OB/GYN: NBME COMPLETE SOLUTIONS

OB/GYN: NBME -ACOG recently updated guidelines that state active phase starts at 6 cm (to reduce # of patients getting unnecessary c-sections). The prior guidelines set active stage at 4 cm which is why the answer is A (NBME assessments typically lag behind a couple of years) Answer to the Previous Question - ✅-A -bisphosphonates are DOC for prevention & treatment of steroid induced osteoporosis. it is preferred to teriperatide. calcitonin is NOT used and consider only if these two fails This woman is premenopausal so you shouldn't do estrogen based interventions. They have normal ovarian function thus already have enough estrogen.

-Osteoporosis PPx: - induce by GC --> PPx with Biphosphonate - general cause in postmenopausal woman : PPx with Biphosphonate or Raloxifene - general cause in premenopausal: Biphosphonate (NOT Raloxifene --> ES Antagonist -> decreases effect ES in bone --> low BMD Answer to the Previous Question - ✅-A -cervical stenosis. secondary dysmenorrhea or amenorrhea after cervical procedures strongly suggests cervical stenosis has developed Answer to the Previous Question - ✅-A -High yield fact to remember about clomiphene is its association with twins and also ovarian hyperstimulation (ascites, abdominal pain, nausea) -Sequence of use is to mimic natural menstrual cycle ... to give clomiphene first to induce ovulation then menotropin/human menopausal gonadotropin(FSH mimic) in pulsatile fashion to trigger dominant follicle formation and then last task is to stimulate LH surge once oocytes mature after few days, by giving hCG (remember alpha subunit is alike in LH and hcg) Answer to the Previous Question - ✅-A -Hypogonadotropic hypogonadism is low FSH/LH that causes low estrogen.

Functional hypothalamic amenorrhea starts higher up in the axis at level of hypothalamus releasing < GnRH as seen w/ atheletes/anorexic.

Some definitions: Gonadotropic = stimulates gonads (ie FSH/LH), while hypogonadism = low function of gonads (ie ovary/testes). Another is hypERgonadotropic hypOgondandism (ie ovarian insufficiency) where have >FSH/>LH but low estrogen.

-This is functional hypothalamic amenorrhea (runs 7 miles per day, three marathons, BMI 17), not menopause.

Answer to the Previous Question - ✅-A -If the baby is not in the correct positioning and there is SROM, there's a risk of cord prolapse. This presents with rapid decrease in fetal heart rate. By doing a pelvic exam, you should be able to see the cord. Tx is to deliver immediately via c-section.

-If the head isn't presenting at at least 0 station when membranes rupture there is increased risk of cord prolapse because there is space for it to fall out from, vs when the head prevents it from prolapsing....plus the decel after rupture of membranes gives us a picture of cord compression from prolapse since there is no bleeding or clue of anything else... so pelvic exam is best to do next Answer to the Previous Question - ✅-A -loss of inhibitory control over bladder secondary to MS -postvoid is low and she is describing urge incontinence -Was so confused, but found it! Ok so if MS affects centrally, you lose upper motor neuron --> hyperactive bladder and no storage (why postvoid residual volume is low). If affect LMN --> hypOtonic bladder and overflow incontinence.

Another helpful way to distinguish hypertonic vs hypotonic is hypertonic have urge to pee while hypotonic has NO urge.

-MS can cause detrusor hyperreflexia and hypotonia, but detrusor overactivity is the MOST COMMON urologic abnormality affecting patients with MS (due to demyelination in the frontal lobe). Of course, you gotta frame everything in the context of this question, so even if you didn't know that, the fact that her PRV is 45 mL should point you to A -Like you said she has a low post residual void (< 150ml in women is normal;< 50 mL in men) if it was greater then it would indicate obstructive incontinence.

Answer to the Previous Question - ✅-A -The lighter the patient the more the risk for osteoporosis. Her smoking history of 2 cigarettes weekly is not that significant.

Tamoxifen is actually a bone strengthening drug.

Family history of fracture plays a very significant role, which might be the next option.

Her hypothyroidism(mild) is well is well controlled with Levothyroxine.

-"Low body weight < 128 lb is associated with an increased risk of fracture because they have a lower peak bone density." UW Answer to the Previous Question - ✅-A -She is a consenting adult and is conscious. You cannot transfer her or do a surgery permission from other sources.

-because patient religious beliefs / personal autonomy for decision making takes precedence. She is awake and has capacity, so she has the right to endanger her own life, just like a Jehovah's witness or anyone else who might decline life-saving medical care. It's best to work with the patient's beliefs collaborateively. I'm sure the elders can convene a meeting over Skype.

Answer to the Previous Question - ✅-A - antibiotic therapy if the delivery does not occur 18 hrs after ROM -Prior delivery complicated by neonatal GBS Infection -GBS Bacteriuria or GBS urinary tract infection during the current pregnancy (regardless of treatment) -GBS positive rectovaginal Culture -Unknown GBS status plus any of the following: <37 weeks gestation Intrapartum fever Rupture of amniotic membranes for >=18 hours Answer to the Previous Question - ✅-A - candida. OCP and antibiotics are risk factors, intact vg pH -Per UTD: -***There can be little or no discharge; when present, it is classically white, thick, adherent to the vaginal sidewalls, and clumpy**** -Physical examination of the external genitalia, vagina, and cervix often reveals erythema of the vulva and vaginal mucosa and vulvar edema -Vulvar excoriation and fissures are present in about one-quarter of patients.

-because chlamydia causes cervicitis not vaginitis.

-these orgonaism cause cervicitis, so you would see cervical discharge but here it says cervix is normal

Answer to the Previous Question - ✅-A - second adm of prednisone in 24 hrs. Dx PPROM. you need to give TWO doses plus MgSO4 (as less than 32 wks) plus antibiotics -Mom is already on antibiotics. At just 28 weeks gestation, steroids are critical to the baby. Betamethasone starts to work as early as 18hrs, but peak effects are seen at 48hrs.

Answer to the Previous Question - ✅-A - test for chlamydia (and gono). STD screening is recommended for all sexually active females less than 25 yrs Answer to the Previous Question - ✅-A - third measurement of BhCG in 1 wks. Dx abortion. After abortion, measure hCG weekly until it is undetectable Answer to the Previous Question - ✅-A confirmed online.

-Urge incontinence = urgency/nocturia d/t erratic detrusor contractions. An anterior fibroid pushing on the bladder might cause increased urgency, but it wouldn't cause the detrusor to overact and there wouldn't be nocturia.

Answer to the Previous Question - ✅-A. -asherman syndrome. Progestin challenge negative can be either estrogen deficiency (ovarian failure) or asherman. This pt has D&C history and normal FSH which points to asherman -lthough the HPO axis will respond appropriately to the progestin challenge, if the endometrium is scarred, there will be inadequate proliferation in the first place and therefore less material to shed. so no menses.

Answer to the Previous Question - ✅-A. -Pap smear Now. It is negative 2 yrs ago only once. Need to do Pap smear twice in the first yr then annually for HIV pt -Immunocompromised patients (HIV) screening is annually.

Answer to the Previous Question - ✅-A. ACTH oversecretion explains why this girl has phallus and scrotum. Dx congenital adrenal hyperplasia. Virilization in a newborn girl -female genotype excludes AIS Answer to the Previous Question - ✅-A. next step is nonstress test. Dx fetal growth restriction FGR.

-not for dx but for antenatal fetal monitoring. if there are BPP, doppler in the option, it wud be a tough choice but the other options are incorrect (these are for aneuploidy testing) Answer to the Previous Question - ✅-Answer is F Answer to the Previous Question - ✅-B -2 gestational sacs + 2 yolk sacs + thick inter twin membrane = dichorionic diamniotic (as in this question); 1 gestational sac + 2 yolk sacs + thin inter twin membrane = monochorionic diamniotic (option c); single gestational sacs and single yolk sac with twin testimony and no intertwine membrane = monochorionic monoamniotic Answer to the Previous Question - ✅-B -aub workup: 1. rule out pregnancy 2. look for anatomical causes by examination,if u get any do workup 3. coagulopathy if suspected 4. anovulation which is most common cause of aub, diagnose it by progesterone challange test by cyclic progesterone -"For women with AUB-O (Ovulatory Dysfunction), estrogen-progestin contraceptives, oral progestin therapy, or the LNg52/5 are first-line treatment options, as these approaches reduce bleeding and decrease the risk of endometrial hyperplasia or cancer" Answer to the Previous Question - ✅-B -due to pre-eclampsia compromises utero-placental supply placental insufficiency Answer to the Previous Question - ✅-B -estrogen deficiency. Dx Urge incontinence. The menopausal symptoms & vg atrophy Answer to the Previous Question - ✅-B -valporate can cause NTD Answer to the Previous Question - ✅-B -we don't know which aspect the problem is with ...passenger, pelvis or power.....she is in stage 1 active phase....and no prolongation or arrest is evident...just do US and wait -C,d,e not indicated....u don't do x ray...so only option left is b -The baby is not very big, her cervix is dilated to 6cm which means she is almost in active phase, you should be able to feel the head. This could be a breech, do an U/S

-Unless you can feel a head on sterile vaginal exam, all patients should be scanned for vertex positioning before allowing them to continue laboring Answer to the Previous Question - ✅-B - androgen insensitivity $ AIS. This is a male with insensitivity to androgens.

Rudimentary vagina, primary amenorrhea, no secondary sex characters except breast deveopment and the pelvic USG shows no uterus -mullerian agenesis shud have full 2' sex characters -also the patient has breast development because the testosterone is converted peripherally to estrogen, which stimulates the breasts to develop Answer to the Previous Question - ✅-B - bartholin duct abscess Answer to the Previous Question - ✅-B - FSH will be increased in Menopause Answer to the Previous Question - ✅-B - granulosa cell tumor. Atypical complex hyperplasia (endometrial hyperplasia with atypia). RF is high estrogen state so the tumor must be the one that produces estrogen Answer to the Previous Question - ✅-B - Hmole. Hgravidarum with bleeding & USG findings suggest dx Answer to the Previous Question - ✅-B - karyotyping is next step. dx turner (or even if not, at least primary hypogonad coz FSH is high) -Kallman is caused by lack of Hypothalamus-Gonad Axis due to Hypothalamus failure to produce GnRH at all. The anosmia is a really cool phenomenon because your olfactory cells and GnRH-producing cells apparently have the same embryologic origin. Since GnRH is responsible for stimulating FSH/LH, you can expect both of those to be low as well.

High FSH with low Estradiol (which is implied by her lack of sexual development) is ultimately a sign of Ovarian Insufficiency because your ovaries are supposed to react to FSH, but the lack of negative feedback for estrogen is showing us that her ovaries are not working.

Turner Syndrome --> streak ovaries --> it paints the picture once you know this background. With that said, this stem probably intentionally left out the patient's physical exam so that they can focus on your attention to pathophysiology of the disease as it pertains to Endocrinology. If they told you she was short AND underdeveloped with a webbed neck, a second year medical student would be able to figure it out.

Answer to the Previous Question - ✅-B. -In obese pt, the androstenedione is converted to estrone E1 in adipose tissues which increases the risk of endometrial CA Answer to the Previous Question - ✅-B. low MCV anemia. Dx IDA. Hb electrophoresis excludes sickle cell ds Answer to the Previous Question - ✅-B. Next do hysterosalpingography to rule out tubal occlusions and asssess uterine cavity. Dx female factor of infertility. Husband's tests are fine.

-FSH should be chosen if menses are irregular -Male is ruled out, and she has regular periods, basically telling you that her entire HPO axis is intact--so you don't need the LH, FSH, Progesterone or Estrogen tests.

Hysterosalpingography is easy, noninvasive and will tell you if there's a physical obstruction, which is pretty likely given her cycles are normal and she's had multiple sexual partners (=STDs=PID=obstruction) Answer to the Previous Question - ✅-C - 5-alpha reductase deficiency, Testosterone unable to convert to DHT, ambiguous genitalia at birth (female or undermasculinized external genitalia) at birth (undervirilization). male internal urogenital tract ( due to AMH). At puberty they experience masculinization due to testosterone (eg inc in phallus size, muscle growth, voice deepening) but lack breast development.

-his is 5-alpha reductase deficiency, not androgen insensitivity. HEre have 46XY (so same answer), but inability to convert testosterone to DHT (potent version of testosterone). Born w/ female or undermasculinized external genitalia. At puberty have NO breast but get masculinization from testosterone like deep voice, muscle...acne and hair I guess too.

Answer to the Previous Question - ✅-C -Ok this is an enterocele. Since it is small bowel it is normal not to affect bowel movements (a rectocele would most likely have bowel movements problems and a cystocele would present with urinary tract symptoms). Also, hysterectomy is a specific cause of enterocele (cystocele and rectocele are generally seen in pelvic muscle relaxation). Finally, it says that the origin is high in the vaginal vault which also points to the enterocele. It's not a uterine prolapse cause she had a hysterectomy.

Answer to the Previous Question - ✅-C - antenatal testing. Polyhydramnios with mild symptoms do not need rx

-if very severe symptoms, in less than 32 wks, amnioreduction and indomethacin can be considered. if >32 wks no indomethacin Answer to the Previous Question - ✅-C - condylomata acuminata by HPV Answer to the Previous Question - ✅-C - give cyclical progestin only to control the irregular menses. Dx endometrial hyperplasia -Think this is irregular menses due to anovulation. Her endometirum is stuck in proliferative phase because missing ovulation/progesterone.

Answer to the Previous Question - ✅-C - IV amp + genta. Dx endometritis. dx endometritis Answer to the Previous Question - ✅-C - Looks like the fetus is descending dt an incompetent cervix. Painless cervical dilatation -No contractions excludes all labor options -breech position "in the vagina" (not uterus) is the key phrase for realizing the answer is cervical incompetence.

Answer to the Previous Question - ✅-C - maternal fever. CTG shows fetal tachycardia with minimal to moderate variability Answer to the Previous Question - ✅-C - Parvo virus B19. Daycare means contact with children, hydrops Answer to the Previous Question - ✅-C - pregnancy test first -A classic USMLE strategy - when in doubt choose the most basic option Answer to the Previous Question - ✅-C - USG pelvis. Fetal station is -2. With 6cm dilation you shud feel the presenting part but you don't feel it now. Contractions are fine. do USG to check for the CPD for transverse fetal lie etc (this is not arrest yet though) -its not arrest of active phase until more than 4 hours (with adequate contractions as in this patient) have passed. she is still at 2nd hour Answer to the Previous Question - ✅-C. -fetal tachycardia is dt maternal fever (Exclusion). can also be dt thyrotoxicosis, intraamniotic infn, beta adrenergic drugs, fetal hypoxia etc

-A - would show sinusoidal pattern, B would be early deceleration, D would be variable deceleration and E is late decelerations Answer to the Previous Question - ✅-C. cervical incompetence -things i've learned: "funneled internal os" = pathognomonic for cervical incompetence Answer to the Previous Question - ✅-C. hemophilus ducreyi. painful genital ulcer (no herpes in choice thus no need to confuse) -C is correct because the lesion is painful. UWorld says these ulcers are multiple and deep. Base may have grey to yellow exudate. However the description here sounds more like the beefy red of choice A now called Klebsiella granulomatis (aka granuloma inguinale) which does not have pain on initial lesion according to UWorld.

Answer to the Previous Question - ✅-D -Bartholin cysts are painLESS inflammation of the DUCT. -Bartholin abscesses are painFUL infections of the GLAND. -Bartholinitis (cellulitis) is a painful complication of Bartholin cysts, and more commonly, Bartholin abscesses.

-Necrotizing fasciitis is a severe complication of Bartholinitis. (Fournier Gangrene aka Nec fascitis of the perineum, associated with diabetics) Answer to the Previous Question - ✅-D -CXR is the next step for PPD positive pt. pts with HIV with >5mm induration is positive -Seems that uptodate says to do CXR regardless of gestational age if have + PPD and risk factor like HIV. "Diagnostic evaluation after positive test — Patients with a positive TST or IGRA must undergo clinical evaluation to rule out active tuberculosis. This includes evaluation for symptoms (eg, fever, cough, weight loss) and radiographic examination of the chest (with appropriate shielding), regardless of gestational age."

Answer to the Previous Question - ✅-D -D - cone biopsy (diagnostic excisional procedure) -- this pt's entire SCJ cannot be visualized meaning inadequate colposcopy result -- In such case, diagnostic excisional procedure (LEEP or conization) shud be done -- Then cotest --> then colposcopy if abn cotest

Xif the question gives pt with adequate colposcopy, you can choose ablation or excision (LEEP, conization, cryo or laser) and even if so, excisional procedures like LEEP are preferred Answer to the Previous Question - ✅-D -Doppler USG of umb artery (exclusion) determines risk of IUFD. Dx asymmetrical FGR -You would be looking for absent or reverse flow in the umbilical artery Answer to the Previous Question - ✅-D -Even though meth seems to increase HTN more than cocaine in pregnancy, cocaine still proves to carry a higher risk of abruptio. The risk of cocaine abuse and abruptio is up around 20% and meth the risk goes down to 10%. A little paradoxical but it seems that all of the Q banks want us to differentiate smoking vs. cocaine rather than meth vs. cocaine. Had a Q on this, so hope it helps!

Answer to the Previous Question - ✅-D -Fibrocystic change = multiple Fibroadenoma = singular, discrete mass Answer to the Previous Question - ✅-D -he has moderate lower abdominal pain (still menstruating just blood is blocked so can't flow out), vaginal canal can't be visualized (hymen is blocking it), and rectal examination shows an anterior tender, central mass which all indicate imperforate hymen -AIS (46 X,Y). MRKH syndrome (complete mullerian agenesis, 46 X,X). AIS (testes present, defective T receptor) and MRKH syndrome both have normal breast development, either absent/rudimentary uterus and upper vagina. Pubic/axillary hair is absent in AIS, but present in MRKH syndrome.

Answer to the Previous Question - ✅-D -If you have high clinical suspicion for malignancy you should image and bx. Since she had mammo recently, don't repeat. Technically for older women (30+) should do a core needle bx rather than FNA. Also helps to consider that if mammogram was negative, this would NOT r/o malignancy and you'd still want a bx. (blueprint) Answer to the Previous Question - ✅-D -PCOS have incur LH/FSH and increase androgen primarily testosterone

Answer to the Previous Question - ✅-D -She is taxhycardic, tachypneic and pco2 is decreased too. Also po2 is lower than usual -pleuritic chest pain in a pregnant woman with a low-grade temp.

Answer to the Previous Question - ✅-D - indirect antiglobulin (Coombs). Dx Rh negative mother 2nd pregnancy. Coombs test is used for Rh typing and antibody screening -just an FYI because I got confused. To check Rh status is Coombs but to check the dose of RhoD is Betke test.

-"In cases of trauma or bleeding during pregnancy in which there is a potential for more than a 30-mL fetomaternal trans- fusion, the extent of the fetomaternal hemorrhage can be assessed using the Kleihauer-Betke test. This test identifies fetal erythrocytes in the maternal circulation. The number of fetal cells as a proportion of the total cells can be deter- mined and the volume of fetomaternal hemorrhage can be estimated. Based on this estimation, the appropriate dose of Rh immune globulin can be determined. An indirect Coombs test can also be used to determine if the patient has received sufficient antibody. A positive test indicates that she has received an adequate dose."

Answer to the Previous Question - ✅-D - injury to C5, C6 nv root. Dx Erb's palsy, pronated forearm, adducted, internally rotated shoulder Answer to the Previous Question - ✅-D - insulin. Dx Infant of DM mother. The hyaline membrane described is dt ARDS dt deficiency of surfactant. Surfactant are deficient as they are being inhibited by insulin produced in the newborn Answer to the Previous Question - ✅-D - intraductal papilloma, MCC of unilateral breast discharge Answer to the Previous Question - ✅-D - respect the pt's wishes and schedule a follow-up visit in 1 wk Answer to the Previous Question - ✅-D - she is almost close to menopause and still having high menstrual flow. Also she is obese which can also cause heavy flow. Her pap smear is benign. Dx: endometrial cancer or hyperplasia -per uworld: >/= 35 atypical glandular cells on pap -> endometrial bx age < 45: AUB + -unopposed estrogen -failed medical management -lynch syndrome

age >/=45: AUB or postmenopausal bleeding Answer to the Previous Question - ✅-D. -torsion of ovarian cyst. Sudden abd pain in the context of a cystic ovarian mass is torsion until proven otherwise -Also, no mention of fluid on ultrasound really points you away from ruptured cyst.

Answer to the Previous Question - ✅-D. Do wet mount (Trichomonas vaginalis) Answer to the Previous Question - ✅-D. polyhydraminos dt maternal DM.fundus higher than date -A,B,C would have been noticed in previous US, text remarks that she has received prenatal care since 7 wks with "NO abnormalities till 24 wks". her last glucose control is from 28th but we don't know her HbA1c status. Besides the fact that around that time placental lactogen reaches its peak. Fundal ht variation can't be as it is FH+/-3wks. So DM1 mom, polyamnios looks right.

Answer to the Previous Question - ✅-D. serum cholesterol concn. His father had MI at young age 39 yrs old and she has other CVS risk factors -Side note from UWorld: All sexually active females age 25 or under should be offered annual Gonorrhea and Chlamydia screening.

Answer to the Previous Question - ✅-D. USG is next step. Dx suspected twin pregnancy. Fundus 15 cm above symphysis for a 10 wk gestation seems higher than nml, conceived by oocyte donation (IVF is a risk factor) Answer to the Previous Question - ✅-E Answer to the Previous Question - ✅-E -Dx - Carcinoma Answer to the Previous Question - ✅-E -Levonorgestrel IUD (Mirena) is the most effective (.1 fail rate) contraception. It is only contraindicated for active PID, not previous. Medroxyprogesterone (Depo-Provera) is a little less effective (.3 fail rate) and she would need to come in for injections every three months.

Answer to the Previous Question - ✅-E

-Parvovirus B19. Dx Hydrops fetalis. Picked up infn from her daughter Answer to the Previous Question - ✅-E -This is not psychosis where she would have symptoms of mania, delusions, hallucinations etc. She has suicidal ideations (SI) which is part of the diagnosis of depression. Psychiatric evaluation would be good to determine severity of her SI (plan or not?) and that would determine if she needs placement (or possibly reveal psychotic symptoms) Without SI, C could be an option in practice since SSRIs take 4-6 weeks to kick in and its better to just start it than wait and let the depression get worse.

Answer to the Previous Question - ✅-E From UTD, postexposure ppx for infants pborn to symptomatic mothers around time of delivery is human varicella-zoster Immune globulin therapy. For disseminated infection in infants treat with IV acyclovir for 10 d.

Answer to the Previous Question - ✅-E -uteroplacental insufficiency. Dx IUGR in a hypertensive mother Answer to the Previous Question - ✅-E - Normal Labor -painFUL contraction + cervixl DILATION --> LABOR painLESS contraction + NO DILATION --> BH contractions Answer to the Previous Question - ✅-E - Pap smear no longer indicated. No cervix no cancer -"Finally, routine cervical cytology is not recommended in women who have had a total hysterectomy for benign indications, and no history of cervical dysplasia. However, if hysterectomy is performed for cervical dysplasia (ie, CIN III), then Pap smear of the vaginal cuff is still needed." Case Files 5th -ACOG, ACS and USPTF all recommend against pap smear post hysterectomy UNLESS there is a hx of CIN 2 or greater.

Answer to the Previous Question - ✅-E - secretory endometrium Answer to the Previous Question - ✅-E - uterine rupture. Fetal parts above the fundus & prev C section Answer to the Previous Question - ✅-E - vaginal foreign body

Answer to the Previous Question - ✅-E - vulvar carcinoma (exclusion) A unifocal ulcer, mild red, they get itchy as they invade but other wise asymptomatic Answer to the Previous Question - ✅-E. -laparoscopy. It is also reasonable to begin medical Rx (which is not in the option so no need to confuse in this question). Surgically confirming the dx by laparoscopy is the preferred next step Answer to the Previous Question - ✅-E. -Cesarean delivery. Dx transverse lie during active labor needs CS. you cant do ECV or internal podalic version if active labor -When the fetus is in tranvserse lie (it can be back up (spine toward maternal head) or back down (like in this pt - fetal spine toward the cervix). This is Dx on U/S. Most fetus spontaneously convert to breech or vertex presentation. BUT IF THE PT IS STILL TRANSVERSE at 37 WKS.... Pt should be offered ECV (external cephalic version can be tried ~50% success rate; ECV is C/I in ROM, abnormal FHR, oligohydramnios) then CS Delivery.

Answer to the Previous Question - ✅-F. OCP are contraindicated in smokers -OCPs are absolutely contraindicated in Smokers over the age of 35 or patients with a history of DVT. Smokers under the age of 35 are at an increased risk but is not an absolute contraindication.

Answer to the Previous Question - ✅-F. pulm hypoplasia (exclusion). It is the one answer with oligohydraminos. potters Answer to the Previous Question - ✅-G -Asherman's syndrome (AS) aka Fritsch syndrome; The cavity of the uterus is lined by the endometrium. This lining is composed of two layers, the functional layer (adjacent to the uterine cavity) which is shed during menstruation and an underlying basal layer (adjacent to the myometrium), which is necessary for regenerating the functional layer.

Trauma to the basal layer, typically after a dilation and curettage (D&C) performed after a miscarriage, or delivery, or for surgical termination of pregnancy, can lead to the development of intrauterine scars resulting in adhesions that can obliterate the cavity to varying degrees. In the extreme, the whole cavity can be scarred and occluded. Even with relatively few scars, the endometrium may fail to respond to estrogen. Often, patients experience secondary menstrual irregularities characterized by a decrease in flow and duration of bleeding (amenorrhea, hypomenorrhea, or oligomenorrhea) and

become infertile. Menstrual anomalies are often but not always correlated with severity: adhesions restricted to only the cervix or lower uterus may block menstruation. Pain during menstruation and ovulation is sometimes experienced and can be attributed to blockages. It has been reported that 88% of AS cases occur after a D&C is performed on a recently pregnant uterus, following a missed or incomplete miscarriage, birth, or during an elective termination (abortion) to remove retained products of conception.

Answer to the Previous Question - ✅-G. test for chlamydia trachomatis (exclusion). she is sexually active, occasional condom use Answer to the Previous Question - ✅-H -Urethrocele. Q tip test positive means stress incontinence. anterior and posterior vg wall appears well supported which means not cysteocele or rectocele -more than 30 degrees of movement from horizontal is uretheral hypermobility - Cystocele would present with a bulging mass on valsalva. Since it says the walls are well supported, urethrocele is most likely Answer to the Previous Question - ✅-H -Wt and ht is normal. Amenorrhea is less than 6 mths -Yes, H confirmed online. In those UWorld questions, the patients were older, previously had regular menses, and trained a lot (gymnastics champion, collegiate athlete). This girl had menarche only one year ago, has had irregular cycles since menarche, and does not do significant exercise. In the first few years after menarche, the hypothalamicpituitary-ovarian axis is not well developed, so cycles are irregular, but it's normal development.

Answer to the Previous Question - ✅-J - wound infection is the cause of this pts post op fever. The incision shows erythema and induration Answer to the Previous Question - ✅-J. pulmonary embolism. Massive PE can also explain cor pulmonale -amniotic fluid embolism would occur essentially in the immediate post partum period.

Given that this pt is 3 days PP, PE is more likely (classic virchow triad: hypercoaguable state (pregnancy), stasis (bed rest/limited mobility from abdominal incision, vascular insult (idk from where, but likely with any operation)) Answer to the Previous Question - ✅-K -Parvovirus B19 causing hydrops

-she is primigravid, plus she works in a preschool--> increase likelihood of obtaining infection from kids--> hinting parvovirus B19 causing the fetal hydrops.

Answer to the Previous Question - ✅A Answer to the Previous Question - ✅A Answer to the Previous Question - ✅A Answer to the Previous Question - ✅A Answer to the Previous Question - ✅A it cant be endometritis as diagnosis is made post 24 hrs of delivery. thrombophlebitis is diagnosis of exclusion and characterised by fever unresponsive to antibiotics, no localizing signs or symptoms.wound infection would show erythema and warmth at the incision site, Answer to the Previous Question - ✅A -This is really more of a Surgery question than an OBGYN question - but OB is a surgical field and this is fair game for the Shelf!

There's a mnemonic for patients presenting with a Post-Operative Fever (i.e. any fever arising after a surgical operation). Given that this patient underwent a C-Section, they count as a post-operative patient! Whenever you see a fever post-op on the exam, consider the "5 Ws" (see attached): Wind Atelectasis (Post-Op Day 1-2) Water UTI (POD 3-5) Walking DVT (POD 4-6) Wound Infection of the surgical wound (POD 5-7) Wonder Could be anything; unlikely related to the Surgery itself (POD 7+) These are considered to be the "most common" causes of post-operative fever. Note that actual bacterial infection (Water/Wound) usually takes several days to develop, as it

takes time for bacteria to infiltrate and duplicate in a susceptible area. So in this case (POD 2), it's fairly unlikely that it's a real bacterial infection!

Atelectasis in particular is caused by shallow breathing. Anyone with an abdominal surgery (e.g. Cholecystectomy, Appendectomy) - of which a C-Section counts! - will experience pain on deep inspiration, and will opt to take more shallow, rapid breaths.

This doesn't utilize the base of the lungs, which causes them to collapse due to underuse, and that's the source of this patient's inflammation/fever.

It's worth noting that this is why we encourage patients to use the Incentive Spirometer after an operation, to 'gamify' taking deep breaths to prevent atelectasis.

I know it sounds dumb, but the decreased breath sounds at both bases and lack of a high fever R/O pneumonia. Really here you need a CXR to differentiate.

Answer to the Previous Question - ✅A "The classic presentation of placental abruption is third-trimester vaginal bleeding associated with severe abdominal pain and/or frequent, strong contractions."

Answer to the Previous Question - ✅A A - Dx is Stress Incontinence - pt urine loss after increase abdominal pressure (coughing, sneezing, lifting). Urethral sphincteric insufficiency due to laxity of pelvic floor musculature. This is common in multiparous women or hx of pelvic surgery Answer to the Previous Question - ✅A Admit to hosp for IV Ab. Dx SEVERE PID. although mild to moderate PID is good to treat at OPD, severe PID is an indication for hospitalizatal treatment

So, it's a PID case - here's what we should be considering: Usually, we have to r/o pregnancy with an ultrasound (which can simultaneously tell us if we're dealing with a TOA or not), but the symptoms are pretty telling - let's skip the step for fulfilling criteria.

In PID, we can elect to treat as outpatient (preferred if possible, generally with Gc/Chl coverage while we wait for cultures to return). What turns us away from this option is 2fold (as opposed to 1-fold so as not to cloud a medical student's untrained judgment). 1) The patient is a teenager. We pretty much admit inpatient as a go-to because of the complication of infertility that can evolve from a PMHx of PID - teens aren't reliable patients for compliance OR f/u in clinic. 2) Her symptoms are pretty severe - super high fever, peritoneal signs, lower abdominal tenderness, discharge; they threw every bad indication of health into the stem (except for hemodynamic instability, which would make us choose surgery) to further encourage us to pick inpatient.

Answer to the Previous Question - ✅A amniotic fluid embolism. symptoms suggesting DIC plus lung $ immediately after labor Answer to the Previous Question - ✅A arrest in 2nd stage of labor: MCC is cephalopelvic disproportion Answer to the Previous Question - ✅A Asherman syndrome - too much curettage from D&C Answer to the Previous Question - ✅A chlyamida = most common cause of cervicitis aka inflammation of the cervix = friable cervix = blood Answer to the Previous Question - ✅A CTS is very common in pregnancy ... cuz the edema bulid-up in the wrist Answer to the Previous Question - ✅A Now, recommend lub, "She breast-feeds her infant, who recently was treated for thrus" Breastfeeding -> Estrogen↓ indirectly affect sexual interest ↓ vaginal lub -> pain with intercourse. You can recommend Water/based lub and you always let them know petroleum/based can cause irritation & condom breakage 🙂 or vaginal moisturizers also help with the dryness & pain.

Answer to the Previous Question - ✅A Trich, BV doesnt usually present with inflammatory symptoms, (erythema of vulva/vagina) while Trich has inflammation especially the "strawberry red patches" in the vulva/vagina Answer to the Previous Question - ✅A Turner Syndrome Answer to the Previous Question - ✅A - autoimmune ovarian failure. High FSH and low estrogen in the setting of autoimmune ds hashimoto Answer to the Previous Question - ✅A mittelschmerz

Answer to the Previous Question - ✅B Answer to the Previous Question - ✅B "Some patients with a history of painful ovarian cysts are managed with hormonal contraceptives to inhibit ovulation. This prevents the formation of new physiologic ovarian cysts."

And then I think you would need to recheck it on exam/US to make sure it didn't grow/rule out rupture before you can do longer follow up intervals.

Answer to the Previous Question - ✅B In prepubertal and postmenopausal females the transformation zone (squamo-columnar junction) of the cervix is located in the endocervix. During puberty, this junction advances to the ectocervix. Chlamydia and Gonorrhea have a predilection for the transformation zone/endocervix, making these patients more at risk for infection.

Answer to the Previous Question - ✅B mcv is low, serum ferritin and iron are normal= no iron def. anemia........next check for thalassemia with electrophoresis!!!

Answer to the Previous Question - ✅B Not 100% sure on the diagnosis, but I think the idea is that irregular periods suggest anovulation, and with anovulation you get a lot of unopposed estrogen, which fuels endometrial hyperplasia.

Answer to the Previous Question - ✅B she's asian (alpha thalass). Pregnant women become more anemic (dilution) -> for people with pre-exising anemia, it can worsen anemia not responded to ion supplement next step hb electrophoresis Answer to the Previous Question - ✅B The duplex is 2 parts (gray-scale imaging with transducer compression maneuvers + Doppler flow) and gives you more information (imaging and anatomy) than just the Doppler alone (velocity of blood flow in the vessel) Oversimplification: Doppler: Arterial insuf.

Ultrasound: DVT

Answer to the Previous Question - ✅B The most important counseling to give (not covered by this question) is that OCPs should NOT be initiated prior to 3 wks postpartum due to risk of DVT. ACOG does NOT recommend using OCPs before 6 wks postpartum because of increased risk of DVT (before 3 wks) + a small risk of decreased milk production (before 4-6 wks) .. I guess this question was trying to get at the latter risk and the rest of the answers are incorrect Answer to the Previous Question - ✅B When one müllerian duct is underdeveloped or fails to develop, a banana-shaped halfuterus is formed. A missing kidney or other kidney problems accompany this asymmetric anomaly more than they do other müllerian anomalies Answer to the Previous Question - ✅B this is just minimal variability, there's no contractions the fetus might be asleep, also membranes ruptured 5 hours ago only, with no evidence of chorioamnionitis prenatal course was uncomplicated, no mentioning of infection Answer to the Previous Question - ✅B - voiding immediately after coitus is the most appropriate. Only if the woman doesn't want to change the behavior then pharmacotherpy is discussed Answer to the Previous Question - ✅B. gestational diabetes. previous Big baby Previous macrosomia, along w/ obesity, strong family hx put mother at high risk for GDM. Answer to the Previous Question - ✅B. Next step for VDRL positivity is FTA-ABS Answer to the Previous Question - ✅C Answer to the Previous Question - ✅C Answer to the Previous Question - ✅C Answer to the Previous Question - ✅C Answer to the Previous Question - ✅C As her plasma phenytoin concentration level is low, increase the dose.

Except Valproate we can use other AEDs in pregnancy. Valproic acid is absolutely contraindicated

C> pregnancy increases proteins that bind to phenytoin decreasing it's concentration. It used to work before, so increase the dose. The stem tells you that phenytoin concentration is decreased.

Do not worry about the teratogenic effects and switch, embryogenesis is over by 8 weeks, whatever damage had to happen has happened. c . recommended to keep antiepileptic minimum enough to keep pt seizure free(all = in efficacy) Answer to the Previous Question - ✅C MC cause of post menopausal bleeding is vaginal atrophy. We just always have to rule out cancer Answer to the Previous Question - ✅C new partner...post coital bleed...no fever...most likely cervicitis Answer to the Previous Question - ✅C Pain with urination that is worst with distended bladder and improve with urination with bladder tenderness ( anterior vaginal wall tenderness) and normal UA = interstitial cystitis Answer to the Previous Question - ✅C postmenopausal HRT associated with high risk of ovarian and breast cancers Answer to the Previous Question - ✅C Prior C-section or other uterine surgeries are the biggest risk factors but other risk factors include maternal age, smoking, multiple gestations and multiparity.

Answer to the Previous Question - ✅C Pt has primary amenorrhea due to unruptured hymen that is resulting in the PE finding of hematocolpos. 1* amenorrhea is defined as absence of menarche by age 15, or 4 years after thelarche. Primary amenorrhea can be due to central regulatory d/o (Kallman syndrome), end organ d/o (Turner's syndrome), or outflow tract obstruction (transverse vaginal septum, unruptured hymen). Tx of hematocolpos.: hymenotomy.

Answer to the Previous Question - ✅C Sickle cell is autosomal recessive. Mom has it 100% (aa), dad is carrier (Aa). Get 50%

FYI, dad has Hgb S but typical percentages of Hgb S in electrophoresis is in the 90's% for SCD, for trait tho ("carrier state") is close to 50% so that even though has some Hgb S, the levels indicate he has Sickle cell trait, not disease, hence the answer is 50% not 100%.

Answer to the Previous Question - ✅C Tx for stress urinary incontinence: pessary placement, kegel exercises, urethral sling surgery.

Answer to the Previous Question - ✅C You have variable decels, which means cord compression. The amnioinfusion will give extra fluid to relieve cord compression. The cord compression started once the membranes ruptured and the patient lost fluid.

This vignette does not show any indications for forceps delivery. (American College of Obstetricians and Gynecologists (ACOG) practice bulletin that considers "prolonged second stage of labor, suspicion of immediate or potential fetal compromise, and shortening the second stage for maternal benefit" appropriate indications for operative vaginal delivery (forceps or vacuum). It indicates a FHR tracing consistent with umbilical cord compression following ROM. The loss of fluid is causing the compression on the cord; hence, you do transfusion to try to reduce the compression on the cord.

Answer to the Previous Question - ✅C - administer prostaglandin. Dx postdate preg >41 wks with oligohydraminos. when the pregnancy is more than 41 wks, you can induce labor. Cervix is not favorable yet. So Ripen the cervix with PG -Oligohydramnios is common in postdates pregnancy, as long as baby is doing fine we can go ahead with induction Answer to the Previous Question - ✅C - copper IUD avoid hormonal contraception in women with current or past history of breast cancer. this leaves us with B and C. most approriate is the more effective one, C. Answer to the Previous Question - ✅C - ectopic pregnancy (ruptured). High BhCG, abd pain, low BP, TVUS finds no gest sac in end cavity -Just a clarification...Ectopics have lower BhCG than expected and dont double every 24 hours. That is the big hint in the stem.

-hydatiform mole BHC > 100 000

Answer to the Previous Question - ✅C - folate deficiency. Macrocytic anemia in alcoholic -no prenatal care --> folate deficiency B12: has neuro sx, would not run out of stores in 2 months iron def: would have a low MCV Liver issues: ALT would be high -WBC and platelets are not too low. Everything gets diluted in pregnancy as plasma volume increases.

Answer to the Previous Question - ✅C - galactocele -there is no fever, breast is not warm or erythematous so it rules out an abscess. Per casefiles: Galactocele or milk-retention cyst is caused by blockage of a milk duct. The milk accumulates in one or more breast lobes, leading to a nonerythematous fluctuant mass.

Answer to the Previous Question - ✅C - HSV1 HSV and haemophilus ducreyi are amongst the two common causes of tender genital lesions.

Answer to the Previous Question - ✅C - intrahepatic cholestasis of pregnancy Answer to the Previous Question - ✅C - USG is next step to exclude the wrong dating -aternal Serum AFP above normal is seen in: - multiple gestation - placental abruption - fetal abnormalities (neural tube defects, spina bifida, anencephaly, and abdominal wall defects) - error in the date of the gestation Answer to the Previous Question - ✅C (bleeding after trauma, ie, intercourse) Answer to the Previous Question - ✅C systemic toxicity of epidural if accidentelly injected into blood vessels Answer to the Previous Question - ✅C. First step of secondary amenorrhea is BhCG to rule out pregnancy.

Answer to the Previous Question - ✅D

Answer to the Previous Question - ✅D Answer to the Previous Question - ✅D Answer to the Previous Question - ✅D Answer to the Previous Question - ✅D

Primary dysmenorrhea - Onset of symptoms is usually within two years on menarche Medication for dysmenorrhea may involve two complementary strategies: decreasing prostaglandin production and hormonal alteration.

Answer to the Previous Question - ✅D Idiopathic hirsutism. If have normal testosterone levels in hirsute woman, check 5-alpha reductase activity in peripheral tissue (Blueprints). It converts testosterone to DHT (more potent at androgen receptor than testosterone).

Answer to the Previous Question - ✅D +ve CTA tenderness Uterine contractions may be induced by cytokines and prostaglandins, which are released by microorganisms Answer to the Previous Question - ✅D according to blueprints: submucosal most commonly causes heaving bleeding and infertility. subserosal most commonly causes pelvic pain and abdominal pressure. intramural is the most common type of fibroid.

Answer to the Previous Question - ✅D dilated cervix with red tissue at os Submucosal fibroids grow from the uterine wall toward and into the inner lining of the uterus (the endometrium ). Submucosal fibroids can also be stalk-like or broad-based.

Fibroids are most common in women who are their 30s through early 50s.

Answer to the Previous Question - ✅D previous preterm delivery is the most important risk factor for preterm delivery.

Answer to the Previous Question - ✅D Sertoli-Leydig Answer to the Previous Question - ✅D Tx of thyroid storm begins initially with Propranolol, PTU/methimazole, and corticosteroid. THEN 1 hr after giving the PTU you add iodine. If we give iodine before PTU then the thyroid will just use that iodine to make more T4. Bad. Also PTU is preferred in thyroid storm because it inhibits T4-->T3 conversion.

Answer to the Previous Question - ✅D Usually, it is observed that there's first thelarche --> pubarche --> menarche. No need to investigate up till age 15 if pt hasn't had menache.

Answer to the Previous Question - ✅D - CA cervix causing obstructive uropathy (hydroureter) -Heres an image because apparently this is a very common presentation of cervical cancer extending and obstructing the ureters.

Answer to the Previous Question - ✅D - Measure urinary ketone for ketonuria for HG decreased PO intake--> body starts using ketones for energy-->spills into urine Answer to the Previous Question - ✅D - Polymicrobial infn. Dx chorioamniitis (intraamniotic infn) Fever with fetal tachycardia. Ampi and genta is a correct drug of choice given. May be 6 hrs is not enough for fever to subside yet (not sure why not subside) Answer to the Previous Question - ✅D Online. Going off of what Maryam said above.

Too much oxytocin Causes insufficient uterine relaxation between contractions causing placental spiral artery constriction & decrease in placental blood flow & fetal hypoxia.

Thats why you get the late deceleration.

Agree. Also, contracting every 2 minutes or quicker is uterine tachysystole or 6 or more contractions per 10 minutes. Indicating this is due to oxytocin.

Answer to the Previous Question - ✅D.

Uteroplacental insufficiency. Both graphs put together indicate late deceleration; deceleration in the top graph follows the contraction (bottom graph). Other decelerations include variable (cord compression) and early deceleration (head compression).

Answer to the Previous Question - ✅D.uterine inversion. A/f delivery, mass in vg, uterus cannot be palpated on abd exam Answer to the Previous Question - ✅E Answer to the Previous Question - ✅E Answer to the Previous Question - ✅E Answer to the Previous Question - ✅E Answer to the Previous Question - ✅E Answer to the Previous Question - ✅E Answer to the Previous Question - ✅E Answer to the Previous Question - ✅E Answer to the Previous Question - ✅E

C is wrong because the question refers to recurrence of genital HSV, which is less severe and lasts 2-12 days, or about a week according to some sources, before resolution (answer choice E). Genital herpes is also less likely to recur than oral.

Primary HSV symptom occurrence, on the other hand, might present with more severe symptoms lasting 20 days or more, with gradual healing (answer choice C).

Answer to the Previous Question - ✅E And E,osteoporosis...regardless of what she has ,absent or low estrogen [no withdrawal bleeding after medroxyprogesteron chalenge test so progesterone normal and estrogen def]for ten years is risk factor for osteoporosis Answer to the Previous Question - ✅E Blood from the mother to fetus travels from uteroplacental artery -> placenta -> umbilical vein so I think uteroplacental artery is more likely to be thrombosed

Answer to the Previous Question - ✅E E confirmed - Staph Aureus ; caused by preformed TSST1 - can occur within 5 days of using tampons. Presents with F, N/V, water diarrhea. A diffuse macular erythematous rash can be seen. Desquamation on the palms and soles usually occur 1-2 weeks after illness. Dx is clinical. The other options present with mucopurulent discharge (chlamydia) thick discharge (Neisseria), vesicles (herpes) or pain chancroid/ulce and painful inguinal LAD (haemophilus ducreyi) Answer to the Previous Question - ✅E I found this. Everything he has is normal postop symptoms. In incisional seroma there is collection of fluid, which is not found here (the pulling feeling is normal, not indicative of any collection). The shotty regional lymph nodes and the pain on the incision site are normal as well. "pulling feeling on the right side of her incision" is due to scar tissue formation wks after post-op. pt needs to massage site to break it down Answer to the Previous Question - ✅E Lupus causes hyalinization of blood vessels, leading to uteroplacental insufficiency.

Pathophysiology may be pretty similar to Pre-eclampsia.

Answer to the Previous Question - ✅E She's Rh -ve and Unsensitized (-ve antibody test). you want keep her unsensitized by giving Rhogam everytime fetal blood cell gets into mother's blood (in this case, vaginal bleeding) 1) Betamethasone is given up till 37 weeks in preterm labor but the patient is not in labor so that excludes D. 2) See UW question. In Rh- mother that has not received Rhogam between 28-32 weeks (she didn't have prenatal care) we give RhD immune globulin for 2nd and 3rd trimester bleeding.

Answer to the Previous Question - ✅E sounds like lichen sclerossis that may be on its way to SCC so gotta punch it.

Answer to the Previous Question - ✅E - Risk of premature labor. Dx multiple gestation at 18 wks -how I ruled out the answer. Yes, you do have hydramnios because of multiple gestations not due to a complication. So it cant be B or D. Yes, abruption and previa can occur but after 20 weeks of gestation. This patient patient is at 18 weeks so that cancels out A and C. Premature labor occurs in about 60% of pregnancies.

Answer to the Previous Question - ✅E - SCC Answer to the Previous Question - ✅E - Surgical exploration for appendicitis Answer to the Previous Question - ✅F Answer to the Previous Question - ✅F Answer to the Previous Question - ✅F Triple D for endometriosis: Dyspareunia, Dyschezia, and Dysmenorrhea Answer to the Previous Question - ✅F - Risk for T2DM, which is ass with acanthosis nigricans described Answer to the Previous Question - ✅H Thin, clear vaginal discharge is physiologic in pregnancy Answer to the Previous Question - ✅J vasa previa because of rupture of membranes + .fetal bradycardia it does not say oxytocin was given so I would go for Vasa Bradycardia is usually the giveaway for Vasa prevue in patient that has ROM. Answer to the Previous Question - ✅K high temp + inc WBC + LAP Foul smelling vaginal discharge lacerated cervix; there might be some instrumentation done I think the cervical laceration and describing the pregnancy as "unintended" both give you enough reason to think that something was done/inserted at or around the os leading to an infection Answer to the Previous Question - ✅K Normal to have implantation bleeding in the 1st trimester.

Answer to the Previous Question - ✅L Answer to the Previous Question - ✅N

Lower abdominal pain and an adnexal mass + free fluid in the posterior cul-de-sac =torsion vs sudden onset of unilateral lower abdominal pain+free fluid in the posterior cul-de-sac + not any mass present=rupture of cyst. Doppler velocimetry, can differentiate the two disorder