of 1 3 .2, and platelet
count of 150.000/mm3. Ultrasound (U/S) reveals a mildly growth-restricted fetus in vertex
presentation with a biophysical profile (BPP) of 8/10. Which statement i s correct
regarding management o f this patient?
(A) Administer antenatal corticosteroids prior to delivery
(B) Assess cervix to determine if favorable for induction
(C) Begin magnesium prophylaxis when in active labor
(D) Due to fetal lung immaturity attempt to delay delivery until at least 37 weeks
(E) Immediately perform Cesarean section

236. A 31-year-old G2P1A0 presents to the emergency room (ER) at 8 week's gestation
complaining of heavy vaginal bleeding over the past week and is concerned about the well-
being of her baby. As part of her workup, the ER draws a quantitative -hCG that is
reported as 1.850 IU/ml. You are consulted to see the p atient on the obstetrical (OB) or
gynecologic team. After interviewing the patient, the physical examination is performed
and reveals a closed cervix, 10 to 15 mL of blood, and no tissue in the vaginal vault. What
is the next step in the management of this patient?
(A) Inform the patient that she is no longer pregnant due to a low -hCG test for 8 weeks
and express condolences
(B) Order an abdominal ultrasound in the radiology department
(C) Perform a transvaginal US in the ER
(D) Perform a Doppler study to look for fetal heart tones (FHTs)
(E) Reassurance

237. A 25-year-old primigravida with gestational hypertension presents to your clinic for
routine prenatal care. She is now at 37-week gestational age (GA) with dates confirmed by
first-trimester ultrasound (U/S). In clinic, she has a BP of 150/85 and you are considering
delivering her early due to potential complications from her disease. Her urine protein is
60
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

negative and she denies any headache, vision changes, or abdominal pain. Which of the
following test results would be most reassuring that the fetus would not have respiratory
distress after birth?
(A) Lamellar body count of 55.000
(B) Lecithin: sphingomyelin of 1.2 : 1
(C) Phosphatidylglycerol of 0.3
(D) Good diaphragmatic movement on biophysical profile (BPP)
(E) Surfactant: albumin of 25

238. A 29-year-old PlA0 is now 4 days post-op from a primary low transverse Cesarean section
for failure to progress complicated by chorioamnionitis. She had been diagnosed with
endometritis and started on intravenous gentamicin and clindamycin on postpartum day 2.
She has continued to spike fevers above 38C despite 48 hours on the antibiotic regimen. A
complete blood count (CBC) reveals white blood cell (WBC) count of 18.200/mm3,
hemoglobin 11 g/dl, and hematocrit 33. A urinalysis per catheter is leukocyte esterase and
nitrite negative. Homan sign is negative. She complains of abdominal pain. Examination
reveals the following: breast examination: no redness, inflammation, or nipple cracks; no
costovertebral angle (CVA) tenderness; lungs are clear to auscultation. Incision is clean,
dry, and intact. Bowel sounds are present. There is exquisite uterine tenderness with
guarding but no rebound in the lower abdomen. Lochia is moderate and foul smelling. The
addition of what antibiotic should be considered at this time:
(A) Ampicillin
(B) Cefazolin
(C) Cefotetan
(D) Doxycycline
(E) Metronidazole
239. An 28-year-old woman presents to the office with lower abdominal pain during
menstruation. She usually has cramping with menstruation, but never as bad as this
particular cycle. She has had a dull pain in her lower abdomen bilaterally for
approximately 2 weeks before presentation. On examination, her temperature is 38,5C
and she is diffusely tender to palpation in her lower abdominal quadrants. On pelvic
examination, purulent discharge from her cervical os is noted, and she cries out in pain
when her cervix is palpated. What organism most likely precipitated the patient's
presentation?
(A) Gardnerella vaginalis
(B) Chlamydia trachomatis
(C) Herpes simplex virus (HSV)
(D) Candida albicans
(E) Trichomonas vaginalis

240. A 24-year-old woman presents to your office complaining of vaginal discharge for the past
week. She describes the discharge as grayish white in color. She says that she has been
sexually active with a monogamous partner for the past 3 years. Her current medications
include only oral contraceptives. On physical examination, a thin, white discharge is
present on the vaginal walls. Cervix is not inflamed and there is no cervical discharge. A
fishy odor is present. The vaginal pH is 5.0. Which of the following is the most likely
diagnosis?
(A) Trichomoniasis
61
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(B) Chlamydia
(C) Bacterial vaginosis
(D) Candidiasis
(E) Cervicitis

241. A 21-year-old woman noticed bleeding from a lesion on her labia. She has noticed this
bleeding over the past few months but waited to go to the physician since she had no
pain. She finally decided to seek medical attention due to the size of the lesion. Her
medication list only includes oral contraceptives. On physical examination, a beefy, red
ulcer is present on the. Fresh granulation tissue surrounds the ulcer. The vaginal wall,
vaginal vault, and cervix appear to be unaffected. The diagnosis can be established by
which of the following?
(A) Staining for Donovan bodies
(B) Presence of serum antibodies to C. trachomatis
(C) Culturing Haemophilus ducreyi
(D) Culturing Calymmatobacterium granulomatis
(E) Presence of target cells

242. While working in the emergency department, a 25-year-old female patient arrives with
severe acute abdominal pain. Before the start of her abdominal pain, the patient recalls
having some fever and chills. She reports that her menses is regular and that she is sexually
active. She recently started having intercourse with a new partner. Pregnancy test is
negative and urinalysis is normal. On physical examination, the patient has muscular
guarding and rebound tenderness. On pelvic examination, patient has cervical motion
tenderness. Vital signs are significant for tachycardia and fever (T 40C) . Which of the
following is the most likely diagnosis?
(A) Ovarian torsion
(B) Endometriosis
(C) PID
(D) Kidney stone
(E) Ruptured ovarian cyst

243. A 30-year- old woman presents to your clinic with a painless macule on her right labia.
She states that she first noticed the spot 3 weeks ago. You notice on examination that the
area has begun to ulcerate and that she has mild, non tender, inguinal lymphadenopathy.
Given this history and subsequent physical examination findings, what is the most
appropriate antimicrobial treatment?
(A) Penicillin G 2.4 million units IM once
(B) Acyclovir 400 mg orally three times a day for 1 week
(C) Ceftriaxone 250 mg IM once
(D) Doxycycline 1 00 mg two times a day for 2 weeks
(E) Metronidazole 500 mg orally twice a day for 2 weeks

244. A 26-year- old woman presents to your clinic. Recently, she has noticed an increase in
odorless discharge and some pelvic cramping. Gram stain and wet prep of her cervical
mucus show many WBCs and no gram-negative diplococci. Which of the medications
would be the best treatment for this patient?
(A) Penicillin G 2.4 million units IM once
62
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(B) Acyclovir 400 mg orally three times a day for 1 week


(C) Ceftriaxone 250 mg IM once
(D) Doxycycline 100 mg two times a day for 1 week
(E) Metronidazole 500 mg orally twice a day for 2 weeks

245. A 29-year-old woman presents to your office after 3 days of general malaise. The patient is
currently sexually active with two male partners and admits that she often has unprotected
sex. She is now complaining of multiple, painful bumps on her genitals. On physical
examination, you see clusters of vesicles on erythematous skin around her vulva and anus.
HSV screen is positive for HSV-2. During the dormant phase of this disease, where does
the virus typically reside?
(A) The virus is typically cleared with acyclovir treatment; there is no dormant stage
(B) Cell bodies in the dorsal root ganglia of sacral sensory nerves
(C) Cell bodies of squamous epithelial cells of mucous membranes
(D) Incorporated into the DNA of squamous epithelial cells
(E) Axons of cutaneous sensory nerves

246. A 45-year-old sex worker is seen at the local health department with complaint of a
malodorous vaginal discharge for 2 weeks. After thorough examination and wet prep you
treat her with metronidazole. What did the wet prep show?
(A) Rods and buds
(B) Clue cells
(C) Flagellated organisms
(D) Parabasal cells
(E) Fat globules

247. A 29-year-old woman presents to her gynecologist for an annual well-woman examination.
She is sexually active with multiple male partners, receives depot medroxyprogesterone inj
ections every 3 months for contraception, and says that she "almost always" uses condoms.
On examination, the gynecologist notices a single 1 cm round ulcer with a clean-cut
margin on the inner surface of the patient's labia majora. The patient reports that she had
noticed this lesion a couple days prior but that it is not painful. Which of the following
pathogens is the likely cause of this patient's lesion?
(A) T. pallidum
(B) H. ducreyi
(C) Herpes simplex
(D) Varicella zoster
(E) C. trachomatis

248. A female presents to clinic for evaluation of a 3-day history of vaginal irritation with
itching and redness. She describes a white odorless discharge. She is a 25-year-old married
school teacher, P1A0, LMP 3 weeks ago on OCPs. Her past medical and surgical histories
are unremarkable. Her medications include her OCPs as well as ampicillin she is taking for
strep throat that she caught from her class. Pulmonary embolism (PE) reveals an
erythematous vulva as well as a thick white odorless discharge. The best treatment option
for this patient is:
(A) Metronidazole gel
(B) Oral metronidazole
63
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

(C) Fluconazole
(D) Azithromycin
(E) Doxycycline

249. You see five postmenopausal patients in the clinic. Each patient has one of the conditions
listed, and each patient wishes to begin hormone replacement therapy today. Which one of
the following patients would you start on therapy at the time of this visit?
a. Mild essential hypertension
b. Liver disease with abnormal liver function tests
c. Malignant melanoma
d. Undiagnosed genital tract bleeding
e. Treated stage III endometrial cancer

250. A 9-year-old girl presents for evaluation of regular vaginal bleeding. History reveals
thelarche at age 7 and adrenarche at age 8. Which of the following is the most common
cause of this condition in girls?
a. Idiopathic
b. Gonadal tumors
c. McCune-Albright syndrome
d. Hypothyroidism
e. Tumors of the central nervous system

251. A mother brings her 14-year-old daughter in to the office for consultation. The mother
says her daughter should have started her period by now. She is also concerned that she is
shorter than her friends. On physical examination, the girl is 148 cm in tall. She shows
evidence of breast development at Tanner stage 2. She has no axillary or pubic hair. You
reassure the mother that her daughter seems to be developing normally. Educating the
mother and daughter, your best advice is to tell them which of the following?
a. The daughter will start her period when her breasts reach Tanner stage 5.
b. The daughter will start her period, then have her growth spurt.
c. The daughters period should start within 1 to 2 years since she has just started
developing breast buds.
d. The daughter will have her growth spurt, then pubic hair will develop, heralding the
onset of menstruation.
e. The daughters period should start by age 18, but if she has not had her period by then,
she should come back in for further evaluation

252. An 18-year-old patient presents to you for evaluation because she has not yet started her
period. On physical examination, she is 150 cm in tall. She has minimal breast
development and no axillary or pubic hair. On pelvic examination, she has a normally
developed vagina. A cervix is visible. The uterus is palpable, as are normal ovaries. Which
of the following is the best next step in the evaluation of this patient?
a. Draw her blood for a karyotype.
b. Test her sense of smell.
c. Draw her blood for TSH, FSH, and LH levels.
d. Order an MRI of the brain to evaluate the pituitary gland.
e. Prescribe a progesterone challenge to see if she will have a withdrawal bleed.

64
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

253. A 7-year-old girl is brought in to see you by her mother because the girl has developed
breasts and has a few pubic hairs starting to show up. Which of the following is the best
treatment for the girls condition?
a. Exogenous gonadotropins
b. Ethinyl estradiol
c. GnRH agonists
d. Clomiphene citrate
e. No treatment; reassure the mother that pubertal symptoms at age 7 are normal

254. A mother brings her daughter in to see you for consultation. The daughter is 17 years old
and has not started her period. She is 140 cm in tall. She has no breast budding. On pelvic
examination, she has no pubic hair. By digital examination, the patient has a cervix and
uterus. The ovaries are not palpable. As part of the workup, serum FSH and LH levels are
drawn and both are high. Which of the following is the most likely reason for delayed
puberty and sexual infantilism in this patient?
a. Adrenogenital syndrome (testicular feminization)
b. McCune-Albright syndrome
c. Kallmann syndrome
d. Gonadal dysgenesis
e. Mllerian agenesis

255. While evaluating a 30-year-old woman for infertility, you diagnose a bicornuate uterus.
You explain that additional testing is necessary because of the womans increased risk of
congenital anomalies in which organ system?
a. Skeletal
b. Hematopoietic
c. Urinary
d. Central nervous
e. Tracheoesophageal

256. In an amenorrheic patient who has had pituitary ablation for a craniopharyngioma, which
of the following regimens is most likely to result in an ovulatory cycle?
a. Clomiphene citrate
b. Pulsatile infusion of GnRH
c. Continuous infusion of GnRH
d. Human menopausal or recombinant gonadotropin
e. Human menopausal or recombinant gonadotropin followed by human chorionic
gonadotropin (hCG)

257. You have just performed diagnostic laparoscopy on a patient with chronic pelvic pain and
dyspareunia. The patient had multiple implants of endometriosis on the uterosacral
ligaments and ovaries and several on the rectosigmoid colon. At the time of the procedure,
you ablated all of the visible lesions on the peritoneal surfaces with the CO2 laser. But
because of the extent of the patients disease, you recommend postoperative medical
treatment. Which of the following medications is the best option for the treatment of this
patients endometriosis?
a. Continuous unopposed oral estrogen
b. Dexamethasone
65
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

c. Danazol
d. Gonadotropins
e. Parlodel

258. A 28-year-old nulligravid patient complains of bleeding between her periods and
increasingly heavy menses. Over the past 9 months, she has had two dilation and
curettages (D&Cs), which have failed to resolve her symptoms, and oral contraceptives
and antiprostaglandins have not decreased the abnormal bleeding. Which of the following
options is most appropriate at this time?
a. Perform a hysterectomy.
b. Perform hysteroscopy.
c. Perform endometrial ablation.
d. Treat with a GnRH agonist.
e. Start the patient on a high-dose progestational agent.

259. You are treating a 31-year-old woman with danazol for endometriosis. You should warn
the patient of potential side effects of prolonged treatment with the medication. When used
in the treatment of endometriosis, which of the following changes should the patient
expect?
a. Occasional pelvic pain, since danazol commonly causes ovarian enlargement
b. Lighter or absent menstruation, since danazol causes endometrial atrophy
c. Heavier or prolonged periods, since danazol causes endometrial hyperplasia
d. More frequent Pap smear screening, since danazol exposure is a risk factor for cervical
dysplasia
e. Postcoital bleeding caused by the inflammatory effect of danazol on the endocervical
and endometrial glands

260. A patient presents to you for evaluation of infertility. She is 26 years old and has never
been pregnant. She and her husband have been trying to get pregnant for 2 years. Her
husband had a semen analysis and was told that everything was normal. The patient has a
history of endometriosis diagnosed by laparoscopy at age 17. At the time she was having
severe pelvic pain and dysmenorrhea. After the surgery, the patient was told she had a few
small implants of endometriosis on her ovaries and fallopian tubes and several others in the
posterior cul-de-sac. She also had a left ovarian cyst, filmy adnexal adhesions, and several
subcentimeter serosal fibroids. You have recommended that she have a
hysterosalpingogram as part of her evaluation for infertility. Which of the patients
following conditions can be diagnosed with a hysterosalpingogram?
a. Endometriosis
b. Hydrosalpinx
c. Subserous fibroids
d. Minimal pelvic adhesions
e. Ovarian cyst

261. During the evaluation of infertility in a 25-year-old female, a hysterosalpingogram showed


evidence of Asherman syndrome. Which one of the following symptoms would you expect
this patient to have?
a. Hypomenorrhea
b. Oligomenorrhea
66
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

c. Menorrhagia
d. Metrorrhagia
e. Dysmenorrhea

262. During the evaluation of secondary amenorrhea in a 24-year-old woman,


hyperprolactinemia is diagnosed. Which of the following conditions could cause increased
circulating prolactin concentration and amenorrhea in this patient?
a. Stress
b. Primary hyperthyroidism
c. Anorexia nervosa
d. Congenital adrenal hyperplasia
e. Polycystic ovarian disease

263. A 25-year-old woman presents to your office for evaluation of primary infertility. She has
regular periods every 28 days. She has done testing at home with an ovulation kit, which
suggests she is ovulating. A hysterosalpingogram demonstrates patency of both fallopian
tubes. A progesterone level drawn in the midluteal phase is lower than expected. A luteal
phase defect is suspected to be the cause of this patients infertility. Which of the following
studies performed in the second half of the menstrual cycle is helpful in making this
diagnosis?
a. Serum estradiol levels
b. Urinary pregnanetriol levels
c. Endometrial biopsy
d. Serum follicle-stimulating hormone (FSH) levels
e. Serum luteinizing hormone (LH) levels

264. A 45-year-old woman who had two normal pregnancies 15 and 18 years ago presents with
the complaint of amenorrhea for 7 months. She expresses the desire to become pregnant
again. After exclusion of pregnancy, which of the following tests is next indicated in the
evaluation of this patients amenorrhea?
a. Hysterosalpingogram
b. Endometrial biopsy
c. Thyroid function tests
d. Testosterone and DHAS levels
e. LH and FSH levels

265. A 22-year-old woman consults you for treatment of hirsutism. She is obese and has facial
acne and hirsutism on her face and periareolar regions and a male escutcheon. Serum LH
level is 35 mIU/mL and FSH is 9 mIU/mL. Androstenedione and testosterone levels are
mildly elevated, but serum DHAS is normal. The patient does not wish to conceive at this
time. Which of the following single agents is the most appropriate treatment of her
condition?
a. Oral contraceptives
b. Corticosteroids
c. GnRH
d. Parlodel
e. Wedge resection

67
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

266. A 20-year-old female with Mllerian agenesis is undergoing laparoscopic appendectomy


by a general surgeon. You are consulted intraoperatively because the surgeon sees several
lesions in the pelvis suspicious for endometriosis. You should tell the surgeon which of the
following?
a. Endometriosis cannot occur in patients with Mllerian agenesis since they do not have a
uterus.
b. Endometriosis is common in women with Mllerian agenesis since they have menstrual
outflow obstruction.
c. Endometriosis probably occurs in patients with Mllerian agenesis as a result of
retrograde menstruation.
d. Endometriosis may arise in patients with Mllerian agenesis as a result of coelomic
metaplasia.
e. Endometriosis cannot occur in patients with Mllerian agenesis because they have a
46,XY karyotype.

267. A 19-year-old patient presents to your office with primary amenorrhea. She has normal
breast and pubic hair development, but the uterus and vagina are absent. Diagnostic
possibilities include which of the following?
a. Androgen insensitivity syndrome
b. Gonadal dysgenesis
c. Mllerian agenesis
d. Klinefelter syndrome
e. Turner syndrome

268. A 23-year-old woman presents for evaluation of a 7-month history of amenorrhea.


Examination discloses bilateral galactorrhea and normal breast and pelvic examinations.
Pregnancy test is negative. Which of the following classes of medication is a possible
cause of her condition?
a. Antiestrogens
b. Gonadotropins
c. Phenothiazines
d. Prostaglandins
e. GnRH analogues

269. Which of the following pubertal events in girls is not estrogen dependent?
a. Menses
b. Vaginal cornification
c. Hair growth
d. Reaching adult height
e. Production of cervical mucus

270. A 9-year-old girl has breast and pubic hair development. Evaluation demonstrates a
pubertal response to a GnRH-stimulation test and a prominent increase in luteinizing
hormone (LH) pulses during sleep. These findings are characteristic of patients with which
of the following?
a. Theca cell tumors
b. Iatrogenic sexual precocity
c. Premature thelarche
68
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

d. Granulosa cell tumors


e. Constitutional precocious puberty

271. An infertile couple presents to you for evaluation. A semen analysis from the husband is
ordered. The sample of 2.5 cc contains 25 million sperm per mL; 65% of the sperm show
normal morphology; 20% of the sperm show progressive forward mobility. You should tell
the couple which of the following?
a. The sample is normal, but of no clinical value because of the low sample volume.
b. The sample is normal and should not be a factor in the couples infertility.
c. The sample is abnormal because the percentage of sperm with normal morphology
is too low.
d. The sample is abnormal because of an inadequate number of sperm per milliliter.
e. The sample is abnormal owing to a low percentage of forwardly mobile sperm.

272. You suspect that your infertility patient has an inadequate luteal phase. She should
undergo an endometrial biopsy on which day of her menstrual cycle?
a. Day 3
b. Day 8
c. Day 14
d. Day 21
e. Day 26

273. You have recommended a postcoital test for your patient as part of her evaluation for
infertility. She and her spouse should have sexual intercourse on which day of her
menstrual cycle as part of postcoital testing?
a. Day 3
b. Day 8
c. Day 14
d. Day 21
e. Day 26

274. You ask a patient to call your office during her next menstrual cycle to schedule a
hysterosalpingogram as part of her infertility evaluation. Which day of the menstrual cycle
is best for performing the hysterosalpingogram?
a. Day 3
b. Day 8
c. Day 14
d. Day 21
e. Day 26

275. You have recommended that your infertility patient return to your office during her next
menstrual cycle to have her serum progesterone level checked. Which is the best day of the
menstrual cycle to check her progesterone level if you are trying to confirm ovulation?
a. Day 3
b. Day 8
c. Day 14
d. Day 21
e. Day 26
69
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

276. Your patient is 43 years old and is concerned that she may be too close to menopause to
get pregnant. You recommend that her gonadotropin levels be tested. Which is the best day
of the menstrual cycle to check gonadotropin levels in this situation?
a. Day 3
b. Day 8
c. Day 14
d. Day 21
e. Day 26

277. Your patient is a 23-year-old woman with primary infertility. She is 150 cm in tall and
weighs 80 kgs. She has had periods every 2 to 3 months since starting her period at age 12.
She has a problem with acne and hair growth on her chin. Her mother had the same
problem at her age and now has adult-onset diabetes. On physical examination of the
patient, you notice a few coarse, dark hairs on her chin and around her nipples. She has a
normal-appearing clitoris. Her ovaries and uterus are normal to palpation. Which of the
following blood tests has no role in the evaluation of this patient?
a. Total testosterone
b. 17 -hydroxyprogesterone
c. DHEAS
d. Estrone
e. TSH

278. You have just diagnosed a 21-year-old infertile woman with polycystic ovarian syndrome.
The remainder of the infertility evaluation, including the patients hysterosalpingogram and
her husbands semen analysis, were normal. Her periods are very unpredictable, usually
coming every 3 to 6 months. She would like your advice on the best way to conceive now
that you have made a diagnosis. Which of the following treatment options is the most
appropriate first step in treating this patient?
a. Dexamethasone
b. Gonadotropins
c. Artificial insemination
d. Metformin
e. In vitro fertilization

279. A patient in your practice calls you in a panic because her 14-yearold daughter has been
bleeding heavily for the past 2 weeks and now feels a bit dizzy and light-headed. The
daughter experienced menarche about 6 months ago, and since that time her periods have
been irregular and very heavy. You instruct the mother to bring her daughter to the
emergency room. When you see the daughter in the emergency room, you note that she
appears very pale and fatigued. Her blood pressure and pulse are110/60 mm Hg and 70
beats per minute, respectively. When you stand her up, her blood pressure remains stable,
but her pulse increases to 100. While in the emergency room, you obtain a more detailed
history. She denies any medical problems or prior surgeries and is not taking any
medications. She reports that she has never been sexually active. On physical
examinations, her abdomen is benign. She will not let you perform a speculum
examination, but the bimanual examination is normal. She is 5 ft 4 in tall and weighs 95 lb.
Which of the following blood tests is not indicated in the evaluation of this patient?
70
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

a. -HCG
b. Bleeding time
c. CBC
d. Type and screen
e. Estradiol level

278. A 32-year-old morbidly obese diabetic woman presents to your office complaining of
prolonged vaginal bleeding. She has never been pregnant. Her periods were regular,
monthly, and light until 2 years ago. At that time she started having periods every 3 to 6
months. Her last normal period was 5 months ago. She started having vaginal bleeding
again 3 weeks ago, light at first. For the past week she has been bleeding heavily and
passing large clots. On pelvic examination, the external genitalia is normal. The vagina is
filled with large clots. A large clot is seen protruding through the cervix. The uterus is in
the upper limit of normal size. The ovaries are normal to palpation. Her urine pregnancy
test is negative. Which of the following is the most likely diagnosis?
a. Uterine fibroids
b. Cervical polyp
c. Incomplete abortion
d. Chronic anovulation
e. Coagulation defect

279. One of your patients with polycystic ovarian syndrome presents to the emergency room
complaining of prolonged, heavy vaginal bleeding. She is 26 years old and has never been
pregnant. She was taking birth control pills to regulate her periods until 4 months ago. She
stopped taking them because she and her spouse want to try to get pregnant. She thought
she might be pregnant because she had not had a period since her last one on the birth
control pills 4 months ago. She started having vaginal bleeding 8 days ago. She has been
doubling up on superabsorbant sanitary napkins 5 to 6 times daily since the bleeding
began. On arrival at the emergency room, the patient has a supine blood pressure of 102/64
mm Hg with a pulse of 96 beats perminute. Upon standing, the patient feels light-headed.
Her standing blood pressure is 108/66 mm Hg with a pulse of 126 beats per minute. While
you wait for lab work to come back, you order intravenous hydration. After 2 hours, the
patient is no longer orthostatic. Her pregnancy test comes back negative, and her Hct is
31%. She continues to have heavy bleeding. Which of the following is the best next step in
the management of this patient?
a. Perform a dilation and curettage.
b. Administer a blood transfusion to treat her severe anemia.
c. Send her home with a prescription for iron therapy.
d. Administer high-dose estrogen therapy.
e. Administer antiprostaglandins.

280. A 51-year-old woman P3A0 presents to your office with a 6-month history of amenorrhea.
She complains of debilitating hot flushes that awaken her at night; she wakes up the next
day feeling exhausted and irritable. She tells you she has tried herbal supplements for her
hot flushes, but nothing has worked. She is interested in beginning hormone replacement
therapy (HRT), but is hesitant to do so because of its possible risks and side effects. The
patient is very healthy. She denies any medical problems and is not taking any medication
except calcium supplements. She has a family history of osteoporosis. Her height is 160
71
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

cm and her weight is 60 kgs. In counseling the patient regarding the risks and benefits of
hormone replacement therapy, you should tell her that HRT (estrogen and progesterone)
has been associated with which of the following?
a. An increased risk of colon cancer
b. An increased risk of uterine cancer
c. An increased risk of thromboembolic events
d. An increased risk of developing Alzheimer disease
e. An increased risk of malignant melanoma

281. A 56-year-old woman presents to your office for her routine wellwoman examination. She
had a hysterectomy at age 44 for symptomatic uterine fibroids. She entered menopause at
age 54 based on menopausal symptoms and an elevated FSH level. She started taking
estrogen replacement therapy at that time for relief of her symptoms. She is fasting and
would like to have her lipid panel checked while she is in the office today. You counsel the
patient on the effects of estrogen therapy on her lipid panel. She should expect which of the
following?
a. An increase in her LDL
b. An increase in her HDL
c. An increase in her total cholesterol
d. A decrease in her triglycerides
e. A decrease in her HDL

282. A 48-year-old woman consults with you regarding menopausal symptoms. Her periods
have become less regular over the past 6 months. Her last period was 1 month ago. She
started having hot flushes last year. They have been getting progressively more frequent.
She has several hot flushes during the day, and she wakes up twice at night with them as
well. She has done quite a lot of reading about perimenopause, menopause, and hormone
replacement therapy. She is concerned about the risks of taking female hormones. She
wants to know what she should expect in regard to her hot flushes if she does not take
hormone replacement. You should tell her which of the following?
a. Hot flushes usually resolve spontaneously within 1 year of the last menstrual period.
b. Hot flushes are normal and rarely interfere with a womans well-being.
c. Hot flushes usually resolve within 1 week after the initiation of HRT.
d. Hot flushes can begin several years before actual menopause.
e. Hot flushes are the final manifestation of ovarian failure and menopause.

283. You are reviewing the notes of a 32-year-old woman in the antenatal clinic. She is 10
weeks pregnant based on her last period date and this is her third pregnancy. Her sons,
aged 4 and 2 years, respectively, are fit and healthy. You are looking for risk factors to offer
her screening for gestational diabetes. Which of the following conditions will you NOT
offer her such screening:
A. Body mass index above 30 kg/m2
B. Family history of diabetes
C. Family origin with a high prevalence of diabetes
D. Previous macrosomic baby weighing 4.5 kg or above
E. Previous type 2 diabetes

72
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

284. Commercial flights of more than 4 hours duration are known to be associated with a small
increase in the relative risk of:
A. Abruptio placentae
B. Antepartum depression
C. Deep vein thrombosis
D. Prelabour rupture of membranes
E. Preterm labour
285. You are preparing for the caesarean section of a multipara with central placenta previa.
She is not anaemic, is haemodynamically stable and has never had any episode of vaginal
bleeding. At least how many units of cross matched blood should be kept ready for use in
anticipation of intraoperative blood loss?
A. 1 unit
B. 2 units
C. 3 units
D. 4 units
E. None required unless the woman has a Hb < 10 g/dL

286. A 28-year-old woman is 22 weeks pregnant. She has long-standing type 1 diabetes
mellitus. Her 20-week fetal anatomy ultrasound showed no structural fetal abnormalities.
However, she is concerned about how her diabetes may cause congenital fetal anomalies in
her unborn child. Of the options listed below, which SINGLE action addresses her anxiety?
A. Amniocentesis at 22 weeks.
B. Fetal cardiac echocardiography at 24 weeks.
C. Obstetric ultrasound scan for growth and umbilical artery Doppler at 28, 32 and 36
weeks.
D. Offer reassurance as normal fetal anatomy survey at 20 weeks.
E. Quadruple maternal biochemical screening test at 20 weeks.

287. A 24-year-old woman is 12 weeks pregnant. She is attending hospital for her dating scan
and routine booking serological investigations. Screening and treating for the presence of a
particular pathogen during early pregnancy will reduce the risk of developing congenital
fetal abnormality. Which of the pathogens listed below fulfils this criterion?
A. Hepatitis B
B. Herpes simplex virus
C. Rubella
D. Syphilis
E. Varicella zoster virus

288. All pregnant women are advised to take folic acid supplements (0.4 mg, once daily) pre-
pregnancy and antenatally. Nonetheless, which of the following groups of women is a
dietary supplementation using a higher dose of folic acid (5 mg once daily) recommended?
A. BMI < 30
B. Impaired glucose tolerance
C. Previous pre-eclampsia
D. Previous preterm delivery
E. Sickle cell disease

73
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

289. Drugs are prescribed in pregnancy upon the assumption that their positive effect on health
outweighs the probability and severity of any harm to mother and fetus. On this basis,
which of the following medications is the most likely to be contraindicated for antenatal
use in pregnancy?
A. Indomethacin
B. Labetalol
C. Low-dose aspirin
D. Low molecular weight heparin
E. Metformin

290. A 20-year-old woman is 36 weeks pregnant in her first pregnancy and is being reviewed in
the antenatal clinic. A recent obstetric growth scan confirms breech presentation of a
normally grown fetus with normal liquor volume. She has no other complicating medical
or obstetric disorders. She is deciding between planned vaginal or elective caesarean
(LSCS) modes of delivery. Which of the following is correct in relation to the counselling
she will receive?
A. External cephalic version (ECV) may be offered and has around a 50 % success
rate for conversion to cephalic presentation.
B. Footling breech presentation is considered favourable for vaginal breech delivery.
C. If opting for vaginal breech delivery, induction of labour at 38 weeks is recommended
to avoid excessive fetal growth.
D. Intermittent fetal heart rate monitoring is recommended for spontaneous onset vaginal
breech labour.
E. LSCS and vaginal breech birth have similar rates of perinatal mortality and early
neonatal morbidity.

291. If the fetal crown rump length is disparate in twins at the 12 weeks scan, select the best
method of dating the pregnancy. Gestation is age can be allotted according to:
A. Average CRL of the two foetuses.
B. CRL of the bigger fetus.
C. CRL of the smaller fetus.
D. CRL of the smaller fetus added to half the CRL of the bigger fetus.
E. Dating is best done by LMP in such cases.

292. A 34-year-old primigravida with dichorionic twins, both fetuses in cephalic presentation,
declines the offer of elective delivery at 37 weeks of gestation. You have explained to her
that with uncomplicated dichorionic twin pregnancies, elective birth from 37 weeks 0 days
does not appear to be associated with an increased risk of serious adverse outcomes and
that continuing uncomplicated twin pregnancies beyond 38 weeks 0 days increases the risk
of fetal death. What is the next step in her antenatal care?
A. Document her decision and allow pregnancy to continue for reassessment at term or
when she sets into labour spontaneously, whichever is earlier.
B. Document her decision and call twice weekly for biophysical profile assessment.
C. Document her decision and call weekly for biophysical profi le assessment.
D. Document her decision and take informed consent for risk of adverse outcome.
E. Refer her to another centre as the outcome is likely to be poor.

293. Ultrasound screening for structural anomalies in the second trimester of pregnancy:
74
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

A. Is optimally offered between 15 week 0 day and 20 week 0 day


B. Can be used for ruling out diagnosis of Down syndrome
C. Can be used to diagnose inborn errors of metabolism
D. Is more sensitive in women with high BMI
E. Involves echocardiography with four chamber view of heart and outflow tract
routinely

294. Routine folic acid supplementation is advised to all pregnant women ideally starting pre-
pregnancy and continuing upto 12 weeks of gestation. The advantages established with this
supplementation are all of the following except:
A. Reduced risk of cardiovascular defects
B. Reduced risk of childhood asthma
C. Reduced risk of limb defects
D. Reduced risk of leukemia and pediatric brain tumors
E. Reduced risk of neural tube defects

295. Which of the following statements regarding physiological blood pressure changes in
pregnancy is incorrect?
A. Blood pressure begins to decrease in early pregnancy and reaches a nadir at 1820
weeks following which there is a steady rise till term.
B. Blood pressure taken in supine position during second and third trimesters of pregnancy
is lower than that taken in sitting position
C. PhaseV (disappearance) rather than phase IV (muffling) of Korotkoff sounds should be
taken as the diastolic reading.
D. Previously normotensive women may become transiently hypertensive following
delivery.
E. Vasodilatation is the primary change in circulation in pregnancy.

296. A 26-year-old X-ray technician is pregnant and you are seeing her at her booking visit. She
is 8 weeks pregnant now and has confi rmed her pregnancy recently. She uses the standard
safety guidelines at work but is concerned about ionising radiation exposure to her fetus.
The most appropriate advice that you can give her in this regard is:
A. Her baby will receive about 1 mSv from sources of natural radiation during pregnancy.
The added exposure at work should be no more than this and in practice is likely to be
considerably less.
B. It is a legal requirement that she must wear an active dose meter at all times.
C. Lead aprons can be avoided as they can be uncomfortable and lead to back pain.
D. She is legally bound inform her employer about her pregnancy in writing as soon as
possible.
E. X-rays affect milk production and she is at high risk of lactation failure

297. A 42-year-old primigravida has come to discuss her antenatal care at 10 weeks of
gestation. She is concerned about the chances of her babys growth being suboptimal.
Which of the following interventions will you offer her in this regard?
A. Serum PAPP-A levels at 1618 weeks of gestation.
B. She should be offered routine abdominal palpation for detecting SGA at 28 weeks.
C. She should be offered umbilical artery Doppler from 26 to 28 weeks of gestation.
75
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

D. She should be offered uterine artery Doppler at 16 weeks of gestation.


E. She should start taking aspirin after 16 weeks of gestation.

298. Chorionicity in multifetal pregnancy is best assessed at what gestation:


A. 56 weeks
B. 1114 weeks
C. 1618 weeks
D. 2024 weeks
E. 3034 weeks

299. A 40-year-old woman is 12 weeks pregnant. She is attending hospital antenatal clinic for
her dating scan. She is concerned about her risk of having a child affected by Down
syndrome. Which SINGLE action is the most appropriate management action given her
anxiety and consistent with current routine antenatal screening advice?
A. Measure nuchal translucency and check for presence/absence of fetal nasal bone at 12
weeks.
B. Measure nuchal translucency and maternal serum PAPP-A and HCG at 12 weeks.
C. Offer amniocentesis at 15 weeks.
D. Offer detailed fetal anatomy ultrasound to check for fetal congenital malformation at 20
weeks.
E. Offer maternal biochemical quadruple screening test at 16 weeks.

300. Mrs. X has come to see you in her booking visit at 9 weeks gestation. This is her second
pregnancy, and her previous pregnancy was terminated at 10 weeks due to confirmed
primary Rubella infection. This time she has been told that she is immune to Rubella, but
she is still very concerned about reinfection in this pregnancy. What fact can you tell her
regarding reinfection of Rubella?
A. Antibiotic prophylaxis can effectively reduce the risk of reinfection.
B. If reinfection occurs, then the risk of fetal infection is 90 % before 12 weeks of
gestation, about 55 % at 1216 weeks, and it declines to 45 % after 16 weeks.
C. Reinfection cannot occur in Rubella; hence, she need not worry further in this regard.
D. Reinfection can occur but is less likely in natural immunity than with vaccine
induced immunity.
E. Reinfection is clinically more severe than the primary infection.

301. All of the following statements regarding surveillance methods for small fro gestational
age fetuses are true except:
A. CTG should not be used as the only form of fetal surveillance.
B. Interpretation of the amniotic fl uid volume on ultrasound should be based on the single
deepest vertical pocket.
C. The BPP is time consuming, and the incidence of an equivocal result is high in severely
SGA fetuses.
D. MCA Doppler should be used to time delivery in preterm SGA fetuses with normal
umbilical artery Doppler.
E. DV Doppler has moderate predictive value for academia and adverse outcome.

302. Twin to twin transfusion occurs in about 15 % of monochorionic pregnancies. When the
Doppler studies are critically abnormal in either twin and are characterised as abnormal or
76
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

reversed end-diastolic velocities in the umbilical artery, reverse flow in the ductus venosus
or pulsatile umbilical venous flow, this corresponds to the following stage in Quinteros
system:
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
E. Stage 5

303. A 28-year-old woman in her fi rst pregnancy was diagnosed to have a chicken pox
infection at 14 weeks gestation. She was referred for a detailed fetal anomaly scan at 19
weeks gestation which revealed no obvious fetal structural defects, and she was reassured
by the doctor. She is very anxious about the risk of fetal varicella syndrome (FVS) and is
considering an amniocentesis. Which of the following statements best describe the role of
amniocentesis in this situation:
A. If the amniotic fluid is negative for varicella DNA, it definitely rules out FVS.
B. If the amniotic fluid is positive for varicella DNA, it definitely confi rms FVS.
C. It is late to do an amniocentesis now as it should have been done during the acute phase.
D. Negative predictive value of amniocentesis is better than positive predictive value
in detecting FVS.
E. The presence of VZV DNA has a high specifi city but a low sensitivity for the
development of FVS.

304. A 38-year-old pregnant woman meets you in the antenatal clinic with the report of her 20
weeks anomaly scan. The report states that there is excessive amniotic fluid and a double
bubble sign in the fetal abdomen. The double bubble sign seen in fetal ultrasound is
suggestive of:
A. Anorectal malformation
B. Arteriovenous fi stula in the fetal liver
C. Colonic perforation
D. Duodenal atresia
E. Tracheoesophageal fi stula

305. Ms XY is a primigravida who is 34 weeks pregnant. Her last two serial scans have shown
an SGA fetus growing on the 9th centile. Her last scan shows positive end diastolic flow
with a normal PI. She reports having good fetal movements. How should further fetal
surveillance be undertaken?
A. Fortnightly umbilical artery Doppler
B. Twice weekly CTG
C. Twice weekly umbilical artery Doppler
D. Weekly CTG
E. Weekly umbilical artery Doppler + CTG

306. Mrs X, primigravida at term is in second stage of labour. After delivery of the fatal head,
shoulder dystocia was diagnosed and the McRoberts manoeuvre has nor effected the
delivery of the shoulders, which is the next method to be used:
A. All-fours position
77
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

B. Delivery of posterior arm


C. Suprapubic pressure
D. Internal rotation manoeuvres
E. Zavanelli manoeuvre

307. A 20-year-old woman is 36 weeks pregnant in her second pregnancy and is being reviewed
in the antenatal clinic. She has had a previous caesarean delivery. A recent obstetric growth
scan confirms cephalic presentation of a normally grown fetus. She has no other
complicating medical or obstetric disorders. She is deciding between planned vaginal birth
after caesarean (VBAC) and elective repeat caesarean section (ERCS) modes of delivery.
Which ONE of the following is correct in relation to the counselling she will receive?
A. ERCS is usually performed at commencement of 38th week of gestation.
B. ERCS is recommended as chances of successful VBAC are less than 50 %.
C. Future pregnancy, after two caesarean deliveries, is not recommended due to increased
surgical risks of a third caesarean delivery.
D. If planning VBAC, induction of labour is safer than spontaneous onset of labour.
E. The risk of uterine scar rupture in spontaneous onset of labour and planned VBAC
is 0.20.5 %.

308. A 32-year-old woman is 36 weeks pregnant in first pregnancy with dichorionic diamniotic
twins and is being reviewed in the antenatal clinic. A recent obstetric growth scan confirms
both fetuses are normally grown. Both twins are longitudinal lie and cephalic presentation.
She has no other complicating medical or obstetric disorders. She is deciding between
planned vaginal or elective caesarean modes of delivery. Which ONE of the following is
correct in relation to the counselling she will receive?
A. About 10 % of twin pregnancies result in spontaneous birth before 37 weeks, 0 days.
B. Continuing twin pregnancies beyond 38 weeks, 0 days increases the risk of fetal
death.
C. Maternal antenatal corticosteroids are routinely recommended for all twin pregnancies.
D. Offer elective birth from 37 weeks, 0 days after a course of maternal corticosteroids has
been administered.
E. There is strong evidence to show caesarean delivery is safer for mother and fetuses than
vaginal mode of delivery.

309. Which ONE of the following statements represents the correct sequence of events in
relation to the mechanism of labour for a vertex presentation?
A. Descent, fl exion, engagement, internal rotation, restitution and external rotation,
extension, expulsion
B. Descent, engagement, flexion, extension, restitution and external rotation, internal
rotation, expulsion
C. Engagement, descent, flexion, extension, restitution and external rotation, internal
rotation, expulsion
D. Engagement, descent, flexion, internal rotation, restitution and external rotation,
extension, expulsion
E. Engagement, descent, flexion, internal rotation, extension, restitution and
external rotation, expulsion

78
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

310. A 25 year old, who is 40 weeks pregnant in her first pregnancy, is in the second stage of
labour. She has been actively pushing for 2 h and is exhausted. CTG shows a baseline of
150 bpm, normal baseline variability, occasional accelerations and infrequent typical
variable decelerations. She is contracting 34 every 10 min. Vaginal examination reveals a
fully dilated cervix with the fetal head in a direct occipito-anterior position and at station
+1 below spines. Which of the following is the most appropriate next management step?
A. Caesarean section delivery
B. Episiotomy
C. Fetal blood sampling
D. Instrumental delivery
E. Start IV oxytocin augmentation

311. A 25 year old, who is 40 weeks pregnant in her first pregnancy, is in the second stage of
labour. She has been actively pushing for 1 h. CTG shows a baseline of 180 bpm, reduced
baseline variability, no accelerations and frequent atypical variable decelerations. She is
contracting 34 every 10 min. Vaginal examination reveals a fully dilated cervix with the
fetal head in a direct occipito-anterior position and at station +1 below spines. Which of the
following is the most appropriate next management step?
A. Caesarean section delivery
B. Episiotomy
C. Fetal blood sampling
4 Labour and Delivery: SBA Questions65
D. Instrumental delivery
E. Start IV oxytocin augmentation

312. Mrs. X, 32-year-old second gravida, previous vaginal birth, suffered a spinal cord injury at
the level of T8 at 32 weeks of gestation. She had a singleton fetus with an anterior high
placenta, and her fetal scan after the accident revealed an AGA fetus with normal amniotic
fluid, fetal activity, Dopplers and no signs of internal bleeding in the placenta. She was
managed as an inpatient with multidisciplinary care at the obstetric unit. Which of the
following statements is appropriate for her care?
A. At caesarean section, regional anaesthesia should not be offered.
B. First choice of muscle relaxant at GA is rocuronium as suxamethonium is avoided.
C. She must be counselled about the chances of lactation failure due to spinal injury.
D. Thromboprophylaxis is avoided as it can lead to spinal hematomas.
E. Vaginal delivery is contraindicated.

313. You are counselling a 28-year-old primigravida with a singleton pregnancy at the antenatal
clinic at 38 weeks regarding her options for delivery. Her clinical history has been normal
so far and is perceiving good fetal movements, and she has a fetus in cephalic presentation.
Which of the following statements is incorrect?
A. Membrane sweeping can be offered as it reduces the need for induction of labour.
B. If she does not set into spontaneous labour, she will be offered induction of labour
at 40 weeks.
C. The choice of induction agent will be intravaginal PGE2.
D. If one attempt of induction fails, another attempt may be made.
E. If one attempt of induction fails, a caesarean section will be offered.

79
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

314. Ms XY is 40 weeks pregnant with one previous CS. She presents in spontaneous labour
and has an agreed plan for a VBAC. She now complains of pain in the site of the CS scar.
Which of the following is most consistently associated with a uterine rupture?
A. Abnormal CTG
B. Acute onset scar tenderness
C. Hematuria
D. Severe abdominal pain, persisting in between contractions
E. Vaginal bleeding

315. Ms XY is 32 weeks pregnant with a cervical cerclage inserted at 14 weeks. She presents to
the labour suite with a confirmed diagnosis of PPROM. Inflammatory markers are normal.
Ms XY is clinically well and demonstrates no uterine activity. Which of the following
treatment options are best suited to her?
A. Delayed removal of the cerclage only if signs of infection appears
B. Delayed removal of the cerclage until labour ensues
C. Immediate removal of the cerclage
D. Removal of cerclage at 34 weeks
E. Removal of the cerclage in 48 h for steroid administration

316. Mrs X, a 28-year-old primigravida has leaking of fluid per vaginam for the past 3 h at 32
weeks of gestation. Per speculum examination confi rms leakage of clear amniotic fluid per
vaginam. She is clinically stable with no signs of infection. Ultrasound shows a singleton
fetus in cephalic presentation, appropriate for gestation with normal liquor and Dopplers.
You are explaining her clinical situation to her. You would be correct to say that:
A. Almost 10 % of pregnancies have PPROM.
B. Digital vaginal examination is recommended to help to assess her Bishop score.
C. Erythromycin should be given orally for 10 days following diagnosis of PPROM.
D. If NICU beds are available, it is better to deliver her immediately after steroid cover.
E. Vaginal PGE2 can be used for inducing her labour now.

317. A primigravida at term, in first stage of labour had uterine hyperstimulation following
oxytocin augmentation. The oxytocin drip was stopped, but after a few minutes, she had
hypotension, tachycardia and a feeble pulse showing signs of collapse. Resuscitative
efforts could not restore any cardiac output for 4 min, and a decision for perimortem
caesarean section was taken. Which of the following is the correct approach in conducting
the perimortem caesarean section?
A. If an epidural is not sited earlier, a general anaesthesia can be used.
B. The patient must be immediately shifted to the nearest emergency operating theatre.
C. The procedure must be done within 5 min of collapse after confi rming fetal viability.
D. There is no need for checking fetal viability.
E. When resuscitation is ongoing, the procedure should be deferred.

318. Ms XY is a G3P2A0 and term undergoing an emergency caesarean section under GA, as
she presents in labour with previous 2 caesarean sections with an APH. During the CS, an
anterior low-lying placenta fails to separate after delivery of the baby. A clear cleavage
plane cannot be identified. The bleeding is minimal. She has consented to a sterilisation, as
her family is now complete. Which of the following treatment options are best suited to
her?
80
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

A. Attempt to separate placenta and caesarean hysterectomy if bleeding occurs


B. Elective caesarean hysterectomy
C. Leaving the placenta in situ with postoperative methotrexate
D. Removal of the bulk of the placenta and cord and closure
E. Removal of the placenta piecemeal and closure of bleeding points

319. Ms XY is primigravida at 41 weeks in spontaneous labour. She is Palembangnese and has


a baby in direct OP position. She has been pushing for 2 h. The total duration of her second
stage has been 3 h. She has been consented for a trial of instrumental delivery in theatre as
birth is not imminent. Which of the following risk factors has the strongest association
with obstetric anal sphincter injury?
A. Ethnicity
B. Occipito posterior position
C. Prolonged 2nd stage
D. Shoulder dystocia
E. Ventouse delivery with episiotomy

320. Ms XY is a primigravida who is 38 weeks pregnant. She presents with a history of PROM
for a few hours. Examination reveals clear liquor. Maternal observations are normal.What
is the percentage of women that will spontaneously labour in 24 h of PROM at term?
A. 30 %
B. 40 %
C. 50 %
D. 60 %
E. 70 %

321. Ms XY is primigravida at 41 weeks in spontaneous labour. She has a baby in direct OA


position. She has been pushing for 1 h. Birth is imminent. Perineum appears overstretched
and distended.What angle of a mediolateral episiotomy is most likely to prevent an OASI?
A. 30 from the midline
B. 40 from the midline
C. 45 from the midline
D. 60 from the midline
E. 90 from the midline

322. Ms XY is a primigravida who is 38 weeks pregnant. She presents with a history of PROM
for a few hours. Examination reveals clear liquor. Maternal observations are normal. What
is the risk of serious neonatal infection with ruptured membranes at term?
A. 0.1 %
B. 0.5 %
C. 1 %
D. 5 %
E. 10 %

323. Ms XY is a primigravida who is 39 weeks pregnant in spontaneous active labour. She also
has diet-controlled GDM. She is theatre as the FHR/CTG showed a fetal bradycardia for 8
mins. At 9 mins in theatre, the FHR has recovered. Examination reveals she is 7 cms

81
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

dilated with clear liquor in direct OA position. Ms XY is very keen on a vaginal birth only
if it safe for her labour to continue. What should be the next appropriate management plan?
A. Allow labour to continue
B. Fetal blood sampling
C. Proceed with CS under spinal anaesthesia
D. Proceed with CS under GA
E. Recommend epidural analgesia

324. Ms XY is 38 weeks pregnant. She has developed confirmed primary genital herpes. She is
presently being treated with acyclovir. She has confirmed PROM since 2 h. Which of the
following treatment options are best suited to her?
A. Caesarean section after adequately nil per oral (6 h later)
B. Caesarean section after corticosteroid cover (2448 h later)
C. Immediate caesarean section
D. Immediate induction of labour with IV acyclovir
E. Induction of labour after 24 h with IV acyclovir

325. You are conducting a lower segment caesarean section on a full-term primigravida with a
free-floating fetal head. Peroperatively, there is difficulty is delivering the fetal head.
Choose the single best option from the alternatives given below:
A. Ask for fundal pressure
B. Avoid any attempts of pushing from below
C. Breech extraction is an unacceptable option
D. Try gently to put your hand into the pelvis
E. Use of forceps is best avoided

326. You have just examined Mrs X in the postpartum clinic. She is complaining of breast pain
and discomfort. You have established a diagnosis of postpartum mastitis. All of the
following are treatment options for her except:
A. Analgesics
B. Antibiotics if infective mastitis
C. Gentle hand expression to promote drainage
D. Local measures like hot and cold compress
E. Stopping breastfeeding

327. The commonest urinary problem occurring in the postpartum period is:
A. Detrusor instability
B. Mixed incontinence
C. Stress incontinence
D. Urinary tract infection
E. Vesicovaginal fistula

328. A 24-year-old woman presents to delivery suite with a 12 h history of right-sided chest
pain and shortness of breath. She is at 7 days postnatal having delivered her baby by
emergency caesarean section at 34 weeks. Her pregnancy was complicated by severe
hypertension and postpartum haemorrhage of 1 L. She has a BMI of 32. Her BP is 130/80

82
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

mmHg, pulse is 108 bpm, temperature is 37.2 and oxygen saturations are 94 % in air. What
is the SINGLE most likely diagnosis?
A. Anaemia
B. Myocardial infarction
C. Pneumonia
D. Pulmonary embolism
E. Subphrenic abscess

329. A 40-year-old woman, who has had a previous caesarean delivery, experiences brisk
vaginal bleeding immediately following vaginal delivery of a 36-week gestation baby
(birth weight 3.8 kg). 10 min prior to the delivery, there was acute onset fetal bradycardia
and cessation of uterine contractile activity. The urinary catheter shows haematuria. The
placenta was delivered without complication. Bimanual compression of the uterus is
extremely painful for the woman. Despite an estimated blood loss of 500 ml, she appears
pale and clammy with BP 90/30 and pulse 120 bpm. Which one of the following is the
most likely cause for the excessive genital tract bleeding?
A. Excessive epidural analgesia
B. Retained placenta
C. Uterine atony
D. Uterine inversion
E. Uterine rupture

330. A 40-year-old woman, who has had three previous vaginal deliveries, experiences brisk
vaginal bleeding immediately following vaginal delivery of 36-week gestation twins (birth
weights 2.0 and 1.9 kg). An episiotomy was not required. The placenta was delivered
without complication. The estimated blood loss is 700 ml. Which one of the following is
the most likely cause for the excessive genital tract bleeding?
A. Excessive epidural analgesia
B. Retained placenta
C. Uterine atony
D. Uterine inversion
E. Uterine rupture

331. A 32-year-old woman presents to delivery suite with a 3-day history of worsening pelvic
pain and vaginal bleeding with clots. She is at 5 days postnatal having delivered her baby
by kiwi cup vacuum delivery at 41 weeks gestation. She has a BMI of 32. Her BP is
130/80 mmHg, pulse is 108 bpm, temperature is 37.9 and oxygen saturations are 95 % in
air. She has pelvic tenderness on examination. What is the SINGLE most likely diagnosis?
A. Cervical carcinoma
B. Bacterial vaginosis
C. Endometritis
D. Urinary tract infection
E. Uterine rupture

332. A 34-year-old woman attends the postpartum clinic with complaints of superficial
dyspareunia. She delivered a 4.5 kg baby with the help of outlet forceps 2 months back.
She is currently breastfeeding. On local examination the perineum is healthy, no signs of

83
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

atrophic vaginitis. On palpation, there is definite tenderness in the episiotomy scar. What
will be your advice to her:
A. Antibiotics to reduce local infection.
B. Avoid sexual intercourse till the pain subsides.
C. Local anaesthetic application 30 min prior to intercourse.
D. Local corticosteroids for a week.
E. Surgical refashioning of the perineum will be a permanent solution.

333. Ms. XY is brought to the emergency department, unwell. She is a para 1, post-SVD 3 days
ago with ragged membranes noted at delivery. Her observations include pulse 128 bpm, BP
80 systolic, RR 24 breaths/min and temp 39 C and she feels cold and clammy. She reports
heavy offensive lochia. She has been fluid resuscitated now and commenced on oxygen by
mask.What is the next immediate step in her management?
A. Broad spectrum IV antibiotics
B. Blood cultures, HVS, MSU
C. EUA in theatre with removal of retained tissue
D. Imagingpelvic ultrasound
E. Measurement of serum lactate

334. Ms. XY is a para 1 who delivered 1 week ago. She was diagnosed to have gestational
diabetic (diet controlled), and her plasma glucose levels have now returned to normal.
What follow-up should she have postpartum?
A. 75 g 2 h OGTT 6 weeks postpartum
B. 75 g 1 h OGTT 6 weeks postpartum
C. Fasting plasma glucose at 4 weeks postpartum
D. Fasting plasma glucose at 12 weeks postpartum
E. Random plasma glucose at 6 weeks postpartum

335. Ms. XY is brought to the A + E department, unwell. She is a para 1, post-SVD 3 days ago
with ragged membranes noted at delivery. Her observations include pulse 128 bpm, BP 80
systolic, RR 24 breaths/min and temp 39 C and she feels cold and clammy. She reports
heavy offensive lochia. She has been fluid resuscitated now and commenced on oxygen by
mask. Which of the following blood results reflect severe sepsis?
A. CRP 160 mg/L
B. D dimer1600 ng/mL
C. ESR 90 mm/h
D. Serum lactate (arterial)6 mmol/L
E. WCC16 109/L

336. Ms. XY is brought to the ER department, unwell. She is a para 1, post-SVD 3 days ago
with ragged membranes noted at delivery. Her observations include pulse 128 bpm, BP 80
systolic, RR 24 breaths/min and temp 39 C and she feels cold and clammy. She reports
heavy offensive lochia. Which of the following antibiotics are best suited to her?
A. Co-amoxiclav
B. Co-amoxiclav + gentamicin
C. Co-amoxiclav + metronidazole
D. Piperacillintazobactam
E. Piperacillintazobactam + clindamycin
84
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

337. Ms. XY was diagnosed to have an acute DVT at 34 weeks of gestation. She received
antenatal LMWH. She has delivered this morning (38 weeks). She would like to discuss
warfarin for postpartum thromboprophylaxis as she would rather avoid needles. She would
like to breastfeed. Which of the following treatment options are best suited to her ?
A. Warfarin commenced at 48 h postpartum.
B. Warfarin commenced at 72 h postpartum.
C. Warfarin commenced at 96 h postpartum.
D. Warfarin commenced at 120 h postpartum.
E. Warfarin contraindicated, as she is breastfeeding.

338. Ms. XY is on day 1 postpartum following a vaginal delivery at home. She presents to the
ER department in septic shock. She gives history of a fever and sore throat leading up to
the delivery. What is the most likely organism responsible for her condition?
A. E. Coli
B. C. difficile
C. H. Influenzae
D. S. aureus
E. S. pyogenes

339. Which one of the following ultrasound descriptions is diagnostic of miscarriage?


A. Mean GS diameter 25 mm, with no obvious yolk sac or fetal pole
B. Mean GS diameter 25 mm containing a fetal pole with CRL = 3 mm without evidence
of FHR
C. Mean GS diameter 40 mm containing a fetal pole with CRL = 7 mm with evidence of
FHR
D. No identifiable intrauterine or extrauterine GS with serum -hCG 200 IU/L
E. No identifiable intrauterine or extrauterine GS with serum -hCG 1500 IU/L

340. A 20-year-old, who is at 12 weeks gestation, has a 2-day history of vaginal bleeding and
lower abdominal pain. Ultrasound shows a 25 mm fetal pole with absent fetal heart rate.
Pelvic examination reveals her cervix to be 4 cm dilated with bulging intact membranes.
Which one of the following is the most likely diagnosis?
A. Cervical incompetence
B. Incomplete miscarriage
C. Inevitable miscarriage
D. Pregnancy of uncertain viability
E. Threatened miscarriage

341. A 29-year-old, who is at 6 weeks gestation, is diagnosed to have a right tubal ectopic
pregnancy by transvaginal pelvic ultrasound. Which one of the following factors would
enable systematic methotrexate to be offered as a medical treatment option for the ectopic
pregnancy?
A. Ectopic adnexal mass is 5 4 cm in size.
B. Initial serum hCG 1000 IU/L.
C. Presence of fetal heart beat in ectopic pregnancy.
D. Ultrasound evidence of haemoperitoneum >50 mL.

85
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

E. The woman has had previous salpingectomy so further salpingectomy surgery is


contraindicated.

342. A 29-year-old, who is at 6 weeks gestation, presents with slight vaginal spotting.
Transvaginal pelvic ultrasound shows no evidence of any intrauterine or extrauterine
pregnancy. A serum -hCG is measured at initial presentation and repeated 48 hours later.
Which one of the following hCG results is suspicious for a clinically significant ectopic
pregnancy?
A. 500, 1200
B. 800, 200
C. 1000, 400
D. 1000, 3000
E. 2000, 2500

343. A patient with a positive pregnancy test, small amount of vaginal bleeding and no
abdominal pain present has a single transvaginal ultrasound scan, showing an intrauterine
gestational sac, with a crown-rump length (CRL) of 5 mm, with no fetal heart beat. Which
of the following would be the most appropriate management plan?
A. Advise a to carry out a pregnancy test in 3 weeks.
B. Offer medical management of miscarriage.
C. Offer rescan after a minimum of 710 days.
D. Offer rescan in 48 h.
E. Offer surgical management of miscarriage.

344. Ms. XY is a primigravida who presents to the ER department with dark-brown vaginal
discharge for 1 day and mild lower abdominal discomfort. She is 7 weeks pregnant as per
her LMP. Her TV scan shows the presence of a gestational sac and yolk sac with a fetal
pole of 7.5 mm and no fetal heart activity. Which of the following treatment options are
best suited to her?
A. Discuss management options for miscarriage
B. Rescan in 1 week
C. Serum -hCG now and in 48 h
D. Serum hCG and progesterone
E. Serum progesterone to assess viability

345. A 25-year-old woman diagnosed with a complete mole (16 weeks) is scheduled to undergo
surgical evacuation in theatre. Which is the only acceptable management plan in her case?
A. Cervical priming using prostaglandins
B. Routine oxytocin infusion prior to commencement of evacuation
C. Oxytocin infusion in cases of life-threatening haemorrhage
D. Routine oxytocin infusion at the end of evacuation
E. IUD for long-term contraception immediately post-procedure

346. Medical management for an ectopic pregnancy can be considered if:


A. Unruptured ectopic pregnancy of <45 mm.
B. Cardiac activity is demonstrable.
C. -hCG is <3500 IU/ml.
D. There is abdominal pain.
86
DEPARTEMEN OBSTETRIK DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA/ RSUP Dr. MOHAMMAD HOESIN
Jalan Jenderal Sudirman Palembang 30126
Telp. : (0711) 354088, 311466 Ext. (709, 710, 711, 712)
(0711) 355550 Fax. : (0711) 373135

E. There is no evidence of intrauterine pregnancy.

347. The commonest pathology identifi ed at diagnostic laparoscopy in patients with chronic
pelvic pain is:
A. Adhesions
B. Endometriosis
C. Fibroids
D. No pathology detected
E. Pelvic inflammatory disease

348. The preferred period for intervention for an ovarian mass in pregnancy is:
A. 8 weeks
B. 10 weeks
C. 12 weeks
D. 14 weeks
E. 20 weeks

349. Pick the correct statement regarding management of ovarian cysts in pregnancy.
A. All suspected dermoid cysts need to be excised due to risk of torsion.
B. Following cyst aspiration, recurrence occurs in <5 % of women.
C. Persistent simple cysts larger than 10 cm can be offered cyst aspiration.
D. Simple cysts smaller than 5 cm persist in 20 % of women.
E. Torsion commonly occurs in the third trimester.

350. Which one of the following is correct in relation to polycystic ovarian syndrome PCOS?
A. Increased risk of type II diabetes or gestational diabetes.
B. Increased risk of uterine polyps.
C. No induction of uterine bleeding following 5 days of oral progestogen therapy.
D. Resistant to clomiphene citrate ovulation induction in 50% of cases.
E. Virilisation is common.

351. Ms. XY is 32 years old, otherwise fit and well and using the progesterone-only pill for
contraception. She has recently been diagnosed (incidentally) with a 55 mm simple right
ovarian cyst with anechoic fluid. Her CA-125 results are 5 u/ml. She is very anxious
about the prospect of surgery. She has been risk assessed for VTE and is at low risk for
using the OCP. Which of the following treatment options are best suited to her?
A. Offer OCP for three cycles and repeat the ultrasound
B. Offer laparoscopic ovarian cystectomy.
C. Repeat utrasound in 12 months, unless symptomatic.
D. Reassure and discharge from care.
E. Stop the OCP as it is associated with ovarian cysts.

87

Вам также может понравиться