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DES Entrance Exams

1. SBA Quel est le mcanisme reli au dveloppement de la pr-clampsie au cours de la


grossesse ?
Une Adhrence anormale du placenta
Une Insertion basse du Placenta
Une mauvaise placentation entrane une insuffissance placentaire
Une Grossesse arrte
Une multiparit

2. SBA Une patiente de 35 ans se prsente en consultation de suivi de grossesse. Vous


suspectez une hypertension artrielle (HTA) gravidique. Concernant la dfinition de lHTA
gravidique, quelle est lassociation exacte de critres de diagnostic positif ? PAs = Pression
Artrielle systolique ; PAd = PA diastolique ; SA = Semaines dAmnorrhes
PAs 140 mmHg PAd 90 mmHg Aprs 20 SA
PAs 140 mmHg PAd 90 mmHg Avant 20 SA
PAs 150 mmHg PAd 100 mmHg Avant l'existance de la grossesse
PAs 150 mmHg PAd 100 mmHg Au cours du travail
PAs 150 mmHg PAd 100 mmHg Aprs la priode de suite de couche
QCM de type SBA GRAV

3. Une patiente de 35 ans se prsente aux urgences 30 SA de grossesse pour des cphales. A
lexamen vous trouvez une hypertension artrielle (HTA) gravidique et vous suspectez une pr-
clampsie.Quelle association de critres dfinit la pr-clampsie svre ?PAs = Pression
Artrielle systolique ; PAd = PA diastolique ; SA = Semaines dAmnorrhes ; BU = Bandelette
Urunaire ; NF : numration Formule sanguine ; BH : bilan hpatique ; N = Normale
PAs 160 mmHg PAd 110 mmHg BU : Protinurie 1 +
PAs 150 mmHg PAd 100 mmHg BU : Hmaturie 1 +
PAs 160 mmHg PAd 100 mmHg NF :Plaquettes 200 G/L
PAs 160 mmHg PAd 100 mmHg BU : Hmaturie 1 +
PAs 160 mmHg PAd 100 mmHg BH : transaminases 2N

4. SBA Une patiente de 25 ans se prsente en consultation de suivi de grossesse pour une
hyperthermie et des signes fonctionnels urinaires. Vous suspectez une pylonphrite. Aprs la
ralisation dune hmoculture et dune ECBU vous dbutez une antibiothrapie.Parmi les
classes dantibiotiques listes ci-dessous, lesquelles sont possibles et indiques dans linfection
urinaire de la femme enceinte ?
Pnicillines Pnicilline Amoxicilline
Cphaloporines Cphalexine Cphalosporine
Macrolides Erythromycine Clarithromycine
Fluoroquinolones Ofloxacine Cyprofloxacine
Aminoglycosides Gentamycine Tobramycine
DES Entrance Exams

5. Une femme de 38ans, consulte aux urgences dun hpital de Phnom Penh 34 SA pour une
fivre 39C depius 12 heures, associe des courbature, des vomissements et une diarrhe.Elle
vous dit avoir eu plusieurs pousses dherps gnital il y a 2 et 3 ans. La patiente vous donne tous
les examens quelle a ralis depuis le dbut de grossesse -Hmogramme : normal, groupe
sanguine : A Rh(-)- Srologies syphilis et VIH : ngatives- Srologie de le toxoplasmose :
negative SBA Concernant les examens complmentaires ncessaires au suivi de grossesse,
lequel manque et aurait d tre ralis chez cette patiente ?
Srologie de la rubole
Srologie de lherps

6. SBA Une femme de 38ans, consulte aux urgences dun hpital de Phnom Penh 34 SA pour
une fivre 39C depius 12 heures, associe des courbature, des vomissements et une
diarrhe.Elle vous dit avoir eu plusieurs pousses dherps gnital il y a 2 et 3 ans. La patiente
vous donne tous les examens quelle a ralis depuis le dbut de grossesse -Hmogramme :
normal, groupe sanguine : A Rh(-)- Srologies syphilis et VIH : ngatives- Srologie de le
toxoplasmose : negative SBA Concernant les examens complmentaires ncessaires au suivi
de grossesse, lequel manque et aurait d tre ralis chez cette patiente ?Vous recherchez un
point dappel cette fivre par un interrogatoire et un examen clinique attentifs. Vous ne
trouvez pas de point dappel vident. Vous faites un bilan infectieux systmatique avec une NF,
CRP, hmocultures, BU et ECBU. Concernant la BU, quel profil est le plus en faveur dune
infection urinaire ?
nitrites ngatifs, leucocytes 1+, sang 0, protines
Nitrites ++ Leucocytes + Sang +
Nitrites + Leucocytes 0 Sang +
Nitrites 0 Leucocytes +++ Protines +
Nitrites 0 Leucocytes +++ Protines +++
Sang +++ Leucocytes ++ Protines +++

7. Une femme de 38ans, consulte aux urgences dun hpital de Phnom Penh 34 SA pour une
fivre 39C depius 12 heures, associe des courbature, des vomissements et une diarrhe.Elle
vous dit avoir eu plusieurs pousses dherps gnital il y a 2 et 3 ans. La patiente vous donne tous
les examens quelle a ralis depuis le dbut de grossesse -Hmogramme : normal, groupe
sanguine : A Rh(-)- Srologies syphilis et VIH : ngatives- Srologie de le toxoplasmose :
negative SBA Concernant les examens complmentaires ncessaires au suivi de grossesse,
lequel manque et aurait d tre ralis chez cette patiente ?Le bilan revient : GB 14 G/L
prdominance de PNN, Hb 11 g/dl, Plaquettes 400 G/L. La BU est contrl ngative, et
lhmoculture est dtecte positive bacilles gram positifs. Quel est le germe pathogne le plus
probable ?
L. monocytogenes
S. aureus
E. Coli
M. tuberculosis
E. Faecalis

8. Une femme de 38ans, consulte aux urgences dun hpital de Phnom Penh 34 SA pour une
fivre 39C depius 12 heures, associe des courbature, des vomissements et une diarrhe.Elle
vous dit avoir eu plusieurs pousses dherps gnital il y a 2 et 3 ans. La patiente vous donne tous
DES Entrance Exams

les examens quelle a ralis depuis le dbut de grossesse -Hmogramme : normal, groupe
sanguine : A Rh(-)- Srologies syphilis et VIH : ngatives- Srologie de le toxoplasmose :
negative SBA Concernant les examens complmentaires ncessaires au suivi de grossesse,
lequel manque et aurait d tre ralis chez cette patiente ?Vous avez dbut un traitement
antibiotique probabiliste et une rhydratation. Mais aprs 12h, son tat hmodynamique
saggrave. Quelle association de signes est un diagnostic de sepsis svre ? critres PAs =
Pression Artrielle systolique ; PAm = PA moyenne ; SA = Semaines dAmnorrhes
PAs90 mmHg Diurse < 0,5 ml/kg/h Confusion
PAs 90 mmHg FC > 90/min FR > 20 min
PAm 90 mmHg Diurse < 500 ml/h T > 39C
PAm 65mmHg FR > 20 min T > 39C
PAs 90 mmHg FC> 90/min T > 39C

9. Melle R , ge de 25ans, primipare, TA : 170/110mmHg, vient daccoucher dun gaon vivant


pesant 3,5kg, 20 minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de
garde que la patiente a perdu de sang dune quantit trs importante saccompagnant dune
trouble de la coagulation.Quel est le facteur de risque de trouble de coagulation par CIVD ou
Fibrinolyse ?
Le placenta praevia
Pr-clampsie
La grossesse multiple
Multiparit
Grossesse rapproche

10. Melle R , ge de 25ans, primipare, TA : 170/110mmHg, vient daccoucher dun gaon vivant
pesant 3,5kg, 20 minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de
garde que la patiente a perdu de sang dune quantit trs importante saccompagnant dune
trouble de la coagulation.Quel est le facteur de risque de trouble de coagulation par CIVD ou
Fibrinolyse ?
Infections graves
Vulvo-vaginite dans les derniers mois de la grossesse
Infections virales
Intoxication alimentaire
Hpatite chronique

11. Melle R , ge de 25ans, primipare, TA : 170/110mmHg, vient daccoucher dun gaon vivant
pesant 3,5kg, 20 minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de
garde que la patiente a perdu de sang dune quantit trs importante saccompagnant dune
trouble de la coagulation.Quel est le facteur de risque de trouble de coagulation par CIVD ou
Fibrinolyse ?
Menace daccouchement prmature
Accouchement prmature
Hmorragie rtro-placentaire
Grossesse prolonge
DES Entrance Exams

Placenta praevia

12. Melle R , ge de 25ans, primipare, TA : 170/110mmHg, vient daccoucher dun gaon vivant
pesant 3,5kg, 20 minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de
garde que la patiente a perdu de sang dune quantit trs importante saccompagnant dune
trouble de la coagulation.Quel est le facteur de risque de trouble de coagulation par CIVD ou
Fibrinolyse ?
Thromboses de membres infrieures
Insuffisante cardiaque
Embolie amniotique
Embolie gazeuse
Rupture prmature des membranes

13. Melle R , ge de 25ans, primipare, TA : 170/110mmHg, vient daccoucher dun gaon vivant
pesant 3,5kg, 20 minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de
garde que la patiente a perdu de sang dune quantit trs importante saccompagnant dune
trouble de la coagulation.Quel signe clinique qui marque le trouble de la coagulation ?
Le saignement massive fait de gros caillot mlang de liquide
Le sang qui saigne ne coagule pas, purement liquide
Etat dagitation
Etat comateuse
La Chute de tension artrielle

14. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale, il sagit dune hmorragie proprement dite de la
dlivrance.Cest une prise en charge en urgence en obststrique devant dune hmorragie de la
dlivrance , quel est le premier intention ?
Transfusion sanguine en urgence
Transfrer au bloc opratoire
Assurer la vacuit utrine et lintgrit de la filire gnitale
Chercher les causes mdicales qui donnent les consquences de ces troubles
Donner des oxytociques

15. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale, il sagit dune hmorragie proprement dite de la
dlivrance. Aprs la rvision utrine, il sagit dune Atonie utrine, quelle geste faut-il ragir ?
Remplissage la volmie
Assurer la contraction utrine
Transfrer au bloc opratoire
Massage utrin
Antibiothrapie
DES Entrance Exams

16. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale, il sagit dune hmorragie proprement dite de la
dlivrance. Quel moyen de prvention de lhmorragie de la dlivrance ?
La dlivrance artificielle
Massage utrin
Les oxytociques
La rvision systmatique, si lintgrit du placenta et des membranes est en doute
En attendant la dlivrance physiologique

17. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale, il sagit dune hmorragie proprement dite de la
dlivrance. Quel moyen de prvention de lhmorragie de la dlivrance ?
La dlivrance naturelle et spontane
Donner des oxytociques
La dlivrance dirige chez toutes les patientes risque datonie
La dlivrance artificielle
La csarienne

18. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale, il sagit dune hmorragie proprement dite de la
dlivrance. Quel prcaution devant la patiente en travail pour prvenir de lhmorragie de la
dlivrance ?
Chez les multipare
Chez les primipare
Travail prolonge
Placenta praevia
Grossesse prolonge

19. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale. Donnez la dfinition de lhmorragie de la dlivrance
proprement dite.
Une perte de sang infrieure 500ml avec un tat convulsivante
Une perte de sang suprieure 500ml avec acclration du pouls
Une perte de sang suprieure 500ml avec prsence du globe utrin
Une perte minime du sang avec un tat de choc
Une perte de sang minime mais continue avec tension artriel et pouls normaux E

20. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
DES Entrance Exams

a perdu de sang dune faon anormale.En face du Mdecin, lcoulement du sang se continue ;
quel signe clinique qui marque lhmorragie de la dlivrance proprement dite de dbut ?
Une chute brutale de tension artriel
Une acclration du pouls artriel
Un tat dinconscience
Un tat dagitation
Un trouble de la coagulation

21. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale.Quel est la premire geste de la prise en charge devant
cette hmorragie ?
La perfusion pour maintenir volmie
La transfusion du sang pour compenser la perte
La rvision utrine
Massage avec compression utrine
Suture de la plaie dpisiotomie

22. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale. Quelle est la plus souvent cause de la rtention partielle
du placenta ?
La traction sur le cordon
Hypercinsie utrine au cours du travail ?
Hypocinsie utrine au cours du travail
Expression abdominale au cours de lexpulsion du foetus
La dlivrance dirige

23. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale. Quelle est la cause la plus frquence de latonie utrine ?
La primiparit
Travail prolong
La dure du travail est plus courte
Utrus cicatricielle
Utrus fibromateuse

24. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale. Quelle est le facteur favorable de latonie utrine ?
La multiparit
Lclampsie
La surdistension utrine au cours de la grossesse
DES Entrance Exams

Raccourcissement de la dure de travail


Le dclenchement du travail

25. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale. Quelle est le facteur favorable de latonie utrine ?
Accouchement prmature
Travail prolong
Lantcdent de latonie utrine de laccouchement rcente
Grossesse prolonge
La rupture prmature des membranes

26. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale. Quelle est le facteur favorable de latonie utrine ?
Grossesse multiple terme
La dlivrance dirige
La Menace daccouchement prmature
LAvortement de rptition
La rtention urinaire

27. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale. Quelle est le facteur favorable de la trouble de la crase
sanguine ?
La multiparit
La dlivrance dirige
Lanmie svre au cours de la grossesse
Lhmorragie de la dlivrance
Lintoxication mdicamenteuse

28. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde que la patiente
a perdu de sang dune faon anormale. Quelle est le facteur favorable de la trouble de la crase
sanguine ?
La multiparit
Mort-in utro
Lhmorragie de consommation massive au cours de lhmorragie de dlivrance
Lavortement de rptition
Lincompabilit foeto-maternelle

29. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde pour la
DES Entrance Exams

rtention totale du placenta On voit aucune perte de sang aprs lexpulsion du ftus, quel est le
diagnostique de cette rtention complte du placenta ?
Lenchatonnement du placenta
Placenta adhrence partielle anormale
Contraction utrine hypertonique
Placenta accreta
Travail prolong

30. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde pour la
rtention totale du placenta Comment peut-on faire le diagnostique en face de cette rtention
totale ?
Expression abdominale avec traction sur le cordon
Lchographie abdominale
La dlivrance artificielle
La coelioscopie exploiratrice
La csarienne

31. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde pour la
rtention totale du placenta Sil ya de lhmorragie, mais la dlivrance ne peut se faire, quelle
est leur premire prise en charge ?
L a traction immdiate sur le cordon ombilicale
La dlivrance artificielle
Donner des oxytociques
Transfrer immdiatement au bloc opratoire
Expectative

32. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde pour la
rtention totale du placenta Aprs la dlivrance artificielle et rvision utrine, lutrus bien
rtract mais lhmorragie persiste, quelle est la premire intention de leur prise en charge ?
La transfusion sanguine
La perfusion du plasma pour compenser la volmie
Chercher autres causes traumatiques des parties molles
Transfrer au bloc opratoire
Suture les plaies de lpisiotomie

33. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde pour la
rtention totale du placenta Quelle est la complication svre de lhmorragie de la dlivrance
prolonge?
L Atonie utrine irrversible
Trouble de la crase sanguine par CIVD
DES Entrance Exams

Lhmorragie interne
Lhmorragie rsidivante au cours de la prochaine accouchement
Besoins de la transfusion massive

34. Melle R , ge de 25ans, primipare, vient daccoucher dun gaon vivant pesant 3,5kg, 10
minutes aprs la dlivrance dirige, la sage femme alerte son mdecin de garde pour la
rtention totale du placenta Quelle tiologie devez-vous rechercher devant une amnorrhe
secondaire avec des gonadotrophines augmentes et un test aux progestatifs ngatif ?
Hyperoestrognie relative
Insuffisance lutale
Insuffisance ovarienne prcoce
Syndrome de Sheehan
Hyperthyrodie

35. Madame X, 60 ans nulligeste,obse ( 100 kg pour 1m56 ),mnopause depuis 10 ans, sans
traitement hormonal substitutif et sans antcdents pathologiques, consulte en raison de
mtrorragie minimes, intermittentes depuis 6 mois. TA = 150/85mmHg. Pouls = 70/mn.
Temprature =37,1C. Quel diagnostic devez-vous suspecter en priorit ? pour quoi ?
Hyperplasie endomtriale
Cancer de lendomtre
Mtrorragie atrophique
Facteurs de risques : mnopause, obsit , mtrorragies post-mnopausiques
Carence oestrognique prolonge

36. Madame X, 60 ans nulligeste,obse ( 100 kg pour 1m56 ),mnopause depuis 10 ans, sans
traitement hormonal substitutif et sans antcdents pathologiques, consulte en raison de
mtrorragie minimes, intermittentes depuis 6 mois. TA = 150/85mmHg. Pouls = 70/mn.
Temprature =37,1C. Hystrographie montre une lacune irrgulire volumineuse daspect
marcageux du fond utrin et de la corne utrine gauche, quel diagnostic voquez-vous ?
Aspect dun myome sous muqueuse
Aspect vocateur de cancer de lendomtre
Aspect dun parquet de polype intra-cavitaire
Aspect dun adnomyose
Aspect dune hyperplasie endomtriale

37. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quels est le facteur de risque de
lhmatome rtro-placentaire ?
La surdistention de la hauteur utrine
DES Entrance Exams

Dans un contexte dHTA , prclampsie


La multiparit de la femme
Diabte et grossesse
Grossesse gemellaire

38. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Ce sont des tableaux cliniques de
lhmatome rtro-placentaire, quelle symptme est fausse ?
Dans un contexte dHTA +++
Mtrorragies de sang rouge caillot sans douleur
Mtrorragie de sang noir, de faible abondance
Douleur abdominale violente, brutale, permanente
Utrus dur ( de bois )

39. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quel contexte qui nest pas en relation
avec lapparition du placenta praevia ?
Contexte dHTA
Multiparit et ge maternel avanc
Antcdents de placenta praevia et csarienne
Antcedents dendomtrite
Mulliparit

40. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quelle proposition est fausse dans le
domaine du placenta praevia ?
Mtrorragie de sang rouge, brutales, non douloureuses
Mtrorragie au cours du premier trimestre
DES Entrance Exams

Parfois asymptomatique
Mtrorragies du troisime trimestre
Toucher vaginal contre-indiqu avant lchographie +++

41. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quelle est la complication qui nest pas en
relation avec les consquences dues au placenta praevia ?
Hmorragies rsidivantes , jusquau choc hmorragique
Mort inutro
Allo-immunisation foeto-maternelle si mre Rhsus ngatif
Risque de prmaturit du ftus cause de linterruption de la grossesse
Placenta accrta sur la plaie cicatricielle

42. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quelle image chographique recherchez
vous devant le tableau dHTA gravidique connue , une image en faveur dun hmatome rtro-
placentaire ?
Trouble du rythme foetale
Disparition des bruits du cur foetal
Lentille bicovexe anchogne entre placenta et utrus
Oligo-amniotique svre
Calcification du placenta

43. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quelle est la complication foetale du
placentta praevia ?
Souffrances ftales aigu
Rupture prmature des membranes
DES Entrance Exams

Prsentation dystocique
Retard de croissance intra-utrin
Accouchement terme

44. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quelle est la complication ftale du
placenta praevia ?
Mortalit post natale
Procidence du cordon
Mort inutro
Menace daccouchement prmatur
Choc hmorragique aigu

45. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quel type de linsertion du placenta qui
nindique pas le placenta praevia ?
Placenta latral
Placenta postro-fondique
Placenta marginal
Placenta recouvrant
Placenta partiellement recouvrant

46. Amnorrhe secondaire et dsir de grossesse 21 ans ( dossier N*23 BENJAMIN )Madame M,
21ans, consulte pour amnorrhe secondaire, apparue aprs une longue priode de
spaniomnorrhe. Marie depuis 2 ans, elle est dsireuse dune grossesse , et na jamais utilis de
moyens contraceptifs. Elle ne prend aucun mdicament. Elle a t rgle lge de 13 ans, avec
des cycles longs et irrgulier. On note une obsit modre de type androde, ainsi quune acn
non inflammatoire, et une hyper-sborrhe du cuir cheveulu. Sa tension est 110/60mmHg. Une
dame 33 ans venant consulter au votre cabinet de consultation pour hmorragie gnitales de 30
SA et de douleur abdominal, sa TA est 150/90mmHg . Quelle est lindication laccouchement
dans le placenta praevia recouvrant :
Dclenchement du travail
Accouchement par csarienne programme
Rupture des membranes
DES Entrance Exams

Csarienne en urgence sil ya des mtrorragies


Abstention

47. Quelle prise en charge proposez vous Madame Z , consultant en urgence la maternit , de 31
SA avec un placenta praevia compliqu de mtrorragies bien tolres ? Il sagit dune urgence
thrapeutique du placenta praevia, mais lobjectif est de poursuivre la grossesse dans le but de
dpasser les 34 SA , quelle proposition qui nest pas ncessaire ?
Transvert materno-ftal, pour hospitalisation en urgence
Repos au lit, groupe Rhsus et bilan complet
Trasfusion sanguine
Prvention de lallo-immunisation foeto-maternelle si Rhsus ngatif
Prescrire de lInhibiteur calcique, sil ya des contractions utrine.

48. Quelle prise en charge proposez vous Madame Z , consultant en urgence la maternit , de 31
SA avec un placenta praevia compliqu de mtrorragies bien tolres ? La conduite de
poursuivre la grossesse dans le but de dpasser les 34 SA , quelle proposition qui est inutile ?
Corticothrapie prnatale car terme < 34 SA
Antibiothrapie large spectre pour prvenir linfection
Surveillance materno-ftale rapproche
Eviter de faire le TV
Si placenta recouvrant : envisager une csarienne programme

49. Quelle prise en charge proposez vous Madame Z , consultant en urgence la maternit , de 31
SA avec un placenta praevia compliqu de mtrorragies bien tolres ? Aprs stabilise de
quelques jours, Madame Z prsente une nouvelle pisode de mtrorragies abondantes et
associes une souffrance ftale importante, quelle est la prise en charge ?
Abstention
Surveillance Le BCF rapproche
Extraction ftale en urgence par csarienne
Corticothrapie en urgence
Dcontraction utrine

50. Quelle prise en charge proposez vous Madame Z , consultant en urgence la maternit , de 31
SA avec un placenta praevia compliqu de mtrorragies bien tolres ? Quel est le vrai signe
clinique de lhmorragie due au placenta praevia devant des hmorragies gnitales ?
Cancer du col utrin
Hmorragie spontanne importante venant de lendocol
Ectropion infecte
Cervico - vaginite aige
Polype du col
DES Entrance Exams

51. Quelle prise en charge proposez vous Madame Z , consultant en urgence la maternit , de 31
SA avec un placenta praevia compliqu de mtrorragies bien tolres ? Si la patiente prsente
un placenta praevia marginal en travail, quelle est la conduite obsttricale quon doit raliser ? :
La csarienne est obligatoire
Expectative
Rupture large des poches des eaux pour acclrer le travail
Corticothrapie
Antibiothrapie large spectre pour prvenir linfection

52. Mme PHALLA, consulte aux urgences gyncologiques ce matin pour mtrorragies ,associes
des douleurs abdominales. Vous russissez comprendre quelle est enceinte, en dbut de la
grossesse. Quel est le premier diagnostic auquel vous devez penser devant tous ces propositions ?
GEU
Colique nphrtique
Avortement tubo-abdominale
Appendicite
Torsion dannexe

53. Mme PHALLA, consulte aux urgences gyncologiques ce matin pour mtrorragies ,associes
des douleurs abdominales. Vous russissez comprendre quelle est enceinte, en dbut de la
grossesse. Quel est lautre possibilit de diagnostics auquels vous devez penser ?
Grossesse extra-utrine
Pylonphrite
Gastro-entrite aigu
Fausse couche spontane prcoce
Dcollement partiel de la partie basse du placenta

54. Mme PHALLA, consulte aux urgences gyncologiques ce matin pour mtrorragies ,associes
des douleurs abdominales. Vous russissez comprendre quelle est enceinte, en dbut de la
grossesse. Pour quoi avez-vous penser dans la majorit des cas de la GEU ?
Parce quon doittoujours penser aux causes de mtrorragies non due la grossesse
Parce quil ya un risque de rupture tubaire et dhmopritoine, ce qui engage le pronostic vital
Parce que cest une urgence chirurgicale : hystrectomie dhmostase
Parce que cest le diagnostic le plus frquent
Parce que cest une urgence chirurgicale : csarienne pour sauvetage foetal

55. Mme PHALLA, consulte aux urgences gyncologiques ce matin pour mtrorragies ,associes
des douleurs abdominales. Vous russissez comprendre quelle est enceinte, en dbut de la
grossesse.Quel est le moyen le plus simple de la mettre en vidence ?
Echographie rnale
Echographie abdominale
Prise des constantes : pouls, tension artrielle
IRM abdomino-pelvienne
DES Entrance Exams

Echographie obsttricale

56. Mme PHALLA, consulte aux urgences gyncologiques ce matin pour mtrorragies ,associes
des douleurs abdominales. Vous russissez comprendre quelle est enceinte, en dbut de la
grossesse. Quel est lexamen complmentaire le plus utile et ncessaire raliser pour aider au
diagnostic de GEU ?
Echographie pelvienne par voie abdominale et endovaginale
Scanner abdomino-pelvienne
Numration globulaire
Ponction du douglas
Bta HCG qualitatif

57. Madame x, 23 ans consulte aux urgences de votre maternit pour douleurs pelviennes, associes
des mtrorragies de faible abondance , elle vous annonce ensuite quelle est enceinte de 2 mois
environ. Quel diagnostic voquez vous de principe, devant toute hmorragie gnitale de la
femme en ge de procrer ?
La grossesse extra-utrine
Avortement spontan prcoce
Grossesse intra-utrine volutive
La menstruation
Mole hydartiforme

58. Madame x, 23 ans consulte aux urgences de votre maternit pour douleurs pelviennes, associes
des mtrorragies de faible abondance , elle vous annonce ensuite quelle est enceinte de 2 mois
environ. Les tiologies de mtrorragies du premier trimestre cites ci-dessous sont vraies , sauf
une qui est fausse ?
Avortement spontan prcoce
Menace davortement
Grossesse intra-utrine volutive
Mole hydatiforme
Endomtrite aigu

59. Madame x, 23 ans consulte aux urgences de votre maternit pour douleurs pelviennes, associes
des mtrorragies de faible abondance , elle vous annonce ensuite quelle est enceinte de 2 mois
environ. Quel est le signe clinique en faveur de lavortement spntan prcoce ?
Douleur sus pubienne irradie au flanc droit
Mtrorragies minime sans douleur
Douleur pigastrique avec vomissement
Toucher vaginal indolore, col entrouvert +++
Douleur sus pubienne avec dysurie
DES Entrance Exams

60. Madame x, 23 ans consulte aux urgences de votre maternit pour douleurs pelviennes, associes
des mtrorragies de faible abondance , elle vous annonce ensuite quelle est enceinte de 2 mois
environ. Quels est le signe clinique qui est en faveur dune grossesse intra-utrine volutive ?
Douleurs sus pubienne avec mtrorragies abondance
Mtrorragies abondance ave col ouvert
Mtrorragies de faible abondance, contraction douloureuse abdomino-pelviennes
Toucher vaginal indolore, col ferm +++
Douleurs abdomino-pelviennes avec coulement de sang noirtre

61. Madame x, 23 ans consulte aux urgences de votre maternit pour douleurs pelviennes, associes
des mtrorragies de faible abondance , elle vous annonce ensuite quelle est enceinte de 2 mois
environ. Ces signes cliniques sont en faveur dun mole hydatiforme sauf un est fausse lequel ?
Mtrorragies rptes
Douleur abdomino-pelvienne avec mtrorragies abodance et le col est entrouvert
Intensification des signes sympathiques de grossesse
Toucher vaginal : utrus mou, hauteur utrine trop importante pour le terme
Mtrorragies mles de vsicules transparentes avec exagration des troubles sympathiques

62. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. Quelle est ltiologie envisager devant des causes dhmorragies spontanes
isoles du 3me trimestre ?
Hmatome rtro-placentaire
Trouble de la crase sanguine
Placenta praevia
Rupture utrine
Hypertension gravidique svre

63. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. Les autres causes de lhmorragie du 3me trimestre en dehors du placenta
praevia sont cites ci-dessous, sauf une est fausse, la quelle ?
Hmatome dcidual marginal
Hmatome rtroplacentaire
Trouble de la spoliation sanguine
Hmorragie de Benckiser
Rupture utrine

64. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. La prise en charge immdiate propose en urgence devant ces deux tiologies les
plus frquentes ( placenta praevia et hmatome rtroplacentaire ) est indique ci-dessous, il
sagit dune urgence diagnostique et thrapeutique,sauf une proposition est fausse,la quelle ?
Palpation abdominale, assurer le tonus utrin
DES Entrance Exams

Prise de la tension artrielle, pouls


Toucher vaginal
Groupage sanguin, Rhsus
Mensuration de la hauteur utrine rapproche

65. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. Suite de la prise en charge pour ces 2 tiologies, sauf une proposition est incorecte
, la quelle ?
Pose dune voie veineuse priphrique
Echographie obsttricale trans-abdominale et endovaginale
Electro-cardiotocographie externe :tonus utrin,RCF
Interrogatoire minutieuse sur les antcdents
Transfusion sanguine en urgence en cas de choc hypovolmique

66. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. Suite de la prise en charge pour ces 2 tiologies, sauf une proposition est incorecte,
la quelle ?
Sil sagit dun hmatome rtro-placentaire :
Extraction ftale en urgence
Surveillance troite
Silsagit dun placenta praevia :
Sans souffrance ftale : extraction ftale en urgence
Si souffrance ftale : extraction ftale en urgence
Sans souffrance ftale : repos, corticothrapie prnatale si <34SA

67. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. HTA ET GROSSESSE Quelle surveillance ftale proposez vous devant un
tableau de pr-clampsie, parmi ces propositions il ya une qui est fausse, la quelle ?
Rechercher les signes de la souffrance foetale
Rythme cardiaque ftal pluriquotidien
ECBU, protinurie des 24 H
Mouvements actifs ftaux ressentis par la patiente
Echographie obsttricale hebdomadaire : vitalit, liquide amniotique, dopplers. E

68. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. HTA ET GROSSESSE Quel bilan biologique demandez- vous lors de ce premier
pisode de pr-clampsie, mais il ya un bilan in correct ,le quel ?
Cholestrolmie
ASAT, ALAT, Bilirubine
DES Entrance Exams

Bilan prtransfusionnel : groupe, Rhsus, RAI, NFS, plaquette


ECBU, protinurie des 24 heures
Bila rnal : cratinmie, ure, uricmie

69. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. HTA ET GROSSESSE Parmi ces complications maternelles de la pr-clampsie, il
ya une seule qui est fausse, la quelle ?
Eclampsie
Hmatome rtro-placentaire
HELLP syndrome
Menace daccouchement prmature
Coagulation intra-vasculaire dissmine

70. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. HTA ET GROSSESSE Parmi ces complications foetales de la pr-clampsie, il ya
une qui nest pas correcte, la quelle ?
Souffrance ftale chronique : RCIU, oligoamnios
Souffrance ftale aigu, jusqu la mort inutro
Risque de retard mental
Prmaturit induite par lextraction ftale avant terme
dme anasarque du foetus

71. Madame R, enceinte de 7 mois prsente un pisode de mtrorragie isole, elle a des antcdents
de lavortement depuis 2 ans, mre de 2 enfants et pas autres antcdents mdicaux et
chirurgicaux. HTA ET GROSSESSE Quel moyen est contre indiqu pour inhiber la lactation
chez une femme qui ne voulant pas allaiter ayant des antcdents de pr-clampsie ?
La bromocriptine
Bandages compressifs des seins
Restriction hydrique
Eviter toute stimulation des mamelons
Les oetroignes

72. Mme M, suivie pour sa 1re grossesse, consulte ce jour 25 SA, elle prsente une tension
artrielle 140/90 mmHg aux 2 bras en position allonge. Quel est le mcanisme reli au
dveloppement de lHTA gravidique au cours de la grossesse ?
Une Adhrence anormale du placenta
Une Insertion basse du Placenta
Une mauvaise placentation entrane une insuffissante placentaire
Une Grossesse arrte
Une multiparit
DES Entrance Exams

73. quel est le critre de diagnostic positif de lHTA gravidique selon les diffrences circonstances
dapparition ci-dessous ?
La Pression artrielle systolique(PAS)140mmHg ou la Pression artrielle diastolique (PAD) 90mmHg
aprs 20SA.
PAS 140mmHg ou PAD90mmHg au dbut de la grossesse
PAS 150mmHg ou PAD 10mmHg avant l^' existance de la grossesse
PAS 160mmHg ou PAD 80mmHg au cours du travail
PAS140mmHg ou PAD 90mmHg aprs la priode de suite de couche

74. Quel est le critre exact de la pr-clampsie, pour une dame en grossesse avec lhypertention ?
HTA gravidique plus dme des membres infrieures sans protinurie
HTA gravidique plus cphale nocturne sans protinurie
HTA gravidique plus protinurie 0,3g/24heures
HTA gravidique plus protinurie modre
HTA gravidique plus malaise de temp en temp mais sans protinurie

75. Quel est le critre de svrit de la pr-clampsie , mme elle est associe ou non un signe
clinique de gravit ?
PAS 160mmHg ou PAD 110mmHg
PAS 160mmHg ou PAD 100mmHg avec Grossesse multiple
PAS 160mmHg ou PAD 100mmHg avec Vomissement post prandiale
PAS 160mmHg ou PAD 100mmHg avec Augmentation de diurse nocturne
PAS 160mmHg ou PAD 100mmHg avec Lanorexie svre

76. La prise en charge devant une pr-clampsie svre : Quelle est votre dcision de faire quand la
patiente est arrive au votre centre de sant primaire ( MPA )?
Faire un bilan complet avant transferer.
Transfert materno-ftal en urgence dans une maternit niveau III ( CPAII ou III )
Surveillance materno-ftale rapproche
Donner de lhypotenseur
Donner de lanti-convulsivante

77. Mme S, suivie pour sa 2me grossesse, consulte ce jour 24 SA, elle prsente une tension
artrielle 150/60 mmHg aux 2 bras en position allonge. quel examen trs simple devez vous
pratiquer dans votre cabinet ? si ce lui-ci est ngatif, quel est le traitement adopter ? Quel est
le geste le plus simple pour liminer la pr-clampsie, pour une patiente hypertensive au cabinet
de votre consultation ?
Surveillance rapproche la domicile
La recherche dune protinurie ngative sur une bandelette urinaire
En basant sur les antcdents
Examen chographique pour rechercher une hydramnos aigu
Rechercher les signes de linsuffissance rnale
DES Entrance Exams

78. Mme S, suivie pour sa 2me grossesse, consulte ce jour 24 SA, elle prsente une tension
artrielle 150/60 mmHg aux 2 bras en position allonge. quel examen trs simple devez vous
pratiquer dans votre cabinet ? si ce lui-ci est ngatif, quel est le traitement adopter ? Quelle est
la dcision faire pour cette patiente HTA gravidique ?
Prise de travail et rgime alimentaire comme ordinaire
Il faut hospitaliser la patiente
Prise en charge ambulatoire, domicile, arrt de travail
De prendre un rgime plus sucr
Remplissage vasculaire sous surveillance stricte

79. Mme S, suivie pour sa 2me grossesse, consulte ce jour 24 SA, elle prsente une tension
artrielle 150/60 mmHg aux 2 bras en position allonge. quel examen trs simple devez vous
pratiquer dans votre cabinet ? si ce lui-ci est ngatif, quel est le traitement adopter ?
Traitement mdicamenteux : quelle est lhypotenseur plus favorable adopter pour cette
patiente ?
diurtique
Inhibiteur enzymatique de conversion
Bta bloquant
Linhibiteurs calciques per os ( nicardipine )
Le rgime hyposod

80. Mme S, suivie pour sa 2me grossesse, consulte ce jour 24 SA, elle prsente une tension
artrielle 150/60 mmHg aux 2 bras en position allonge. quel examen trs simple devez vous
pratiquer dans votre cabinet ? si ce lui-ci est ngatif, quel est le traitement adopter ? Quelle est
la mode de surveillance de la patiente quand elle est la domicile ?
La prise de la TA le matin et le soir
Il faut des surveillances rapproches de la TA la domicile
La surveillance de lapparition des oedmes
Sil ya lapparition de signes urinaires
Contrler rgulirement son rgime alimentaire

81. Mme S, suivie pour sa 2me grossesse, consulte ce jour 24 SA, elle prsente une tension
artrielle 150/60 mmHg aux 2 bras en position allonge. quel examen trs simple devez vous
pratiquer dans votre cabinet ? si ce lui-ci est ngatif, quel est le traitement adopter ? Quel est
le critre et le motif dhospitalisation en urgence de cette patiente pour ce schma de traitement
dj adopt ?
Amlioration du symptme
Etat stastionnaire
Sans amlioration rapide aprs traitement
Besoin de surveiller laccroissement du foetus
Trop de souci sur lavenir de sa grossesse
DES Entrance Exams

82. INFECTION ET GROSSESSE La prvention des risques ftaux en face de diversit des
infections : quelle proposition incorrecte pour la prise en charge en face de la toxoplasmose
chez une grossesse ?
Rgles hygino-dittiques +++
Srologie mensuelle si ngative +++
Vaccination contre la toxoplasmose
Prise en charge nonatale : Echographie transfontanellaire, Srologies ftales au cordon, Histologie
placentaire
Toxoplasmose congnitale est installe de 4 10 SA

83. INFECTION ET GROSSESSE La prvention des risques ftaux en face de diversit des
infections : Dans La prise en charge en face de la Rubole chez une grossesse, quelle examen
demande Qui est inutile ?
Vaccin est contre-indiqu pendant la grossesse
Hmoculture
Srologie maternelle systmatique en dbut de grossesse
Vacciner en dehors de la grossesse
Rubole congnitale si linfection est installe avant 18 SA

84. INFECTION ET GROSSESSE La prvention des risques ftaux en face de diversit des
infections : La prise en charge en face de Hpatites B et C chez une grossesse, quelle proposition
est incorrecte ?
Recherche systmatique de lAgHbs au dbut de la grossesse
Recherche systmatique de lAgHbs au 6me mois
Recherche dune co-infection VIH chez les femmes infectes par le VHC
Prvention de lhpatite nonatale ( mre infecte ) : Srovaccination
Vaccination de la mre contre hpatite B avant la grossesse

85. INFECTION ET GROSSESSE La prvention des risques ftaux en face de diversit des
infections : Prise en charge en face de la VIH chez une grossesse, quelle proposition est fausse ?
Srologie obligatoirement propose
Isolement obligatoire
Recherche des co-infections+++
Allaitement contre indiqu +++
Csarienne prophylactique 38 SA sauf si charge virale indtectable

86. INFECTION ET GROSSESSE La prvention des risques ftaux en face de diversit des
infections : La prise en charge en face de la Listriose chez une grossesse , quelle proposition qui
est fausse?
Rgle hygino-dittique, sur tout alimentaire
Premire cause de dficit neurologique congnital ( surdit )
Hmoculture, recherche spcifique de listria monocytognes
Traitement : Amoxicilline 4g/jour pendant 4 semaines
DES Entrance Exams

Toute fivre de la femme enceinte est une listriose jusqu preuve du contraire.

87. Une femme de 38ans,consulte aux urgences le 26 mai 2012 34 SA +2jours pour une fivre
39C depius 12 heures,associe des courbature,des vomissements et une diarrhe.Vous ne
trouvez pas de pointdappel urinaire ou poulmonaire cette fivre. Elle vous dit avoir eu
plusieurs pousses dherps gnital en 2006,2008et 2009. Les examens de dbut de grossesse sont
les suivants :-Hmogramme : normal, - groupe sanguine : A Rh(-), - Absence dAgglutinines
irrgulires,- VDRL , TPHA et Anticorps Anti-HIV : ngatives, - Srodiagnostic de la Rubole et
Toxoplasmose : absence dimmunits. Quel est Lexamen paraclinique qui a d tre ralis chez
cette patiente avant 20 SA et inutile aprs 20SA ?
La srologie toxoplasmose
La srologie VIH
La srologie rubole
La srologie de lanticorps et lantigne VHB
La srologie de VHC

88. Une femme de 38ans,consulte aux urgences le 26 mai 2012 34 SA +2jours pour une fivre
39C depius 12 heures,associe des courbature,des vomissements et une diarrhe.Vous ne
trouvez pas de pointdappel urinaire ou poulmonaire cette fivre. Elle vous dit avoir eu
plusieurs pousses dherps gnital en 2006,2008et 2009. Les examens de dbut de grossesse sont
les suivants :-Hmogramme : normal, - groupe sanguine : A Rh(-), - Absence dAgglutinines
irrgulires,- VDRL , TPHA et Anticorps Anti-HIV : ngatives, - Srodiagnostic de la Rubole et
Toxoplasmose : absence dimmunits. Quelle est lexamen qui nest pas de valeur de
diagnostique durant lexploration de cette infection?
La srologie toxoplasmose
Une chographie foetale B
Lalbuminurie et glucosurie
Lionogramme
La srologie VIH

89. Une femme de 38ans,consulte aux urgences le 26 mai 2012 34 SA +2jours pour une fivre
39C depius 12 heures,associe des courbature,des vomissements et une diarrhe.Vous ne
trouvez pas de pointdappel urinaire ou poulmonaire cette fivre. Elle vous dit avoir eu
plusieurs pousses dherps gnital en 2006,2008et 2009. Les examens de dbut de grossesse sont
les suivants :-Hmogramme : normal, - groupe sanguine : A Rh(-), - Absence dAgglutinines
irrgulires,- VDRL , TPHA et Anticorps Anti-HIV : ngatives, - Srodiagnostic de la Rubole et
Toxoplasmose : absence dimmunits. Devant ce tableau clinique,quelle est la conduite tenir
choisissez-vous parmi les propositions suivantes ?
Extraction immdiate de lenfant en vue dune srothrapie anti-hpatite B
Antibiothrapie per os par amoxicilline et hmoculture la recherche de Listria monocytogenes
Hospitalisation pour antibiothrapie IV en urgence car il sagit dune endomtrite
Hospitalisation et csarienne en urgence car il sagit dune chorioamniotite aigu
Antibiothrapie probabiliste par fluoroquinolone car les pylonphrites peuvent tre frustes chez la femme
enceinte
DES Entrance Exams

90. Une femme de 38ans,consulte aux urgences le 26 mai 2012 34 SA +2jours pour une fivre
39C depius 12 heures,associe des courbature,des vomissements et une diarrhe.Vous ne
trouvez pas de pointdappel urinaire ou poulmonaire cette fivre. Elle vous dit avoir eu
plusieurs pousses dherps gnital en 2006,2008et 2009. Les examens de dbut de grossesse sont
les suivants :-Hmogramme : normal, - groupe sanguine : A Rh(-), - Absence dAgglutinines
irrgulires,- VDRL , TPHA et Anticorps Anti-HIV : ngatives, - Srodiagnostic de la Rubole et
Toxoplasmose : absence dimmunits. Quelle est la premire pathologie laquelle vous devez
penser devant un tel tableau ?
Toxoplasmose
Grippe
Gastro-entrite aigu
Listriose
Chorio-amniotite aigu

91. Une femme de 38ans,consulte aux urgences le 26 mai 2012 34 SA +2jours pour une fivre
39C depius 12 heures,associe des courbature,des vomissements et une diarrhe.Vous ne
trouvez pas de pointdappel urinaire ou poulmonaire cette fivre. Elle vous dit avoir eu
plusieurs pousses dherps gnital en 2006,2008et 2009. Les examens de dbut de grossesse sont
les suivants :-Hmogramme : normal, - groupe sanguine : A Rh(-), - Absence dAgglutinines
irrgulires,- VDRL , TPHA et Anticorps Anti-HIV : ngatives, - Srodiagnostic de la Rubole et
Toxoplasmose : absence dimmunits. Votre diagnostic se confirme, Quelle est la prise en charge
incorrecte parmi les mesures ci-dessous ?
Dclaration obligatoire
Hydratation abondante
Prlvement multiples chez le nouveau-n ( sang, LCR, gastrique, mconium...)
Anatomopathologie du placenta la recherche dabcs placentaire
Isolement infectieux

92. HEMORRAGIE DU 1er TRIMESTRE La Fausse couche spontane ( FCS ) et la mole


hydatiforme Parmi ces signes cliniques de fausse couche spontane, un qui est faut lequel ?
Mtrorragies de sang rouge vif pouvant tre trs abondantes
Douleur abdominale avec signe de choc
Douleurs pelviennes type de contractions
Explusion du produit de concept dans le vagin
TV : col dhiscent ou permable

93. HEMORRAGIE DU 1er TRIMESTRE La Fausse couche spontane ( FCS ) et la mole


hydatiforme les examens complmentaires pour diagnostiquer la FCS ci-dessous sont
incorrectes, sauf une qui est ncessaire, laquelle ?
Beta HCG en diminution 2semaines dintervalle
Test de grossesse positif
Echographie : si le sac est visible, il apparat aplati, hypotonique, en voie dexpulsion.
Echographie : sac amniotique arrondie, col long
Echographie : ftus encore vivant, dcollement de la partie basse du placenta
DES Entrance Exams

94. HEMORRAGIE DU 1er TRIMESTRE La Fausse couche spontane ( FCS ) et la mole


hydatiforme Quelle est la prises en charges thrapeutique correcte en cas dhmorragies
cataclismique de la FCS ?
Antispasmodique pour calmer la douleur
Evacuation utrine en urgence ( aspiration ou curetage de propreter )
Abstention thrapeutique
Aider lexpulsion par lanalogues de prostaglandine Cytotec
Donner de lanalgsique et de lanti-coagulant

95. HEMORRAGIE DU 1er TRIMESTRE La Fausse couche spontane ( FCS ) et la mole


hydatiforme La physio-pathologie et les signes cliniques de la mole hydatiforme ci-dessous sont
correctes, sauf une proposition est incorrecte, laquelle ?
Dgnrescence kystique des villosits du trophoblaste
Tumeur bnigne du trophoblaste
Mtrorragies irrgulires de moyenne abondance
Augmenter du volume utrin proportionnelle lge de la grossesse
Signes sympatiques de grossesse exacerbs +++

96. HEMORRAGIE DU 1er TRIMESTRE La Fausse couche spontane ( FCS ) et la mole


hydatiforme Les Bilans paracliniques de la grossesse molaire ci-dessous sont vrais , sauf un qui
est faut, lequel :
Beta HCG +++ > 10.000
Radiographie de labdomen sans prparation
Image chographique : aspect en ( tempte de neige )
Souvent kystes ovariens bilatraux
Beta HCG dcroit progressivement dans 2 semaines aprs vacuation complte

97. FIEVRE ET GROSSESSE Une femme de 30ans, vient consulter au votre cabinet 34 SA pour
une fivre 39C depius 12 heures, associe des courbature, des vomissements et une diarrhe
Quel est le bilan complmentaire le plus ncessaire que vous allez prescrire devant une fivre
chez une femme enceinte ,dorigine indtermine au cabinet de votre consultation?
Biologie : NFS, CRP
Bactriologie : ECBU plus Hmoculture pour rechercher de Listria monocytognes
Srologie : Toxoplasmose, CMV, Hpatitevirale, VIH
Culot urinaire
Si suspicion de Paludisme : frottis sanguin et goutte paisse.

98. FIEVRE ET GROSSESSE Une femme de 30ans, vient consulter au votre cabinet 34 SA pour
une fivre 39C depius 12 heures, associe des courbature, des vomissements et une diarrhe
Parmi ces tiologies que vous devez voquer devant toute fivre de la grossesse, quelle est la
pathologie qui est la propre consquence possible de cette infection ?
Listriose, par argument de gravit
Pylonphrite aigu, cause la plus frquente
DES Entrance Exams

Menace daccouchement prmature ( MAP )


Infection materno-ftales : Rubole, Toxoplasmose, CMV, Hpatite, virale, VIH
Causes digestives : Appendicite aigu, Cholcystite aigu

99. FIEVRE ET GROSSESSE Une femme de 30ans, vient consulter au votre cabinet 34 SA pour
une fivre 39C depius 12 heures, associe des courbature, des vomissements et une diarrhe
Quel est le bilan clinique ou paraclinique pour valuer le retentissement ftale de cette fivre ?
Un examen clinique : Rechercher la prsentation du foetus
Prise de la temprature maternelle rgulirement
Mensuration de la hauteur utrine
Prlvement vaginal et ECBU
Une chographie obsttricale : Evaluation du bien-tre ftal

100. FIEVRE ET GROSSESSE Une femme de 30ans, vient consulter au votre cabinet 34 SA pour
une fivre 39C depius 12 heures, associe des courbature, des vomissements et une diarrhe
Aprs la ralisation dune hmoculture et dune ECBU vous dbutez une antibiothrapie. Parmi
les classes dantibiotiques listes ci-dessous, lesquelles sont possibles et indiques dans linfection
urinaire de la femme enceinte ?
Pnicillines Pnicilline Amoxicilline
Cphaloporines Cphalexine Cphalosporine
Macrolides Erythromycine Clarithromycine
Fluoroquinolones Ofloxacine Cyprofloxacine
Aminoglycosides Gentamycine Tobramycine

101. FIEVRE ET GROSSESSE Une femme de 30ans, vient consulter au votre cabinet 34 SA pour
une fivre 39C depius 12 heures, associe des courbature, des vomissements et une diarrhe
La fivre chez la femme enceinte doit tre traite comme une Listriose, et quand elle est
allergique aux pnicillines, Quelle lantibiotique est indique pour ce schma de traitement ?
Ttracycline 1000mg/jour per os pendant 10 jours
Aminoglycosides ( 160mg/jour IM pendant 10 jours
Macroloide ( rytromycine 3g/jour per os pendant 21 jours )
Amoxicilline 3g/jour per os pendant 10 jours
Quinolone ( ofloxacine 400mg/jour per os pendant 15 jours

102. HEMORRAGIE GYNECOLOGIQUE EN DEHORS DE LA GROSSESSE Une jeune fille dit


qu'elle est vierge, refuse l'examen gyncologique, quel bilan hormonal que vous devez demander
devant toute hmorragie gnitale chez cette fille en ge de procration ?
Dosage du taux d'oesrogne
Dosage du taux de progestrone
Dosage du taux de FSH
Dosage du taux de LH-RH
Dosage du taux de hCG
DES Entrance Exams

103. HEMORRAGIE GYNECOLOGIQUE EN DEHORS DE LA GROSSESSE Quel examen que


vous devez demander pour confirmer que la jeune fille a eu une immaturit hypothalamique,
qui cause l'anomalie du cycle menstruelle ?
Dosage du taux d'oestrogne
Dosage du taux de progestrone
Dosage du taux de FSH
Dosage du taux de LH-RH
Dosage du taux de hCG

104. HEMORRAGIE GYNECOLOGIQUE EN DEHORS DE LA GROSSESSE Dans le contexte de


l'hmorragie gnitale de la petite fille , quel est la cause organique le plus probable ?
Infection ou corps tranger intravaginale
Adnocarcinome du vagin ( enfant des distilbne )
Maladie hmatologique ( thrombopathie, maladie de willebrand )
Tumeur estrognoscrtante de l'ovaire
Prise sauvage de contraceptifs oraux

105. HEMORRAGIE GYNECOLOGIQUE EN DEHORS DE LA GROSSESSE Quel est le schma


de traitement devant une insuffissance luale provoquant une hmorragie fonctionnelle de
moyenne abondance ?
Oestroprogestatif pendant 6mois
Pilule de contraception ( strogne + progestrone ) au long cours
Progestatif du 15 au 25me jour du cycle pendant 6 mois
Injection intraveineuse d'strogne avec ou sans transfusion
Oestroprogestatif deux mois + progestatif pendant 4 mois

106. HEMORRAGIE GYNECOLOGIQUE EN DEHORS DE LA GROSSESSE Quel est le


traitement hormonal devant une hmorragie fonctionnelle de forme grave ?
Oestroprogestatif pendant 6 mois
Pilule contraception ( strogne + progestrone ) au long cours
Progestatif du 15 au 25me jour du cycle pendant 6 mois
Injection intraveineuse de progestrone avec ou sans transfusion
Oestroprogestatif deux mois + progestatif pendant 4 mois

107. Quel est la faute ne pas compromettre dans le cadre de traitement hormonal ?
Oestroprogestatif pendant 6 mois
Pilule de contraception ( strogne + progestrone ) au long cours
Progestatif du 15 au 25me jour du cycle pendant 6mois
Injection intraveineuse de progestrone avec ou sans trasfusion
Oestroprogestatif deux mois + progestatif pendant 4 mois
DES Entrance Exams

108. Dans le traitement de lhmorragie fonctionnelle de forme grave , quelle est la dose de
lthinylestradiol dans les 2 premier mois que vous devez choisir ?
Ethinylestradiol 50g/j pendant 10j, puis Ethinylestradiol 100g/j + progestatif 2cps/j pendant 10j.
Ethinylestradiol 50g/j pendant 10j, puis Ethinylestradiol 50g/j + progestatif 2cps/j pendant 10j.
Ethinylestradiol 100g/j pendant 10j, puis Ethinylestradiol 100g/j + progestatif 2cps/j pendant 10j.
Ethinylestradiol 100g/j pendant 10j, puis Ethinylestradiol 50g/j + progestatif 2cps/j pendant 10j.
Ethinylestradiol 50g/j pendant 10j, puis Ethinylestradiol 25g/j + progestatif 2cps/j pendant 10j.

109. Quel signe qui marque la gurison en fin du traitement hormonal ?


La prolactine normale
La courbe thermique monophasique
La courbe thermique biphasique
La persistance de lanovulation
Besoin de linduction de lovulation

110. Quel est lexamen le plus rapide que vous devez demander pour liminer une grossesse mlaire
chez une femme ayant deux mois de retard de rgle et accompagner de troubles sympathique
trs svre ?
Echographie abdomino-pelvienne
Echographie pelvienne endovaginale
Hystroscopie diagnostic
Dosage des hCG plasmatique
Radiographie de labdomen sans prparation

111. Quel est lexamen le plus sr que vous devez demander pour liminer un fibrome utrin sous
muqueux ou polype intracavitaire chez une femme ayant des hmorragies gnitales rptes
Echographie abdomino-pelvienne
Echographie pelvienne endovaginale
Hystroscopie diagnostic
Dosage des hCG plasmatique
Radiographie de labdomen sans prparation

112. Quel est type de menstruation qui correspond avec le terme de Mnorragie ?
Rgles la fois trop frquentes et trop abondantes
Rgles trop abondantes
Hmorragie utrine survenant en dehors de la priode des rgles
Hmorragie utrine excessive et prolonge frquence irrgulier.
Les rgles prolonges et abondantes avec notion de priodicit

113. Quel est le type de menstruation qui correspond avec le terme de Polymnorrhe ?
Rgles prolonges et abondantes avec notion de priodicit
Rgles trop abondantes
DES Entrance Exams

Hmorragie utrine survenant en dehors de la priode des rgles


Rgles la fois trop frquentes et trop abondantes
Hmorragie utrine excessive et prolonge frquence irrgulier.

114. Quel est le type de menstruation qui correspond avec le terme dHypermnorrhe ?
Rgles prolonges et abondantes avec notion de priodicit
Rgles la fois trop frquentes et trop abondantes
Hmorragie utrine survenant en dehors de la priode des rgles
Hmorragie utrine excessive et prolonge frquence irrgulier.
Rgles trop abondantes

115. Quel le type de menstruation qui correspond avec le terme de Mtrorragie ?


Rgles prolonges et abondantes avec notion de priodicit
Rgles la fois trop frquentes et trop abondantes
Hmorragie utrine survenant en dehors de la priode des rgles
Rgles trop abondantes
Hmorragie utrine excessive et prolonge frquence irrgulier.

116. Quel le type de menstruation qui correspond avec le terme de Mnomtrorragie ?


Rgles prolonges et abondantes avec notion de priodicit
Rgles la fois trop frquentes et trop abondantes
Rgles trop abondantes
Hmorragie utrine survenant en dehors de la priode des rgles
Hmorragie utrine excessive et prolonge frquence irrgulier.

117. Quel
est lexamen paraclinique le sr que vous devez demander pour liminer une grossesse
chez une femme ayant un ou deux jours de retard de rgle ?
Echographie abdomino-pelvienne
Echographie pelvienne endovaginale
Hystroscopie diagnostic
Radiographie de labdomen sans prparation
Dosage du taux de hCG plasmatique

118. Quel
est lexamen paraclinique le sr que vous devez demander pour liminer une hyperplasie
utrine chez une femme a eu des rgles trop abondantes ?
Echographie abdomino-pelvienne
Hystroscopie diagnostic
Radiographie de labdomen sans prparation
Echographie pelvienne endovaginale
Dosage du taux de hCG plasmatique
DES Entrance Exams

119. Quel
est lexamen paraclinique le sr que vous devez demander pour liminer un fibrome utrin
chez une femme ayant en cours des rgles trop abondantes ?
Echographie abdomino-pelvienne
Echographie pelvienne endovaginale
Hystroscopie diagnostic
Dosage du taux de hCG plasmatique
Radiographie de labdomen sans prparation

120. Quel
est lexamen paraclinique le sr que vous devez demander pour liminer un fibrome utrin
sous muqueux ou polype intracavitaire chez une femme ayant des hmorragies gnitales rpts
?
Echographie abdomino-pelvienne
Echographie pelvienne endovaginale
Hystroscopie diagnostic
Dosage du taux de hCG plasmatique
Radiographie de labdomen sans prparation

121. Quel
est lexamen paraclinique le plus rapide que vous devez demander pour liminer une
grossesse mlaire chez une femme ayant deux mois de retard de rgle et accompagner de
troubles sympathique trs svres ?
Echographie abdomino-pelvienne
Echographie pelvienne endovaginale
Hystroscopie diagnostic
Dosage du taux de hCG plasmatique
Radiographie de labdomen sans prparation

122. Mme B 50 ans vient consulter pour une perte de sang rouge importantes de quantit abondante
depuis une semaine. A linterrogatoire, elle prcise que ses rgles antrieures taient rgulires.
Elle a eu ses mnarches 12ans, se marie 16 ans. Sa fille unique a 35 ans en bonne sant. Elle
pratique de gymnastique 5 fois par semaine. Elle est encore rgle. Son dernier frottis cervico-
utrin a t ralis par un mdecin gyncologue il ya un an et tait normal. A lexamen : TA :
105/62 mmHg, pouls 110/mn, temprature 37,2C, taille 1,60m, poids 55kg, Abdomen souple et
non douloureux. Au spculum, le col est normal, le sorte de lendocol. Le TV met en vidence un
utrus volumineux comme une grossesse de 2 mois, les annexes sont non perceptibles. Lexamen
ne dclenche aucune douleur. A lchographie,on trouve que la cavit utrine spaissie. Quel
type de rgle quelle souffre cette dame ?
Polymnorrhe
Hypermnorrhe primnopausique
Mtrorragie primnopausique
Pollakimnorrhe
Rgles abondantes

123. Mme B 50 ans vient consulter pour une perte de sang rouge importantes de quantit abondante
depuis une semaine. A linterrogatoire, elle prcise que ses rgles antrieures taient rgulires.
DES Entrance Exams

Elle a eu ses mnarches 12ans, se marie 16 ans. Sa fille unique a 35 ans en bonne sant. Elle
pratique de gymnastique 5 fois par semaine. Elle est encore rgle. Son dernier frottis cervico-
utrin a t ralis par un mdecin gyncologue il ya un an et tait normal. A lexamen : TA :
105/62 mmHg, pouls 110/mn, temprature 37,2C, taille 1,60m, poids 55kg, Abdomen souple et
non douloureux. Au spculum, le col est normal, le sorte de lendocol. Le TV met en vidence un
utrus volumineux comme une grossesse de 2 mois, les annexes sont non perceptibles. Lexamen
ne dclenche aucune douleur. A lchographie,on trouve que la cavit utrine spaissie. Quel est
le diagnostic le plus probable de cette dame ?
Le cancer du corps utrin
Le cancer du col utrin
Lendomtrite
Les cancers de lovaire
Le Fibrome sous muqueuse

124. Mme B 50 ans vient consulter pour une perte de sang rouge importantes de quantit abondante
depuis une semaine. A linterrogatoire, elle prcise que ses rgles antrieures taient rgulires.
Elle a eu ses mnarches 12ans, se marie 16 ans. Sa fille unique a 35 ans en bonne sant. Elle
pratique de gymnastique 5 fois par semaine. Elle est encore rgle. Son dernier frottis cervico-
utrin a t ralis par un mdecin gyncologue il ya un an et tait normal. A lexamen : TA :
105/62 mmHg, pouls 110/mn, temprature 37,2C, taille 1,60m, poids 55kg, Abdomen souple et
non douloureux. Au spculum, le col est normal, le sorte de lendocol. Le TV met en vidence un
utrus volumineux comme une grossesse de 2 mois, les annexes sont non perceptibles. Lexamen
ne dclenche aucune douleur. A lchographie,on trouve que la cavit utrine spaissie. Quelle
est la cause fonctionnelle la plus probable de cette dame ?
Cause iatrogne par hyperplasie de lendm`tre
Atrophie par carence oestrognique
Adnomyose utrin
Endomtriose cervicale
Maladie de willebrand

125. Mme B 50 ans vient consulter pour une perte de sang rouge importantes de quantit abondante
depuis une semaine. A linterrogatoire, elle prcise que ses rgles antrieures taient rgulires.
Elle a eu ses mnarches 12ans, se marie 16 ans. Sa fille unique a 35 ans en bonne sant. Elle
pratique de gymnastique 5 fois par semaine. Elle est encore rgle. Son dernier frottis cervico-
utrin a t ralis par un mdecin gyncologue il ya un an et tait normal. A lexamen : TA :
105/62 mmHg, pouls 110/mn, temprature 37,2C, taille 1,60m, poids 55kg, Abdomen souple et
non douloureux. Au spculum, le col est normal, le sorte de lendocol. Le TV met en vidence un
utrus volumineux comme une grossesse de 2 mois, les annexes sont non perceptibles. Lexamen
ne dclenche aucune douleur. A lchographie,on trouve que la cavit utrine spaissie. Quel est
le premier geste thrapeutique le plus appropri pour cette dame ?
Hystrectomie demble
Coelioscopie opratoire
Pratique un curetage biopsique pour lexamen danapath
Hystroscopie opratoire
Le traitement progestatif
DES Entrance Exams

126. Mme B 50 ans vient consulter pour une perte de sang rouge importantes de quantit abondante
depuis une semaine. A linterrogatoire, elle prcise que ses rgles antrieures taient rgulires.
Elle a eu ses mnarches 12ans, se marie 16 ans. Sa fille unique a 35 ans en bonne sant. Elle
pratique de gymnastique 5 fois par semaine. Elle est encore rgle. Son dernier frottis cervico-
utrin a t ralis par un mdecin gyncologue il ya un an et tait normal. A lexamen : TA :
105/62 mmHg, pouls 110/mn, temprature 37,2C, taille 1,60m, poids 55kg, Abdomen souple et
non douloureux. Au spculum, le col est normal, le sorte de lendocol. Le TV met en vidence un
utrus volumineux comme une grossesse de 2 mois, les annexes sont non perceptibles. Lexamen
ne dclenche aucune douleur. A lchographie,on trouve que la cavit utrine spaissie. Si cette
dame a eu 45 ans et lexamen anatomopathologique dcle aucune malignit de ce produit de
curetage, et affirme de lhyperplasie de lendomtre relative une hyperestrognie entrainant
un cycle anovulatoire, quel est le traitement le plus probable ?
Progestatif du 5me au 25me jour du cycle
Anticoagulant
Stimulation de lovulation
Blocage de lovulation
strogne 10g/jour du Jour 0 au Jour 10

127. Enconsultation une jeune fille de 18 ans, vierge, se plainte des hmorragies gnitales anarchique
depuis 2mois , mnarchie l'ge de 13 ans.A l'interrogatoire : les saignements sont espacs une
dizaine quinzaine de jours, et chaque fois dure 3 4 jours faite de sang rouge vif. Elle change 8
fois de linge par jour. Sa mre n'tait jamais prise de tel hormone.A l'chographie vous notez
que l'utrus mesure 30mm d'paisseur, et sa cavit non largie, les 2 ovaires sont normaux. La
TA 90/50mmHg , temprature 37C, pouls 105/mn, taille 163cm, poids 45 kg. Donnez le type de
menstruation qui indique le symptme que souffre la jeune fille ?
Saignement gnital
Mnorragie
Mnomtrorragie
Polymnorrhe
Rgles abondantes

128. Enconsultation une jeune fille de 18 ans, vierge, se plainte des hmorragies gnitales anarchique
depuis 2mois , mnarchie l'ge de 13 ans.A l'interrogatoire : les saignements sont espacs une
dizaine quinzaine de jours, et chaque fois dure 3 4 jours faite de sang rouge vif. Elle change 8
fois de linge par jour. Sa mre n'tait jamais prise de tel hormone.A l'chographie vous notez
que l'utrus mesure 30mm d'paisseur, et sa cavit non largie, les 2 ovaires sont normaux. La
TA 90/50mmHg , temprature 37C, pouls 105/mn, taille 163cm, poids 45 kg. Quel est le
diagnostic le plus probable de ce contexte ?
Hyperplasie endomtriale
Mtrorragie fonctionnelle
Adnomyose
Polype endomtriale
Fibrome sous muqueuse

129. En
consultation une jeune fille de 18 ans, vierge, se plainte des hmorragies gnitales anarchique
depuis 2mois , mnarchie l'ge de 13 ans.A l'interrogatoire : les saignements sont espacs une
DES Entrance Exams

dizaine quinzaine de jours, et chaque fois dure 3 4 jours faite de sang rouge vif. Elle change 8
fois de linge par jour. Sa mre n'tait jamais prise de tel hormone.A l'chographie vous notez
que l'utrus mesure 30mm d'paisseur, et sa cavit non largie, les 2 ovaires sont normaux. La
TA 90/50mmHg , temprature 37C, pouls 105/mn, taille 163cm, poids 45 kg. Dans le contexte de
la jeune fille, quelle est la cause iatrogne le plus probable ?
Prise sauvage de contraceptifs oraux
Infection ou corps tranger intravaginale
Adnocarcinome du vagin ( enfant des distilbne )
Maladie hmolytique ( thrombopathie, maladie de willebrand )
Tumeur estrognoscrtante de lovaire

130. Enconsultation une jeune fille de 18 ans, vierge, se plainte des hmorragies gnitales anarchique
depuis 2mois , mnarchie l'ge de 13 ans.A l'interrogatoire : les saignements sont espacs une
dizaine quinzaine de jours, et chaque fois dure 3 4 jours faite de sang rouge vif. Elle change 8
fois de linge par jour. Sa mre n'tait jamais prise de tel hormone.A l'chographie vous notez
que l'utrus mesure 30mm d'paisseur, et sa cavit non largie, les 2 ovaires sont normaux. La
TA 90/50mmHg , temprature 37C, pouls 105/mn, taille 163cm, poids 45 kg. Quel examen que
vous demandez pour confirmer que la jeune fille a eu une immaturit hypothalamique, qui cause
cette anomalie menstruelle ?
Dosage du taux dOestrogne
Dosage du taux de progestrone
Dosage du taux de FSH
Dosage du taux de hCG
Dosage du taux de LH-RH

131. Enconsultation une jeune fille de 18 ans, vierge, se plainte des hmorragies gnitales anarchique
depuis 2mois , mnarchie l'ge de 13 ans.A l'interrogatoire : les saignements sont espacs une
dizaine quinzaine de jours, et chaque fois dure 3 4 jours faite de sang rouge vif. Elle change 8
fois de linge par jour. Sa mre n'tait jamais prise de tel hormone.A l'chographie vous notez
que l'utrus mesure 30mm d'paisseur, et sa cavit non largie, les 2 ovaires sont normaux. La
TA 90/50mmHg , temprature 37C, pouls 105/mn, taille 163cm, poids 45 kg. Quel est votre
schma de traitement devant une insuffisance lutale provoquant une hmorragie foctionnelle de
moyenne abodance ?
Progestatif du 15me au 25mejour du cycle pendant 6mois
Pilule contraception ( strogne + progestrone ) au long cours
Oestroprogestatif pendant 6 mois
Injection intraveineuse dstrogne avec ou sans transfusion
Oestroprogestatif deux mois + progestatif pendant 4 mois

132. Madame B, 48 ans, dorigine africaine , consulte en urgence pour saignement important par voie
vaginale : Docteur, je me suis change 10 fois depuis ce matin et a fait 10j que a dure. Je suis
trs fatigu, cela fait 3 mois que je saigne beaucoup plus pendant mes rgles et parfois aussi en
dehors des rglesA linterrogatoire : Teste urinaire de grossesse ngative (fait par elle-
mme).G3 P3 A0. Mnarche 12 ans, rgles rgulires, pas encore mnopause. Contraceptif
orale par oestro-progestatif depuis plus de 10 ans. FCV normale il y a 1 ans.A lexamen : -
TA=105/62, poule= 106/min,temprature 37,3C Abdomen indolore. Spculum : col sain,
DES Entrance Exams

coulement abondant de sang provenant endo-utrine. TV : utrus augmente de volume, forme


irrgulire, annexes non perceptible, aucun douleur dclench par TV. Quel est le terme
mdicale pour dcrire ce symptme?
saignement gnitale
Mtrorragie
Mnorragie
Mno- mtrorragie
Hmorragie vaginale

133. Madame B, 48 ans, dorigine africaine , consulte en urgence pour saignement important par voie
vaginale : Docteur, je me suis change 10 fois depuis ce matin et a fait 10j que a dure. Je suis
trs fatigu, cela fait 3 mois que je saigne beaucoup plus pendant mes rgles et parfois aussi en
dehors des rglesA linterrogatoire : Teste urinaire de grossesse ngative (fait par elle-
mme).G3 P3 A0. Mnarche 12 ans, rgles rgulires, pas encore mnopause. Contraceptif
orale par oestro-progestatif depuis plus de 10 ans. FCV normale il y a 1 ans.A lexamen : -
TA=105/62, poule= 106/min,temprature 37,3C Abdomen indolore. Spculum : col sain,
coulement abondant de sang provenant endo-utrine. TV : utrus augmente de volume, forme
irrgulire, annexes non perceptible, aucun douleur dclench par TV. Quel est le diagnostic le
plus probable de ce contexte?
cancer de lendomtre
GEU
cancer du col utrin
fibrome sous-sreux
Fibrome sous-muqueux

134. AMENORRHHEE PRIMAIRE ET SECONDAIRE Laquelle est laction principale de FSH :


hyperthermique
dclencher ovulation
scrtion de glaire cervicale
dveloppement de plusieurs follicules
prparer lorganisme la gestation

135. AMENORRHHEE PRIMAIRE ET SECONDAIRE Quelle est la dfinition de lamnorrhe


primaire ?
Absence de la mnarche chez une jeune fille de plus de 16 ans
Absence de rgle aprs une priode des rgles irrgulire
Absence de rgle aprs laccouchement
Absence de rgle aprs contraception injectable
Absence de rgle aprs avoir de la grossesse

136. Quelle est la dfinition de lamnorrhe secondaire ?


Absence de rgle au cours de la grossesse
Absence de rgle depuis plus de 3 mois
DES Entrance Exams

Absence de rgle depuis 4 semaines


Absence de rgle ds la pubert
Absence de rgle temporairement avec des rgles irrgulires

137. AMENORRHEE PRIMAIRE Quelle est ltiologie la plus frquente damnorrhe primaire ?
Retard pubertaire simple
Retard de croissance somatique
Retard de croissance mentale
Facteur denvironnement
Malnutrition

138. CANCER DU COL UTERIN Quelle est la localisation la plus frquence des cancers du col
utrin ?
Sur la totalit de lectropion
Zone de jonction pavimento-cylindrique
Sur le quadrant supro-externe droit
Au niveau de lorifice interne du col
Au niveau de la museau de tanche postrieure

139. CANCER DU COL UTERIN Quel est le moyen de prvention primaire des cancers du col
utrin ?
Frottis cervico-utrin
Vaccination anti HPV
La colposcopie
La biopsie
La recherche de HPV

140. CANCER DU COL UTERIN Que faites-vous devant un frottis cervico-utrin anormal ?
Conisation du col
Biopsie du col
Colposcopie avec ralisation dun schma dat et de biopsie pour examen anatomopathologique
Frottis de contrle
Cautrisation du col

141. CANCER DU COL UTERIN Que faites-vous si , au cours dune colposcopie ralise pour frottis
cervico-utrin anormal , la jonction pavimento-cylindrique nest pas visible ?
Refaire la colposcopie
Conisation but diagnostique
Cautrisation du col
Hystrectomie totale
Refaire la frottis cervico-utrin
DES Entrance Exams

142. CANCER DU COL UTERIN Quel est le principe de prise en charge dune LIEBG ( LSIL ) ?
Frottis cervico-utrin et colposcopie 6 mois
Frottis cervico-utrin 3 mois
Biopsie sous colposcopique
Abstention
Conisation

143. CANCER DU COL UTERIN Quel est le moyen de prvention secondaire des cancers du col
utrin ?
Interrogatoire sur les antcdents familiaux
La recherche de HPV
Frottis cervico-utrin de dpistage tous les 3 ans
Traiter les lsions dystrophiques du col
Traiter les MST

144. CANCER DU COL UTERIN Quel est le principe de prise en charge dune LIEBG ( LSIL ),si
persistance>18mois et pour la patiente non compliante la surveillance ?
Rptition de frottis cervico-utrin
Traitement par vaporisation au laser ou cautrisation
Conisation avec examen anatomopathologique
Abstention
Prvention de MST

145. CANCER DU COL UTERIN Quel est le moyen de surveillance dont vous disposez aprs une
conisation ?
Prlvement vaginal pour culture et antibiogramme
Frottis cervico-vaginal
Colposcopie rechercher les lsions restantes
Antibiotiques pour prvenir les infections
Biopsie le col restant aprs 3 mois

146. CANCER DU COL UTERIN A quelle frquence effectuez-vous ces examens , aprs une
conisation ?
Tous les mois pendant 1 an
Tous les 6 mois pendant 3 ans
A 3-6 mois puis 18 mois puis annuel pendant au moins 10 ans
Tous les 2 ans pendant 5 ans
Seulement chaque anne

147. CANCER DU COL UTERIN Quel est le moyen le plus intressant de surveillance, aprs une
conisation ?
Test HIV
DES Entrance Exams

Test CA 125
Test HPV
Test HBV et HCV
Test de Lugol iodo-iodure

148. Quel est le principe de prise en charge dune LIEHG ( HSIL ) ?


Exrse chirurgicale : Conisation avec examen anatomopathologique
Abstention
Vaporisation au laser
Hystrectomie totale
Rptition de Colposcopie

149. Quel est le principal facteur de risque de cancer du col ?


Infections chroniques causes par MST
Infection HPV de haut risque : HPV type 16 et 18
Lsions dystrophiques chronique
Immunodficient ( HIV, DIABETE )
Multiparit

150. Quel est le type histologique le plus frquent concernant les cancers du col utrin ?
Adnocarcinome
Carcinome cellule clair
Carcinome pidermoide
Carcinome embryonnaire
Trato-carcinome

151. Quel est llment principal rechercher linterrogatoire devant une suspicion de cancer du
col ?
Leucorrhe
Mtrorragies provoques
Les antcdents familiaux
Notions de rgles
Douleurs pelviennes

152. A lexamen physique : Au spculum quel lment qui marque le cancer du col ?
Ectropion rouge saignant
Tumeur bourgeonnante,ulcre, saignant au contact
Vgtation avec leucorrhe ftide
Tumeur rouge lisse de lexocol
Une masse arrondie venant de lendocol rouge vif
DES Entrance Exams

153. A lexamen physique : Au toucher vaginal , quel lment qui prouve la malignit ?
Mou souple saignant au contact
Une masse lisse fait corp avec le col
Induration, saignement au contact
Une masse arrondie avec pdicule venant de lendocol
Une masse lisse friable et saignant venant de lendocol

154. Quel est lexamen physique qui value le bilan dextension ?


Le toucher vaginal
Toucher vaginal combin au palper abdominal
Le toucher rectal
Palper abdominal
Rectoscopie

155. Quel examen physique pour chercher les aires ganglionnaires priphriques de bilan dextension
?
Toucher rectale
Toucher vaginal
Palpation inguinale
TV combin au palper
Palper abdominal

156. Pour complter lexamen physique, On va faire lexamen gnral , quel est le but de cet examen
?
A la recherche des tumeurs pelviennes associes
A la recherche de la mtastases osseuse, hpatique, pulmonaire et cerveau
A la recherche des maladies mdicales associes
A la recherche dautres cancers initiales
A la recherche du cancer de lovaire

157. Quel est lexamen paraclinique que vous prescrivez pour faire le diagnostic de certitude ?
Frottis de dpistage prcoce
Test de lugol
Test de lacide actique
Biopsie pour examen anatomopathologique
Colposcopie

158. Quel est le meilleur examen raliser pour valuer lextension locorgional dun cancer du col ?
Scanner multibarette
IRM pelvienne
Radiographie du pelvis
DES Entrance Exams

Echographie vaginale
Syntillographie pelvienne et hpatique

159. Quel bilan complmentaire devez-vous raliser chez une femme ayant un cancer du col ?
Bilan MST
Hmogramme
CRP
Glycmie
Graphie pulmonaire

160. Quel est le principal facteur pronostic dun cancer du col ?


Cancer invasif du col
Cancer au Stade clinique
Classification de FIGO
HIV positif
MST

161. Quelle est la bonne date pour raliser la colposcopie ?


Entre J3-J14 du cycle
Entre J4-J14 du cycle
Entre J5-J14 du cycle
Entre J6-J14 du cycle
Entre J8-J14 du cycle

162. Quel point peut-on reprer lexamen aprs lapplication dacide actique sous colposcopie ?
Reprer les lsions normaux et anormaux
Reprer la jonction pavimento-cylindrique et les lsions intra-pithliales
Reprer les lsions CIN1,CIN2 etCIN3
Reprer les lsions intra-pithliales directement
Reprer les lsions LSIL et HSIL

163. Comment peut-on raliser la biopsie dune zone suspecte sous colposcopie pour
anatomopathologique ?
Directement aprs acide actique
Directement sans prparation
Aprs lapplication de lugol
Biopsie de la zone blanche
Biopsie de la zone hypervascularise
DES Entrance Exams

164. Aquoi correspondent les lsions intra-pithliales de bas grade ( LSIL ) dans la classification de
Bethesda ( Dysplasie lgre ) ?
Anomalies cellulaires localises au tiers suprieur des couches cellulaires
Anomalies cellulaires localises au tiers infrieur des couches cellulaires
Anomalies cellulaires les 2/3 suprieur des couches cellulaires
Anomalies cellulaires les 2/3 infrieur des couches cellulaires
Anomalies toute la totalit des couches cellulaires

165. Quelle prise en charge thrapeutique des lsions intra-pithliales proposz-vous en fonction des
rsultats de la colposcopie ? Si la jonction pavimento-cylindrique nest pas visible, quel que soit
le stade lsionnel ?
Lexrse chirurgicale est ncessaire pour ne pas mconnatre une lsion de lendocol ( conisation )
Abstention et surveillance
Vaporisation au laser
Biopsie plusieur locations
Hystrectomie

166. Quelle prise en charge thrapeutique des lsions intra-pithliales proposz-vous en fonction des
rsultats de la colposcopie ? Devant une lsion intra-pithliale de haut grade avec jonction
visible ?
Vaporisation au laser
Biopsie de controle
Conisation avec examen anatomopathologique
Hystrectomie
Abstention

167. Quel bilan dextension demandez-vous en pr-thrapeutique ? Quel type dexamen paraclinique
rgional de rfrence, pour prciser le volume,extension aux paramtres, cloison recto-vaginale
et recherche dadnopathies ?
Echographie vaginale
Tomo- densito mtrie ( TDM ) abdomino-pelvienne
IRM pelvienne
Graphie abdomino-pelvienne sans prparation
Syntillographie

168. Quelbilan dextension demandez-vous en pr-thrapeutique ? Quel type dexamen paraclinique


pour valuer la tumeur et lintrt dans la recherche dadnopathies, de mtastases dune
compression des voies urinaires ?
Echographie vaginale
TDM abdomino-pelvienne
IRM abdomino-pelvienne
Graphie abdomino-pelvienne sans prparation
DES Entrance Exams

Syntillographie

169. Quelbilan dextension demandez-vous en pr-thrapeutique ? Quel lintrt de faire


lymphadnectomie per-coelioscopique pr-opratoire de premier intention pour valuer avec
certitude la prsence des ganglions pelviens et lombo-aortiques ?
Il faut enlever ces ganglions pour arrter les mtastases
Cela modifie le pronostic et lattitude thrapeutique
Pour confirmer la prsence ou non des mtastases loco-rgionales
Pour prciser le degrs dextension
Lymphadnectomie pr-opratoire nest pas ncessaire

170. Quelbilan dextension demandez-vous en pr-thrapeutique ? Quel test est plus intrt pour le
bilan dextension pr-thrapeutique ?
Rechercher les infections MST associes
Rechercher HIV
Marqueur CA 125
Marqueur SCC
Test des fonctions hpatiques

171. Une
femme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ?
Quelle lindication souvent pratique mais reste discute de premier choix proposez-vous ?
Hystrectomie totale avec annexectomies
Curiethrapie utro-vaginale pr-opratoire
Chirurgie radicale avec lymphadnectomie
Hystrectomie totale avec cobalthrapie
Curie et cobalthrapies associes

172. Une
femme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ?
Quelle tape classique quon doit proposer pour le cancer de ce stade ?
Colpo-hystrectomie totale simple
Colpo- hystrectomie totale avec annexectomie bilatrale
Colpo-hystrectomie totale avec annexectomie bilatrale et lymphadnectomie
Chirurgie radicale lieu demble ou 6 semaines aprs une curie thrapie
Une seule cure de curie thrapie est suffissante

173. Unefemme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ?
En per-opratoire, on a trouv des envahissements ganglionnaires diagnostiques lors de
lanatomopathologie, quelle prise en charge proposez-vous ?
Une simple cobalthrapie
Une chimiothrapie seule
DES Entrance Exams

Une radio-chimio thrapie concomitante post opratoire


Cobalthrapie associe un traitement palliative
Chimiothrapie associe un traitement palliative

174. Une
femme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ?
Quelle type de surveillance post-0pratoire proposez-vous pour cette dame ?
La Surveillance de tous les ans par frottis du dome vaginal
La Surveillance de ltat gnral
La surveillance doit tre rapproche et prolonge par examen clinique et frottis du dome vaginal
La surveillance pour rechercher de la mtastase
La surveillance se fait en une seule fois 3mois

175. Une
femme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ?
Tous les procdures thrapeutiques sont bien raliss, Quel est le pronostic de survie moyenne
pour cette dame ?
Au plus 1an
Au plus 3 ans
A 5 ans
A 10 ANS
A vie

176. Unefemme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ? A
qulle lge quon doit tre effectu le frottis cervico-vaginal en gnral chez les femmes ?
Aprs la pubert tous les 3ans jusqu 65 ans
Aprs la marriage tous les 3ans jusqu 65 ans
A nimporte quel ge tous ans
A 25 ans tous les 3ans jusqu 65 ans
A 40ans tous les 3 ans jusqu 65 ans

177. Une
femme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ?
Quels sont les principaux types de HPV en cause du cancer du col utrin ?
HPV types 11 et 12
HPV types 16 et 18
HPV types 21 et 22
HPV types 42 et 35
HPV types 110 et 180

178. Une
femme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ?
DES Entrance Exams

Quelle est lindication dune manire systmatique pour HSIL, si la jonction pavimento-
cylindrique nest pas visible sous colposcopique ?
Vaporisation au laser
Hystrectomie totale
Conisation et examen anatomopathologique
Biopsie de la zone suspecte
Colposcopie de rptition

179. Une
femme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ?
Quelle est le futur comprhension exacte, pour la patiente vaccine danti-HPV 16 et 18 ?
Une fois vaccine, la protection du cancer du col est dfinitive
Pas besoins de frottis cervico-vaginal de contrle aprs la vaccination
La vaccination anti- HPV ne dispense pas du frottis cervico-vaginal
Il faut vacciner de rappel ultrieurement
Vaccination des patientes ges est ncessaire pour la prvention du cancer du col

180. Une
femme 35 ans prsentant un cancer du col au stade IIA , valu 3cm , sans envahissement
mtastatique ganglionnaire et viscral , Quelle prise en charge thrapeutique proposez-vous ? Le
cancer du col utrin est il dpendant des autres facteurs ?
L e cancer du col est hormonodpendant
Le cancer du col est non hormonodpendant
Le cancer du col est souvent secondaire un cancer des autres organes
Le cancer du col est une maladie contagieuse
Le cancer du col est souvent spontan chez les femmes ges

1. A27-year-old woman has used oral contraceptives


(OCs) without problems for 5 years.
However, she just read an article about complications
of OCs in a popular womens magazine
and asks you about the risks and hazards
of taking OCs. You correctly tell her which of
the following?
(A) The risk of developing ovarian cancer is
increased.
(B) The risk of developing pelvic inflammatory
disease (PID) is increased.
(C) The risk of developing endometrial cancer
is decreased. @
(D) The risk of bearing a child with major
congenital anomalies is increased if
taken while pregnant.
(E) The risk of ectopic pregnancy is
increased

2. You are seeing a 38-year-old woman for her


DES Entrance Exams

annual gynecologic examination. She asks you


for some information regarding the HPV vaccine
and whether you think it would be appropriate
for her 17-year-old daughter. Which of
the following statements regarding the quadrivalent
human papillomavirus vaccine and
HPV is true?
(A) The vaccine is recommended for women
ages 1126 but can be given as young as
age 9. @
(B) After vaccination, women no longer
need routine Pap smears.
(C) The vaccine is given every month for
3 months.
(D) The vaccine is prepared from the proteins
of four oncogenic (e.g., high-risk
for cervical cancer) strains of HPV.
(E) Women with a prior history of abnormal
Pap smears are not candidates for vaccination

3. During this womans labor, the nurse describes


the presenting part as engaged when the
woman is 6 cm dilated. Which of the following
is the most accurate definition of engagement
in a woman with a vertex presentation?
(A) The vertex has passed through the
pelvic inlet.
(B) The vertex reaches the pelvic floor.
(C) The biparietal diameter has passed
through the pelvic inlet. @
(D) The biparietal diameter has reached the
pelvic floor.
(E) The vertex is at plus 1 station.

4. In which of the following circumstances is the


administration of anti-D immune globulin not
necessary?
(A) threatened abortion and first-trimester
bleeding
(B) genetic amniocentesis at 16 weeks
gestation
(C) at 28 weeks
(D) at 40 weeks with the onset of labor @
(E) after delivery of an Rh-positive fetus

5. A 46-year-old G3P3 woman has had postcoital spotting


for 6 months. On pelvic examination, she has a
fungating, exophytic lesion arising from her cervix
that is approximately 2 cm in diameter. Biopsy of this
lesion is interpreted as invasive squamous cell carcinoma
of the cervix. There is no evidence of extension
of the cancer onto the vagina. The parametria are
indurated on bimanual examination, though not to
the pelvic sidewall. CT scan of her pelvis and
abdomen discloses enlarged paraaortic lymph nodes
and metastatic lesions in the parenchyma of her liver.
DES Entrance Exams

Which of the following is the FIGO stage of


her cancer?
(A) IA
(B) IB
(C) IIB @
(D) IIIB
(E) IVB

6. A22-year-old G3P1102 is admitted to the Labor


and Delivery ward at 28 weeks gestation complaining
of watery vaginal discharge. You confirm
the diagnosis of preterm premature
rupture of amniotic membranes (PPROM).
Fetal monitoring demonstrates reassuring fetal
heart tones and no contractions are noted. The
patient is understandably concerned and asks
you why this happened and what this means
for her pregnancy. Which of the following
should you tell her?
(A) The incidence of PPROM is directly correlated
to maternal age.
(B) Most patients with PPROM before
30 weeks will remain pregnant until
at least 34 weeks.
(C) Management at home is a reasonable
option for most patients until the onset
of contractions.
(D) Patients with bacterial vaginosis are at
increased risk for PPROM during pregnancy. @
(E) Pulmonary hypoplasia is a common
complication of PPROM at this gestational
age

7. A 37-year-old pregnant woman with type 2


diabetes mellitus and chronic hypertension is
35 weeks pregnant. Which of the following is
the best test to screen for fetal well-being?
(A) nonstress test (NST)
(B) oxytocin challenge test
(C) amniocentesis
(D) fetal movement counting
(E) fetal biophysical profile @

8. A 39-year-old woman at 16 weeks gestation


complains of headaches, blurred vision, and
epigastric pain. Her blood pressure is now
156/104 mmHg. Her uterine fundus is palpable
22 cm above her symphysis pubis. Fetal
heart tones could not be heard with a handheld
Doppler. She has 3+ proteinuria. Which of the
following is the most likely diagnosis?
(A) anencephaly
(B) twin gestation
(C) maternal renal disease
(D) hydatidiform mole @
(E) gestational diabetes mellitus
DES Entrance Exams

9. After an appropriate diagnostic evaluation, a


59-year-old woman with postmenopausal bleeding
had a total abdominal hysterectomy and
bilateral salpingo-oophorectomy (TAH-BSO).
The pathologic diagnosis is adenocarcinoma of
the endometrium. An endometrial adenocarcinoma
that is confined to the uterus and extends
more than 50% through the myometrium is at
which stage?
(A) IC @
(B) IIA
(C) IIB
(D) IIIA
(E) IVA

10. A 38-year-old G4P3013 woman is seeing you


for her annual gynecologic examination. She
has no specific complaints, but notes that her
menses have gradually become heavier over
the past 23 years. Your pelvic examination is
normal aside from an enlarged uterus, which
you estimate at 12 weeks size. Office ultrasonography
confirms that she has multiple
uterine fibroids. Which of the following statements
is true regarding leiomyomata?
(A) OCs cause leiomyomata to grow more
rapidly.
(B) Leiomyomata not removed by hysterectomy
may eventually degenerate into
malignant tumors (i.e., leiomyosarcoma).
(C) Submucosal fibroids are more likely to
cause painful, heavy periods than are
subserosal fibroids. @
(D) Leiomyomata occur in up to 5% of all
women.
(E) Typical bleeding abnormalities seen
with uterine fibroids are heavy menstrual
bleeding as well as frequent intermenstrual
bleeding episodes.

11. Your patient comes back 6 months later with a


calendar demonstrating continued worsening
of her menstrual bleeding, now 10 days in
duration and requiring one pad hourly during
her heaviest days. Which of the following
statements are true regarding treatment of
leiomyomata?
(A) Because fibroids are responsive to sex
steroids, treatment with GnRH agonists
(e.g., leuprolide) will produce up to a
50% reduction in volume. @
(B) Treatment with leuprolide appears to be
long lasting, making this an attractive
alternative to hysterectomy or myomectomy.
(C) Myomectomy (i.e., removal of uterine
DES Entrance Exams

fibroids without removal of the uterus)


is replacing hysterectomy as it is associated
with less complications and less
blood loss.
(D) Because it requires no abdominal or
uterine incisions, uterine artery
embolization is the preferred method of
treatment for women who desire future
pregnancy.
(E) Any leiomyoma larger than 5 cm should
be removed by either hysterectomy or
myomectomy to rule out leiomyosarcoma.
12. A 28-year-old woman with 28-day menstrual
cycle is attempting to conceive and is considering
the use of a home ovulation predictor kit
to time intercourse at ovulation. She asks you
what day of her menstrual cycle her luteinizing
hormone (LH) peak is most likely to occur.
What should you tell her?
(A) day 12
(B) day 14 @
(C) day 18
(D) day 20
(E) day 27

13. A 48-year-old woman had a biopsy of a friable,


bleeding lesion on her cervix. She had not had a
pelvic examination or Pap smear for about 12 years.
The biopsy is reported as invasive squamous cell
carcinoma of the cervix. On bimanual examination,
there is induration to the side wall of her pelvis.
Which of the following is the stage of her cervical
cancer?
(A) IA
(B) IB
(C) IIB
(D) IIIB @
(E) IV

14. To complete the staging of her cancer according


to International Federation of Gynecology and
Obstetrics (FIGO) standards, she should have
which of the following?
(A) lymphangiogram
(B) pelvic venogram
(C) cystoscopy @
(D) magnetic resonance imaging (MRI) scan
of her abdomen
(E) laparoscopy

15. Which of the following is the most important


prognostic factor for 5-year survival after
appropriate treatment of cervical cancer?
(A) presence of high-risk strains of human
papilloma virus (HPV)
(B) stage of the cancer @
DES Entrance Exams

(C) age of the patient


(D) histologic grade of the tumor
(E) presence of positive regional (pelvic)
lymph nodes

16. A 23-year-old married woman consults you


because she and her husband have never consummated
their marriage because she has
severe pain with attempts at vaginal penetration.
Her pelvic examination is normal except
for involuntary tightening of her vaginal muscles
when you attempt to insert a speculum.
Which of the following conditions would best
be treated with the use of vaginal dilators?
(A) primary dysmenorrhea
(B) vaginismus @
(C) deep-thrust dyspareunia
(D) anorgasmia
(E) vulvar vestibulitis

17. If the patient has a placental abruption, which


of the following is the most likely risk factor?
(A) advanced maternal age
(B) low parity
(C) coitus immediately before the onset of
bleeding
(D) hypertension @
(E) a step aerobic class immediately before
the onset of bleeding

18. This patient has an external fetal monitor


placed. Uterine tone seems to be increased, and
there are occasional variable decelerations of
the fetal heart to 90 BPM. Which of the following
is the most appropriate management?
(A) tocolysis with a -receptor agonist
(B) Pitocin induction of labor
(C) continued monitoring of mother and
baby
(D) amniotomy
(E) cesarean section @

Uworld 2011
A 29-year-old woman presents for her first prenatal visit. She is 1 0 weeks pregnant as determined by her last
menstrual period. She does not have any medical problems and does not take any medications. She is
devoutly religious and has been in a monogamous relationship with her husband since getting married 5
years ago. They live in a house built in 1983 where she works as a homemaker. Her husband is an
accountant. She does not smoke cigarettes or drink alcohol. Her physical exam is within normal limits.
Which of the following screening tests is indicated at this time?
A. Rapid plasma reagin test
B. Hepatitis C antibody
C. Serum lead level
D. Red blood cell folic acid level
E. Chlamydia PCR
DES Entrance Exams

Explanation:
It is recommended that all pregnant women be screened for syphilis regardless of risk factors. Screening
should be performed at the first prenatal visit and is typically accomplished via the rapid plasma reagin (RPR)
or venereal disease research laboratory (VORL) test. When the screening test is positive, the diagnosis can
be confirmed with the fluorescent treponema! antibody absorption (FTA-ABS) test. Treatment is with
penicillin.
(Choice B) There is no indication for hepatitis C screening in low-risk adults, pregnant or otherwise. This
patient does not have any obvious risk factors for hepatitis C infection.
(Choice C) The United States Preventive Services Task Force (USPSTF) recommends against testing lead
levels in asymptomatic pregnant women. The incidence of lead toxicity in the United States is low and there
are no studies to suggest that screening and treatment of asymptomatic pregnant women is beneficial.
(Choice D) Folic acid deficiency early in pregnancy is associated with neural tube defects in newborns. The
USPSTF and other organizations recommend that women of child-bearing age eat a diet rich in folic acid
and/or take a folic acid supplement. Routine testing of folic acid levels is not indicated, however.
(Choice E) The USPSTF recommends screening for Chlamydia infection in all women age 24 and younger
and those at increased risk (history of sexual transmitted infections, new or multiple partners). This pregnant
woman is not at increased risk and thus does not require screening.
Educational objective:
Screening for syphilis is strongly recommended in all pregnant women, regardless of their risk factors for
sexually transmitted infections.

A 35-year-old female complains of nipple discharge. The discharge is from both breasts, brown in color and
occurs intermittently. She has two children who are 5 and 8 years old. She has not been recently pregnant.
Her last menstrual period was one week ago. She describes no other symptoms. Examination shows
normal breasts without palpable lumps or nipple abnormalities. Brownish discharge is expressed from the
nipples, and it is guaiac negative Which of the following is the most appropriate next step in management?
A. Mammogram
B. Ultrasonogram
C. Cytologic examination
D. Serum prolactin and TSH levels
E. Surgical evaluation
F. No further workup
Explanation:
The woman's nipple discharge is most consistent with galactorrhea. Galactorrhea presents as bilateral
nipple discharge that is most often milky or clear in color, but can also be yellow, brown, or green. Further
evaluation for the causes of galactorrhea should thus be pursued in this patient via testing of serum prolactin
and TSH levels.
The red flags to watch out for in cases of nipple discharge are unilateral secretion, guaiac positive fluid, and
breast lump. In the case of bilateral guaiac negative discharge, and in the absence of a breast mass,
mammography is not necessary. The patient can be reassured that breast cancer is very unlikely.
Pregnancy, another common cause of bilateral nipple discharge, is unlikely given that the patient had her LMP
one week ago.
(Choice A} Mammography is used both in screening for breast cancer, and in evaluating certain cases of
breast lump or nipple discharge. If this patient had blood or guaiac positive fluid in her nipple discharge, or a
breast lump on exam, mammography would be indicated.
(Choice B) Ultrasonogram is one test that can be used in the evaluation of a breast mass. It is most useful
at discerning fluid-filled masses from solid masses, evaluating the denser breast tissue of younger women,
and in guided biopsies. Ultrasound is not part of the work-up for galactorrhea.
(Choice C) Cytologic examination is indicated in cases of uniductal and guaiac positive nipple discharge. It
allows the pathologist to examine cells from the duct to distinguish carcinoma, proliferative changes, and
inflammatory processes. It is not indicated for guaiac negative discharge.
(Choice E) Surgical evaluation would have been indicated for this patient had her nipple discharge involved
gross blood, tested guaiac positive, or been associated with a breast lump.
(Choice F) Galactorrhea has many potential causes. Depending on the etiology, it can be associated with
infertility and other health issues. Further testing is indicated.
Educational objective:
Galactorrhea presents as guaiac negative bilateral nipple discharge. Prolactinoma, hypothyroidism,
overstimulation of the nipple, oral contraceptive pills, and medications which lower dopamine levels are
DES Entrance Exams

common causes. Workup includes ruling out pregnancy, measuring serum prolactin and TSH levels, and
possible MRI of the brain to rule out prolactinoma.

A 22-year-old woman is being followed by her family physician during her first pregnancy. She is currently at
28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual
intercourse for the past 15 weeks. Her first prenatal exam was at 12 weeks' gestation, at which time her HIV,
chlamydia, gonorrhea, Rh(D)-antibody, and urine cultures were negative. Her blood type is A negative. She
does not know who the father of the child is but is excited to raise the child with the help of her mother. She
is unable to recall or confirm her immunization status for a number of vaccines. Which of the following
measures is warranted at this time?
A. MMR vaccination
B. Urine culture
., C. Rh(D) antibody test
D. HIV antibody test
E. Pneumococcal vaccine
Explanation:
The United States Preventive Services Task Force (USPSTF) strongly recommends Rh-blood typing and
testing for Rh antibodies at the first prenatal visit, as well as repeat Rh antibody testing at 28 weeks' in
unsensitized women with Rh-positive or Rh-unknown partners. This particular patient is Rh-negative and
does not know the father's Rh status; thus, her Rh antibody status should be rechecked at this time.
(Choice A) In pregnant women whose immunization status is unknown or unconfirmed, the physician should
check for rubella immunity. However, the live MMR vaccine is not recommended for pregnant
women. Instead, susceptible individuals should be advised to avoid individuals potentially infected with rubella.
(Choice B) Screening and treatment for asymptomatic bacteriuria between 12 and 16 weeks' gestation
significantly decreases symptomatic urinary tract infections, lower birth weight babies, and preterm
deliveries, and is strongly recommended by the USPSTF. This woman has already been screened and is not
known to have predisposing risk factors for recurrent urinary tract infections like urinary tract anomalies,
sickle cell disease, etc.
(Choice D) The USPSTF strongly recommends that pregnant women be screened for HIV infection at the
first prenatal visit because early initiation of anti-retroviral medications can significantly decrease disease
transmission to the fetus. This patient had a negative test at her first visit and, given her lack of new
exposures, does not need to be rescreened.
(Choice E) It is recommended that pregnant women be vaccinated against influenza but not against
pneumococcus.
Educational objective:
At the first prenatal visit, blood typing and Rh antibody testing (in Rh-negative women) should be
performed. Unsensitized Rh-negative women potentially carrying an Rh-positive fetus should have their Rh
antibody status retested between 24 and 28 weeks' gestation. Patients at risk of alloimmunization should be
given anti-Rh immune globin at 28 weeks and again at the time of delivery.

A 16-year-old girl is brought to your office by her mother for evaluation of primary amenorrhea. Her older
sister had her first period at age 13. Vitals signs are within normal limits. Physical examination shows
absense of breast development and external genitalia at Tanner stage 1 . Examination shows no other
abnormalities. Which of the following is the most appropriate next step in management?
A. Estrogen levels
B. Serum LH levels
C. Serum FSH levels
D. Karyotyping
E. GnRH stimulation test
F. Reassurance
Explanation:
This patient has primary amenorrhea and underdevelopment of secondary sexual characteristics. Isolated
amenorrhea with well-developed secondary sexual characteristics can be considered normal up to the age of 16.
However, if secondary sexual characteristics are absent as with this patient, work-up should not be
delayed. The absence of breast development indicates a lack of estrogen, so measuring estrogen levels
provides no additional information.
Primary amenorrhea can be due to either hypothalamic/pituitary abnormalities (central), or to gonadal
(peripheral) abnormalities. The distinction can be made by measurement of the FSH level (Choice
C). Increased FSH indicates a peripheral cause and decreased FSH indicates a central cause. If
DES Entrance Exams

amenorrhea is of central origin, a GnRH stimulation test is then indicated to detect whether the anomaly is of
hypothalamic or pituitary origin. If amenorrhea is of peripheral origin, karyotyping would be the next step. If
FSH is normal, this establishes the diagnosis of ovarian agenesis or dysgenesis. Measurement of LH has no
diagnostic value.
Educational objective:
In a patient with primary amenorrhea
FSH measurement should be ordered if there is no breast development
GnRH stimulation test is the next step if FSH is decreased
Karyotyping is the next step if FSH is increased

A 20-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling in her
hands and ankles. She has no headache, visual disturbances or epigastric pain. She has no previous
medical problems. She does not use tobacco, alcohol or illicit drugs. Her previous prenatal check-up at
28-weeks gestation was normal. Her medical records show no preexisting hypertension or proteinuria. Her
blood pressure is 156/ 100 mmHg, and after 15 minutes of lateral rest, a repeat reading is 154/98 mmHg.
Physical examination shows 2+ pitting edema in both legs and hands. Deep tendon reflexes are normal.
Fundoscopic examination shows no abnormalities. Fetal heart tones are audible by Doppler. Laboratory
studies show:
Hb
Hct
Platelets
Creatinine
Item 1 of2
13.0 g/dl
50%
300,000/mm3
1.1 mg/dl
Urinalysis shows 1 +proteinuria, which is new Which of the following is the most likely diagnosis?
A Mild preeclampsia
B. Severe preeclampsia
C. Chronic hypertension
D. Transient hypertension of pregnancy
E. Eclampsia
F. Chronic hypertension with superimposed preeclampsia
Explanation:
The patient described has mild preeclampsia. Mild preeclampsia is defined clinically by hypertension greater
than 140/90 mmHg and proteinuria greater than 0.3g/24h (300mg/24h) after the 201h week of
gestation. Dependent and nondependent edema is also commonly present though edema is a common
finding in pregnancy in general.
(Choice B) Severe preeclampsia is characterized by hypertension greater than 160/ 110 mmHg, proteinuria
greater than 5g/24h, oliguria, elevated liver enzymes, thrombocytopenia and possibly pulmonary edema.
(Choices C & F) Chronic hypertension in pregnancy implies hypertension that is not pregnancy induced
such as essential hypertension. It is diagnosed when hypertension exists prior to pregnancy or when it
appears before the 20th week of gestation. If proteinuria appears during the course of pregnancy, the
condition is then called chronic hypertension with superimposed preeclampsia.
(Choice D) Transient hypertension occurs in the second half of pregnancy or during labor and
delivery. Proteinuria may be present but does not exceed 300mg/24hr. If at some point the proteinuria
exceeds 300mg/24hr, the diagnosis of preeclampsia is made.
(Choice E) Eclampsia is defined as the occurrence of grand mal seizures in patients with either mild or
severe preeclampsia.
Educational objective:
Mild preeclampsia is defined clinically by hypertension greater than 140/90 mmHg and proteinuria greater
than 0.3g/24h (300mg/24h) after the 20th week of gestation.

Item 2 of2
Which of the following is the most appropriate initial medication to treat her hypertension and proteinuria?
A Lisinopril
., B. Methyldopa
DES Entrance Exams

C. Furosemide
D. Nitroprusside
E. Verapamil
Explanation:
The most definitive treatment for preeclampsia and eclampsia is delivery of the fetus, but delivery of a fetus at
32 weeks gestation would cause harm to the fetus that is greater than continuing the pregnancy closer to
term. Management in this setting would include monitoring and bed rest as well as an antihypertensive
medication. Methyldopa has a long history of safety in pregnancy and is considered the first-line treatment of
hypertension in pregnancy. Methyldopa functions as a centrally-acting alpha adrenergic agonist thereby
decreasing sympathetic outflow and producing vasodilation.
(Choice A} Lisinopril is an angiotensin converting enzyme (ACE} inhibitor. ACE inhibitors are absolutely
contraindicated in pregnancy as they can cause fetal renal dysgenesis and fetal death.
{Choice C) Furosemide and other diuretics are typically avoided in pregnancy as they can prevent the normal
physiologic intravascular volume expansion that occurs as a normal function of pregnancy.
(Choice D) Nitroprusside is a pregnancy category C agent, but its production of cyanide as a metabolic
byproduct makes it a less favorable option for use in pregnancy.
(Choice E) Verapamil is a calcium channel blocker and is pregnancy category C, meaning its safety in pregnancy
has not yet been established. Of the calcium channel blockers, nifedipine is more commonly used than verapamil
in pregnancy.

Educational objective:
Methyldopa is a pregnancy category B agent and is the first-line medication for treatment of hypertension in pregnancy.

A 17 -year-old female comes to the physician's office for a routine physical examination. She has no
complaints and has no previous medical problems. She has been having sex since the age of 14 and has
had 3 sexual partners so far. Vital signs are stable and physical examination is unremarkable. Pap smear is
performed and the report came back as "satisfactory for evaluation" and shows mild dysplasia (low grade
intraepithelial lesion) Which of the following is the most appropriate next step in management?
A. Repeat Pap smear in 2 weeks
.; B. Repeat Pap smear in 12 months
C. Reflex HPV testing
D. Colposcopy
E. Endometrial curettage
Explanation:
The management of a low-grade squamous epithelial lesion (LSIL) differs based on the age of the patient. In
general, LSIL discovered on cervical cytology indicates the presence of cytologically atypical squamous cells
on the cervix. The atypicality of these cells may be due to HPV infection or cervical intraepithelial neoplasia
( CIN). CIN is graded as type 1 - 3. The majority of LSIL lesions not attributable simply to HPV infection are
CIN 1, which does not require treatment, only observation. Uncommonly, LSIL may be observed in the
setting of CIN 2 or 3, which require treatment. In an adolescent female, the abnormal cervical cells are most
likely due to HPV infection. Because frank cervical cancer in this population is uncommon, the best
management strategy is a follow-up Pap smear in 1 year. Most LSIL lesions in this population will resolve
spontaneously.
(Choice A} Repeat Pap smear in 2 weeks is not a routine method used to follow-up an abnormal Pap smear .
(Choice C) Reflex HPV testing in this population where the incidence of HPV is quite high is not likely to
assist in making or excluding the diagnosis of cervical neoplasia.
(Choice D) Colposcopy is not typically done in adolescents with low-grade lesions as LSIL and ASCUS
lesions tend to resolve spontaneously in the overwhelming majority of cases. The patient should, however,
be monitored for this resolution or a progression of her lesion with a repeat Pap smear in one year.
(Choice E) Endometrial curettage is a diagnostic test used in making the diagnosis of endometrial
cancer. Endocervical curettage is used to obtain tissue for histologic examination following an abnormal Pap
smear when a colposcopy is indicated and a lesion can not be identified or when atypical glandular lesions
are identified.
Educational objective:
In adolescent females, ASCUS or LSIL cervical lesions are most likely due to HPV infection. Because frank
cervical cancer in this population is uncommon, the best management strategy is a follow-up Pap smear in 1 year.

A 57 -year-old woman comes to the physician's office for evaluation of vaginal dryness, burning and
DES Entrance Exams

dyspareunia. She also has dysuria and increased urinary frequency. The symptoms have been present for
several months but have intensified recently. She has tried over-the-counter lubricants with little relief. Her
last menstrual period was seven years ago. She takes hydrochlorothiazide for hypertension and pravastatin
for hypercholesterolemia. Physical examination shows scarce pubic hair and reduced elasticity and turgor of
the vulvar skin. Pale, dry and smooth vaginal epithelium is noted. Urine dipstick is normal. Which of the
following is the most appropriate next step in management?
A. Ciprofloxacin for one week
B. Metronidazole for one week
C. Discontinue hydrochlorothiazide
D. Vaginal estrogen replacement
E. High-potency corticosteroid cream
Explanation:
Atrophic vaginitis is a clinical diagnosis made based on history and physical exam findings. Typical
symptoms include vaginal dryness, pruritus, dyspareunia, dysuria, and urinary frequency. Pelvic exam in
atrophic vaginitis is characterized by pale, dry and smooth vaginal epithelium, scarce pubic hair, and loss of the labial fat
pad. This condition occurs in post-menopausal females as a result of decreased estrogen
levels. This patient's history and physical are typical of atrophic vaginitis. Many symptoms of atrophic
vaginitis can also be seen in urinary tract infection (UTI). This patient's urine dipstick rules out UTI, and
therefore it is appropriate to proceed with treatment for atrophic vaginitis. Use of moisturizers and lubricants is an
appropriate first step in management of mild atrophic vaginitis; for moderate to severe cases the firstline treatment is
local low-dose vaginal estrogen therapy (Choice D).
(Choice A) Ciprofloxacin is an appropriate treatment for UTI. Many of this patient's symptoms (burning,
dysuria, and urinary frequency) can be seen in UTI. However, her urine dipstick is negative, making atrophic
vaginitis the most likely diagnosis.
(Choice B) Metronidazole is appropriate for the treatment of Trichomonas. This patient's exam does not
show findings consistent with trichomonas, and her history is more consistent with atrophic vaginitis.
{Choice C) Discontinuation of hydrochlorothiazide will not ameliorate the symptoms of atrophic vaginitis.
{Choice E) Steroids have no role in the management of atrophic vaginitis, but high-potency corticosteroid
cream is used in the management of vulvar lichen planus and lichen sclerosus. While these conditions may
present with some of the symptoms seen in this patient, her physical exam findings and post-menopausal
status are most consistent with atrophic vaginitis.
Educational objective:
Suspect atrophic vaginitis in post-menopausal females with symptoms of vaginal dryness and dysuria, and
physical exam findings of pale, dry vaginal mucosa, diminished labial fat pad, and scarce pubic
hair. Moderate and severe cases require local estrogen therapy.
A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit. According to her history, she is at
18-weeks gestation. Her family history is significant for Down syndrome on her maternal side. She does not
use tobacco, alcohol or drugs. Vital signs are normal, and physical examination is unremarkable. Initial
laboratory studies show a decreased maternal serum alpha-fetoprotein (MSAFP). Which of the following is
the most appropriate next step in management?
A. Amniocentesis
B. Chorionic villus sampling
C. Ultrasonogram
D. Cordocentesis
E. Urinary estradiol levels
Explanation:
Alpha-fetoprotein (AFP) measurement can be used to screen for fetal anomalies. Increased levels are seen
in the presence of neural tube defects, abdominal wall defects (gastroschisis, omphalocele), multiple
gestation and inaccurate gestational age. Low levels of MSAFP can be associated with chromosomal
anomalies, such as Down syndrome and trisomy 18, and inaccurate gestational dates. Ultrasonography
should first be performed in the patient described to rule out inaccurate dates. Other tests can be done after
the dates have been confirmed by an ultrasound.
(Choice A) Amniocentesis is indicated in cases where the MSAFP or triple/quadruple screen is abnormal,
but only after ultrasonography has ascertained gestational age accuracy and ruled out nonviable pregnancy
or multiple gestation. It is best performed between 16 and 20 weeks gestation.
(Choic e B) Chorionic villus sampling is indicated for early screening in women with known genetic diseases
or who have had children affected by a genetic condition. It is performed between 1 0 and 12 weeks
gestation, and therefore offers the advantage of a first trimester termination of pregnancy if the fetus is
affected.
DES Entrance Exams

(Choice D) Cordocentesis is used for rapid karyotype analysis, or when fetal blood dyscrasias, such as fetal
anemia and Rhesus isoimmunization, are suspected. In the present case, ultrasound should be performed
first to rule out causes of MSAFP elevation other than genetic anomalies.
(Choice E) An estradiol level has no clinical value in pregnancy. Serum estriol levels can be measured in
pregnancy along with MSAFP and beta-hCG (triple test) as a screening tool for chromosomal anomalies in
the fetus.
Educational objective:
If maternal serum alpha- fetoprotein (MSAFP) levels are abnormal in a pregnant patient, the next step is
ultrasonography to confirm gestational age, detect fetal structural anomalies, detect multiple gestation and
confirm a viable pregnancy.

A 24-year-old woman presents to your office with a self-palpated breast lump. She discovered the mass 2
days ago while taking a shower and noted that it is mildly tender. Her menstrual periods are regular, occurring
every 26 days. Her last menstrual period (LMP) was 3 weeks ago. Her past medical history is insignificant.
She has no family history of breast cancer. Physical examination reveals a lump in the superior outer
quadrant of the right breast without palpable lymphadenopathy. Which of the following is the most reasonable
next step in the management of this patient?
v A. Ask her to return shortly after the menstrual period
B. Order mammography
C. Proceed with fine needle aspiration biopsy
D. Suggest excisional biopsy
E. Reassure that the mass is benign and no follow-up is necessary
Explanation:
A self-palpated breast mass is a very common clinical presentation of various benign and malignant breast
diseases. Unfortunately, it is usually very difficult to differentiate a benign breast mass from cancer by history
and physical examination. Further work-up is frequently necessary (choice E).
A young woman who presents with a breast lump can be asked to return after her menstrual period for
reexamination if no obvious signs of malignancy are present. If the mass decreases in size after the
menstrual period, the probability of a benign disease is very high. Otherwise, it is advisable to proceed with
ultrasonography, fine needle aspiration biopsy (choice C) and/or excisional biopsy (choice 0}.
Mammography is usually not helpful in interpreting the mass because the density of breast tissue is high in
young women (choice B). A 24-year-old woman presents to your office with a self-palpated breast lump. She discovered
the mass 2
days ago while taking a shower and noted that it is mildly tender. Her menstrual periods are regular, occurring
every 26 days. Her last menstrual period (LMP) was 3 weeks ago. Her past medical history is insignificant.
She has no family history of breast cancer. Physical examination reveals a lump in the superior outer
quadrant of the right breast without palpable lymphadenopathy. Which of the following is the most reasonable
next step in the management of this patient?
v A. Ask her to return shortly after the menstrual period
B. Order mammography
C. Proceed with fine needle aspiration biopsy
D. Suggest excisional biopsy
E. Reassure that the mass is benign and no follow-up is necessary
Explanation:
A self-palpated breast mass is a very common clinical presentation of various benign and malignant breast
diseases. Unfortunately, it is usually very difficult to differentiate a benign breast mass from cancer by history
and physical examination. Further work-up is frequently necessary (choice E).
A young woman who presents with a breast lump can be asked to return after her menstrual period for
reexamination if no obvious signs of malignancy are present. If the mass decreases in size after the
menstrual period, the probability of a benign disease is very high. Otherwise, it is advisable to proceed with
ultrasonography, fine needle aspiration biopsy (choice C) and/or excisional biopsy (choice 0}.
Mammography is usually not helpful in interpreting the mass because the density of breast tissue is high in
young women (choice B).

Educational Objective:
A young woman who presents with a breast lump can be asked to return after her menstrual period for
reexamination (which may reveal regression of the mass) if no obvious signs of malignancy are present.
DES Entrance Exams

A 76-year-old woman presents with complaints of severe vulvar itching for the past six months. She has tried
over-the-counter topical lubricants without relief. Physical examination reveals numerous vulvar
excoriations. The vulvar skin is thin, dry and white in color. The labia minora are difficult to visualize.
Item 1 of2
Which of the following is the most appropriate next step in management?
A. Vaginal Pap smear
B. Vulvar punch biopsy
C. Radical vulvectomy
D. Estrogen cream
E. Wet mount smear
Explan ation:
Lichen sclerosus (lichen sclerosus et atrophicus, LS&A) is a chronic inflammatory condition of the anogenital region that
most commonly affects women. This condition may have an autoimmune pathogenesis. It is characterized clinically by
anogenital discomfort including pruritus, dyspareunia, dysuria and painful defecation. Physical examination reveals
porcelain-white polygonal macules and patches with an atrophic, "cigarette paper" quality. Sclerosus and scarring can
lead to obliteration of the labia minora and clitoris and a decrease in the diameter of the introitus. While the diagnosis can
readily be made clinically, vulvar squamous cell carcinoma (SCC) occurs more commonly in women with LS&A. When
the diagnosis is in question, punch biopsy of any suspicious lesions should be performed.

{Choice A) Vaginal Pap smear can be utilized to assess for intravaginal malignancies.
{Choice C) Radical vulvectomy is reserved for the treatment of high-risk vulvar malignancies.
{Choice D) Estrogen cream is helpful in the treatment of menopause-related atrophic vaginitis, which can also be
a cause of vaginal pruritus and dyspareunia.
{Choice E) Wet mount smear is useful in making the diagnosis of bacterial vaginosis, trichomoniasis or vaginal
candidiasis.

Educational objective:
Lichen sclerosus most commonly affects postmenopausal women and manifests with vulvar pruritus and
discomfort. Exam shows porcelain-white atrophy. Biopsy should be considered to rule out vulvar SCC.

Item 2 of2
A diagnosis of lichen sclerosus is made. Which of the following is the most appropriate next step in
management?
A. Radical vulvectomy
B. Topical corticosteroid
C. Topical estrogen
D. Cryotherapy
E. Topical clotrimazole
Explanation:
Lichen sclerosus (lichen sclerosus et atrophicus, LS&A) is a chronic inflammatory condition of the anogenital region that
most commonly affects women. LS&A is considered a premalignant lesion of the vulva as vulvar squamous cell
carcinoma (SCC) occurs with greater frequency in these patients as compared to the generalpopulation. As such,
surveillance with regular clinical examinations and biopsies of suspicious lesions is necessary. LS&A is one of the few
conditions for which use of high-potency topical steroids on the genitals is encouraged. A class I topical corticosteroid in
ointment form should be applied twice daily for four weeks, at which point transition to a less potent topical steroid or
topical calcineurin inhibitor for maintenance therapy is appropriate.

(Choice A) Radical vulvectomy is reserved for the treatment of high-risk vulvar malignancies such as
invasive squamous cell carcinoma or melanoma. Less disfiguring procedures can be used for basal cell
carcinomas and smaller squamous cell carcinomas.
(Choice C) Estrogen cream is helpful in the treatment of menopause-related atrophic vaginitis, which can
also be a cause of vaginal pruritus and dyspareunia.
(Choice D) Cryotherapy is commonly utilized to treat genital warts.
(Choice E) Clotrimazole cream is useful in the treatment of vaginal candidiasis.
Educational objective:
High-potency topical steroids are considered first-line therapy for lichen sclerosus.

A 30-year-old G2 P 1 woman at 38 weeks gestation presents to the hospital complaining of regular and painful
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uterine contractions that started two hours earlier. Pelvic examination reveals bulging membranes, and her
cervix is 50% effaced and dilated to 3 em. Her pregnancy was complicated by first trimester hemorrhage of
unknown cause. Her past medical history is unremarkable. After placing a fetal heart monitor and an
external tocometer on the patient, you note 3 separate 15 beat/min decreases in the fetal heart rate not
coinciding with uterine contractions, each lasting for 25 seconds. Which of the following is the most
appropriate next step in the management of this patient?
A. Oxygen administration and change in maternal position
B. Artificial rupture of membranes
C. Amnioinfusion
D. F eta I scalp pH testing
E. Emergent cesarean section
Explanation:
Variable decelerations represent a non-reassuring fetal heart rate (FHR) pattern, and are characterized by the erratic onset
of abrupt slowing of the FHR in association with uterine contractions. They are the most
commonly encountered FHR deceleration seen in pregnancy, and are thought to be the result of umbilical
cord compression. Variable decelerations usually occur during the onset of uterine contractions. Mild or
moderate variable decelerations are of short duration, shallow, and are associated with a rapid return to
baseline FHR. Persistent decelerations to less than 70 beats/min and of long duration are concerning for
fetal hypoxia. The first step in the presence of variable decelerations is to administer oxygen and have the mother change
her position so that she is lying on her side. If the variable decelerations persist, the patient should be placed in the
Trendelenburg position and the presenting fetal part should be elevated. Persistent variable decelerations may require
amnioinfusion, which consists of the infusion of fluid into the amniotic cavity.
(Choice B) Rupture of the membranes will result in the loss of amniotic fluid and may worsen fetal cord
compression.

(Choice C) Amnioinfusion may be indicated if persistent variable decelerations are present, but should be
used only after more conservative measures have failed.
(Choice D) Fetal scalp pH testing should be performed to assess for fetal hypoxia if the abnormal FHR
pattern persists after the initial measures of position change, oxygen administration, and discontinuation of
oxytocin have been tried.
(Choice E) Cesarean section is indicated when fetal distress is confirmed. The patient in this case has had
only three decelerations, and more conservative measures should be attempted first.
Educational objective:
The most appropriate first steps in the management of variable decelerations are oxygen administration and
change in maternal position.

A 15-year-old girl is being evaluated for primary amenorrhea. She is otherwise healthy and has no previous
medical problems. Vital signs are within normal limits. Physical examination reveals normal breast
development, normal pubic and axillary hair, and a blind vagina; the uterus and adnexae could not be
appreciated. Pelvic ultrasonography reveals 2 ovaries and no uterus is seen. The karyotype is 46
XX. Which of the following is the most likely diagnosis?
A. Mullerian agenesis
B. Androgen insensitivity
C. 5-alpha-reductase deficiency
D. Imperforate hymen
E. Turner's syndrome
Explanation:
This patient has a female phenotype but lacks a normal vagina and uterus, which narrows the etiology of her primary
amenorrhea to mullerian agenesis, androgen insensitivity, or 5-alpha-reductase deficiency. The
karyotype is the determining test, with both androgen insensitivity and 5-alpha-reductase deficiency being
seen in patients with a )('( genotype. This patient's genotype is XX, which leaves mullerian agenesis as the
best explanation for her condition. The mullerian duct normally leads to the development of the proximal
vagina and the uterus; therefore patients with mullerian agenesis normally have a blind ended vagina with little to no
uterine tissue.
{Choice B) Patients with androgen insensitivity have a male)('( genotype but there is an abnormality in the
androgen receptor. The external genitalia develop as female, but mullerian inhibiting factor is still secreted by the testes
which prevents the development of internal female organs.
{Choice C) Patients with 5-alpha-reductase deficiency cannot convert testosterone to the more potent
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dihydrotestosterone {DHT). They have a male )('( genotype and female external genitalia, but typically show virilization
at puberty.
(Choice D) An imperforate hymen can cause primary amenorrhea but can generally be distinguished from
mullerian agenesis by the distal location of the vaginal blockage. Patients have a normal uterus on ultrasound.
(Choice E) Patients with Turner's syndrome have a XO genotype and do not have normal ovaries on
ultrasound.
Educational objective:
Patients with mullerian agenesis have a blind ended vaginal pouch with little or no uterine tissue and a XX
genotype.

A 24-year-old woman delivered a healthy baby by vaginal delivery at 36 weeks gestation. She had a
prolonged premature rupture of the membranes, and mid forceps application was required during
delivery. On the second postpartum day she complained of fever and chills. She cannot breast-feed
because her "nipples are tender". Her temperature is 38.5C (101 .3F), blood pressure is 120/55 mmHg and
pulse is 92/min. Bimanual examination shows tender uterus and foul-smelling lochia. Her nipples are
cracked but without surrounding erythema or warmth. Physical examination otherwise shows no
abnormalities.
Item 1 of3
Which of the following is the most likely diagnosis?
A. Normal postpartum
B. Puerperal mastitis
v C. Endometritis
D. Deep venous thrombosis
E. Aspiration pneumonia
Explan ation:
The patient described is experiencing postpartum endometritis. A puerperal infection should be suspected if
a woman experiences a fever greater than 38 C ( 1 DO .4 F) outside of the first 24 hours postpartum. Risk
factors for endometritis include, but are not limited to prolonged rupture of the membranes (> 24 hours),
prolonged labor (> 12 hours), cesarean section and use of intrauterine pressure catheters or fetal scalp
electrodes. This patient has at least two of these risk factors. Clinically, endometritis is characterized by
fever, uterine tenderness, foul smelling lochia and leukocytosis. Broad spectrum antibiotics are required to
treat this typically polymicrobial infection.

(Choice A) While the normal postpartum period is associated with persistent vaginal discharge (lochia), this
discharge should steadily resolve over the first two weeks and should never be foul-smelling.
(Choice B) Puerperal mastitis occurs in breastfeeding mothers and can begin with a sore or fissured nipple,
but this diagnosis would be unlikely this soon after delivery.
(Choices D & E) Deep venous thrombosis and aspiration pneumonia would be associated with physical
examination findings consistent with each of these diagnoses. The physical examination in this patient is normal
other than the abnormalities such as uterine tenderness and foul-smelling lochia that indicate a puerperal
infection rather than one of these conditions.

Educational objective:
Endometritis is characterized clinically be fever and uterine tenderness in the postpartum period and is often
associated with foul-smelling lochia. Risk factors include prolonged ROM, prolonged labor, operative vaginal
delivery and caesarian section among others.

Item 2 of3
Which of the following pathogens is most likely responsible for this patient's current condition?
A Chlamydia trachomatis
B. Group B Streptococcus
C. Neisseria gonorrhea
D. Staphylococcus aureus
E. Polymicrobial infection
Explanation:
This patient has postpartum endometritis. Endometritis is the most common cause of puerperal fever on the
2nd and 3rd day postpartum. Endometritis is a polymicrobial infection caused by a combination of gram
positive and gram negative organisms, aerobic and anaerobic organisms and occasionally other organisms
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such as Mycoplasma and Chlamydia.


(Choice A} Chlamydia trachomatis is a common cause of pelvic inflammatory disease in nonpregnant
women, and can uncommonly cause postpartum endometritis. Postpartum endometritis due to Chlamydia often
occurs many days following delivery, not in the first 48 - 72 hours.
(Choice B) Group B Streptococcus is a potential cause of both postpartum endometritis and neonatal
sepsis. Women are often screened for this organism and treated if colonized before delivery. Despite this
screening, GBS can be isolated along with other organisms in approximately one-third of cases of
postpartum endometritis.
(Choice C) Neisseria gonorrhea is one gram-negative organism that can be associated with postpartum
endometritis. It occurs in less than 1 0% of cases.
(Choice D) Staphylococcus aureus is not commonly isolated in cultures from women with
endometritis. Staphylococcus epidermidis, however, can often be recovered as part of a polymicrobial infection in
such women.

Educational objective:
Postpartum endometritis is most commonly a polymicrobial infection composed of gram positive and gram
negative organisms, aerobic and anaerobic organisms and occasionally other organisms.

ltem3 of3
Which of the following is the most appropriate initial therapy for this patient?
A. Vancomycin and gentamicin
B. Clindamycin and metronidazole
C. Vancomycin and clindamycin
D. Clindamycin and gentamicin
E. Ceftriaxone and azithromycin
Explanation:
Endometritis is a polymicrobial infection caused by a combination of gram positive and gram negative organisms,
aerobic and anaerobic organisms and occasionally other organisms such as Mycoplasma and Chlamydia.
Commonly isolated organisms include group B streptococci, group D streptococci, Staphylococcus epidermidis,
Escherichia coli, Neisseria gonorrhoeae, Gardnerel/a vagina/is, Bacteroides fragilis, peptostreptococci and peptococci.
Given the polymicrobial nature of postpartum endometrial infections, the most appropriate therapy is intravenous
clindamycin combined with an intravenous aminoglycoside such as gentamicin.
(Choice A) Vancomycin is only effective against gram-positive organisms and gentamicin provides excellent gram-
negative coverage, but this regimen would not be as effective against anaerobic organisms.
(Choice B) Clindamycin and metronidazole are both active against anaerobic organisms but would not be
effective in eliminating gram-negative aerobic organisms.
(Choice C) Vancomycin and clindamycin would not provide adequate coverage of gram-negative aerobic
organisms.
(Choice E) Ceftriaxone and azithromycin is the treatment of choice for pelvic inflammatory disease. The
cephalosporin treats N. gonorrhoeae while the macrolide treats C. trachomatis.

Educational objective:
The treatment of choice for postpartum endometritis, which is a polymicrobial infection, is intravenous
clindamycin and gentamicin.

A 30-year-old woman, gravida 2, para 1 , at 37 weeks gestation is brought to the emergency department
because of acute onset intense uterine contractions and vaginal bleeding. She has been followed closely for
pre-eclampsia since her 32nd week of gestation. Her temperature is 37.0 C (98.7F), blood pressure is
140/86mmHg, pulse is 92/min and respirations are 18/min. Physical examination shows uterine tenderness
and hyperactivity and moderate vaginal bleeding. Pelvic examination shows an effaced and 3cm dilated
cervix. Ultrasonography shows a fundic placenta and a fetus in the cephalic position. F eta I heart tracing
shows 140/min with good long-term and beat-to-beat variability. After initial resuscitation the bleeding is
stopped Which of the following is the most appropriate next step in management?
..; A. Vaginal delivery with augmentation of labor, if necessary
B. Emergency cesarean section
C. Perform tocolysis and schedule cesarean section within 48 hours
D. Forceps delivery
E. Conservative management at home
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Explanation:
According to the clinical signs and the associated pre-eclampsia, the patient most likely has a placental
abruption. Ultrasonography detects only 25% of cases of abruption, and it is more useful in ruling out
placenta previa than in diagnosing abruption. Placental abruption is a condition that can progress rapidly; so
careful monitoring of both the mother and the fetus is mandatory. Once the diagnosis is made, a large-bore
IV line as well as a Foley catheter must be placed. Blood products should always be available. Patients with
placental abruption in labor must be managed aggressively to insure a rapid vaginal delivery because this will
remove the retroplacental hemorrhage which acts as the impetus for DIC and hemorrhage in the setting of
placental abruption. Cesarean section is used only when there are obstetric indications for that procedure or
when there is a rapid deterioration of the state of either the mother or the fetus. In this case, the patient is
stable, the fetus is at term and doing well, and labor has already started (presence of cervical changes), so a
vaginal delivery can be attempted and oxytocin can be used to augment labor.
(Choices B & C) Cesarean section is indicated if the mother and/or the fetus are not stable, and the risk of
serious complications is imminent, or in the case of obstetrical contraindications to vaginal delivery (placenta
previa, dystocia, breech presentation, prior caesarian). Furthermore, delivery in this case should be
expedited; there is no reason to perform tocolysis.
(Choice D) Forceps can be used ifthere is dystocia, but the cervix is only 3 em dilated and it is too early to
know whether the forceps will be necessary or not.
(Choice E) Because the fetus is at term and labor is progressing, there is no reason to wait. Additionally,
because of the maternal and fetal mortality associated with placental abruption, the patient described must be
managed immediately.

Educational objective:
Patients with placental abruption in labor must be managed aggressively to insure a rapid vaginal
delivery. Cesarean section is used only when there are obstetric indications, or when there is a rapid
deterioration of the state of either the mother or the fetus and labor is in an early stage.

A 20-year-old, G 1 PO, woman at 35 weeks gestation comes to the hospital because of regular uterine
contractions and passage of clear fluid per vagina. She has no other symptoms. Her pregnancy thus far has
been uncomplicated Her temperature is 38.2 C ( 1 DO. 7 F), blood pressure is 120/68 mmHg, pulse is 11 0/min
and respirations are 17/min. Speculum examination shows a closed cervix and clear fluid pooling in the
vaginal fornix. The pH of the fluid is 7.5. F eta I heart monitoring shows a rate of 165/min and uterine
contractions occurring every 3-4 minutes. Initial laboratory studies show:
Hemoglobin 10.2 g/L
Platelets 198 ,OOO/mm3
Leukocyte count 18 ,500/mm3
Neutrophils 86%
Lymphocytes 14%
Item 1 of2
Which of the following is the most likely diagnosis?
A. Abruptio placenta
B. lntraamniotic infection
C. Urinary tract infection
D. Trichomonas vaginitis
E. Normal labor
Expl anation:
The patient described has experienced spontaneous premature rupture of the membranes (PROM), which is
defined as a rupture of the amniotic membranes before 37 weeks of gestation but with the onset of labor, as
evidenced by her regular uterine contractions. Normal amniotic fluid pH is 7.0 to 7.5, while normal vaginal pH
is 4.5 to 5.5, so the more neutral pH of the fluid described in this patient indicates it is of amniotic origin. One
of the risks associated with PPROM is intraamniotic infection. lntraamniotic infection ( chorioamnionitis)
should be suspected in mothers presenting with prolonged or premature rupture of the membranes, fever
and any one of the following findings: maternal tachycardia (> 1 DO/min), fetal tachycardia (> 160/min),
maternal leukocytosis (> 15,000/mm3), uterine tenderness or foul-smellinq amniotic fluid.
(Choice A) Abruptio placenta commonly presents with bleeding from the vagina; though, a subset of
placental abruptions is concealed and does not cause clinical bleeding. Abdominal or back pain, uterine
tenderness and abnormal uterine contractions are typical. F eta I distress due to poor placental perfusion may
be evident.
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(Choice C) A urinary tract infection may cause leukocytosis if the infection was ascending. Dysuria would
likely be present and fetal tachycardia would not be expected.
(Choice D) Trichomonas vaginitis is not associated with obstetric complications other than a possible
association with early labor.
(Choice E) Maternal leukocytosis (>15,000/cmm) with fever and fetal tachycardia are not components of
normal labor.
Educational objective:
lntraamniotic infection should be suspected in the setting of prolonged or premature rupture of the
membranes when maternal fever, leukocytosis, uterine tenderness or tachycardia is detected. Fetal
tachycardia is another feature of chorioamnionitis.
Item 2 of2
Which of the following is the most appropriate next step in management?
A. Administer tocolytics
B. Betamethasone
C. Cesarean section
D. Immediate induction
E. Expectant management
Explanation:
The patient described has experienced spontaneous preterm rupture of the membranes (PROM) that has
been complicated by an intraamniotic infection ( chorioamnionitis). The most important first intervention is
treatment of the mother with broad spectrum antibiotics as chorioamnionitis is frequently a polymicrobial
infection. The preferred regimen includes a combination of intravenous clindamycin and
gentamicin. Concomitantly with the administration of antibiotics, delivery of the fetus should be expedited as
the fetus in question is near term (35 weeks gestation) and the amniotic membrane has ruptured. The most
appropriate means of expediting labor in this case would be administration of oxytocin as the patient is
already experiencing regular uterine contractions and appears to be in the first stage of labor.
(Choice A) Tocolysis would be contraindicated in this setting.
(Choice B) Betamethasone administered in an effort to improve fetal lung maturity would have little benefit
beyond 32-34 weeks gestational age.
(Choice C) While delivery should be expedited in this case, caesarean section should be reserved for cases
where fetal distress is evident. F eta I tachycardia is a sign of maternal infection.
(Choice E) Expectant management may be attempted if a fetus is not yet viable provided antibiotic therapy is
successful in eradicating the infection. Once the membranes have ruptured, however, delivery typically
follows.

Educational objective:
The most appropriate treatment of chorioamnionitis associated with premature rupture of the membranes is
systemic, broad-spectrum antibiotic therapy and expedited delivery of the fetus.

A 23-year-old G 1 PO female presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at
that time and a high grade squamous intraepitheliallesions (HSIL) is seen at cytology. A test for HPV
discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no
site of abnormalities. At this time the next best step is:
A. Loop electrosurgical excision procedure (LEEP)
B. Repeat pap smear 12 months
C. Termination of pregnancy
D. Repeat colposcopy after delivery
E. Endocervical curettage
Explanation:
During pregnancy the primary goal of colposcopy is the exclusion of invasive cervical cancer. The
management of any woman with a cytologic specimen suggesting HSIL consists of colposcopy and directed
biopsy. Among women with HSIL cytology results, 1-2% harbor invasive cancer. The patient also has the
presence of an oncogenic strain of HPV and is therefore considered an especially high risk patient. If the
initial biopsy is negative, a repeat colposcopy and biopsy should be done at 6-8 weeks after delivery.
(Choice A) LEEP procedure is an excisional therapy and is recommended for all patients except adolescents
and pregnant woman with HSIL on Pap smear but without CIN II or greater on biopsy since the abnormal area
may have been missed by the biopsy. Excisions in pregnant women should be considered only if a lesion
suggestive of invasive cancer is detected at colposcopy.
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(Choice B) Repeating the Pap smear will not change management of the patient; a repeat colposcopy is still
required after delivery.
(Choice C) There is no indication for termination of pregnancy with an abnormal pap smear.
(Choice E) Endocervical curettage is contraindicated in pregnant patients.
Educational objective:
During pregnancy, the primary goal of colposcopy is the exclusion of invasive cancer. Any woman with a
cytologic specimen suggesting HSIL should undergo colposcopy and directed biopsy. If the biopsy is
negative, a second biopsy is recommended 6-8 weeks after delivery.
A 25-year-old primiparous woman comes to your office 12 weeks after vaginal delivery of a healthy female
baby. She has not had a menstrual period since delivery. She is nursing, and is using barrier methods for
contraception. Examination shows no abnormalities. Which of the following is the most likely mechanism for
this patient's amenorrhea?
A. Inhibitory effect on FSH and LH by placental estrogens
B. Inhibitory effect on GnRH by prolactin
C. Suppression of endometrial proliferation by oxytocin
D. Suppression of ovulation by human placental lactogen
E. Physiologic postpartum endometrial atrophy
Explanation:
The amenorrhea that occurs in lactating mothers is the result of high levels of circulating prolactin, which
have an inhibitory effect on the production of the hypothalamic hormone GnRH. Pulsatile GnRH release from the
hypothalamus is necessary for the production and release of LH and FSH by the anterior pituitary. LH and FSH are
required to induce ovulation; menses do not occur when ovulation is suppressed in this
manner. Because lactation suppresses ovulation, it is used as a contraceptive method, but it is not
considered a reliable method of birth control. In fact, 50% of nursing mothers ovulate within 6 to 12 months of delivery.
(Choice A} Placental estrogens inhibit gonadotropin secretion during pregnancy, but as soon as the placenta is evacuated
their levels quickly drop.
(Choice C) Oxytocin has no effect on the endometrium. It has an effect on the uterine muscle and plays an
important role in uterine involution in the postpartum period. Oxytocin levels are elevated during lactation as this
hormone also stimulates the expulsion of milk from the lactiferous glands.
(Choice D) Human placental lactogen (hPL) is produced by the placenta, and serum levels quickly decrease
after delivery of the placenta. hPL has an insulin antagonist effect and plays an important role in nutrition of the fetus by
causing maternal lipolysis and insulin resistance thus increasing delivery of fatty acids and
glucose to the fetus.
(Choice E) There is no physiologic endometrial atrophy in the postpartum period. The endometrium
proliferates normally as soon as estrogen levels rise and the first ovulation occurs.
Educational obj ective:
Elevated prolactin levels suppress GnRH release thereby suppressing LH and FSH production and
ovulation. This is the reason for anovulation and amenorrhea in lactating mothers.
A 20-year old GOPO woman presents to the emergency room with complaints of vaginal bleeding and right
lower quadrant pain. Her last menstrual period was approximately 5 weeks ago. She is sexually active and
uses condoms occasionally. Her temperature is 37.2 C (98.9 F), blood pressure is 120/74 mm Hg, pulse is
80/min and respirations are 14/min. Examination shows mild right lower quadrant tenderness, but no
rebound or guarding. There is no active vaginal bleeding and the cervical os is closed. Her initial hemoglobin
is 11 .0 g/dl. She is Rh positive and a quantitative 13-HCG is 1000 miU/mL. A vaginal ultrasound is done and
no intrauterine or extrauterine pregnancy can be seen. Which of the following is next best step in
management?
A. Consent for laparoscopy
B. Methotrexate administration
C. Repeat 13-HCG in 48 hours
D. Administration of anti-0 immune globulin
E. Consent for dilatation and curettage
Explanation:
This patient has a positive pregnancy test but no evidence of an intrauterine or extrauterine pregnancy. The
differential includes early viable intrauterine pregnancy, ectopic pregnancy, or nonviable intrauterine
pregnancy (completed abortion). Serial 13-HCG levels are usually required when the results of the initial
ultrasonography examination are indeterminate. 13-HCG should generally double about every 48 hours in
viable pregnancies, but increases at a slower rate in ectopic and nonviable intrauterine pregnancies. An
intrauterine pregnancy should be seen with transvaginal ultrasonography at levels from 1 ,500-2,000
miU/mL. One would not expect to see an intrauterine pregnancy with a 13-HCG level of 1 ,000 miU/mL. The patient is
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currently hemodynamically stable, with a nonsurgical abdomen. It is safe in her case to repeat the 13-HCG levels in 48
hours. Once the 13-HCG level is above 1500 miU/mL a repeat transvaginal ultrasound should be performed.
(Choice A) Even though laparoscopy is the gold standard for the diagnosis of an ectopic pregnancy, it is
rarely required for diagnostic purposes as 13-HCG and transvaginal ultrasound are usually sufficient for
diagnosis.
(Choice B) Methotrexate is sometimes used for the medical management of a nonruptured ectopic
pregnancy, but the diagnosis must first be confirmed because it is still possible that this patient has a viable
intrauterine pregnancy.
{Choice D) Anti-0 immune globulin (RhoGAM) is used in Rh negative patients to prevent hemolytic disease of the
newborn in future pregnancies. This patient is Rh factor positive and therefore does not warrant Anti-0 immune globulin.
(Choice E) Dilatation and curettage is performed when the pregnancy has been confirmed to be nonviable
via serial 13-hCG measurements and the location of the pregnancy cannot be determined by
ultrasonography. This decision must be made with caution so as not to interrupt a viable intrauterine
pregnancy. It is essential to confirm the presence of trophoblastic tissue in the specimen.
Educational objective:
An intrauterine pregnancy should be seen with transvaginal ultrasonography at 13-HCG levels of 1 ,500-2,000 miU/mL.
If the level is < 1 ,000 miU/ml, both 13-HCG and transvaginal ultrasonography should be repeated in 2-3 days.

A 28-year-old primigravid woman comes to the physician for a follow-up prenatal visit. According to prenatal
records, ultrasound at 16 weeks gestation showed an intrauterine gestation consistent with dates and
showed no abnormalities. She is now at 40 weeks gestation. Examination shows a fundal height consistent
with dates and the cervix is not favorable. F eta I heart tracing is reassuring. She wishes to continue the
pregnancy for two more weeks rather than undergoing induction. She should be closely monitored for which
of the following?
A. Polyhydramnios
.; B. Oligohydramnios
C. Abruptio placenta
D. Placenta previa
E. Preeclampsia
Explanation:
Prolonged (postterm) pregnancy is defined as any pregnancy at or beyond 4 2 weeks gestational age
measured form the last menstrual period. Postterm pregnancy can be managed with either induction of labor
or close twice weekly assessment of fetal well being. Patients with an unfavorable cervix are typically
managed expectantly while those with a favorable cervix are managed with induction. Biweekly monitoring with
ultrasonography is required to evaluate for oligohydramnios in postterm pregnancies because amniotic fluid can become
drastically reduced within 24 to 48 hours. Oligohydramnios in these cases is defined as no vertical pocket of amniotic
fluid greater than 2 em or an amniotic fluid index of 5 em or less.
(Choice A) Polyhydramnios is associated with congenital fetal malformations. The most commonly
associated malformations are those of the Gl tract and CNS.
(Choice C) Risk factors for abruptio placenta include uncontrolled maternal hypertension, maternal cocaine
use and a history of prior episodes of placental abruption.
(Choice D) Risk factors for placenta previa include advancing maternal age, multiparity, multiple gestations, smoking
and prior caesarian section.
(Choice E) Preeclampsia risk factors are numerous. Some risk factors include extremes of maternal age,
diabetes, renal diseases, collagen vascular diseases, baseline uncontrolled maternal hypertension and a
family history of preeclampsia.
Educational objective:
Postterm pregnancies are at an increased risk for oligohydramnios, which itself is associated with increased
fetal morbidity. Postterm pregnancies should be monitored for oligohydramnios twice weekly.

A 24-year-old female presents to you for the evaluation of acne. Further questioning, reveals that she also
has had irregular periods for a long time. She is single and not sexually active. On examination, her BMI is
31 Kg/m2 and she has evidence of hirsutism. Further evaluation reveals increase in serum free testosterone
and LH/FSH ratio of 2.4. Glucose tolerance testing reveals two-hour blood glucose of 155 mg/dl . Apart from
prescribing oral contraceptive pills, which of the following is indicated in this patient?
A. Clomiphene citrate
.; B. Metformin
C.lnsulin
D. Glipizide
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E. No other medication needed


Explanation:
This patient's history of abnormal menstrual periods and hirsutism in the form of acne points towards
polycystic ovarian syndrome (PCOS). The elevated testosterone level and increased LH/FSH ratio are both
consistent with the diagnosis as well. Type II diabetes and impaired glucose tolerance are common findings
in patients with PCOS. A glucose tolerance test is recommended in all patients diagnosed with PCOS as it
is more sensitive in detecting abnormal glucose metabolism than a fasting glucose. A two-hour glucose of
> 140 mg/dl on glucose tolerance test is presumptive of insulin resistance and > 200 is consistent with
diabetes mellitus. Life style modification, oral contraceptive or clomiphene (depending on desire to conceive), and
antiandrogen agents may be used as treatment. In addition, metformin is indicated in women with polycystic ovarian
syndrome and impaired glucose tolerance. The benefits of metformin use in polycystic ovarian syndrome are as follows:
1 . It helps prevent type 2 diabetes mellitus.
2. Helps losing weight (most of the patients with polycystic ovarian syndrome are obese).
3. In conjugation with clomiphene citrate, it helps to induce ovulation in infertile polycystic ovarian
syndrome patients with anovulation; however, it is not FDA approved to be used just for this purpose.
4. It has modest effect in suppressing androgen production and, thus, helps correct hirsutism to some
extent.

(Choice A) Clomiphene citrate is used to induce ovulation in polycystic ovarian syndrome patient with
infertility. However, this patient is single and has not expressed any wish to bear children, so it is not
indicated at this point.
(Choice C & D) Metformin is the initial drug of choice for impaired glucose tolerance in diabetes mellitus
because of its additional beneficial effects aside from glucose metabolism.
(Choice E) This patient has impaired glucose tolerance and is at risk of type 2 diabetes mellitus; thus, she needs
metformin treatment.

Educational objective:
Metformin is indicated in polycystic ovarian syndrome patients with impaired glucose tolerance. It helps in
preventing type 2 diabetes mellitus as well as improving obesity, hirsutism, menstrual irregularity, and infertility.

A 21 -year-old woman at 36 weeks gestation is admitted for delivery. She has severe preeclampsia. Her
blood pressure is 190/ 110 mmHg, pulse is 80/min and respirations are 16/min. Physical examination shows
3+ pitting edema of the legs and brisk deep tendon reflexes. Fundoscopic examination shows no
abnormalities. Laboratory studies show elevated BUN, serum creatinine and serum
transaminases. Urinalysis shows 4+ proteinuria. Intravenous hydralazine and magnesium sulfate was
initiated on admission. After stabilization, intravenous oxytocin and artificial rupture of membranes (AROM)
was administered for induction of labor. Two hours later, her blood pressure is 150/90 mmHg, pulse is
78/min and respirations are 9/min. Repeat examination shows hyporeflexia and a completely effaced cervix
that is 5 em dilated. Which of the following is the most appropriate next step in management?
A. Stop hydralazine and do an emergency caesarian section
., B. Stop magnesium sulfate and give calcium gluconate
C. Stop hydralazine and monitor serum cyanide level
D. Stop intravenous oxytocin and intubate the patient
E. Continue current treatment and proceed with delivery
Explanation:
The second neurologic exam performed in this patient shows depressed deep tendon reflexes, which is the
earliest sign of magnesium sulfate toxicity. Magnesium causes toxicity by acting as a CNS depressant and
by blocking neuromuscular transmission. It is very important for patients on magnesium sulfate to be closely
observed with regular examination of their deep tendon reflexes. The second sign of toxicity is respiratory
depression. The treatment of magnesium sulfate toxicity is immediate discontinuation of the infusion and
administration of calcium gluconate.
(Choice A) There is no need to stop hydralazine as her BP is stable. Stopping hydralazine would be
indicated if the BP dropped abruptly.
(Choice C) Monitoring a cyanide level is irrelevant because the patient is not being treated with nitroprusside.
(Choice D) The patient may necessitate artificial ventilation due to respiratory depression related to
magnesium toxicity, but stopping magnesium sulfate and administration of calcium gluconate is the more
urgent intervention. Oxytocin is not responsible for her condition; it is analogous to ADH and therefore, may
be responsible for hyponatremia and water intoxication.
(Choice E) If magnesium sulfate infusion is not stopped immediately there is a risk of death due to cardiac or respiratory
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arrest.
Educational objective:
Depression of the deep tendon reflexes is the earliest sign of magnesium sulfate toxicity. Treatment requires stopping the
magnesium sulfate infusion and administration of calcium gluconate.

A 1 9-year-old woman comes to the emergency department because of a 2-day history of fever, shaking chills
and lower abdominal pain. She had an abortion at an outside clinic 3 days ago. Her temperature is 39 .SC
( 1 03. 7F), blood pressure is 1 00/65mmHg, pulse is 114/min and respirations are 26/min. Physical
examination shows mild rigidity and guarding. Fundal height is at 12 weeks gestation, the adnexae are free
and no mass is noted. Bimanual examination shows uterine tenderness with purulent, offensive vaginal
discharge coming out of a dilated cervical os. Which of the following is the most appropriate sequence in
management?
A. Cervical and blood cultures, antibiotics, vigorous and thorough curettage
B. Cervical and blood cultures. antibiotics, gentle suction curettage
C. Antibiotics, suction curettage, cervical and blood sampling
D. Cervical and blood cultures, antibiotics and close observation
E. Laparotomy and antibiotics
Explanation:
Septic abortion can result from infection of retained products of conception in the case of missed,
incomplete, inevitable or elective abortions. This condition is clinically characterized by fever, chills,
abdominal pain and a bloody I purulent vaginal discharge. Examination shows lower abdominal tenderness
and an enlarged, tender uterus with a dilated cervix. Septic abortion is a medical emergency. Broad
spectrum antibiotics are given immediately after obtaining the blood and cervical / endometrial cultures.
Immediate surgical evacuation of the uterine contents is then required in order to remove the infectious
nidus. This is best done with gentle suction curettage. Vigorous curettage should be avoided because of the
risk of uterine perforation .
(Choice C) Cervical and blood sampling should be done prior to the administration of antibiotics and suction
curettage.
(Choice D) Cervical and blood cultures and antibiotics are indicated, but evacuation of the infected
intrauterine products of conception is required to resolve the infection in much the same way that an abscess
must be drained in order to resolve.
{Choice E) Laparotomy and antibiotics may be indicated if antibiotics and suction curettage are not sufficient
to resolve the infection.
Educational objective:
Septic abortion is managed with cervical and blood cultures followed by IV antibiotics and gentle suction
curettage. Vigorous suction curettage may cause perforation of the uterus and should be avoided.

A 28-year-old woman, gravida 2, para 0, aborta 1 , at 30 weeks' gestation comes to the physician because of
a decrease in fetal movements. She has felt no fetal movements the past 18-hours. Her prenatal course,
prenatal tests, and fetal growth have been normal up to this point. Triple test was performed at 14-weeks and
showed no abnormalities. Her first pregnancy was terminated because her fetus was diagnosed with
Down's syndrome. She does not use tobacco, alcohol, or drugs. F eta I heart tones are heard by Doppler.
Non-stress test is non-reactive; therefore, biophysical profile is performed and shows a score of 8. Which of
the following is the most appropriate next step in management?
., A. Reassurance and repeat biophysical profile in one week
B. Perform contraction stress test
C. Give steroids and repeat biophysical profile with in 24 hrs
D. Advise continuous home fetal monitoring
E. Deliver the baby immediately
Explanation:
Biophysical profile (BPP) is a scoring system designed to evaluate fetal well being. It is indicated in high risk
pregnancies, or in case of maternal or physician concern, decreased fetal movements, or a non-reactive
NST. It includes the NST in addition to four parameters assessed by ultrasonography: 1/F eta I tone; 2/fetal
movements (3/1 Omin); 3/fetal breathing (30/1 0 min); 4/amniotic fluid index, (5-20). Each of these five
variables is given a score of two when present, and a score of zero when absent or abnormal. A total score
of 8- 1 0 is considered normal, and should only be repeated once or twice weekly until term for high risk
pregnancies.
1 . In the presence of oligohydramnios (AFI <5) delivery is to be considered since it can result in umbilical
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cord compression and therefore fetal compromise.


2. If the score is 6 without oligohydramnios, contraction stress test should be ordered. If this latter gives
non-reassuring results, delivery is usually indicated; if it gives suspicious results, repeat the next day.
3. If the score is 4 without oligohydramnios and fetal lungs are mature, delivery should be considered. If
fetal lungs have not yet reached their maturity, steroids injection should be administered and BPP
assessed within 24 hours.
4. If the score is <4, the fetus should be delivered.
(Choice B) Contraction stress test is indicated when the BPP score is 6.
(Choice C) BPP is reassuring in this patient and repeat in one week is enough .
(Choice E) Delivery is indicated when BPP score is < 4.
Educational Objective:
Total biophysical profile score of 8-1 0 is considered normal, and should only be repeated once or twice
weekly until term for high risk pregnancies.

A 25-year-old woman at 28 weeks gestation comes to the ER because of strong, regular and painful uterine
contractions that started 4 hours earlier with the passage of clear fluid from her vagina. She denies any
vaginal bleeding. She has had no prenatal care. Vital signs are normal. A sterile speculum examination
shows pooling of amniotic fluid within the vagina, and a cervix that is 4 em dilated and 80% effaced.
Ultrasonogram in the emergency department shows an amniotic fluid index of 4 and bilateral renal agenesis
in the fetus. Which of the following is the most appropriate next step in management?
A. Allow spontaneous vaginal delivery
B. Consent for cesarean section
C. Administer corticosteroids
D. Amnioinfusion and tocolysis
Explanation:
This patient has preterm labor with rupture of the membranes. In this case, the fetus has a severe congenital
anomaly incompatible with life, so labor should be allowed to proceed. Patients with bilateral renal agenesis
will not survive outside the uterus because of the severe pulmonary hypoplasia associated with renal
agenesis. They will survive in utero because the placenta oxygenates the fetal blood and removes waste
products from the fetal circulation.
(Choice B) There is no need for a cesarean section, which increases maternal morbidity, as the fetus can
be evacuated vaginally.
(Choices C & D) Since the fetal anomaly is not compatible with life, all attempts to prolong pregnancy will not
improve fetal mortality, and delivery should be allowed to proceed .
Educational objective:
Labor should be allowed to proceed in patients where the fetus has been diagnosed with a severe congenital
anomaly incompatible with life.

A 24-year-old woman comes to your office complaining of an 8-week history of amenorrhea. She is sexually
active and uses OCPs for contraception. Her medical history is unremarkable. She does not have any
particular complaints except moderate fatigue and a decline in mood. She denies headaches, visual
disturbances, or any gastrointestinal symptoms. She denies cigarette smoking or any drug use, and drinks
alcohol socially. Breast examination reveals a white, milky secretion upon expression of both nipples. A
pelvic examination reveals a uterus of normal size. BMI is 28 kg/m2. Initial investigations reveal a negative
serum beta-hCG level. According to these findings, which of the following is the most appropriate next step in
the management of this patient?
.; A. Determine serum TSH level
B. Determine serum TRH level
C. Perform visual field study
D. Order sellar MRI
E. Order sellar CT scan
Explanation:
Prolactin production is inhibited by dopamine and stimulated by serotonin and TRH. An increase in TSH and
TRH production and, consequently, in prolactin release may be the result of
hypothyroidism. Hyperprolactinemia may also affect GnRH and gonadotropin secretion and, thus, result in
amenorrhea. Other causes of high prolactin levels include dopamine antagonists ( antipsychotics, tricyclic
antidepressants, and MAO Is), hypothalamic and pituitary tumors. In the present case, the patient is not under
any dopamine antagonists and has no clinical signs indicating the presence of a hypothalamic or pituitary
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tumor; therefore, the most appropriate next step in the management of this patient is to rule out the most
benign etiology, that is, hypothyroidism, by measuring TSH .
(Choice B) TRH is not useful in diagnosing hypothyroidism.
(Choices C, 0, and E) Sellar MRI or CT scan, as well as visual field study, may all be useful if a
hypothalamic or pituitary tumor is suspected. At this stage, hypothyroidism has to be ruled out first.
Educational Objective:
In the case of amenorrhea-hyperprolactinemia, first rule out hypothyroidism by measuring serum TSH.

A 32-year-old woman, gravida 1 , is in active labor. Lumbar epidural anesthesia is being used for pain
control. She is having contractions every two to three minutes. The cervix is 4 em dilated. F eta I heart rate is
reassuring. Her blood pressure is 90/55 mmHg and heart rate is 120/min. What is the most probable cause
of her hypotension?
A. Depressed myocardial contractility
B. Intravascular fluid loss
C. Blood venous pooling
D. Blood redistribution to the upper trunk
E. CNS involvement
Explanation:
The clinical scenario described is suggestive of hypotension as a side effect of epidural
anesthesia. Hypotension complicates up to 10% of epidural blocks given during labor, but if considered early,
can be easily prevented and treated. The cause of hypotension is sympathetic fiber block that results in
vasodilatation of the lower extremity vessels. Blood redistribution to the lower extremities (Choice D) and
venous pooling occur. Cardiac output decreases and hypotension results.
(Choice A) Depressed myocardial contractility develops during myocardial infarction and is usually
accompanied by chest pain and dyspnea, and the hypotension due to cardiogenic shock has dismal
prognosis.
(Choice B) Intravascular fluid loss is typically caused by external or internal hemorrhage, which is unlikely in
this case because no obvious source of blood loss is present.
(Choice E) CNS involvement with vasoregulatory center block is a rare, but very dangerous complication of
epidural anesthesia. CNS symptoms (e.g., excitation, disorientation, seizure) usually precede cardiovascular
symptoms in such a case.
Educational objective:
Hypotension is a common side effect of epidural anesthesia. The cause of hypotension is blood redistribution
to the lower extremities and venous pooling.

A 23-year-old woman complains of breast pain two days after delivering her first child. The delivery was
complicated by mild postpartum bleeding. On exam, both breasts are tense, warm, and tender to touch. Her
blood pressure is 130/70 mmHg, heart rate is 100/min, and temperature is 994F (374.C). What is the
most likely diagnosis?
A Mastitis
B. Breast abscess
v C. Breast engorgement
D. Plugged ducts
E. Superficial vein thrombosis
Explanation:
This woman has breast engorgement, common in the first 24 to 72 hours after childbirth secondary to milk
accumulation. While it may occur at any point during breast feeding, it is especially common early in the
postpartum period when milk production is particularly robust. Symptoms include breast fullness,
tenderness, and warmth. It typically peaks 3 to 5 days postpartum and improves spontaneously in most
patients. Cool compresses, acetaminophen, and NSAIDs may be used for symptom control.
(Choice A) Mastitis is a breast infection that causes unilateral breast pain with an isolated firm, tender,
erythematous area accompanied by fever greater than 38 .3c. It is distinguished from plugged ducts by the
presence of fever. Anti-staphylococcal agents are first-line therapy. This patient has bilateral, not unilateral,
symptoms, which would be unusual for mastitis.
(Choice B) Breast abscesses are rare and present similarly to mastitis but with a palpable, fluctuant
mass. They are treated with antibiotics and drainage.
(Choice D) Plugged ducts present similarly to mastitis but lack fever or systemic symptoms. They are
treated by improving the quality of breastfeeding. Persistently plugged ducts resulting in galactocele may be
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treated with aspiration.


(Choice E) Superficial vein thrombosis can cause tenderness and localized erythema but is unlikely to cause
bilateral tense breasts.

Educational objective:
Breast engorgement is a common problem associated with breast feeding. Characterized by bilateral breast
tenderness and swelling, it typically presents 24 to 72 hours postpartum, peaks 3 to 5 days after delivery,
and resolves spontaneously.

A 34-year-old obese female returns to the physician's office for a follow-up appointment at 16 weeks
gestation. She was diagnosed with gestational diabetes at 12 weeks gestation and since then has been
following dietary recommendations. She eats a balanced diabetic diet three times a day and avoids
snacks. Her fasting blood sugars for the past two weeks have been in between 120 to 150 mg/dl. Her
temperature is 37.0C (98.7F), blood pressure is 130/88 mmHg, pulse is 76/min and respirations are
14/min. Physical examination is unremarkable.
Item 1 of2
Which of the following is the most appropriate therapy for this patient?
A Chlorpropamide
B. Tolbutamide
C. lnsulin
D. Exenatide
E. Continue dietary therapy
Explanation:
The patient described has gestational diabetes that has not responded to a trial of a diabetic diet. Diagnosing
and appropriately treating gestational diabetes is important as pregnancies in the setting of uncontrolled
disease are at increased risk of miscarriage, abnormally large size, congenital malformations, preterm birth,
pyelonephritis, preeclampsia, meconium aspiration and stillbirth. The ideal range of maternal fasting glucose is between
75 and 90 mg/dl . Treatment of gestational diabetes is best accomplished with subcutaneous insulin, which is classified as
a category B agent and does not cross the placenta.
(Choices A & B) Chlorpropamide and tolbutamide cross the placenta and can cause fetal hyperinsulinemia, macrosomia
and prolonged neonatal hypoglycemia. These agents are classified as pregnancy category C.

(Choice E) Continue dietary therapy is insufficient to treat this patient's gestational diabetes as she has thus
far been unable to obtain good glycemic control. The risks of continued hyperglycemia demand treatment at this time.
Educational objective:
Gestational diabetes is most commonly first treated with a low sugar diet, but if diet fails to produce
euglycemia, insulin is the treatment of choice.

A 25-year-old female comes to the physician because of abdominal bloating, headache, fatigue, weight gain,
anxiety, and decreased libido. She experiences these symptoms seven to ten days before the start of each
menstrual cycle. She has a past history of postpartum depression, but she denies any recent feelings of
hopelessness or guilt. Physical examination shows no abnormalities. Complete blood count, serum
chemistries and thyroid stimulating hormone levels are within normal limits. Which of the following is the
most appropriate next step in management?
A. Cognitive behavioral therapy
B. Prescribe selective serotonin reuptake inhibitors
C. Advise menstrual diary
D. Insight oriented and supportive psychotherapy
E. Prescribe alprazolam
Explanation:
This woman's presentation is most consistent with premenstrual syndrome (PMS). The most common
physical manifestations of PMS are bloating, fatigue, headaches, and breast tenderness. Psychological
symptoms may include anxiety, mood swings, difficulty concentrating, decreased libido and
irritability. Symptoms usually begin one to two weeks prior to menses, and regress around the time of
menstrual flow. Symptoms are then typically absent until the next ovulation.
Maintaining a menstrual diary for at least 3 cycles is a useful aid for confirming the diagnosis in suspected
cases; PMS is confirmed when symptoms occur repeatedly and predictably in the days prior to menstruation
and are absent or less severe during the follicular (proliferative) phase. If symptoms are present throughout
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the menstrual cycle, then other conditions such as mood disorder are more likely .
(Choices A, B, 0, & E) Once the diagnosis of PMS is confirmed, treatment depends on the patient's
complaints. There is no universally accepted treatment. Reduction of caffeine intake may reduce breast
symptoms. An exercise program may be effective in improving the general well being of the patient. In
women whose symptoms are more severe and cause socioeconomic dysfunction, selective serotonin
reuptake inhibitors (SSRis) are the drug of choice. When SSRis fail to alleviate symptoms in such patients
despite therapy over multiple cycles, low dose alprazolam is indicated. Relaxation techniques and bright light
therapy have some proven effect in management of PMS, but cognitive behavioral therapy and insight
oriented and supportive psychotherapy do not play a role. Treatment should not be initiated until the
diagnosis is made.
Educational objective:
A menstrual diary for at least 3 cycles is a useful aid for confirming the diagnosis in suspected cases of
PMS. Confirmation of the diagnosis must be made before initiating treatment.

A 23-year-old, gravida 2, para 1 woman at 30 weeks gestation comes to the ER after she noticed a sudden
gush of clear fluid coming from her vagina. She has had no uterine contractions or vaginal bleeding. Her
pregnancy has been uncomplicated; she has had consistent prenatal care. Vital signs are normal. Sterile
speculum examination shows the cervix is minimally effaced and 2 em dilated; there is pooling of clear fluid in
the vaginal fornix, and when pressure is applied to the fundus, clear fluid comes out of the cervix. Emergency
ultrasound shows a fetus of average size in the vertex presentation and an Amniotic Fluid Index (AFI) of
15. Nonstress test shows a baseline of 120 bpm and frequent accelerations. Amniotic fluid analysis shows
lecithin/sphingomyelin ratio of 1 0 Which of the following is the most appropriate next step in management?
A. Amnioinfusion
B.lmmediate vaginal delivery
C. Cesarean section
D. Betamethasone
E. Repair of ruptured membranes
Explanation:
Rupture of the fetal membranes at any time before the onset of labor is referred to as premature rupture of
membranes (PROM). When rupture occurs before term, it is known as pre term PROM (PPROM). The
diagnosis of ROM is mainly clinical. The patient usually complains of either a gush or continual leakage of
clear fluid from the vagina. On examination, amniotic fluid may be noted in the vagina or leaking from the
cervix when the Valsalva maneuver or slight fundal pressure is applied. In this case, PPROM is the
diagnosis, and amniotic fluid sampling to measure fetal lung indices is mandatory. Ultrasound examination
should also be performed to detect fetal anomalies, determine gestational age and measure amniotic
volume. In this case of PPROM, the pregnancy is less than 34 weeks gestational age, and the US ratio is
less than 2.0; therefore, prematurity is a major concern. Steroid treatment is effective at this stage of
pregnancy (between 24 and 34 weeks) in accelerating lung maturity and should be used. No tocolysis is
indicated as the patient has no uterine contractions.
(Choice A} The amniotic fluid index is normal (>5 and <25), so there is no need for amnioinfusion. It is
sometimes used in oligohydramnios to prevent its complications.
(Choices B & C) There are no signs of fetal distress at this point so delivery should not be expedited. The
fetus would be best served by systemic corticosteroid treatment as fetal lung immaturity is associated with
the neonatal respiratory distress syndrome, which is associated with increased morbidity and mortality in the fetus.
(Choice E) Membrane repair is an investigational technique whereby the membranes are sealed by insertion of a gelatin
sponge to plug the cervix. The fetus described has a normal AFI and is not presently in distress.

Educational objective:
The most important complication of PPROM is pulmonary hypoplasia (immaturity). Steroids are used to
enhance fetal lung maturity when premature rupture of membranes occurs at less than 34-weeks of
gestation.

A 93-year-old woman is sentto your office from the nursing home for evaluation of vaginal bleeding. She is a
poor historian and history is provided by her caregiver. Per her caregiver, she has a history of
cerebrovascular accident with residual weakness, myocardial infarction, hypertension, type 2 diabetes
mellitus and chronic renal insufficiency. She has been wheelchair-bound and living in the nursing home since
her stroke five years ago. She takes multiple medications. Her temperature is 37.2 C (98.9 F), blood
pressure is 176/76, pulse is 74/min and respirations are 14/min. She is awake, alert, and oriented to person,
place and time. Physical examination reveals a friable, bleeding vaginal mass 3 em in si ze, and a
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malodorous vaginal discharge. The remainder of the examination reveals left-sided spasticity and
weakness. Biopsy of the mass reveals squamous cell carcinoma of the vagina, that does not extend to the
pelvic wall. CT scan of the abdomen and pelvis shows no evidence of metastasis. You call the patient's
daughter, who is the power of attorney, and she requests that you do the best you can. Which of the
following is the most appropriate next step in management?
A. Surgical resection
..; B. Radiation therapy
C. Combination chemotherapy
D. Biologic agent therapy
E. Send her to hospice
Explanation:
This 93-year-old woman presents with a vaginal tumor that is identified as squamous cell carcinoma (SCC)
on biopsy. SCC is the most common form of vaginal cancer, and risk for SCC of the vagina increases with
age (most common in women >60 years of age). The most common symptoms are vaginal bleeding and
malodorous vaginal discharge. Definitive diagnosis is made by biopsy. Treatment of vaginal cancer depends
on staging. Stage I and II tumors (no extension to the pelvic wall and no metastases) which are less than 2
em in size may be removed surgically, while stage I and II tumors which are greater than 2 em in size are
treated with radiation therapy. However, the point in this question is to recognize the best treatment modality
given her age and co-morbid conditions. Even if her tumor is less than 3 em in size she is a poor surgical
candidate given her age and multiple medical problems. Radiation alone may be sufficient.

(Choice A) Surgical therapy is the treatment of choice for isolated stage I and II vaginal tumors which are
less than 2 em in size.
(Choice C) Combination chemotherapy is used for Stage Ill and IV tumors as well as tumors greater than 4
em in size. Again, she may not be a good candidate for chemotherapy; radiation alone might be sufficient
(Choice D) Biologic agent therapy does not play a role in management of SCC of the vagina.
(Choice E) It would be inappropriate to send this patient to hospice against the wishes of her power of
attorney. Furthermore, the survival rates for Stage I and II vaginal cancers are high with radiation therapy.
Educational objective:
Radiation therapy is highly effective for squamous cell carcinoma of vagina. It is an excellent alternative for
patients who are poor surgical candidates.

A 28-year-old woman at 39 weeks gestation is admitted to the hospital. She has regular uterine
contractions. Her blood pressure is 120/70mmHg, pulse is 80/min and respirations are 18/min. F eta I heart
monitoring is placed and shows a baseline rate of 130 beats/min, without any associated
abnormalities. Pelvic examination shows the cervix is 50% effaced and 3cm dilated. Amniotomy is
performed and a bloody show is noted. Immediately after the rupture of membranes, the baseline fetal heart
rate increases to 160 beats/min and then drops to 70 beats/min. As labor progresses, repetitive late
decelerations are noted, as well as an increase in vaginal bleeding. Repeat vital signs of the patient shows a
blood pressure of 130/70mmHg, pulse of 80/min and respirations of 18/min. Which of the following is the
most likely cause of the current condition?
A. Premature separation of the placenta
B. Abnormal placental implantation
.; C. Abnormal umbilical vessels
D. Excessive amniotic fluid
E. Tear in uterine musculature
Explanation:
This is a typical presentation of a ruptured fetal umbilical vessel: an antepartum hemorrhage with very
characteristic fetal heart changes progressing from tachycardia to bradycardia to a sinusoidal pattern. If fetal
bleeding is suspected, an Apt test - which differentiates maternal from fetal blood - can be performed to
confirm the diagnosis. Vasa previa is a rare condition in which the fetal blood vessels traverse the fetal
membranes across the lower segment of the uterus between the baby and the internal cervical os
(velamentous cord insertion). These vessels are vulnerable to tearing during natural or artificial rupture of the
membranes. The condition carries a high fetal mortality rate (75%) due to fetal exsanguination. When this
condition is diagnosed, the treatment is an immediate caesarian section delivery ("crash C-section").
(Choice A) Abruptio placenta is a premature placental separation initiated by hemorrhage in the decidua
basalis. It typically presents with dark red antepartum hemorrhage along with abdominal pain, uterine
tenderness and increased uterine tone. The bleeding is of maternal origin.
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(Choice B) Placenta previa is an abnormal insertion in the placenta on the lower segment of the uterus near
or over the cervical os. It manifests as painless antepartum hemorrhage, and the bleeding is maternal in
origin.
(Choice D) Excessive amniotic fluid (hydramnios, polyhydramnios) causes symptoms in the mother as a
result of compression on the lungs, abdominal organs and vasculature. Difficulty breathing and lower
extremity edema are common. Placental abruption and postpartum hemorrhage due to uterine atony are
associated with hydramnios.
(Choice E) Uterine rupture presents with intense abdominal pain associated with vaginal bleeding that can
range from spotting to severe hemorrhage. The bleeding is maternal in origin. Regression of the fetal
presenting parts and palpability of fetal limbs on abdominal exam is typical.
Educational objective:
An antepartum hemorrhage with fetal heart changes progressing from tachycardia to bradycardia and finally
to a sinusoidal pattern occurring suddenly after rupture of membranes suggests the diagnosis of vasa
previa. The bleeding in this setting is fetal in origin, so maternal vital signs will remain stable while the fetus
exsanguinates.

A 28-year-old woman, gravida 3, para 2, at 28 weeks gestation comes to the physician because she has only
felt 2-3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes,
which is under good control with diet and mild exercise. She does not use tobacco, alcohol or drugs. Vital
signs are normal. Physical examination is unremarkable. F eta I heart tones are heard. Which of the
following is the next most appropriate step in management?
.; A. Non-stress test
B. Biophysical profile
C. Contraction stress test
D. Ultrasonography
E. Deliver the baby immediately
Explanation:
In the presence of decreased fetal movements, fetal compromise should be suspected and the best next
step in management is a nonstress test (NST). NST is usually performed in high risk pregnancies starting at
32-34 weeks gestation or when there is a loss of perception of fetal movements in any pregnancy. NST is
carried out by recording the fetal heart rate while monitoring for spontaneous perceived fetal movements. A
test is considered reactive (normal) if in 20 minutes 2 accelerations of the fetal heart rate of at least 15 beats
per minute above the baseline lasting at least 15 seconds each are noted. If less than 2 accelerations are
noted in 20 min, the test is considered nonreactive (abnormal) and further assessment is required. The most
common cause of a nonreactive NST is a sleeping baby, not a diseased baby, so vibroacoustic stimulation is used to wake
the baby up and allow a timely test.
(Choice B) A biophysical profile (BPP) is a scoring system designed to evaluate fetal well-being. It is
indicated in high risk pregnancies and in cases of maternal or physician concern, decreased fetal
movements or a non-reactive NST.
(Choice C) In a contraction stress test (Oxytocin challenge test), the mother is given an infusion of oxytocin sufficient to
result in 3 contractions per 1 0 minutes, and the effect these contractions have on fetal heart activity is recorded. If a late
deceleration is noted at each contraction, the test is positive and delivery is
usually recommended. Because this is a more invasive test, it is not used as an initial examination.
(Choice D) Ultrasonography is not as sensitive as NST or BPP for evaluation of decreased fetal movements
and fetal well-being. It is, however, the first step if fetal demise is suspected as it can document the
presence or absence of fetal heart movement
(Choice E) Delivery is indicated when significant signs of fetal distress or maternal deterioration are present
Educational objective:
If fetal movement decreases or becomes imperceptible by the mother, then a nonstress test should be
carried out to document fetal well-being.

A 29-year-old woman, gravida 3, para 2, at 35 weeks gestation is brought to the emergency department
because of vaginal bleeding. She has had no uterine contractions. Her prenatal course, prenatal tests and
fetal growth have been normal. Prenatal ultrasound at the 12th week showed an intrauterine gestation
consistent with dates. Four years ago, she had a low transverse cesarean section in her second
pregnancy. Physical examination shows bright red vaginal bleeding. Her temperature is 37.0 C (98.7 F),
blood pressure is 1 00/70 mm Hg, pulse is 90/min and respirations are 16/min. F eta I heart monitoring is
reassuring. Which of the following is the most likely diagnosis?
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A. Abruptio placenta
B. Placenta previa
C. Vasa previa
D. Uterine rupture
E. Normal labor
Explanation:
Placenta previa refers to insertion of the placenta in a way that obstructs the internal cervical os partially or
completely. This abnormal insertion may cause bleeding as the inferior segment of the uterus develops and
stretches the placenta. Placenta previa is responsible for 20 % of all cases of antepartum hemorrhage and is
typically painless. Risk factors include multiparity, advanced maternal age, prior caesarian section, smoking,
multiple gestation (as multiple placentas cover a larger surface and have a higher risk of low insertion) and
prior placenta previa.
(Choice A) Abruptio placenta is a premature placental separation initiated by hemorrhage in the decidua
basalis. It is classically associated with underlying maternal hypertension. The clinical presentation is
variable. Patients may be asymptomatic with intrauterine fetal death or may present with dark red vaginal
bleeding associated with painful uterine contractions.
(Choice C) Vasa previa is a rare condition in which the fetal blood vessels cross the fetal membranes in the
lower segment of the uterus between the fetus and the internal cervical os. It also presents as painless
antepartum hemorrhage but is associated with rapid deterioration of the fetal heart tracing as the hemorrhage is of fetal
origin.
(Choice D) Uterine rupture classically presents with a sudden onset of intense abdominal pain and vaginal
bleeding associated with hyperventilation, agitation and tachycardia.
(Choice E) Normal labor presents with regular contractions associated with cervical dilation, release of the
mucous plug and bloody show due to tearing of small cervical veins. Frank hemorrhage is not associated
with normal labor.
Educational objective:
In the presence antepartum hemorrhage, pelvic examination must not be done before ruling out placenta
previa. Placenta previa presents with painless third trimester vaginal bleeding.

A 27 -year-old woman, gravida 2, para 1 , at 12 weeks gestation comes to the physician because of a dark
brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any
intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had
nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or
drugs. Her temperature is 37.0C (98.7F), blood pressure is 110/60 mmHg, pulse is 85/min and respirations
are 15/min. Physical examination shows a soft uterus and a closed cervix. F eta I heart tones are not present.
Item 1 of2
Which of the following is the most appropriate next step in management?
A. Quantitative beta-HCG measurement
B. Pelvic ultrasonography
C. Chorionic villous sampling
D. Check PT/INR and PTT
E. Reassurance and routine follow-up
Explanation:
The patient described has experienced a spontaneous abortion, which is defined as fetal demise before the
20th week of gestation and with a fetus weighing less than 500 grams. There are numerous forms of
spontaneous abortion; the form described here is a missed abortion. Missed abortion is characterized by
fetal demise with retained products of conception (fetus, placenta, etc.) and a closed
cervix. Characteristically, patients with a missed abortion will experience a loss of their pregnancy symptoms
(i.e. decreased nausea and breast tenderness) and some brown discharge may be noted following fetal
demise. The most appropriate next step in making the diagnosis of a spontaneous abortion is a transvaginal
ultrasound to document the presence of intrauterine products of conception and to attempt to visualize
motion of the fetal heart.

(Choice A) Quantitative beta-HCG measurement can continue to be elevated following a spontaneous


abortion with retained products of conception.
(Choice C) Chorionic villous sampling is a procedure used to obtain fetal tissue for genetic analysis. It is
typically used to diagnose chromosomal abnormalities.
(Choice D) Checking the PTIINR and PTI is appropriate if DIC is suspected, and DIC may occur in the
setting of a missed abortion with prolonged retention of the products of conception.
DES Entrance Exams

(Choice E) Reassurance and routine follow-up are not indicated until fetal well-being has been established by
a transvaginal ultrasound that indicates size in agreement with dates, fetal motion and I or fetal heart
movement.
Educational objective:
A missed abortion is a form of spontaneous abortion that is characterized by intrauterine fetal death before 20
weeks gestational age with complete retained products of conception and a closed cervix. Patients typically
present with loss of pregnancy symptoms and some brown vaginal discharge, and a transvaginal ultrasound
is necessary to confirm the diagnosis.
Item 2 of2
Quantitative beta-HCG level is similar to her previous value, which was obtained 4 weeks ago. Pelvic
ultrasonogram reveals absent fetal cardiac activity and small gestational sac. Coagulation studies are within
normal limits Which of the following is the most appropriate next step in management?
A Serial beta-HCG monitoring
B. Dilatation and curettage
C. Hospitalization and bed rest
0 . Methotrexate therapy
E. Oxytocin infusion
Explanation:
The diagnosis of a missed abortion can be confirmed by transvaginal ultrasound as described in the question
stem. In this case, documenting the absence of fetal heart movement on ultrasound is the most significant
indicator that the fetus has expired. The mother's coagulation studies are within normal limits. This is
reassuring as retained products of conception (POC) can rarely cause a coagulopathy. The appropriate
treatments in this setting all involve ensuring that there is complete elimination of the POC from the
uterus. This can be accomplished surgically with a dilation and curettage, medically with misoprostol or
mifepristone and expectantly by simply monitoring the mother to ensure that the POC eliminate naturally,
which does occur in the majority of cases in time.

(Choice A) Serial beta-HCG monitoring will show a downward trend to normal following death of the fetus,
but this intervention will not directly address the retained POC.
(Choice C) Hospitalization and bed rest is not necessary as the fetus is not viable. Conservative
management can be carried out with the patient at home with regular clinical follow-up and transvaginal
ultrasound to ensure complete natural evacuation of the uterus.
(Choice D) Methotrexate therapy is used in some cases of early ectopic pregnancy as an abortifacient due to
its specificity for rapidly dividing cells. The fetus in this case is dead, and methotrexate would not facilitate
elimination of the POC from the uterus. A dead fetus is, in fact, a contraindication to the use of methotrexate.
(Choice E) Oxytocin infusion would stimulate uterine contractions and likely expel the retained fetus, but this
can more readily be accomplished with vaginal misoprostol without systemic effects and the additional
invasiveness of an intravenous catheter.
Educational objective:
The most appropriate treatment for a missed abortion is removal of the POC from the uterus. This can be
accomplished surgically with dilation and curettage, medically with vaginal misoprostol or expectantly with
serial imaging to ensure complete natural expulsion of the POC.

A 24-year-old woman, gravida 2, para 1 , at 36 weeks' gestation is brought to the emergency department after
passing out. She is drowsy and moaning, complaining of abdominal pain. Her husband accompanies
her. He states that she has not experienced any trauma, but that she experienced the sudden onset of
severe abdominal pain before she passed out. She has no significant past medical history. Her pregnancy
has been uncomplicated thus far. She does not use tobacco, alcohol, or drugs. She takes supplemental
vitamins, but no other medications. Her temperature is 36.9 C (98.4F), blood pressure is 90/60 mm of Hg,
and pulse is 130/min. Physical examination shows a cold and diaphoretic female. Examination shows a
uterus consistent in size with a 36-week gestation; the cervical os is closed and no vaginal bleeding is
noted. Which of the following is the most likely diagnosis?
A. Placenta previa
B. Abruptio placentae
C. Preeclampsia
D. Amniotic fluid embolism
E. Septic shock
Explanation:
Abruptio placentae is the most likely diagnosis in this patient given her sudden onset of abdominal pain in the third
DES Entrance Exams

trimester and the absence of trauma. There is no vaginal bleeding noted on exam in this patient, but the absence of
hemorrhage does not rule out placental abruption. Bleeding is seen in 80% of placental
abruptions, and in some cases bleeding may be retroplacental and not appear on vaginal exam. The most
common risk factor for abruptio placentae is maternal hypertension. Other risk factors include cocaine
abuse, trauma, excessive uterine distention, tobacco use, and previous placental abruption .
(Choice A) Placenta previa presents with painless vaginal bleeding.
(Choice C) Preeclampsia is associated with hypertension, proteinuria and edema.
(Choice D) Amniotic fluid embolism usually occurs during amniocentesis or labor, and presents with
respiratory failure and cardiac shock. Abdominal pain is not expected.
(Choice E) Septic shock is unlikely without fever or any precipitating factors such as rupture of membranes
or urinary tract infection.
Educational objective:
The classic manifestations of acute abruptio placentae include vaginal bleeding, abdominal pain, uterine
contractions, and uterine tenderness. The absence of blood on pelvic exam does not rule out this condition.

A 14-year-old female is brought to the physician's office for evaluation of excessive menstrual bleeding. She
experienced menarche at age 13, and since then her menses have been irregular and unpredictable. Her
last menstrual period was 6 weeks ago and for the past week she has been having heavy menstrual
bleeding. She has never been sexually active. Vital signs are stable. Her external genitalia are normal. She
refused pelvic examination, and a pregnancy test is negative. Which of the following is the most likely cause
of her symptoms?
A. Bleeding disorder
B. Anovulation
C. Cervical polyp
D. Endometrial carcinoma
E. Uterine fibroids
Explanation:
The patient described is most likely experiencing menorrhagia, which is defined as prolonged or heavy
menstruation, typically lasting longer than 7 days or exceeding 80 ml. In a young patient that has only
recently experienced menarche, heavy menses with an irregular cycle can be attributed to anovulatory
cycles. Females in this age group have an immature hypothalamic-pituitary-ovarian axis that may fail to
produce gonadotropins (LH and FSH) in the proper quantities and ratios to induce ovulation. Up to 90% of all
menstrual cycles in the first year after menarche may be anovulatory. Because the endometrium is
responsive to baseline estrogen levels during the female's cycle, the endometrium will develop and eventually
slough resulting in some cyclic bleeding due to a breakthrough phenomenon.

(Choice A) Bleeding disorders (coagulopathies) result in unusually heavy menses (not irregular) that may
frequently require blood transfusions.
(Choice C) Cervical polyps are common benign neoplasms of the cervix that may cause occasional
bleeding, especially following trauma as may occur during intercourse. Irregular periods are not
seen. Polyps are not common in this age group.
(Choices D & E) Endometrial carcinoma and uterine fibroids are potential causes of abnormal uterine
bleeding particularly in the postmenopausal age group. These are unlikely in the patient described.
Educational objective:
Most menstrual cycles in the first one to two years following menarche are anovulatory. These cycles are
typically irregular and may be complicated by menorrhagia.

A 25-year-old female presents to the physician's office for evaluation of infertility. Her menstrual periods are
regular. She has mild chronic pelvic pain. Her husband's semen analysis is within normal limits. She has
no history of sexually transmitted diseases in the past. Her temperature is 37.2 C (98.9 F), and her blood
pressure is 120/72 mmHg. Physical examination shows a normal sized uterus and enlarged left
adnexae. Ultrasonography shows a homogeneous mass on the left ovary, but is otherwise normal. Which of
the following is the most likely diagnosis?
., A. Endometriosis
B. Ovarian malignancy
C. Chronic pelvic inflammatory disease
D. Adenomyosis
E. Pelvic congestion syndrome
F. Submucosal fibroid
DES Entrance Exams

Explanation:
Endometriosis is a benign condition where foci of endometrial glandular and stromal tissue are found in
locations outside the uterus. These foci react to hormonal stimuli in the same manner as the endometrium
does, and thus increase in size throughout the menstrual cycle and bleed when the hormonal stimuli is
suspended. The most frequently affected sites are the ovaries, the peritoneal surfaces of the cul-de-sac, the
broad and uterosacral ligaments and the rectovaginal septum, but any site including the bladder, intestine and
skin may be involved though far less commonly.
Patients present most frequently with dysmenorrhea, dyspareunia (when the endometriomas are located in
the cul-de-sac, the fornices or the uterosacral ligaments), dyschezia (pain on defecation), hematochezia,
hematuria, and premenstrual or postmenstrual spotting. Endometriosis can also result in subfertility or
infertility. Physical examination may reveal a tender adnexal mass or firm nodularity in the broad ligaments,
the uterosacral ligament or in the cul-de-sac. Ultrasound examination may demonstrate homogenous
endometriomas on the adnexae or within the peritoneal or pelvic regions. The diagnosis can only be made
with certainty by laparoscopic examination of the pelvis and peritoneum.
(Choice B) A malignancy of the ovary is a possible cause of infertility, but ovarian cancer is typically a
disease of perimenopausal women. Additionally, this patient's clinical presentation is most typical of
endometriosis.
(Choice C) Chronic PID can cause adhesions within the uterus or the uterine tubes and may be responsible
for chronic pelvic pain and infertility. The patient does not have a history of PID and has no fever or any other
systemic symptoms consistent with this diagnosis.
(Choice D) Adenomyosis is the presence of endometrial glands in the uterine muscle. It occurs most
frequently in women above 40 and typically presents with secondary dysmenorrhea and menorrhagia. The
physical examination reveals an enlarged and generally symmetrical uterus.
(Choice E) Pelvic congestion syndrome is a cause of chronic pelvic pain but would not cause ovarian
abnormalities.
(Choice F) A submucosal uterine fibroid may cause irregular menstrual bleeding, dysmenorrhea and
impaired fertility; these tumors are most commonly asymptomatic.
Educational objective:
Endometriosis is a cause of subfertility and infertility. Women may be asymptomatic, but typically experience
pelvic pain, dyspareunia and pain with defecation.

A 32-year-old, gravida 3, para 2 woman at 35 weeks gestation comes to the hospital because of regular and
painful uterine contractions occurring every 5 - 6 minutes. She also has continuous leakage of clear fluid
from her vagina that started 1 0 hours earlier. She has chronic hypertension and was prescribed methyldopa
throughout pregnancy but has been noncompliant. She also has a history of drug abuse and has missed two
previous antenatal appointments. Her temperature is 37.0C (98.7F), blood pressure is 160/100 mmHg, pulse
is 80/min and respirations are 16/min. Sterile speculum examination shows pooling of amniotic fluid in the
vagina; the cervix is 80% effaced and 3 em dilated. Ultrasound shows a small for gestational age fetus in the
vertex presentation with a decreased amniotic fluid index. F eta I heart monitoring shows repetitive late
decelerations. Uterine contractions are now occurring every 4 minutes. Which of the following is the most
appropriate next step in management?
A. Augmentation of labor
B. Tocolysis
C. Cesarean section
D. Betamethasone IM
E. Expectant management
Explanation:
In this case of preterm labor (labor before 37 weeks gestation), the fetus seems to be in distress judging by
the decelerations in the fetal heart tracing, so delivery should be accomplished urgently. Moreover, the fetus
is small for gestational age, probably as a result of the chronic hypertension and drug abuse of the mother, so
it not likely to withstand the stress of a vaginal labor and delivery. Regardless of gestational age or the
concern for prematurity, the fetus should be evacuated by the fastest means possible, an emergent cesarean
section.
(Choice A) The fetus is already in distress and augmentation of labor may expose it to further stress and
hypoxia.
(Choices B & E) The fetus is in distress and there is no benefit in leaving it in utero. The fetus will benefit
most from prompt delivery, which will remove it from the intrauterine environment that is presently insufficient
to maintain adequate fetal oxygenation.
DES Entrance Exams

(Choice D) Corticosteroid treatment is not proven to have a benefit after 34 weeks gestation; its use is
limited to the period between 24 and 34 weeks. Additionally, corticosteroids require 24 - 48 hours to have
maximum benefit on fetal lung maturity, and this fetus requires an urgent delivery.
Educational objective:
Fetal distress (repetitive late decelerations) is an indication for emergent cesarean section.

A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only
complaint is low back pain. She has no significant past medical history, and she has had no complications of
pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal
limits. Complete physical examination shows no abnormalities. During the interview she requests screening
for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of
the following is the most appropriate screening procedure for this patient?
A. Fa sting and random urine sugar
B. One time fasting blood sugar
C. 75 gram oral glucose tolerance test
.; D. One hour 50 gram oral glucose tolerance test
E. Three hour 1 00 gram oral glucose tolerance test
Explanation:
Screening for gestational diabetes should be performed in all pregnant women. In high-risk women it is done
at the first prenatal visit; in all other patients it is done between the 24th and 28th weeks of gestation. The one
hour 50 gram oral glucose tolerance test (OGTT) is used as the initial screening test (Choice D). After one
hour, if the blood glucose value is less than 140 mg/dl , gestational diabetes is ruled out. If the blood glucose
value is > 140 mg/dl , a three hour 1 00 gram OGTT is then performed. Gestational diabetes is diagnosed if
two or more of the serum glucose values obtained during the three hour test are elevated above the values
listed below:
Fa sting serum glucose concentration >95 mg/dl
One-hour serum glucose concentration > 180 mg/dl
Two-hour serum glucose concentration > 155 mg/dl
Three-hour serum glucose concentration > 140 mg/dl
(Choice C) A two hour 75 gram glucose tolerance test is an acceptable alternative to the three hour 100
gram glucose tolerance test in women who screen positive during the one hour 50 gram glucose tolerance
test.

Educational objective:
Diabetes screening is performed between 24 and 28-weeks of gestation. The proper initial screening test is
the one hour 50 gram oral glucose tolerance test. After one hour, if the blood glucose value is less than 140
mg/dl , then gestational diabetes is ruled out. If the blood glucose value is > 140 mg/dl , then a three hour
OGTT is performed.

A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department
because of gushing bright red vaginal bleeding. She has had no uterine contractions. She does not take any
medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been
normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with
dates. Her temperature is 37.0 C (98.7F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations
are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial
resuscitation, bleeding is stopped. She is anxious and concerned about her baby. Which of the following is
the most appropriate next step in management?
A. Prompt induction of labor
B. Emergency cesarean section
..; C. Scheduled cesarean section
D. Forceps delivery
E. Conservative management at home
Explanation:
As in the clinical description of this case, placenta previa presents with painless vaginal bleeding in the third
trimester with 2/3 of cases presenting at 30-weeks of gestation. Ultrasound is the method of choice for
diagnosis. Ultrasonography diagnoses placenta previa with an accuracy of 95% with transabdominal
ultrasonography and virtually 100% with transvaginal ultrasonography. Pelvic examination is contraindicated
in any patient with antepartum hemorrhage until placenta previa is ruled out by ultrasound.
DES Entrance Exams

The management of placenta previa depends on the gestational age of the fetus and the severity of the
bleeding. If the mother is stable and the fetus is at term (as in this case), scheduled cesarean section is the
treatment of choice. Until the cesarean section is performed, the patient must be monitored closely; her
hematocrit should be followed and autologous blood made available. If the pregnancy is not yet term and the
mother is stable, expectant management with close monitoring of the mother and fetus is the treatment of
choice. At 36 weeks gestation, amniocentesis should be done in order to assess lung maturity. If the fetal
lungs are mature, elective cesarean section can be performed.
(Choice A) Induction of labor in this setting is dangerous as it will trigger uterine contractions and aggravate
bleeding from a placenta previa.
(Choice B) Emergency cesarean section is done in the case of extended or massive bleeding, regardless of
gestational age. Most women with placenta previa respond well to conservative management and can be
treated with elective cesarean section once stabilized.
(Choice D) Using the forceps implies an advanced stage of labor, which would not be seen in a case of
complete placenta previa.
(Choice E) Since the risk of recurrent bleeding is high, management at home can be considered only in rare
instances wherein the patient is stable, the fetal well being is ascertained and the patient's house is near the
hospital. In the present case, the baby is at term and may be delivered, so there is no reason for the patient
to go back home and risk further bleeding.
Educational objective:
Management of placenta previa depends on the severity of bleeding and the age of the pregnancy. Complete
placenta previa requires delivery by cesarean section as the placenta completely covers the os cervix and the
fetus cannot be delivered vaginally.

A 22-year-old woman presents to office with a 3-week history of scant vaginal discharge. She has no other
complaints. She is sexually active and uses oral contraceptives. She has regular 26-day menstrual cycles
and her last menstrual period was ten days ago. She does not smoke or consume alcohol. Her temperature
is 36.7C (98 F), blood pressure is 120/80 mmHg, pulse is 80/min, and respirations are 14/min. On
examination, the abdomen is non-tender. Yellow mucopurulent discharge is seen at the cervical os. Which of
the following organisms is the most probable cause of this patient's problem?
..; A. Chlamydia trachomatis
B. Neisseria gonorrhoeae
C. Herpes simplex
D. Trichomonas vaginalis
E. Candida albicans
Explanation:
This patient presents with signs and symptoms suggestive of mucopurulent cervicitis. Mucopurulent cervicitis
is a common gynecologic problem, but it is asymptomatic in more then 50% of women with this disease. The
prevalence of this condition in young women is estimated to be as high as 1 0%. The most common cause of
mucopurulent cervicitis is Chlamydia trachomatis. Besides that, cervical ectopy created by oral
contraceptives may preferentially predispose to colonization with C. trachomatis.
Although N. gonorrhoeae (Choice B) is a less common cause, gonococcal infection should be carefully
excluded by Gram staining and culture.
T. Vagina/is (Choice D) and C. albicans (Choice E) are frequent causes of ectocervicitis that is typically
associated with vulvovaginitis.
Herpes simplex (Choice C) can cause cervical inflammation and ulceration, but does not cause
mucopurulent discharge.
Educational objective:
The most common cause of mucopurulent cervicitis is Chlamydia trachomatis.

A 24-year-old female and her husband come to the physician's office for evaluation of infertility. They have
not been able to conceive after 12 months of frequent intercourse without contraception. She has no other
medical problems and takes no medication. Physical examination shows an obese woman with excess thick
hair over her chin and along the linea alba of the lower abdomen. There is no increase in muscles
mass. When asked about the excess hair, she states that she has had it for a long time. Serum
testosterone levels are elevated Which of the following is the most likely cause of her infertility?
A. Abnormal cervical mucus
B. Luteal phase defect
C. Impaired oocyte transport
DES Entrance Exams

D. Impaired zygote implantation


E. Anovulation
Explanation:
The patient described is most likely suffering from polycystic ovary syndrome (PCOS), which is
characterized by anovulation, signs of androgen excess and ovarian cysts. PCOS results from abnormal
GnRH secretion that stimulates the pituitary to secrete excessive luteinizing hormone (LH) and insufficient
follicle stimulating hormone (FSH). Excess LH stimulates excess androgen production by ovarian theca cells
resulting in hirsutism, male escutcheon, acne and androgenic alopecia. Anovulation is caused in part by
imbalances LH and FSH production and in part by insulin resistance in these patients. Anovulation in this
condition can be associated both with amenorrhea and irregular menses occasionally complicated by
menometrorrhagia.
(Choice A) Abnormal cervical mucus can be a cause of infertility. In the setting of cervicitis, the mucus can
become inflamed, thickened or modified in pH. All of these factors impede penetration of the cervical mucus
by spermatozoa.
(Choices B & D) A luteal phase defect indicates poor preparation of the endometrium for implantation due to
a progesterone deficiency. Following ovulation, progesterone is produced in increased amounts by the
corpus luteum.
(Choice C) Impaired oocyte transport in the fallopian tube is commonly the result of previous pelvic
inflammatory disease or endometriosis. Other uncommon causes of ciliary dysmotility may also play a role.
Educational objective:
PCOS is characterized by anovulation or oligo-ovulation, signs of androgen excess, such as male-pattern
hair growth and acne, and ovarian cysts.

A 41-year-old woman, gravida 3, para 3, comes to the physician because of a 2-year history of dysmenorrhea
and menorrhagia that has been increasing in intensity. She has no dyspareunia or any other symptoms. She
has a history of chronic hypertension. She had a cesarean section in her 3rd pregnancy followed by surgical
sterilization. Vital signs are normal. Bimanual examination shows a symmetrically enlarged and tender
uterus with soft consistency and free adnexae. Which of the following is the most likely diagnosis?
., A. Adenomyosis
B. Endometriosis
C. Leiomyomata
D. Endometrial carcinoma
E. Endometritis
Explanation:
Adenomyosis is defined as the presence of endometrial glands in the uterine muscle. This invasion can
extend through the full thickness of the myometrium and in some instances to the serosa of the uterus. It
occurs most frequently in women above 40 and typically presents with severe dysmenorrhea and
menorrhagia. The physical exam reveals an enlarged and generally symmetrical uterus. The differential
diagnosis includes leiomyoma and endometrial carcinoma. For women above 35, it is mandatory to perform
an endometrial curettage to rule out endometrial carcinoma.
(Choice B) Endometriosis is a benign condition where foci of endometrial glands and stroma are found in
locations outside the uterus. The uterus is not diffusely enlarged.
(Choice C) Leiomyomas or uterine fibroids can be very difficult to distinguish from adenomyosis because
both can present with dysmenorrhea, menorrhagia and a large-sized uterus. A uterus affected by fibroids is
usually irregularly shaped.
(Choice D) Endometrial carcinoma typically occurs after menopause. Because this patient is over 35,
endometrial curettage is mandatory to rule it out endometrial carcinoma.
(Choice E) Endometritis manifests with fever, an enlarged and tender uterus and foul smelling vaginal
discharge. It usually occurs after a septic abortion or in the postpartum period (puerperal fever}.
Educational objective:
Adenomyosis occurs most frequently in multiparous women above 40 years of age and typically presents
with dysmenorrhea and menorrhagia. The physical exam reveals an enlarged and generally symmetrical
uterus. In contrast, a fibroid uterus is usually irregularly shaped.

A 28-year-old primigravid woman at 34 weeks gestation is brought to the emergency department following a
motor vehicle accident. She had intense abdominal pain and became agitated and restless in the
ambulance. She has mild vaginal bleeding and diffuse abdominal pain. She is on continuous fetal heart
monitoring. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at
DES Entrance Exams

the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her blood
pressure is 11 0/60mmHg, pulse is 11 0/min and respirations are 32/min. Physical examination shows
hyperventilation, cold extremities and a distended abdomen with irregular contours. F eta I heart monitoring
shows repetitive late decelerations and a long-term variability of 2 cycles/min. Which of the following is the
most likely diagnosis?
A. Abruptio placenta
B. Placenta previa
C. Vasa previa
D. Uterine rupture
E. Rupture of ectopic pregnancy
Explanation:
The patient most likely has a uterine rupture secondary to abdominal trauma. Typically, uterine rupture
presents with intense abdominal pain associated with vaginal bleeding which can range from spotting to
massive hemorrhage. The symptoms the patient had in the ambulance correspond with pain and may
indicate an imminent rupture. After the rupture occurs, the patient may feel slightly relieved, but soon after,
the pain returns in a more diffuse fashion. The presenting part may retract and no longer be palpable on
pelvic exam, whereas the fetal limbs can become easily palpable on abdominal examination. The clinical
presentation is, however, highly variable, so a high index of suspicion is required because any delay in
diagnosis may be fatal for both the mother and the fetus.
(Choice A} Uterine rupture can be difficult to distinguish from abruptio placenta, especially because they can
both be caused by trauma. The abdominal physical findings in this case clearly indicate a uterine rupture,
and uterine rupture is more likely to cause signs of hypovolemia and shock due to rapid exsanguination.
(Choice B) Placenta previa typically presents with painless vaginal bleeding and does not generally lead to
signs of rapid exsanguination as described.
(Choice C) Vasa previa is a rare condition in which the fetal blood vessels traverse the fetal membranes
across the lower segment of the uterus between the fetus and the internal cervical os. It presents with a
painless antepartum hemorrhage associated with rapid deterioration of the fetal heart tracing as it is fetal
blood that is being lost in this condition.
(Choice E) Rupture of an ectopic pregnancy occurs most commonly in the first trimester. The patient
described had a normal ultrasound at 16 weeks gestation.
Educational objective:
Uterine rupture presents with intense abdominal pain associated with vaginal bleeding which can range from
spotting to massive hemorrhage. Patients also typically exhibit vital signs consistent with hypovolemia,
retraction of presenting parts on pelvic exam, and palpability of fetal extremities on abdominal exam.
A 22-year-old, gravida 1 , para 0, at 13 weeks gestation is brought to the emergency department because of
vaginal discharge and lower abdominal discomfort. She has had no passage of tissue from her vagina. She
does not use tobacco, alcohol or drugs. She has no history of trauma. Her temperature is 37.0C (98.7F),
blood pressure is 128/80 mmHg, pulse is 76/min and respirations are 14/min. Physical examination shows a
closed cervix, a slightly tender uterus with a size consistent with gestational age, free adnexae and scant
bright red bleeding from the introitus. Ultrasonogram in the emergency department shows normal fetal heart
motion. She is anxious and concerned about her baby.
Item 1 of2
Which of the following is the most likely diagnosis?
A. Incomplete abortion
B. Threatened abortion
C. Completed abortion
D. Inevitable abortion
E. Ectopic pregnancy
Explan ation:
This patient has a threatened abortion. Threatened abortion is a term used to describe any hemorrhage
occurring before the 20th week of gestation with a live fetus. The cervix is closed and there is no passage of
fetal tissue. Mild lower abdominal pain may be noted and the fetal heart is active on ultrasound. Twenty five
percent of pregnancies have some extent of vaginal bleeding in the first trimester. In half of these cases, a
spontaneous abortion will actually occur.
(Choice A} Incomplete abortion involves the evacuation of some fetal tissue while a remainder is retained in
the uterine cavity. Clinical symptoms include vaginal discharge of blood and tissue-like material, abdominal
cramps and cervical dilation. Retained products of conception can be visualized with transvaginal
ultrasonography.
(Choice C) In complete abortion, the whole conceptus passes through the cervix. After this passage, the
DES Entrance Exams

cervix closes and uterine contractions subside. Ultrasonography shows an empty uterus.
(Choice D) Inevitable abortion manifests with vaginal bleeding, lower abdominal cramps that may radiate to
the back and perineum and a dilated cervix. Ultrasonography demonstrates a ruptured or collapsed
gestational sac with absence of fetal cardiac motion.
(Choice E) Ectopic pregnancy typically presents with acute onset abdominal pain and dark red vaginal
bleeding in the first trimester. Physical exam reveals an adnexal mass, and ultrasonogram shows no
gestational sac in the uterus.
Educational objective:
Threatened abortion is characterized by any hemorrhage occurring before the 20th week of gestation with a
live fetus and a closed cervix.
Item 2 of2
Which of the following is the most appropriate next step in management?
A. Quantitative beta-HCG measurement
B. Hospitalization, bed rest and close observation
C. Intravenous infusion of methotrexate
D. Dilation and suction curettage
.; E. Reassurance and outpatient follow up
Explanation:
The patient described is experiencing a threatened abortion. The first step in a threatened abortion is to
ascertain that the fetus is present and alive. Once this is confirmed with ultrasound, management is
essentially reassurance and performance of an ultrasonogram one week later. Bed rest and abstaining from
sexual intercourse are usually recommended because this will prevent any feelings of guilt on the part of the
parents in the case that pregnancy is actually lost; however, there is no evidence of the benefit of these
interventions on the outcome.
{Choice A} Beta-HCG measurement will not provide any more information and is not needed.
{Choice B) Hospitalization is not necessary in threatened abortion. Bed rest and abstaining from sexual
intercourse can be recommended for the aforementioned reasons.
{Choice C) Methotrexate is used for treatment of ectopic pregnancy. Use of methotrexate in this patient
would terminate the pregnancy - an undesired effect in an otherwise normal intrauterine pregnancy.
{Choice D) Dilation and curettage is a common treatment for missed abortion as the cervix is closed and
expulsion of the expired fetus does not always occur spontaneously.
Educational objective:
Reassurance and outpatient follow up is the standard of care for threatened abortion.

A 28-year-old nulliparous woman presents to your office complaining of fatigue, low mood, and amenorrhea.
She says that it all started two months ago and progressively worsened. She is sexually active and uses
condoms for contraception. Her medical history is unremarkable, and she denies taking any drugs or
medications. Examination reveals dry skin, short eyebrows, a painless and enlarged thyroid gland, and
galactorrhea. The uterus has a normal size, and the adnexae are not palpable. Initial investigations reveal the
following:
Serum pregnancy test
Free T4
Serum TSH
Prolactin
Antimicrosomal antibodies
Negative
2.5 IJg/dL (N= 5- 12)
11 .0 IJU/ml (N= 0.5-5.0)
30 ng/ml ( < 20 ng/ml)
Positive
Of the following, which represents the association between hypothyroidism and hyperprolactinemia in the
above patient?
.; A. TRH stimulates prolactin production
B. TRH stimulates dopamine production
C. TSH inhibits dopamine production
D. TSH stimulates dopamine production
E. Antimicrosomal antibodies stimulate dopamine production
F. Antimicrosomal antibodies inhibits dopamine production
Explanation:
DES Entrance Exams

Prolactin production is inhibited by dopamine and stimulated by serotonin and TRH. An increase in TSH and
TRH production and, consequently, in prolactin release may be the result of hypothyroidism.
Hyperprolactinemia may also affect GnRH and gonadotropin secretion and, thus, result in amenorrhea. Other
causes of high prolactin levels include dopamine antagonists ( antipsychotics, tricyclic antidepressants, and
MAO Is), hypothalamic and pituitary tumors.

Educational Objective:
Prolactin production is stimulated by serotonin and TRH and inhibited by dopamine. Hypothyroidism may
result in amenorrhea and galactorrhea.

A newborn rnale has srnall body size, srnall eye openings, low-set ears, a sunken nasal bridge, flat philtrum
and a thin upper lip. Which of the following is the most likely cause of the fetal condition?
A. Group B streptococcal infection
B. Maternal opioid abuse
C. Maternal alcohol abuse
D. Uncontrolled diabetes mellitus
E. Mycoplasma infection
Explanation:
F eta I alcohol syndrome presents with intrauterine growth retardation (IUGR), microcephaly and facial
dysmorphology. Typical facial findings include midfacial hypoplasia, micrognathia, a flattened (smooth)
philtrum, microphthalmia, short palpebral fissures and a thin upper lip. CNS damage is also typical of the
fetal alcohol syndrome. CNS manifestations include irritability, attention deficit hyperactivity disorder, learning
disabilities and frank mental retardation.
(Choice A) Group B streptococcal infection acquired during birth from a colonized mother can cause
pneumonia, meningitis and sepsis in newborn infants within the first seven days of life.
(Choice B) Maternal opioid abuse results in withdrawal symptoms in the infant following birth. These
symptoms include irritability, tremors, vomiting, diarrhea and salivation. There are long-term CNS deficits in
these infants and an increased risk of SIDS.
(Choice D) Uncontrolled diabetes mellitus results in fetal macrosomia, birth injuries, congenital
malformations, hypoglycemia, polycythemia, respiratory distress and cardiomyopathy among other possible
findings.
(Choice E) Mycoplasma infection is not known to cause any specific fetal defects or malformations.
Educational objective:
Fetal alcohol syndrome is characterized by growth restriction, midfacial hypoplasia, a smooth philtrum, short
palpebral fissures, a thin upper lip and CNS abnormalities.

A 23-year-old female comes to your office to review her daily prescription medications. She had a positive
pregnancy test three days ago despite strict contraception. Her last menstrual period was 5 weeks ago. She
is on albuterol and beclomethasone inhalers for bronchial asthma, isotretinoin for acne, and lithium for bipolar
disorder. Her bipolar disorder has been stable for the past several years. She does not use tobacco,
alcohol, or drugs. Physical examination shows no abnormalities; vital signs are stable. Which of the
following is the most appropriate advice for this patient?
A. Ask her to stop beclomethasone and lithium
B. Ask her to stop beclomethasone, isotretinoin and lithium
C. Ask her to stop isotretinoin and wean lithium
D. Ask her to stop all 4 medications
E. Ask her to continue all 4 medications
Explanation:
The use of lithium in the first trimester is associated with an increased risk of congenital heart disease,
classically Ebstein's anomaly. In patients who have stable bipolar disease, slow tapering of lithium should be
considered. Abrupt discontinuation is not recommended as this may increase the risk of relapse.
lsotretinoin is associated with many congenital abnormalities, including craniofacial dysmorphism, heart
defects, and deafness. It must not be taken by women of reproductive age unless two effective forms of
contraception have been used for at least 1 month prior to initiating treatment. Contraception must be
continued during treatment, and for 1 month after isotretinoin is discontinued. In addition, patients must have
a pregnancy test the week before beginning treatment, and should have periodic pregnancy tests during
therapy, to make sure the patient is not pregnant.
(Choices A & B) There is no evidence that inhaled beclomethasone or albuterol are associated with birth
defects in humans. These can be safely used in pregnancy.
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Educational objective:
Lithium is associated with congenital heart disease, classically Ebstein's anomaly, and should be weaned in
pregnant women with stable bipolar disorder. When a woman is treated with isotretinoin, she should receive
strict contraception. Inhaled steroids can be used during pregnancy.

A 15-year-old girl is being evaluated for primary amenorrhea. She has no other symptoms. She has not
been sexually active. She has no other medical problems and does take any medication. Her family history
is unremarkable. On examination, you note fully developed breasts and absent axillary and pubic
hair. External genitalia have a normal appearance, but the vagina is abnormally short and blind ended. Initial
work-up reveals no uterus on ultrasound, a testosterone level of 400 ng/dl (Normal is 20-80 for a female),
and a 46 XY karyotype. Which of the following events is most likely to have caused the absence of in utero
development of the internal reproductive organs?
A. Absence of mullerian inhibiting factor
B. Presence of mullerian inhibiting factor
C. Agenesis of Wolffian ducts
D. Agenesis of mullerian ducts
E. Testosterone surge
Explanation:
Androgen insensitivity syndrome, sometimes called testicular feminization, is characterized by a defect or
absence of androgen receptors resulting in androgen resistance of peripheral tissues. Consequently,
patients have a female phenotype with a 46 XY genotype. There are still normal testes that are typically found
in the abdomen or inguinal canal, and patients are prone to the development of inguinal hernias. The
mullerian inhibiting factor (MIF) is produced by the testes and prohibits formation of the uterus, fallopian tubes,
and upper portion of the vagina. The testosterone level is elevated for a female, but within the normal range
for a male. Breasts develop because of peripheral conversion of testosterone to estrogen, whereas axillary
and pubic hair does not develop since it is dependent on testosterone. Treatment involves testicular
resection at puberty and creation of a neo vagina
(Choice A) Absence of MIF secretion will result in development of normal female internal organs.
(Choice C) Wolffian ducts are the embryonic precursors of seminal vesicles, epididymis, ejaculatory ducts,
and ductus deferens in males.
(Choice D) Patients with mullerian agenesis may present with primary amenorrhea and nondeveloped
internal reproductive organs, but they have a normal XX karyotype with normal female levels of
testosterone. Patients also have normal axillary and pubic hair development since they can respond
appropriately to testosterone.
(Choice E) A testosterone surge at the appropriate time of gestation can cause virilization of the external
genitalia in female fetuses, but this patient has an XY genotype and normal female external genitalia .
Educational objective:
Patients with androgen resistance present with amenorrhea, normally developed breasts, absent pubic and
axillary hair, absent internal reproductive organs, and a 46 XY karyotype . Serum testosterone levels are in a
range typical for males. The internal reproductive organs do not develop because the testes are still present
and secrete mullerian inhibiting factor.

A 34-year-old primigravida develops severe postpartum bleeding requiring aggressive volume resuscitation
and transfusion of 5 units of packed red blood cells. Her pregnancy was complicated by mild hypertension
and trace proteinuria that was treated with low-dose methyldopa. Her mother suffered from premature
menopause and severe osteoporosis. Seven days after giving birth, she has failed to lactate. Her urinalysis
is insignificant and her blood pressure has ranged from 95 to 110 mmHg systolic and 69 to 75 mmHg
diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in this
patient?
A lnhibin
B. Progesterone
C. Aldosterone
.; D. Prolactin
E. Oxytocin
Explanation:
This patient had a severe postpartum hemorrhage and is unable to lactate several days after delivery. This is
concerning for Sheehan's syndrome. Under normal conditions, the postpartum fall in estrogen and
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progesterone combine with nipple stimulation by a suckling child to increase prolactin concentrations and
promote lactation. However, women who have massive postpartum hemorrhage may develop anterior
pituitary necrosis, or Sheehan's syndrome, due to pituitary hypoperfusion. Hormones secreted from the
anterior pituitary include prolactin , thyroid stimulating hormone (TSH), and follicle stimulating hormone
(FSH). Failure of lactation due to prolactin deficiency is the classic initial presentation of Sheehan's
syndrome. Other complications resulting from anterior pituitary failure include hypothyroidism, amenorrhea,
genital atrophy, loss of pubic and axillary hair, and fatigue.
(Choice A) lnhibins are made by the granulosa cells of ovarian follicles and exert feedback inhibition of
pituitary FSH release. An inhibin deficiency would not be expected to affect postpartum lactation.
(Choice B) Progesterone levels normally fall in the postpartum period and contribute to the disinhibition of
prolactin's lactogenic effects. A postpartum progesterone deficiency would not prevent lactation.
(Choice C) Primary adrenal insufficiency due to adrenal hemorrhage has been associated with postpartum
hemorrhage. Adrenal failure would worsen hypotension and potentially increase the risk of pituitary necrosis,
but it would not directly inhibit this patient's ability to lactate.
(Choice E) Oxytocin causes contraction of mammary gland myoepithelial cells and promotes milk
ejection. A deficiency of this hormone might inhibit milk let down but would not significantly decrease milk
production.
Educational objective:
Failure to lactate is the classic initial presentation of Sheehan's syndrome, or postpartum ischemic necrosis
of the anterior pituitary due to hemorrhagic shock. Failure to produce milk in this condition results from
prolactin deficiency.

A 28-year-old woman is admitted for delivery. She began experiencing regular, painful uterine contractions
three hours ago and her water broke en route to the hospital. The cervix is 5 em dilated and 80%
effaced. The fetal presentation is vertex and the baby's head is at -1 station. After placing a fetal heart
monitor and external tocometer, repetitive decreases in fetal heart rate are noted which begin at the same
time as the contractions and end before the contractions have ceased. Which of the following is most likely
responsible for the fetal heart pattern?
A. Periods of fetal sleep
B. Umbilical cord compression
C. Feta I head compression
D. Uteroplacental insufficiency
E. Intrauterine infection
Explanation:
The pattern of fetal heart rate decelerations described in this vignette is consistent with early
decelerations. An early deceleration is characterized by a drop in fetal heart rate of 15 beats/min which lasts
for at least 15 seconds. The deceleration in heart rate begins with initiation of the uterine contraction, and
resolves by the time the contraction has ceased. Early decelerations are not associated with fetal acidosis or
negative neonatal outcomes. Therefore, they are not classified as a nonreassuring heart rate pattern. Late
decelerations, on the other hand, are associated with fetal acidosis and negative neonatal outcomes, and are
classified as a nonreassuring heart rate pattern. Late decelerations are distinguished from early
decelerations by heart rate depression which begins at or after the peak of the uterine contraction and
continues after the uterine contraction has ceased. Early decelerations occur in the setting of fetal head
compression {Choice C), while late decelerations occur in the setting of uteroplacental insufficiency.
(Choice A) Fetal sleep presents with decreased long-term variability.
(Choice B) Fetal cord compression presents with variable decelerations.
(Choice D) Uteroplacental insufficiency presents with late decelerations.
(Choice E) Intrauterine infections may present with fetal tachycardia (HR > 160).

A 24-year-old primigravid woman at 28 weeks gestation comes to the physician because she has not felt her
baby's movements for the past two weeks. Fetal heart tones are not heard by Doppler. Ultrasonogram
shows absence of fetal cardiac activity. Fetal demise is diagnosed. Laboratory studies show:
Serum fibrinogen level 250 mg/dl (normal is 150 - 450 mg/dl )
Platelets 130 ,OOO/mm3
Prothrombin time
Partial thromboplastin time
15 sec
33 sec
There are no signs of active bleeding. Which of the following is the most appropriate next step in
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management?
A. Transfusion of fresh frozen plasma
B. Platelet transfusion and fibrinogen replacement
C. Immediate induction of labor
0. Emergency cesarean section
E. Weekly fibrinogen monitoring and expect spontaneous delivery
Explanation:
Intrauterine fetal demise (IUFD) refers to death of a fetus in utero that occurs after 20 weeks gestation and
before the onset of labor. Ultrasonography demonstrates an absence of fetal movement and fetal cardiac
activity. After the diagnosis is confirmed, a coagulation profile should be drawn to detect incipient
DIC. Fibrinogen values in the low normal range may be an early sign of consumptive coagulopathy,
especially if there is an associated decrease in platelet count, increase in PT and PTI or the presence of
FOP. If OIC is suspected, delivery should be performed without delay. When fibrinogen levels are normal,
the management decision will depend on the patient's preference: the options are either watchful expectancy
or induction of labor. The logic behind watchful expectancy is that labor occurs spontaneously in 80% of
cases within 2-3 weeks of I UFO. However, this choice is often inappropriate because of the emotional strain
that carrying a dead fetus can cause the mother, as well as the higher risk of complications, such as
chorioamnionitis and DIC, that may occur when the fetus has been retained for several weeks.

(Choice A) Fresh frozen plasma is indicated if DIC and hemorrhage are evident or if the coagulation profile is
profoundly abnormal. In the described patient, fibrinogen levels are low normal and prompt delivery is the
appropriate treatment. Mild coagulation disturbances will correct spontaneously thereafter.
(Choice B) The patient does not need platelet transfusion or fibrinogen replacement because she is not
bleeding and her coagulation profile is not profoundly disturbed.
(Choice D) Vaginal delivery is sufficient to eliminate the risk of DIC. Cesarean section will expose the patient
to further stress and hazards.
(Choice E) The patient's fibrinogen is in the low normal range. If delivery is not accomplished promptly, the
patient may develop frank DIC.
Educational objective:
Labor should be induced immediately in patients with intrauterine fetal demise who develop coagulation
abnormalities. A fibrinogen level in the low-normal range can indicate developing DIC.

A 37-year-old G4 P3 woman delivered a 4,100 gram (9 .02 1bs) infant by spontaneous vaginal delivery one
hour ago. This pregnancy has been complicated by gestational diabetes for which she is being treated with
insulin. The patient is currently on magnesium sulfate for elevated blood pressures and proteinuria. You are
called to evaluate her because she began to have very heavy vaginal bleeding and is feeling lightheaded. Her
blood pressure is 90/60 mmHg and pulse is 98/min. On physical examination you see heavy vaginal bleeding
and numerous blood clots. Her cervix is closed and the uterus can be palpated 3 em above the
umbilicus. The uterus feels boggy.
Item 1 of2
The next best step in management is:
A. Dilatation and curettage
B. Oxytocin infusion
C. Packing of the uterine cavity
D. Cesarean hysterectomy
E. Immediate uterine artery embolization
Explanation:
The first step in a situation of postpartum hemorrhage is general supportive measures. These include:
1 . Fundal or bimanual massage (stimulates the uterus to contract and resolves hemorrhage in most
cases)
2. Intravenous access
3. Crystalloid infusion to keep SBP above 90 mm Hg
4. Notification of blood bank for PRBC
Uterine atony is a common cause of postpartum hemorrhage. Risk factors include uterine hyperdistention
due to a large fetus, as in this case, hydramnios or a multiple gestation and increased parity. A uterotonic
agent such as oxytocin should be administered immediately. Oxytocin will cause contraction of myometrial
fibers and retraction of myometrial blood vessels, thereby controlling bleeding in most cases.
(Choice A) A search for retained intrauterine products of conception is important and if found manual
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removal is attempted. If manual removal is unsuccessful curettage can be performed. However, the initial
important measures are fundal massage, and infusion of crystalloids and uterotonic agent.
(Choice C) Uterine packing for tamponade is performed if medical therapy fails and in conjunction with
preparations for surgery.
(Choice D) Caesarean hysterectomy is used as the last resort but can be effective and lifesaving in the
treatment of postpartum hemorrhage.
(Choice E) Uterine artery embolization or ligation of the uterine or internal iliac arteries can be used for a
patient with stable vital signs and persistent bleeding if the rate of loss is not excessive. It can be used as an
alternative to a hysterectomy in a stable patient who wishes to preserve fertility.
Educational objective:
The most common cause of excess postpartum blood loss is uterine atony. Initial treatment includes
bimanual uterine massage, fluid resuscitation, uterotonic agents (oxytocin, methylergonovine, carboprost),
and blood transfusion as needed.

Item 2 of2
What is the most likely cause of her current condition?
A. Placenta accreta
B. Preeclampsia
C.lnsulin
D. Magnesium sulfate
E. Uterine atony
Explanation:
Uterine atony is the single most common cause (80%) of postpartum hemorrhage (PPH). Risk factors for
uterine atony include uterine overdistention (multiple gestation, polyhydramnios and macrosomia) and uterine
fatigue (prolonged labor).
(Choices A & B) Placenta accreta and preeclampsia are known risk factors for PPH but are not the most
common causes.
(Choice C) Insulin prevents fetal macrosomia if used carefully to avoid hyperglycemia in diabetic mothers
throughout gestation. Use of insulin is therefore helpful in preventing excessive uterine distention and
postpartum uterine atony by preventing macrosomia.
(Choice D) Magnesium sulfate has uterine relaxing properties and can be used as a tocolytic agent for the
prevention of acute preterm labor as well as in the setting of preeclampsia in order to prevent
seizures. However, this alone is less likely to cause PPH.
Educational objective:
The single most common cause of postpartum hemorrhage is uterine atony. Risk factors for uterine atony
include multiparity, prolonged labor and any condition that results in uterine hyperdistention.

A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic
examination reveals abundant mucous and a clear cervical secretion, which when lifted vertically extends in a
long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?
A. Early follicular phase
B. Ovulatory phase
C. Mid luteal phase
D. Late luteal phase
E. The secretion is abnormal
Explanation:
In the ovulatory phase, cervical mucus is profuse, clear and thin in contrast to the mucus of the post- and preovulatory
phases, which is scant, opaque and thick. Evaluation of the cervical mucus is part of the infertility
workup as "hostile" cervical mucus can disallow penetration of spermatozoa into the uterus. Normally,
cervical mucus in the ovulatory phase stretches to approximately 6 em when lifted vertically ( spinnbarkeit), its
pH is 6.5 or greater (more basic than at other phases), and will demonstrate "ferning" when smeared on a
microscope slide.
(Choice A) The early follicular phase immediately follows menstruation. The cervical mucus in this phase is
thick, scant and acidic. It does not allow penetration by spermatozoa.
(Choices C & D) In the mid- and late-luteal phase, ovulation has already occurred. In these phases, the
cervical mucus becomes progressively thicker and exhibits less stretching ability. This mucus is also
inhospitable to sperm .
(Choice E) The secretion described is not abnormal. Abnormal secretions would have a purulent
appearance, a foul odor or other features not typical of ovulatory cervical mucus.
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Educational objective:
In the ovulatory phase of the menstrual cycle, cervical mucus is profuse, clear and thin. It will stretch to
approximately 6 em and exhibit ferning on a microscope slide smear preparation.

A 32-year-old woman, gravida 3, para 2, at 30 weeks gestation comes to the hospital because of new onset
painful, regular uterine contractions that began 5 hours ago. Her pregnancy has been uncomplicated. Her
second pregnancy was complicated by pre term labor at 28 weeks gestation. She has no discharge, leakage
of fluid or bleeding from the vagina; she has no dysuria or urgency. Her temperature is 37.0C (98.7F), blood
pressure is 125/70 mmHg, pulse is 80/min and respirations are 18/min. Pelvic examination shows a soft,
partially effaced and posterior cervix dilated to 2 em. A Nitrazine test is negative. Nonstress test shows a
reassuring fetal heart pattern and uterine contractions occurring every 7 minutes. Which of the following is
the most appropriate next step in management?
-.; A Tocolysis
B. Amnioinfusion
C. Reassure and discharge home
D. Augment delivery
E. Cervical cerclage
Explanation:
Preterm labor is defined as labor occurring after 20 weeks gestation and before 37 weeks gestation. Labor in
this case requires the occurrence of documented uterine contractions at a rate of 4 per 20 minutes or more
and documented cervical changes consistent with labor. Respiratory distress syndrome (RDS) is a
common complication in preterm infants as fetal lung maturity has not yet been reached. Other
complications of pre term birth include intraventricular hemorrhage, sepsis, necrotizing enterocolitis and
kernicterus. The mortality rate in pre term infants is greatly influenced by the gestational age.
The management of acute pre term labor is dependent on the gestational age of the fetus and the presence or
absence of comorbidities that pose extreme risk to the mother and fetus that would mandate a delivery
regardless of dates. In otherwise normal pregnancies, systemic corticosteroids are administered when the
gestational age is between 24 and 34 weeks. This decreases the risk of neonatal respiratory distress.
Tocolysis should then be attempted with the goal being to maintain the pregnancy for at least 48 hours in
order to realize maximum benefit from the steroids. Bed rest and tocolysis are continued as long as possible
with a long-term goal of reaching 34-36 weeks gestational age.
(Choice B) There is no indication that the patient has oligohydramnios.

(Choice C) According to the condition of the cervix, the patient described is in actual labor; therefore, she
cannot be discharged home. This decision would be appropriate in the setting of false labor, which presents
with painless, sporadic contractions without cervical changes.
(Choice D) Delivery would result in preterm birth with all its associated fetal complications.
(Choice E) Cerclage is used to treat or prevent first trimester abortions when the cause is an incompetent
cervix.
Educational objective:
For acute preterm labor bed rest and tocolysis are continued as long as possible with a long-term goal of
reaching 34-36 weeks gestational age.

A 15-year-old girl is being evaluated for primary amenorrhea. Her previous medical history is unremarkable
and she denies taking any medications. Examination reveals absent breasts as well as pubic and axillary
hair. Vaginal examination could not be performed. Olfactory exam reveals an inability to identify different
odors. Ultrasound shows a uterus and two ovaries; serum FSH level is 2 U/L (Normal is 4-30). Which of the
following is the most likely karyotype to be found in this patient?
A 45 XO
B.45 YO
C. 46 XX
D. 46 XY
E. 47 XXY
Explanation:
Kallmann's syndrome consists of a congenital absence of GnRH secretion (i.e. hypogonadotropic
hypogonadism) associated with anosmia. Patients have a normal XX genotype and normal female internal
reproductive organs. They present with amenorrhea and absent secondary sexual characteristics such as
breast development and pubic hair; the addition of anosmia to the presentation may suggest the
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diagnosis. Abnormal development of the olfactory bulbs and tracts result in hyposmia or anosmia
(decreased sense of smell). The FSH and LH levels are low, in contrast to the levels in primary ovarian
failure which are usually elevated.
(Choice A) 45 XO is the genotype found in patients with Turner syndrome. These patients have primary
amenorrhea, but the FSH level is generally elevated due to primary ovarian failure.
(Choice B) The X chromosome has many genes that are necessary for life, therefore 45 YO is not a viable
genotype.
(Choice D) 46 XY is the normal male genotype, but can result in a female phenotype in patients with
androgen insensitivity or 5-alpha-reductase deficiency. Patients with these disorders will not have normal
ovaries.
(Choice E) Patients with 47 XXY have Klinefelter's syndrome, which is associated with a male phenotype
with small testes.
Educational objective:
Patients with Kallmann's syndrome present with primary amenorrhea and anosmia. They have a normal
female karyotype and will have laboratory findings consistent with GnRH deficiency (i.e. low FSH and LH).

A 34-year-old woman presents to the physician's office for infertility evaluation. Her cycles have been
irregular for the past 12 months and she hasn't had any periods for the past 3 months. Previously, her cycles
were quite regular. She also has hot flashes, dyspareunia and mood disturbances. She has been married
for 6 years and has a three-year-old daughter. She has a history of Hashimoto thyroiditis and is on thyroid
replacement therapy. She smokes one pack of cigarettes daily. Vital signs are normal. Pelvic examination
reveals atrophic vaginal mucosa. Serum FSH is markedly elevated, and serum prolactin is normal. Serum
TSH is within normal limits Which of the following is the most appropriate treatment for her infertility?
A. Clomiphene citrate
B. Metformin
C. GnRH agonist
D. Progesterone supplement
E. In vitro fertilization
Explanation:
Premature ovarian failure is characterized by amenorrhea, hypoestrogenism, and elevated serum
gonadotropin levels in women younger than 40 years of age. It may be secondary to accelerated follicle
atresia or a low initial number of primordial follicles. It is most commonly idiopathic but may also be due to
mumps, oophoritis, irradiation or chemotherapy. It can be associated with autoimmune disorders such as
Hashimoto thyroiditis, Addison disease, type I diabetes mellitus and pernicious anemia, which supports the
hypothesis that at least some cases of idiopathic premature ovarian failure are of autoimmune
origin. Women present with signs and symptoms that are similar to those seen in menopause. The
diagnosis is confirmed by demonstrating increased serum FSH and LH levels and decreased estrogen
levels. Patients with premature ovarian failure lack viable oocytes, so the only option available to allow
pregnancy in such patients is in-vitro fertilization.
(Choice A} Clomiphene citrate is an estrogen analog that can be used to induce ovulation in anovulatory
women who do have some ovulatory reserve, such as patients with PCOS.
(Choice B) Metformin may be used to promote ovulation in patients with PCOS as the insulin resistance
seen in this condition may contribute to the inability to ovulate normally.

(Choice C) GnRH agonists are used in a pulsatile fashion to induce ovulation and as a chronic therapy to
suppress ovulation. The patient described can not be made to ovulate with this agent for the same reason
that clomiphene treatment would be ineffective.
(Choice D) Progesterone is used to correct a luteal phase defect, which is characterized by failure of the
corpus luteum to produce sufficient progesterone to maintain the endometrium and allow implantation of an
embryo.
Educational objective:
Infertility in premature ovarian failure is treated with in vitro fertilization in women who desire pregnancy.

A 36-year-old woman comes to your office complaining of a 12-month history of inter-menstrual bleeding and
heavy menses. She has had type-2 diabetes for the past 4-years, managed with glipizide and
metformin. She has no family history of gynecological malignancies. She does not use tobacco or
alcohol. Her temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg. Her BMI is 30
Kg/m2. Physical examination shows pale mucus membranes. Pelvic examination is within normal limits; no
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vaginal lesions are noted. Urine pregnancy test is negative. Her hemoglobin is 1 0.8 g/dl and platelet count is
223 ,OOO/mm3. Coagulation studies are within normal limits. Which of the following is the most appropriate
next step in management?
A. Prescribe combined oral contraceptive pills
B. Conjugated estrogens for 3-months
C. Cyclic progestins
D. Endometrial ablation
., E. Endometrial biopsy
Explanation:
Dysfunctional Uterine Bleeding (DUB) refers to heavy vaginal bleeding that occurs in the absence of
structural or organic disease. This woman's normal pelvic exam and negative pregnancy test suggest
DUB. Endometrial biopsy is required in selected patients to rule out endometrial hyperplasia or
carcinoma. These patients include those who are > 35 years of age, obese, chronically hypertensive, or
diabetic. This patient has 3 of 4 risk factors; therefore, she is a high-risk patient and should undergo
endometrial biopsy prior to any form of treatment. If biopsy is negative for hyperplasia or carcinoma, then she
can be treated with cyclic progestins. Endometrial ablation or hysterectomy is indicated only if hormonal
therapy fails.
Educational objective:
Endometrial biopsy is indicated in cases of DUB affecting women > 35 years old. It is also indicated in cases
of DUB if hypertension, diabetes, or obesity are present.

99. A 16-yea r-ol d pri mi gra vi da pres ents to your office a t 38 weeks ges ta on. Her firs t tri mes ter bl ood
pres s ure wa s 100/72. Toda y i t i s 170/110 mm
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Hg a nd s he ha s 4+ protei nuri a on a cl ea n ca tch s peci men of uri ne. She ha s s i gni fica nt s wel l i ng of
her fa ce a nd extremi es . She deni es ha vi ng
contra cons . Her cervi x i s cl os ed a nd uneffa ced. The ba by i s breech by beds i de ul tra s onogra phy. She
s a ys the ba bys movements ha ve decrea s ed
i n the pa s t 24 hours . Whi ch of the fol l owi ng i s the bes t next s tep i n the ma na gement of thi s pa ti ent?
a . Send her to l a bor a nd del i very for a BPP.
b. Send her home wi th i ns tructi ons to s ta y on s tri ct bed res t unti l her s wel l i ng a nd bl ood pres s ure i
mprove.
c. Admi t her to the hos pi ta l for enforced bed res t a nd di ureti c thera py to i mprove her s wel l i ng a nd bl
ood pres s ure.
d. Admi t her to the hos pi ta l for i nducti on of l a bor.
e. Admi t her to the hos pi ta l for ces a rea n del i very. @
The answer is e. (Cunningham, pp 707, 729-733, 992.) Hypertens i on i s di a gnos ed i n pregna ncy when
the res ng bl ood pres s ure i s 140/90 mm Hg or
grea ter. The pa ent ma y ha ve a hi s tory of chroni c hypertens i on. Ges ta ona l hypertens i on i s di a gnos
ed i f the pa ent devel ops hypertens i on
wi thout protei nuri a duri ng the pregna ncy. Preecl a mps i a i s di a gnos ed when the hypertens i on i s a s s
oci a ted wi th protei nuri a of grea ter tha n 300 mg
i n a 24 hour col l econ or pers i s tent 1+ protei nuri a i n ra ndom uri ne s a mpl i ng. The trea tment for ges
ta ona l hypertens i on a nd preecl a mps i a i s
del i very. Sel ect preterm pa ents ma y be ma na ged cons erva vel y a t home or i n the hos pi ta l dependi
ng upon the s everi ty of the hypertens i on. BPP
tes ng i s us eful when fol l owi ng the pa ent cons erva vel y. Al though bed res t ma y tra ns i entl y i
mprove el eva ted bl ood pres s ure, a pa ent a t ful l
term s houl d be del i vered. Ba s ed on the s everi ty of thi s pa ents bl ood pres s ure a nd the 4+ protei nuri
a , s he ha s s evere preecl a ms i a a nd s he
s houl d be del i vered. Si nce thi s pa ents fetus i s breech, ces a rea n del i very ra ther tha n i nducon of l a
bor i s the next bes t s tep i n her ma na gement.
Di urecs s houl d not be us ed i n the ma na gement of preecl a mps i a , a s they depl ete the ma terna l i ntra
va s cul a r vol ume a nd ma y compromi s e
pl a centa l perfus i on.

97. A new pa ent pres ents to your office for her firs t prena ta l vi s i t. By her l a s t mens trua l peri od s he i
s 11 weeks pregna nt. Thi s i s the firs t
pregna ncy for thi s 36-yea r-ol d woma n. She ha s no medi ca l probl ems . At thi s vi s i t you obs erve tha t
her uterus i s pa l pa bl e mi dwa y between the
pubi c s ymphys i s a nd the umbi l i cus . No feta l hea rt tones a re a udi bl e wi th the Doppl er s tethos cope.
Whi ch of the fol l owi ng i s the bes t next s tep i n
the ma na gement of thi s pa ti ent?
a . Rea s s ure her tha t feta l hea rt tones a re not yet a udi bl e wi th the Doppl er s tethos cope a t thi s ges ta
ti ona l a ge.
b. Tel l her the uteri ne s i ze i s a ppropri a te for her ges ta ti ona l a ge a nd s chedul e her for routi ne ul tra s
onogra phy a t 20 weeks .
c. Schedul e geneti c a mni ocentes i s ri ght a wa y beca us e of her a dva nced ma terna l a ge.
d. Schedul e her for a di l a on a nd curea ge beca us e s he ha s a mol a r pregna ncy s i nce her uterus i s
too l a rge a nd the feta l hea rt tones a re not
a udi bl e.
e. Schedul e a n ul tra s ound a s s oon a s pos s i bl e to determine the gestational age a nd vi a bi l i ty of the
fetus . @
The answer is e. (Cunningham, pp 199-200, 257-259.) At 11 weeks of ges ta on, the uterus i s s l l wi thi
n the pel vi s a nd s houl d not be pa l pa bl e
a bove the s ymphys i s pubi s . A uterus tha t i s pa l pa bl e mi dwa y between the s ymphys i s pubi s a nd the
umbi l i cus i s 14 to 16 weeks i n s i ze. The feta l
hea rt tones a re a udi bl e i n mos t pa ents a t 10 weeks . If no feta l hea rt tones a re a udi bl e by Doppl er a
DES Entrance Exams

us cul ta on a nd the pa ent i s 10 weeks or


more, a n ul tra s ound of the pregna ncy s houl d be ordered. Mol a r pregna ncy, twi n ges ta on, i ncorrect
da tes , a nd uteri ne fibroi ds a re a l l pos s i bl e
di a gnos es when the uterus i s l a rge for da tes ; therefore, ul tra s onogra phy i s the firs t s tep i n the eva l
ua on of s i ze/da te di s crepa ncy. Al though
mol a r pregna ncy i s a n i ndi ca on for di l a on a nd curea ge, the procedure i s not i ndi ca ted before
eva l ua on of the pa ent wi th ul tra s onogra phy.
Thi s pa ent i s of a dva nced ma terna l a ge (>35 yea rs of a ge a t the me of del i very), however, genec a
mni ocentes i s s houl d not be performed
wi thout fi rs t knowi ng the ges ta ti ona l a ge a nd vi a bi l i ty of the pregna ncy.

98. A hea l thy 30-yea r-ol d G2P1001 pres ents to the obs tetri ci a ns office a t 34 weeks for a roune prena
ta l vi s i t. She ha s a hi s tory of a ces a rea n
s econ (l ow tra ns vers e) performed s econda ry to feta l ma l pres enta on (footl i ng breech). Thi s
pregna ncy, the pa ent ha s ha d a n uncompl i ca ted
prena ta l cours e. She tel l s her phys i ci a n tha t s he woul d l i ke to undergo a tri a l of l a bor duri ng thi s
pregna ncy. However, the pa ent i s i nteres ted i n
perma nent s teri l i za on a nd wonders i f i t woul d be beer to undergo a nother s chedul ed ces a rea n s
econ s o s he ca n ha ve a bi l a tera l tuba l
l i ga ti on performed a t the s a me ti me. Whi ch of the fol l owi ng s ta tements i s true a nd s houl d be rel a
yed to the pa ti ent?
a . A hi s tory of a previ ous l ow tra ns vers e ces a rea n s ecti on i s a contra i ndi ca ti on to va gi na l bi rth a
fter ces a rea n s ecti on (VBAC).
b. Her ri s k of uteri ne rupture wi th a ttempted VBAC a fter one pri or l ow tra ns vers e ces a rea n s ecti on i
s 4% to 9%.
c. Her cha nce of ha vi ng a s ucces s ful VBAC i s l es s tha n 60%.
d. The pa ti ent s houl d s chedul e a n el ecti ve i nducti on i f not del i vered by 38 weeks .
e. If the pa ent des i res a bi l a tera l tuba l l i ga on, i t i s s a fer for her to undergo a va gi na l del i very fol l
owed by a pos tpa rtum tuba l l i ga on ra ther
tha n a n el ecti ve repea t ces a rea n s ecti on wi th i ntra pa rtum bi l a tera l tuba l l i ga ti on. @
The answer is e. (Cunningham, pp 567-571.) The des i re for s teri l i za on i s not a n i ndi ca on for a n el
ecve repea t ces a rea n s econ. The morbi di ty
of repea t ces a rea n s econ i s grea ter tha n tha t of va gi na l bi rth wi th pos tpa rtum tuba l l i ga on. The
ri s k of uteri ne rupture i n a woma n who
undergoes a tri a l of l a bor a nd ha s ha d one pri or ces a rea n s econ i s a pproxi ma tel y 0.6%. Wi th a hi s
tory of two pri or ces a rea n s econs , the ri s k of
uteri ne rupture i s a bout 1.8%. The ri s k of uteri ne rupture i n s omeone who ha s ha d a cl a s s i ca l or T-s
ha ped uteri ne i nci s i on i s 4% to 6%. The
s ucces s ra te for a tri a l of l a bor i s genera l l y a bout 60% to 80%. Succes s ra tes a re hi gher when the ori
gi na l ces a rea n s econ wa s performed for
breech or a nonrea s s uri ng feta l hea rt ra te tra ci ng ra ther tha n dys toci a . Inducon of l a bor s houl d
not be performed wi thout a n obs tetri ca l
i ndi ca ti on (eg, preecl a mps i a ) a t l es s tha n 39 weeks .

100. Whi l e you a re on ca l l a t the hos pi ta l coveri ng l a bor a nd del i very, a 32-yea r-ol d G3P2002, who i
s 35 weeks of ges ta on, pres ents compl a i ni ng
of l ower ba ck pa i n. The pa ti ent i nforms you tha t s he ha d been l i fti ng s ome hea vy boxes whi l e fi xi ng
up the ba bys nurs ery. The pa ti ents pregna ncy
ha s been compl i ca ted by di et-control l ed ges ta ona l di a betes . She deni es a ny regul a r uteri ne contra
cons , rupture of membra nes , va gi na l
bl eedi ng, or dys uri a . She deni es a ny fever, chi l l s , na us ea , or emes i s . She reports tha t the ba by ha s
been movi ng norma l l y. She i s a febri l e a nd her
bl ood pres s ure i s norma l . On phys i ca l exa mi na on, you note tha t the pa ent i s obes e. Her a bdomen
i s s o a nd nontender wi th no pa l pa bl e
contra cons or uteri ne tendernes s . No cos tovertebra l a ngl e tendernes s ca n be el i ci ted. On pel vi c exa
DES Entrance Exams

mi na on her cervi x i s l ong a nd cl os ed. The


externa l feta l moni tor i ndi ca tes a rea cve feta l hea rt ra te s tri p; there a re ra re i rregul a r uteri ne
contra cons demons tra ted on the tocometer. The
pa ti ents uri na l ys i s comes ba ck wi th tra ce gl ucos e, but i s otherwi s e nega ti ve. The pa ti ents mos t l i
kel y di a gnos i s i s whi ch of the fol l owi ng?
a . La bor
b. Mus cul os kel eta l pa i n @
c. Uri na ry tra ct i nfecti on
d. Chori oa mni oni ti s
e. Round l i ga ment pa i n
The answer is b. (Cunningham, p 210.) Lower ba ck pa i n i s a common compl a i nt i n pregna ncy a nd i s
reported by a bout 50% of pregna nt women. It
i s ca us ed by s tres s pl a ced on the l ower s pi ne a nd a s s oci a ted mus cl es a nd l i ga ments by the gra vi d
uterus , es peci a l l y i n l a te pregna ncy. The pa i n
ca n be exa cerba ted wi th exces s i ve bendi ng a nd l i i ng. In a ddi on, obes i ty predi s pos es the pa ent
to l ower ba ck pa i n i n pregna ncy. Trea tment
opons i ncl ude hea t, ma s s a ge, a nd a na l ges i a . Thi s pa ent ha s no evi dence of l a bor s i nce s he i s l
a cki ng regul a r uteri ne contra cons a nd cervi ca l
cha nge. Wi thout a ny uri na ry s ymptoms or a uri na l ys i s s ugges ve of i nfecon, a uri na ry tra ct i
nfection i s unl i kel y. The di a gnos i s of
chori oa mni oni s does not fit s i nce the pa ent ha s i nta ct membra nes , no fever, a nd a nontender uterus
. Round l i ga ment pa i n i s cha ra cteri zed by
s ha rp groi n pa i n.

77. A 26-yea r-ol d G1P0 pa tient a t 34 weeks ges ta tion i s bei ng eva l ua ted wi th Doppl er ul tra s ound s
tudi es of the feta l umbi l i ca l a rteri es . The
pa tient i s a hea l thy s moker. Her fetus ha s s hown evi dence of i ntra uteri ne growth res tri con (IUGR) on
previ ous ul tra s ound exa mi na ons . The
Doppl er s tudi es currentl y s how tha t the s ys tol i c to di a s tol i c ra o (S/D) i n the umbi l i ca l a rteri es i
s much hi gher tha n i t wa s on her l a s t ul tra s ound
3 weeks a go a nd there i s now revers e di a s tol i c fl ow. Whi ch of the fol l owi ng i s correct i nforma ti on to
s ha re wi th the pa ti ent?
a . The Doppl er s tudi es i ndi ca te tha t the fetus i s doi ng wel l .
b. Wi th a dva nci ng ges ta ti ona l a ge the S/D ra ti o i s s uppos ed to ri s e.
c. Thes e Doppl er fi ndi ngs a re norma l i n s omeone who s mokes .
d. Revers e di a s tol i c fl ow i s norma l a s a pa ti ent a pproa ches ful l term.
e. The Doppl er s tudi es a re worri s ome a nd i ndi ca te tha t the feta l s ta tus i s deteri ora ti ng. @
77. The answer is e. (Cunningham, pp 343-345, 363-364, 850-851.) Si mpl e connuous -wa ve Doppl er ul
tra s ound ca n be us ed to di s pl a y flow vel oci ty
wa veforms a s a function of time. Wi th i ncrea s ed ges tationa l a ge, i n norma l pregna ncy there i s a n i
ncrea s e i n end-di a s tol i c flow vel oci ty rel a ve
to pea k s ys tol i c vel oci ty, whi ch ca us es the S/D ra o to decrea s e wi th a dva nci ng ges ta on. An i
ncrea s e i n S/D ra o i s a s s oci a ted wi th i ncrea s ed
res i s ta nce i n the pl a centa l va s cul a r bed a s ca n be noted i n preecl a mps i a or feta l growth reta rda
on. Ni cone a nd ma terna l s moki ng ha ve a l s o
been reported to i ncrea s e the S/D ra tio. Ma ny s tudi es document the va l ue of umbi l i ca l Doppl er flow s
tudi es i n recogni on of feta l compromi s e. It
s eems tha t the S/D ra o i ncrea s es a s the feta l condi tion deteri ora tes ; thi s i s mos t s evere i n ca s es of
a bs ent or revers ed end di a s tol i c flow. In
norma l twi ns , the S/D ra o fa l l s wi thi n the norma l ra nge for s i ngl etons . Doppl er s tudi es ha ve been
us ed for i ntens i ve s urvei l l a nce i n ca s es of
twi n-to-twi n tra ns fus i on.

78. A 17-yea r-ol d pri mi pa ra pres ents to your office a t 41 weeks . Her pregna ncy ha s been uncompl i ca
ted. Beca us e her cervi x i s unfa vora bl e for
DES Entrance Exams

i nducon of l a bor, s he i s bei ng fol l owed wi th bi ophys i ca l profil e (BPP) tes ng. Whi ch of the fol l owi
ng i s correct i nforma on to s ha re wi th the
pa ti ent rega rdi ng BPPs ?
a . BPP tes ng i ncl udes a s s es s ment of a mni oc flui d vol ume, feta l brea thi ng, feta l body movements ,
feta l body tone, a nd contra con s tres s
tes ti ng.
b. The fa l s e-nega ti ve ra te of the BPP i s 10% s o a rea s s uri ng BPP s houl d be repea ted i n 48 hours .
c. Fa l s e-pos i ti ve res ul ts on BPP a re ra re even i f the a mni oti c fl ui d l evel i s l ow.
d. Sponta neous decel era ti ons duri ng BPP tes ti ng a re a s s oci a ted wi th s i gni fi ca nt feta l morbi di ty. @
e. A norma l BPP s houl d be repea ted i n 1 week to 10 da ys i n a pos tterm pregna ncy.
78. The answer is d. (Cunningham, pp 341-346.) The BPP i s ba s ed on FHR moni tori ng (genera l l y NST) i
n a ddi on to four pa ra meters obs erved on rea l -
me ul tra s onogra phy: a mni oc flui d vol ume, feta l brea thi ng, feta l body movements , a nd feta l body
tone. Ea ch pa ra meter gets a s core of 0 or 2. A
s core of 8 or 10 i s cons i dered norma l , a s core of 6 i s equi voca l , a nd a s core of 4 or l es s i s a bnorma l a
nd prompts del i very. The fa l s e-nega ve ra te
for the BPP i s l es s tha n 0.1%, but fa l s e-pos i ve res ul ts a re rel a vel y frequent, wi th poor s peci fici ty.
Ol i gohydra mni os i s a n omi nous s i gn, a s a re
s ponta neous decel era ons . In pa ents wi th profil e s cores of 8 but wi th s ponta neous decel era ons ,
the ra te of ces a rea n del i very i ndi ca ted for
feta l di s tres s ha s been 25%. Tes ng more frequentl y tha n every 7 da ys i s recommended i n pa ents wi
th pos erm pregna nci es , connecve s s ue
di s ea s e, chroni c hypertens i on, a nd s us pected feta l growth reta rda ti on, a s wel l a s i n pa ti ents wi th
previ ous feta l dea th.

79. A pa ent comes to your office wi th her l a s t mens trua l peri od 4 weeks a go. She deni es a ny s
ymptoms s uch a s na us ea , fa gue, uri na ry
frequency, or brea s t tendernes s . She thi nks tha t s he ma y be pregna nt beca us e s he ha s not ha d her
peri od yet. She i s very a nxi ous to find out
beca us e s he ha s a hi s tory of a previ ous ectopi c pregna ncy a nd wa nts to be s ure to get ea rl y prena ta l
ca re. Whi ch of the fol l owi ng a cons i s mos t
a ppropri a te a t thi s ti me?
a . No a cti on i s needed beca us e the pa ti ent i s a s ymptoma ti c, ha s not mi s s ed her peri od, a nd ca nnot
be pregna nt.
b. Order a s erum qua nti ta ti ve pregna ncy tes t. @
c. Li s ten for feta l hea rt tones by Doppl er equi pment.
d. Perform a n a bdomi na l ul tra s ound.
e. Perform a bi ma nua l pel vi c exa mi na ti on to a s s es s uteri ne s i ze.
79. The answer is b. (Cunningham, pp 242-246.) Na us ea , fa gue, brea s t tendernes s , a nd uri na ry
frequency a re a l l common s ymptoms of pregna ncy, but
thei r pres ence ca nnot defini vel y ma ke the di a gnos i s of pregna ncy beca us e they a re nons peci fic a nd
a re not cons i s tentl y found i n ea rl y
pregna ncy. Thes e s ymptoms ma y a l s o be pres ent jus t pri or to mens trua on. On phys i ca l exa mi na
on, the pregna nt uterus enl a rges a nd becomes
more boggy a nd s o, but thes e cha nges a re not us ua l l y a ppa rent unl a er 6 weeks ges ta ona l a ge.
In a ddi on, other condi ons s uch a s
a denomyos i s , fibroi ds , or previ ous pregna nci es ca n res ul t i n a n enl a rged uterus pa l pa bl e on phys i
ca l exa mi na on. Abdomi na l ul tra s ound wi l l
not demons tra te a ges ta ona l s a c unl a ges ta ona l a ge of 5 to 6 weeks i s rea ched nor wi l l i t detect
a n ectopi c pregna ncy a t the me of the
mi s s ed mens trua l peri od. It i s therefore not i ndi ca ted i n thi s pa ent. A Doppl er s tethos cope wi l l
detect feta l ca rdi a c a con us ua l l y no s ooner
tha n 10 weeks . A s ens i ve s erum qua nta ve pregna ncy tes t ca n detect HCG l evel s by 8 to 9 da ys pos
tovul a on, a nd i t i s therefore the mos t
a ppropri a te next s tep i n the eva l ua ti on of thi s pa ti ent.
DES Entrance Exams

80. A pa ent pres ents for her firs t i ni a l OB vi s i t a er ha vi ng a pos i ve home pregna ncy tes t. She
reports a l a s t mens trua l peri od of a bout 8
weeks a go. She s a ys s he i s not enrel y s ure of her da tes , however, beca us e s he ha s a l ong hi s tory of i
rregul a r mens es . Her uri ne pregna ncy tes t i n
your offi ce i s pos i ti ve. Whi ch of the fol l owi ng i s the mos t a ccura te wa y of da ti ng thi s pa ti ents
pregna ncy?
a . Determi na ti on of uteri ne s i ze on pel vi c exa mi na ti on
b. Qua nti ta ti ve s erum huma n chori oni c gona dotropi n (HCG) l evel
c. Crown-rump l ength on a bdomi na l or va gi na l ul tra s ound @
d. Determi na ti on of proges terone l evel a l ong wi th s erum HCG l evel
e. Qua nti fi ca ti on of a s erum es tra di ol l evel
80. The answer is c. (Cunningham, pp 78, 195, 352-353, 598-600.) Mea s urement of the feta l crown-rump
l ength i s the mos t a ccura te mea ns of es ma ng
ges ta ona l a ge. In the firs t tri mes ter, thi s ul tra s ound mea s urement i s a ccura te to wi thi n 3 to 5 da ys
. Es ma ng the uteri ne s i ze on phys i ca l
examination can result in an error of 1 to 2 weeks in the first trimester. Quantification of s erum HCG ca nnot
be us ed to determi ne ges ta tiona l age,
because a t a ny gestational age the HCG number can vary widely in normal pregnancies . A single serum
progesterone l evel cannot be used to date a pregnancy; however, it can be used to esta blish that an early
pregnancy is developing normally. Serum progesterone levels less than 5 ng/mL
usually indicate a nonviable pregnancy, while levels greater than 25 ng/mL indicate a norma l intrauterine
pregnancy. Progesterone levels in conjunction wi th qua nti ta ti ve HCG l evel s a re often us ed to determine
the presence of an ectopic pregnancy.

81. A healthy 20-year-old G1P0 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 fol lowing tests is not part of the
recommended first trimester blood testing for this patient?
a . Complete blood count (CBC)
b. Screeni ng for huma n i mmunodefi ci ency vi rus (HIV)
c. Hepatitis B surface antigen
d. Blood type and screen
e. One-hour glucos e challenge testing @
81. The answer is e. (Cunningham, pp 194, 197, 1105-1107.) A 1-hour gl ucos e cha l l enge tests hould be
performed between 24 a nd 28 weeks for women
a t ri s k for gestational diabetes . It is recommended that all women undergo tests for hepatitis B, HIV, type
and screen, and CBC at the first prenatal visit.

83. A hea l thy 31-year-ol d G3P2002 pa ti ent pres ents to the obs tetri ci a ns offi ce a t 34 weeks ges ta ti
ona l a ge for a routi ne return vi s i t. She ha s ha d a n
unevenul pregna ncy to da te. Her ba s el i ne bl ood pres s ures were 100 to 110/60 to 70 i n the firs t tri
mes ter, a nd s he ha s ga i ned a tota l of 20 l b s o
far. During the visit, the patient complains of swelling i n both feet a nd a nkl es that ometimes ca us es her
feet to a che a t the end of the da y. Her
urine dip indicates trace protein, and her blood pressure in the office is currently 115/75. She deni es a ny
other s ymptoms or complaints . On
physical examination, there is piting edema of both feet and ankles extending to the lower one-half of the legs
. There is no calf tendernes s .
Which of the following is the mos t appropriate respons e to the patients concern?
a . Prescribe furosemide to relieve the painful swelling.
b. Send the patient to the radiology department to have venous Doppler studies done to rule out deep vein
thromboses .
c. Admit the patient to Labor nd Delivery 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 s welling is caused by too much salt intake and instruct her to follow a l ow-
DES Entrance Exams

sodium diet.
83. The answer is d. (Cunningham, pp 112 119, 1019-1024.) Increa s ed flui d retention manifested by
piting edema of the ankles and legs is a normal
finding in late pregnancy. During pregnancy, there is a decrease in colloid osmotic pressure and a fa ll in
plasma osmolality. Moreover, there is an increase in venous pressure created by partial occlusion of the vena
cava by the gravid uterus . These physiologic changes contribute to bilateral pedal edema . Diuretics are
sometimes given to pregnant women who have chronic hypertension, but should not be g ven in pregnancy
to treat
physiologic pedal edema . More commonly, furosemide is used in the acute seting to treat pulmonary edema
associated with severe
preeclampsia . This patient is not hypertens i ve a nd does not ha ve any other signs or s ymptoms of preecl a
mps i a a nd therefore does not need to be
admitted for a further workup. Trace protein in the urine is common in normal pregna ncies and is not of
concern. Doppler studies of the lower
extremities are not indicated in thi patient since the history and examination (specifically, the lack of calf
tenderness ) are consistent with
physiologic edema . The normals welling detected in pregnancy is not prevented by a low-sodium diet or
improved with a lower intake of salt

84. A 28-yea r-ol d G1P0 pres ents to your office a t 24 weeks ges ta ona l a ge for a n uns chedul ed vi s i t s
econda ry to ri ght-s i ded groi n pa i n. She
des cri bes the pa i n a s s ha rp a nd occurri ng wi th movement a nd exerci s e. She deni es a ny cha nge i n uri
na ry or bowel ha bi ts . She a l s o deni es a ny
fever or chi l l s . The a ppl i ca on of a hea ng pa d hel ps a l l evi a te the di s comfort. As her obs tetri ci a n,
wha t s houl d you tel l thi s pa ent i s the mos t
l i kel y eti ol ogy of thi s pa i n?
a . Round l i ga ment pa i n @
b. Appendi ci ti s
c. Preterm l a bor
d. Ki dney s tone
e. Uri na ry tra ct i nfecti on
84. The answer is a. (Cunningham, pp 22-26, 1034-1039.) The pa ent i s gi vi ng a cl a s s i c des cri pon
of round l i ga ment pa i n. Ea ch round l i ga ment
extends from the l a tera l poron of the uterus bel ow the ovi duct, tra vel s i n a fol d of peri toneum downwa
rd to the i ngui na l ca na l a nd i ns erts i n the
upper poron of the l a bi um ma jus . Duri ng pregna ncy, thes e l i ga ments s tretch a s the gra vi d uterus
grows fa rther out of the pel vi s a nd ca n thereby
ca us e s ha rp pa i ns , pa rcul a rl y wi th s udden movements . Round l i ga ment pa i n i s us ua l l y more
frequentl y experi enced on the ri ght s i de due to the
dextrorota on of the uterus tha t commonl y occurs i n pregna ncy. Us ua l l y thi s pa i n i s grea tl y i
mproved by a voi di ng s udden movements a nd by ri s i ng
a nd s ing down s l owl y. Loca l hea t a nd a na l ges i cs ma y a l s o hel p wi th pa i n control . The di a gnos i
s of a ppendi ci s i s not l i kel y beca us e the
pa ent i s not experi enci ng a ny fever or a norexi a . In a ddi on, beca us e the gra vi d uterus pus hes the a
ppendi x out of the pel vi s , pregna nt women
wi th a ppendi ci s oen ha ve pa i n l oca ted much hi gher tha n the groi n a rea . The di a gnos i s of
preterm l a bor i s unl i kel y beca us e the pa i n i s
l oca l i zed to the groi n a rea on one s i de a nd i s a l l evi a ted wi th a hea ng pa d. La bor contra cons
genera l l y ca us e genera l i zed a bdomi na l a nd l ow
ba ck pa i n. In a ddi on, when l a bor occurs , the pa i ns connue a t res t, not jus t wi th movement. A uri na
ry tra ct i nfecon i s unl i kel y beca us e the
pa ent ha s no uri na ry s ymptoms . A ki dney s tone i s unl i kel y beca us e us ua l l y the pa ent woul d
compl a i n of pa i n i n the ba ck a nd fla nknot l ow i n
the groi n. In a ddi ti on, wi th a ki dney s tone the pa i n woul d occur not onl y wi th movement, but woul d
pers i s t a t res t a s wel l .
DES Entrance Exams

85. A 19-yea r-ol d G1P0 pres ents to her obs tetri ci a ns office for a roune OB vi s i t a t 32 weeks ges ta
on. Her pregna ncy ha s been compl i ca ted by
ges ta ona l di a betes requi ri ng i ns ul i n for control . She ha s been noncompl i a nt wi th di et a nd i ns ul i
n thera py. She ha s ha d two pri or norma l
ul tra s ound exa mi na ons a t 20 a nd 28 weeks ges ta on. She ha s no other s i gni fica nt pa s t medi ca l or
s urgi ca l hi s tory. Duri ng the vi s i t, her funda l
hei ght mea s ures 38 cm. Whi ch of the fol l owi ng i s the mos t l i kel y expl a na on for the di s crepa ncy
between the funda l hei ght a nd the ges ta ona l
a ge?
a . Feta l hydrocepha l y
b. Uteri ne fi broi ds
c. Pol yhydra mni os @
d. Breech pres enta ti on
e. Undi a gnos ed twi n ges ta ti on
85. The answer is c. (Cunningham, pp 490-494.) The funda l hei ght i n cenmeters ha s been found to
correl a te wi th ges ta ona l a ge i n weeks wi th a n
error of 3 cm from 16 to 36 weeks . Uteri ne fibroi ds , pol yhydra mni os (exces s i ve a mni oc flui d), feta l
ma cros omi a , a nd twi n ges ta on a re a l l
pl a us i bl e expl a na ons of why the uteri ne s i ze woul d mea s ure l a rger tha n expected for the pa ents
da tes . Breech pres enta on does not ca us e
the uterus to be l a rger tha n expected for the ges ta ona l a ge. Si nce thi s pa ent ha s ha d two pri or ul tra
s ound exa mi na ons , hydrocepha l y,
fibroi ds , a nd twi ns woul d ha ve previ ous l y been di a gnos ed. In thi s uncontrol l ed di a bec, the mos t l i
kel y ca us e for the exces s i ve funda l hei ght i s
pol yhydra mni os . Pol yhydra mni os i s a n exces s i ve a mount of a mni oti c fl ui d a nd i s a s i gn of poor gl
ucos e control .