OBGYN Questions

1 After MINOR abdominal trauma ina viable (> 24 weeks) pregnancy, fetal outcome is best predicted by which of the following?

	Maternal vital signs
	Abdominal tenderness
	Serum D-dimer level
	Ultrasound
	Cardiotocographic monitoring

2 The most sensitive indicator of placental abruption is:

	vaginal bleeding
	fetal distress
	uterine tenderness
	abdominal cramps
	ultrasound findings consistent with abruption

3 A 30 year old G2P1 32 weeks EGA was in a minor motor vehicle crash and sustains a laceration and has no abdominal tenderness to palpation although she did “bump” her lower abdomen. She has a normal exam other than having a gravid, nontender uterus, as well as a small 3cm laceration on her forearm with no neurovascular deficits. She is Rh negative. In managing this patient, which of the following statements is FALSE?

	The patient should have 4 hours of cardiotocographic monitoring.
	The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 3 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes.
	Tetanus toxoid should be administered to the patient if she has not been vaccinated in the last 10 years.
	A 50 microgram dose of Rh immune globulin (RhIG) should be administered.
	The most common obstetric problem that is likely to occur in this patient is uterine contractions.

4 Above what serum hCG level is the absence of intrauterine pregnancy by transvaginal ultrasound (and no fluid in the pouch of Douglass or an ectopic mass) presumptive evidence of ectopic pregnancy?

	300
	400
	500
	2000
	600

5 What is the frequency of treatment failure in methotrexate therapy for ectopic pregnancy and its implication for ED management?

	1-20%
	90-100%
	20-30%
	6-36%
	80-90%

6 According to the CDC, empiric treatment of PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if which of the following criteria are met?

	cervical motion tenderness
	uterine tenderness
	adnexal tenderness
	if any one of the above are present

7 Regarding Pelvic Inflammatory Disease (PID), which of the following statements is FALSE?

	Up to 10 percent of women with untreated gonorrhea and 20 percent of women with untreated chlamydia infection may go on to develop PID.
	Quinolones, such as levofloxacin and ciprofloxacin are first-line agents in treating gonorrhea.
	The spectrum of antibiotic coverage must include Chlamydia trachomatis, Neisseria gonorrhoeae, streptococci, gram-negative enteric bacilli, and anaerobes.
	The optimal duration of therapy is unknown, although most authorities favor 14 days of treatment.
	Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the previous 60 days prior to the patient's onset of symptoms.

8 There has been a persistent trend toward outpatient treatment of PID with only 10 to 25 percent of women now being hospitalized. The CDC recommends that the decision to hospitalize for PID should be individualized and at the discretion of the clinician. The CDC’s recommended indications for hospitalization include all of the following EXCEPT:

	pregnancy
	tubo-ovarian abscess
	lack of response to oral medications
	severe clinical illness
	HIV positivity

9 Regarding ovarian torsion, which of the following statements is FALSE?

	ovarian torsion may occur in all ages.
	ovarian torsion may occur in a normal ovary
	the gold standard for diagnosis is ultrasound
	The clinical diagnosis of ovarian torsion should be considered in women with the lower abdominal or pelvic pain and an ovarian cyst/mass, after exclusion of ectopic pregnancy, pelvic inflammatory disease, appendicitis, and leiomyoma-related symptoms.
	Expedient diagnosis of ovarian torsion is important to preserve ovarian function and prevent adverse sequelae (necrosis, infarction, local hemorrhage, peritonitis, systemic infection).

10 Which of the following types of deliveries predisposes to the highest risk of post-partum endometritis?

	elective caesarean delivery
	emergency caesarean delivery
	emergency vaginal delivery
	induced vaginal delivery
	natural vaginal delivery

11 A 22 year old female present with vaginal bleeding and pelvic pain. She thinks she is 7 weeks pregnant by LMP. She has not had an U/S confirming an IUP. You express your concern for an ectopic pregnancy. What would NOT be accurate to tell her about ectopic pregnancies?

	Ectopic pregnancies are the third leading cause of maternal death
	IUDs and previous abortions are risk factors for ectopic pregnancies
	The risk of having an ectopic pregnancy after a prior ectopic is 22%
	Predisposing risk factors for ectopic pregnancy are present in nearly all ectopic pregnancies
	Tubal surgeries and advanced age are risk factors for ectopic pregnancies

12 You are called to the parking lot for a woman who is delivering her baby in the car. You are able to assist her into the ED and safely deliver the baby. Within a few minutes after the placenta is removed, the mother begins to hemorrhage, and you believe that she has a uterine inversion. There is no obstetrician in the house. You should do all of the following EXCEPT:

	Attempt manual replacement of the uterus
	Administer uterotonic agents, such as pitocin
	Administer two large bore ivs and begin administering blood
	After hemodynamic stabilization is achieved, administer intravenous nitroglycerine
	After hemodynamic stabilization is achieved, administer terbutaline

13 You are in the ER when suddenly a man bursts in and says he thinks his wife about to deliver a baby in the car. You run out to the parking lot to find a woman in the backseat with the fetal head at the perineum. As you begin to attempt to deliver the fetus with slight traction on the head, you realize neither shoulder is able to be delivered. Which of the following are included in your approach to dealing with shoulder dystocia:

	Call for backup (obstetrics/neonatology)
	Episiotomy
	Flex mother’s legs and apply suprapubic pressure
	Corkscrew the shoulders
	all the above

14 A 30 year old G1P0 EGA 10 weeks pregnant patient presents with vaginal spotting. She has a closed os and an IUP with good cardiac acitivy, confirmed by ultrasound. She asks you how common it is for clinically pregnant women to experience some bleeding, and what percent of women who bleed during early pregnancy miscarry. To respond correctly, you should state that:

	About 20 to 25% of clinically pregnant patients experience some bleeding, and approximately 50% of all women who have bleeding during early pregnancy miscarry.
	Less than 10% of clinically pregnant patients experience some bleeding, and approximately 5% of all women who have bleeding during early pregnancy miscarry.
	80% of clinically pregnant patients experience some bleeding, and approximately 75% of all women who have bleeding during early pregnancy miscarry.
	90% of clinically pregnant patients experience some bleeding, and approximately 20% of all women who have bleeding during early pregnancy miscarry.
	75% of clinically pregnant patients experience some bleeding, and approximately 90% of all women who have bleeding during early pregnancy miscarry.

15 Regarding pelvic inflammatory disease (PID), which of the following is NOT a criteria for which hospitalization should be considered (according to the CDC)?

	Pregnancy
	Tuboovarian abscess
	vaginal bleeding
	A surgical emergency can not be excluded (e.g., appendicitis).
	The patient is unable to tolerate an outpatient oral regimen.

16 Gynecologic question: Most breast abscesses occur 1 to 3 months post-partum, but post-menopausal women may also develop mastitis and abscesses. Which of the following are common to both types?

	The abscesses are often found in the subareolar region in association with duct ectasia
	causative bacteria are most commonly E coli and group D strep.
	the abscess is caused by normal skin pathogens that invade cracks in the nipple.
	Staph is a causative species
	infection is most often located away from the areola.

17 You are practicing in a rural ED without immediate obstetric back-up. A patient presents with a crowning fetus and shoulder dystocia. All of the following maneuvers may be helpful EXCEPT:

	hyperextend the mother’s thighs
	drain the maternal bladder to create space anteriorly
	perform an episiotomy to allow posterior shoulder delivery
	have an assistant apply suprapubic pressure on the maternal abdomen in an attempt to dislodge the impacted fetal shoulder while you place gentle downward traction on the fetal head.
	place the laboring mother on her hands and feet (the all-fours maneuver).

18 Gynecologic question: Metrorrhagia is bleeding at irregular intervals other than the usual time of menstruation, and metorrhagia usually represents an anovulatory disorder. All of the following are causes of anovulatory bleeding except:

	Polycystic ovarian syndrome
	poorly controlled diabetes
	Von Willebrand’s disease (VWD)
	primary ovarian dysfunction
	hyperprolactinemia

19 Ectopic pregnancy results form implantation of a fertilized ovum at a site other than the endometrium of the uterus. The most frequent site of implantation is:

	the lateral two-thirds of the fallopian tube
	the medial one-third of the fallopian tube
	interstitial or corneal
	within the ovary
	in the abdomen

20 There are multiple risk factors for ectopic pregnany, such as one or more episodes of salpingitis, the use of an IUD associated with a pregnancy (14% of women who become pregnant with an IUD have an ectopic), prior tubal sterilization associated with a pregnancy (16% of women who become pregnant after being sterilized have an ectopic), and a history of a prior ectopic pregnancy. Approximately what proportion of women diagnosed with an ectopic pregnancy DO NOT have risk factors?

	5%
	10%
	20%
	40%
	60%

21 A 30 year old G4P4 patient who is post-partum day #3 presents with subjective fevers, abdominal pain, and foul smelling lochia. You suspect post-partum endometritis. All of the following are risk factors for endometritis, EXCEPT:

	operative delivery
	prolonged rupture of membranes
	prolonged stage 2 of labor
	frequent or excessive pelvic examinations
	urinary tract infection in the third trimester

22 OB question: About 0.4 to 1.3% of pregnant women have asthma. Which of the following statements is FALSE about asthma during pregnancy?

	Asthma improves during pregnancy in over 90% of patients.
	asthma therapy during pregnancy is directed at providing adequate oxygenation for both mother and fetus.
	the management of pregnant asthmatics is essentially the same as that for nonpregnant asthmatics.
	inhaled beta agonists and corticosteroids appear to be safe in pregnancy.
	theophylline is safe in pregnancy.

23 Which of the following is NOT an absolute or relative contraindication for use of methotrexate for the medical treatment of ectopic pregnancy?

	hemodynamic instability
	beta hcg of 2000
	ectopic mass of 6cm
	> 300 ml of free fluid in the pelvis
	fetal cardiac activity

24 The leading cause of death in pregnancy is:

	appendicitis
	trauma
	placental abruption
	thromboembolic disease
	ectopic pregnancy

25 You are seeing a G3P2 36 year old female who is 10 weeks by dates. She presents with vaginal bleeding. The pelvic ultrasound demonstrates a subchorionic bleed. True statements about this finding on ultrasound include which of the following:

	The finding of such a bleed has no prognostic impact for the pregnancy outcome
	The outcome of the pregnancy depends upon the size of the hematoma
	The outcome of the pregnancy depends upon the age of the fetus
	The outcome of the pregnancy depends upon the age of the mother
	The outcome of the pregnancy depends upon the age of the father

26 You are seeing a 29 year old female who is post-partum day #8. She presents with fever, uterine tenderness, foul lochia, and some mild vaginal bleeding. You suspect post-partum endometritis. What is the most important risk factor for this entity?

	history of Group B strep colonization
	history of pelvic inflammatory disease
	history of pre-term labor
	history of cesarean section
	history of bacterial vaginosis

27 You are seeing a G4P4 34 year old obese female (with hx of asthma) who is 28 weeks by dates, and she complains of shortness of breath and dry cough. Which of the following should be part of your differential diagnosis?

	asthma exacerbation
	decreased functional residual capacity due to gravid uterus and obesity
	pulmonary embolus
	peripartum cardiomyopathy
	viral URI

28 You are seeing a 27 year old female in whom your suspect ovarian torsion. True statements about this entity include all of the following EXCEPT:

	Classically, patients present with sudden onset, severe, unilateral lower abdominal pain that worsens intermittently over many hours.
	Fever may occur as a late finding as the ovary becomes necrotic.
	A unilateral, tender adnexal mass has been reported in between 50 and 90% of patients. However, absence of such a finding does not exclude the diagnosis.
	Torsion of a normal ovary does not occur.
	Computed tomography may demonstrate an enlarged ovary and adnexal masses but is unable to evaluate the presence or absence of blood flow to the involved ovary.

29 You are seeing a 50 year old female with a complaint of profuse vaginal bleeding. You suspect dysfunctional uterine bleeding (DUB). True statements about DUB include all of the following EXCEPT:

	Approximately 10% of DUB results from anovulation, and 90% occur with ovulatory cycles.
	In ovulatory DUB, prolonged progesterone secretion causes irregular shedding of the endometrium. This probably is related to a constant low level of estrogen that is around the bleeding threshold. This causes portions of the endometrium to degenerate and results in spotting.
	Obese females tend to have irregularities in their menstrual cycles due to nonovarian endogenous production of estrogen often related to their degree of adipose tissue. This usually results in prolonged cycles of amenorrhea that alternate with cycles of metrorrhagia or menometrorrhagia.
	Although, DUB in itself is rarely fatal, distinguishing this presentation from that of endometrial cancer is important. Development of endometrial cancer is related to estrogen stimulation and endometrial hyperplasia. Symptoms include postmenopausal bleeding, which is usually considered cancer until proven otherwise.
	DUB is most common at the extreme ages of a woman's reproductive years, either at the beginning or near the end, but it may occur at any time during her reproductive life.

30 You are seeing a G1P0 patient who is 10 3/7 weeks pregnant with vaginal bleeding. She has not previously had an ultrasound confirming an intrauterine pregnancy. Which of the following sites outside the endometrial cavity results in a presentation of an ectopic pregnancy typically AFTER 8 weeks’ gestation?

	fallopian tube
	fibriae
	ovary
	cervical
	cornual (interstitial)

31 Which of the following is NOT a known risk factor for ectopic pregnancy?

	prior ectopic pregnancy
	prior sexually transmitted disease
	tubal infection or pelvic adhesions
	assisted reproductive treatment (ART)
	increased maternal age

32 The radiology resident refuses to do the pelvic ultrasound you ordered to rule out an ectopic because the beta on your patient is 100, and he states that women can not rupture an ectopic pregnancy when the beta is that low. Is his statement true or false?

The radiology resident’s statement is false. A single beta hcg level cannot rule in or rule out an ectopic pregnancy. A beta-hcg in a patient who presents to the ED with abdominal pain or vaginal bleeding with a beta-hcg < 1500 are less likely to have a normal IUP. A beta < 1500 in these patients more than doubles the odds of having an ectopic pregnancy. Women can rupture, however, an ectopic pregnancy with beta hcg at any level. The risk of ectopic pregnancy is in fact increased when the likelihood of a normal IUP is low. Therefore, transvaginal ultrasound should be performed in women at risk for ectopic pregnancy regardless of the beta hcg level.

33 A 32 year old g3p2 patient who is 20 weeks by dates presents after a Tylenol ingestion. True statements about Tylenol in pregnancy include which of the following?

	acetaminophen does not cross the placenta
	acetaminophen is a teratogen
	n-acetylcysteine does not cross the placenta
	the Rumack-Matthew nomogram should be adjusted in pregnancy
	the management is the same for pregnant and non-pregnant patients

34 Your patient with an ectopic pregnancy wants to know if she is a candidate for non-surgical treatment (methotrexate). Which of the following statements about methotrexate for ectopic pregnancy is true?

	40% of patients with ectopic pregnancy meet criteria for medical management.
	To be eligible, the nonruptured ectopic pregnancy should be < 4 cm
	To be eligible, the beta-hcg should be < 1000
	To be eligible, there should be no cardiac activity in the fetus
	To be eligible, the patient must be hemodynamicallys table, be reliable, and be amenable to the treatment regimen

35 Regarding venous thromboembolism and pregnancy, which of the following is TRUE?

	30% of isolated episodes of pulmonary embolism are associated with silent deep-vein thrombosis, and in patients with symptoms of deep-vein thrombosis, the frequency of silent pulmonary embolism ranges from 40 to 50%.
	The majority of cases of pulmonary embolism occur in the first trimester.
	DVTs occur more commonly in the right leg, rather than the left leg.
	Ultrasound reliably detects DVT in the iliac vein.
	50% of cases of venous thromboembolism in pregnant women are associated with an inherited or acquired thrombophilia.

36 An intrauterine pregnancy can be diagnosed by sonographic findings in the following CORRECT order of appearance:

	fetal pole, double gestational sac, double ring sign, and fetal heart rate activity
	double gestational sac, fetal pole, double ring sign, and fetal heart rate activity
	double ring sign, double gestational sac, intrauterine fetal pole, and intrauterine fetal heart activity

37 The most common symptom of placenta previa is:

	painful uterine contractions
	signs of fetal distress
	painful vaginal bleeding
	painless fresh vaginal bleeding
	hemodynamic instability of the mom

38 A 29 yo female presents with vaginal spotting for the last 5 days associated with llq abdominal pain. You suspect possible ectopic pregnancy. True statements about this entity include which of the following?

	Incidence of ectopic pregnancy has decreased in incidence over the last several decades.
	90% of women who have ectopic pregnancies have a risk factor for an ectopic.
	A single serum hcg value neither identifies the presence of an intrauterine or ectopic pregnancy nor predicts rupture, but it can serve as a surrogate marker for gestational age.
	Discriminatory hcg value has been reported to be between 1500 to 3000 mIU.
	In 8 to 31% of women in whom ectopic pregnancy is suspected, the initial ultrasound does not show a pregnancy in either the uterus or in the fallopian tubes.

39 A 29 yo female presents with vaginal spotting for the last 5 days associated with llq abdominal pain. You suspect possible ectopic pregnancy. True statements about DIAGNOSING this entity include which of the following?

	serial measurement of hcg can help distinguish potentially viable IUPs from an ectopic.
	50% of women with ectopics present with increasing hcg levels and 50% present with decreasing hcg levels.
	In women who have decreasing hcg levels, serial hcg should be performed until hcg is no longer detectable in the serum (this may take 6 weeks).
	Sensitivity and specificity of progesterone level is not sufficiently high to rule in or rule out an ectopic pregnancy.
	The accuracy of ultrasound varies according to the serum hcg level.

40 A 29 yo female presents with vaginal spotting for the last 5 days associated with llq abdominal pain. You suspect possible ectopic pregnancy. True statements about TREATING this entity include which of the following?

	The preferred surgical treatment is laparotomy
	Medical management may be with single-dose, two-dose, or multidose regimens of methotrexate
	Tubal patency for medical treatment is better than surgical treatment
	Medical treatment decreases the recurrence rate
	Surgical treatment improves potential for future fertility

41 Which of the following are factors associated with failure of medical management with methotrexate for an ectopic pregnancy?

	Initial hcg > 5000mIU
	Ultrasound detection of moderate to large amount of free pelvic fluid
	Presence of fetal cardiac activity
	Pretreatment increase in serum hcg of more than 50% over a 48 hour period
	All of the above