Académique Documents
Professionnel Documents
Culture Documents
1. A. Patient autonomy: The right of patients to make decisions about their medical care
without their health care provider trying to influence the decision. Patient
autonomy does allow for health care providers to educate the patient but does not
allow the health care provider to make the decision for the patient.
Patient’s capacity: means the patient has the mental capacity to make decisions
regarding his or her medical care. A patient lacks capacity might be declared
“incompetent” by the legal/judicial system, to be judged competent the patient must”
(1) Not be diagnosed as presently psychotic or intoxicated
(2) Have an understanding of his or her medical situation
(3) Must be capable of making decisions that are in agreement with his or her history of
values
Competent patient can decide to accept or refuse or discuss medical care options
according to his or her religious views.
B. do not shift patients to others in USMLE
C. Patient is competent and has the right to decide no guardian needed
D. E. Can’t perform C/S against patient’s will
6. D. UTD states that Arrest of labor is diagnosed at cervical dilation ?6 cm in a patient with ruptured membranes and
No cervical change for 4 hours despite adequate contractions (200 MVUs). Here ihe contractions are adequate
and the arrest lasted 4 hours although the the cervix is dilated to 5 cm only. UTD mentioned on the other hand that
"at 6 cm dilation, nearly all women should be in active labor, so this means that in some women it may start
earlier specially when we find in this case that there are molded cervix and caput succedaneum.
Also protraction means that cervical dilation is slower than normal range but not that the dilation is completely arrested though.
Contraversial Q but answer is confirmed
8. E. Vaginal foreign body (a very similar Uworld q exists with those signs and symptoms
are mostly goes with vaginal FB due to tissues or similar things used improperly by kids)
9. A. BMI The burden of suffering associated with osteoporosis is related to the increased
incidence of fractures in individuals with low bone mass and microarchitectural
deterioration. Fragility fractures are defined as fractures that occur following a fall from
standing height or less or with no trauma. Although the greatest relative risk of fracture is
in individuals with osteoporosis, the absolute number of fractures in those with BMD T-
scores in the low bone mass (osteopenia) range is the same or greater than in those
with T-scores in the osteoporosis range.
ASSESSMENT OF FRACTURE RISK — Screening for osteoporosis involves fracture
risk assessment and measurement of BMD. Most fractures occur in women and men
who do not have osteoporosis by DXA criteria. Individuals with osteoporosis are at the
highest relative risk of fracture, but there are more fractures in patients with low bone
mass or osteopenia (T-score between -1.0 and -2.5) because there are so many more
patients in this category. Therefore, assessment of risk factors that are independent of
BMD(Bone Mineral Density) is important for fracture prediction. Validated risk factors
that are independent of BMD include the following:
Advanced age
Previous fracture
Long-term glucocorticoid therapy
Low body weight (less than 58 kg [127 lb])
Family history of hip fracture
Cigarette smoking
Excess alcohol intake
The most robust non-BMD risk factors are age and previous low trauma fracture.
B. Family History of Fracture: will be important in this question if was non traumatic D.
Tamoxifen increases mean bone mineral density but not sure if has any effect on
fracture reduction or not. E. current Tobacco is a risk factor but in this question it seems
to be not of big significance.(2 cigarettes weekly only)
10. E. Arrange for immediate psychiatric evaluation is the answer, which might lead to
prescribing Antipsychotics, Anti depressants and not leaving the baby with the mother(
most are bipolar disorders and to a lesser extent brief psychotic disorder.
11. B. Fetal Growth Restriction The main impact on the fetus is undernutrition as a result
of utero-placental vascular insufficiency, which leads to growth retardation.
18. D. Sustained uterine contraction exaggerated by oxytocin can decrease the blood flow to the fetus,
thus causing late decelerations.
21. E. VZ IG therapy
The onset of maternal varicella from 5 days before to 2 days after delivery may result in
overwhelming infection of the neonate and a fatality rate as high as 30%. This severe disease is
believed to result from fetal exposure to varicella virus without the benefit of passive maternal
antibody. Infants born to mothers with onset of maternal varicella 5 days or more prior to
delivery usually have a benign course, presumably due to passive transfer of maternal antibody
across the placenta, so babies in this condition are given Varicella Zoster immunoglobulin
23. A. Amenorrhea
Risk of overzealous sharp curettage is Asherman syndrome
24. A. Atelectasis
30. C. Cervisitis
Signs and symptoms — A significant proportion of women with cervicitis are
asymptomatic. Cervicitis in these women may be detected incidentally during physical
examination.
When present, symptoms are often nonspecific. All women have:
Purulent or mucopurulent vaginal discharge and/or
Intermenstrual or postcoital bleeding
Some women also have one or more of the following:
Dysuria, urinary frequency
Dyspareunia
Vulvovaginal irritation
New partner with the signs and symptoms suggest acute cervicitis.
Treatment —elliptical incision in the membrane close to the hymenal ring followed by
evacuation of the obstructed material.
Transverse vaginal septum — A transverse vaginal septum results when there is failure
of fusion and/or canalization of the urogenital sinus and müllerian ducts. These septa
may be located at various levels in the vagina The majority of transverse vaginal
septums have a fenestration and are thus not completely obstructed.
Clinical manifestations — The external genitalia appear normal, but internally the vagina
is shortened (a blind pouch if there is obstruction). Children may present with
mucocolpos, whereas adolescents can develop hematocolpos ( figure 6 ) or
pyohematocolpos due to an ascending infection through the small perforation. A mass
may be palpated above the examining finger on rectoabdominal examination.
Evaluation and treatment — Ultrasonographic or magnetic resonance (MR) imaging
helps to define the location and thickness of the septum and to differentiate between a
high septum and congenital absence of the cervix.
A small septum can be resected, followed by an end-to-end anastomosis of the upper
and lower vaginal mucosa. A thick septum is more difficult to excise and repair;
excision should be attempted only by surgeons experienced with this procedure.
32. D. Pyelonephritis
PRETERM LABOR CAUSES
It is usually difficult to identify the cause of preterm labor. Four general categories
causes include:
Uterine bleeding — Conditions like placenta previa (when the placenta partially or
completely covers the cervix) and placental abruption (when the placenta separates from
the uterus before delivery) can cause the fetal membranes to rupture prematurely and
can trigger preterm labor.
Stretching of the uterus — Having twins, triplets, or more, or having polyhydramnios (an
excessive amount of amniotic fluid around the baby) causes stretching of the uterus,
which can lead to uterine contractions and preterm labor.
Bacteria or inflammation — Bacteria or inflammation caused by an infection in the uterus
can stimulate the production of substances that trigger uterine contractions.
Physical or psychological stress — Severe stress can lead to the release of hormones
that cause uterine contractions and preterm labor.
A. chorioamnionitis you will need to have history of either PPROM, uterine tenderness
and other features
B.CLINICAL FINDINGS OF Cervical insuffiecieny
Past obstetrical history — The past obstetrical history of women with cervical
insufficiency is characterized by:
●History of second-trimester pregnancy losses/deliveries, often associated with a short
labor
●History of progressively earlier deliveries in successive pregnancies
Symptoms — Women with cervical insufficiency may be asymptomatic or may present
with mild symptoms, such as pelvic pressure, premenstrual-like cramping or
backache, and/or a change in the volume, color, or consistency of vaginal discharge.
Volume may increase; color may change from clear, white, or light yellow to pink, tan, or
spotting; and consistency may become thinner. These symptoms may begin between 14
and 20 weeks of gestation and may be present for several days or weeks before
diagnosis of cervical insufficiency.
Contractions are absent or mild.
Physical examination — The initial clinical examination may reveal a soft, somewhat
effaced cervix, with no or minimal dilation [10]. Provocative maneuvers such as
suprapubic or fundal pressure or the Valsalva maneuver may reveal fetal membranes in
the endocervical canal or vagina; this is always an abnormal finding. Tocodynamometry
shows no or infrequent contractions at irregular intervals.
Late clinical presentation is characterized by advanced dilation and effacement (eg, ≥4
cm dilated and ≥80 percent effaced), spotting, unprovoked grossly prolapsed
membranes or ruptured membranes, or contractions that seem inadequate to explain the
advanced effacement and dilation.
Imaging — The cervix may be short (below the 10th percentile [25 mm]), the fetal
membranes may be separated, and debris (sludge) may be seen in the amniotic fluid. A
rapid rate of decrease in cervical length over time [11] and cervical shortening before 20
weeks [12-14] may be noted. (See "Second-trimester evaluation of cervical length for
prediction of spontaneous preterm birth", section on 'Technique'.)
Also the signs and symptoms of preterm labor should not be attributed to any of the
causes mentioned earlier to support the diagnosis of cervical insufficiency
Rupture of an ovarian cyst may be asymptomatic or associated with the sudden onset of
unilateral lower abdominal pain. The pain often begins during strenuous physical activity,
such as exercise or sexual intercourse. It may be accompanied by light vaginal bleeding
due to a drop in secretion of ovarian hormones and subsequent endometrial sloughing.
Blood from the rupture site may seep into the ovary, which can cause pain from
stretching of the ovarian cortex, or it may flow into the abdomen, which has an irritant
effect on the peritoneum. However, it is also possible for large amounts of blood to be
present in the abdomen without producing symptoms. Serous or mucinous fluid released
upon cyst rupture is not very irritating; the patient may remain asymptomatic despite
accumulation of a large volume of intraperitoneal fluid. On the other hand, spillage of
sebaceous material upon rupture of a dermoid cyst causes a marked granulomatous
reaction and chemical peritonitis, which is usually quite painful.
Ovarian torsion — Lower abdominal pain and an adnexal mass are the most common
findings associated with ovarian torsion. Nausea and vomiting frequently accompany
torsion, but are less common with cyst rupture. Imaging studies, particularly Doppler
velocimetry, can help distinguish the two disorders, but the presence of a cystic or
solid adnexal mass and free fluid in the posterior cul-de-sac are common with both
entities this is just to make the answer confusing
35. C. Amnioinfusioin
Variable deceleration — A variable deceleration reflects the fetal autonomic reflex
response to transient mechanical compression of the umbilical cord. Initially,
compression of the umbilical cord occludes the thin-walled, compliant umbilical vein,
decreasing fetal venous return and triggering a baroreceptor-mediated reflex rise in FHR
(sometimes referred to as a "shoulder"). Further compression occludes the umbilical
arteries, causing an abrupt increase in fetal peripheral resistance and blood pressure.
Baroreceptors detect the abrupt rise in blood pressure, triggering an increase in
parasympathetic outflow and an abrupt decrease in heart rate. As the cord is
decompressed, this sequence of events occurs in reverse.
Cord compression with or without other sources of disruption of fetal oxygenation may
result in recurrent variable decelerations with absent/minimal variability and no
accelerations. Prompt attention is required because ongoing hypoxic injury cannot be
excluded.
Amnioinfusion — Amnioinfusion, the instillation of isotonic fluid into the amniotic cavity, has
been advocated to improve neonatal outcome in women laboring with thick meconium in the
amniotic fluid. The proposed benefits of amnioinfusion include dilution of thick clumps of
meconium by the instilled fluid, and possible prevention or relief of cord compression. The fetal
heart rate should be monitored continuously to determine whether the variable decelerations
resolve and to identify the occurrence of new nonreassuring fetal heart rate patterns. However,
amnioinfusion is not beneficial in reducing meconium-related neonatal morbidity, with the possible
exception of settings with limited facilities to monitor the fetus during labor [3]. As a result,
amnioinfusion is not recommended as a routine approach for mothers with meconium-stained
amniotic fluid
A. Technique for breech presentation and this delivery has vertex presentation
B. Forceps use requires full dilatation of the cervix to begin with then the rest of indications like
prolonged 2nd stage or fetal heart deccelarations and so on.
D. Amniocentesis ?? E. Cordocentesis ?? they seem totally far away from this situation
36. C. 50%
Sickle cell is autosomal recessive, she has hb S and her husband has sickle cell trait
which means that one sickle anemia gene will be definitely taken from the mother and
the other gene will be a 50% chance taken from father and the overall probability is 50%
Presence of HbS, but with a higher proportion of HbA than HbS: Sickle cell trait (HbAS)
or sickle α-thalassemia
Presence of HbS and HbF, but no HbA: Sickle cell anemia (HbSS), sickle beta 0 -
thalassemia (hereditary persistence of fetal hemoglobin [HPFH]), or sickle–HPFH
Overall higher proportion of HbS than HbA and HbF: Sickle beta + -thalassemia (most
likely)
Presence of HbC, but with a higher proportion of HbA than HbC: HbC trait (HbAC)
Presence of HbC and HbF, but no HbA: HbC disease (HbCC), HbC –beta 0 -thalassemia
(HbC-HPFH)
A higher proportion of HbC than HbA: HbC beta + -thalassemia
Presence of HbS and HbC: HbSC disease
Presence of HbH: HbH disease
Increased HbA 2 : Beta-thalassemia minor
Increased HbF: Hereditary persistence of fetal hemoglobin, sickle cell anemia, beta-
thalassemia, HbC disease, HbE disease
39. A
Serum markers for epithelial ovarian carcinoma — Serum CA 125 is the most commonly used
laboratory test for the evaluation of adnexal masses for EOC. In our practice, we measure CA
125 in all postmenopausal women with an adnexal mass. In premenopausal women, we measure
a serum CA 125 only if the ultrasound appearance of a mass raises sufficient suspicion of
malignancy to warrant a repeat ultrasound or surgical evaluation. Biomarkers that are used to
decide whether to refer a patient with suspected EOC to a gynecologic oncologist are OVA1 and
the Risk of Malignancy Algorithm
40. D. Testosterone (Hyperandrogenic state, could be PCOS and even if not testosterone
is still the answer in this case).
A category III tracing is “abnormal” because studies have demonstrated that these
findings are associated with an increased risk of fetal hypoxic acidemia, which can lead
to cerebral palsy and neonatal hypoxic ischemic encephalopathy
Therefore, when a category III pattern is identified, preparations for delivery should be
made while initiating resuscitative measures to improve uteroplacental perfusion and
oxygen delivery. (See 'In utero resuscitation' below.) If in utero resuscitation leads to
resolution of the category III tracing, cesarean delivery can be averted.
Scalp stimulation to provoke FHR acceleration should be attempted. In general, when
scalp stimulation induces an acceleration, the probability of fetal acidosis is less than 10
percent versus about 50 percent when no acceleration occurs in this setting. The time
from the decision to delivery should consider the health of both mother and fetus: there
may be circumstances (eg, difficult maternal airway, maternal coagulopathy, severe
obesity) where safe delivery cannot be performed expeditiously.
In utero resuscitation — for management of category II and III tracings
●Reposition the patient onto her left or right side
●Administer oxygen (eg, 8 to 10 L/min of oxygen via nonrebreather mask)
●Administer an intravenous (IV) fluid bolus (eg, 500 to 1000 mL of lactated Ringer's or
normal saline solution)
●Discontinue uterotonic drugs
●Administer a tocolytic drug (eg, terbutaline 250 mcg subcutaneously)
●For patients who were recently given epidural drugs for labor pain, ask the anesthesia
team to evaluate the patient for administration of an alpha-adrenergic agonist
(eg, phenylephrine, ephedrine) to reduce sympathetic blockade
Fetal tachycardia — Fetal tachycardia is defined as a baseline FHR greater than 160
bpm for at least 10 minutes. Causes of fetal tachycardia include:
●Maternal-fetal infection
●Medications (eg, beta-agonists, atropine, cocaine)
●Maternal hyperthyroidism
●Placental abruption
●Fetal hypoxia
●Elevated maternal catecholamine levels
Rarely, fetal tachycardia can be due to a fetal tachyarrhythmia, such as atrial flutter or
supraventricular tachycardia. These tachyarrhythmias are characterized by a very high
FHR, often in excess of 200 bpm. Fetal tachycardia less than 200 bpm alone has not
been strongly associated with fetal acidemia, unless associated with recurrent
decelerations, absent accelerations, orminimal/absent variability [53-56].
The evaluation of fetal tachycardia should include assessment for maternal
infection or abruptio placentae and a review of maternal medications. Appropriate
treatment should be initiated if the underlying cause can be identified and treated
(eg, acetaminophen for reduction of fever and antibiotics for treatment of intraamniotic
infection). In addition, fetal scalp stimulation should be performed to provoke FHR
acceleration, which is a sign that the fetus is not acidotic. Delivery is indicated if
acidemia or placental abruption is suspected. Tachycardia due to chorioamnionitis is
generally not an indication for delivery unless decelerations or category III tracing, or if
the patient is remote from delivery and the tachycardia is unable to be resolved with
maternal hydration and antipyretic therapy.
B. Cervical Cancer Risk factors — The two major histologic types of cervical cancer,
adenocarcinoma and squamous cell carcinoma, and the preinvasive disease]. Most of
these are associated with an increased risk of acquiring or having appropriate
compromised immune response to infection with HPV.
●Early onset of sexual activity
●Multiple sexual partners
●A high-risk sexual partner (eg, a partner with multiple sexual partners or known HPV
infection)
●History of sexually transmitted infections (eg, Chlamydia trachomatis, genital herpes)
●History of vulvar or vaginal squamous intraepithelial neoplasia or cancer (HPV infection
is also the etiology of most cases of these conditions)
●Immunosuppression (eg, human immunodeficiency virus infection)
Cervical cancer is less common in sexual partners of circumcised males [13]. Early age
at first birth (younger than 20 years old) and increasing parity (3 or more full term births)
are also associated with an increased risk of cervical cancer; these are also likely due to
exposure to HPV through sexual intercourse [12].
Low socioeconomic status is associated with an increased risk of cervical cancer.
Oral contraceptive use has been reported to be associated with an increased risk of
cervical cancer.
In contrast to squamous cell cancer of the cervix, cigarette smoking is not associated
with a significantly increased risk of adenocarcinoma of the cervix
C. Endometrial
E. Ovarian
46. C. Increasing her current anticonvulsant medication
Drug levels and dose adjustment — Pregnancy is accompanied by many alterations in
drug metabolism, including increased liver metabolism, renal clearance, and volume of
distribution, and decreased gastrointestinal absorption and plasma protein binding
[20,30-32]. As an example, for antiseizure drugs that are highly protein bound
(eg, phenytoin, valproate), the total plasma drug level may decrease with impaired
protein binding, but the physiologically important free or unbound drug concentration
may not change. As a result, free drug levels for these antiseizure drugs may be more
reliable during pregnancy. However, medication dosage should be adjusted if the
patient's seizures are not controlled, not because the free or total level has decreased.
Both total and free plasma drug levels, where available, should be checked at weeks five
to six and week 10 to evaluate the environment for organogenesis, and then at least
once each trimester. Antiseizure drugs that may warrant closer monitoring
include lamotrigine, levetiracetam, oxcarbazepine, phenytoin andtopiramate [11]:
47. D. Prostaglandin production
Primary dysmenorrheal: due to prostaglandin, a very similar question present in
UWorld no. 2395 (6547482)
48. C. Stress Incontinence
49. K. Septic abortion
50. Uteroplacental artery
According to up to date the Factor V leiden deficiency has not proved to be correlated
with early pregnancy losses but there is a correlation with late pregnancy losses due to
placental thrombosis and infarction and in this question the only related answer to this
piece of information is uteroplacental artey (spiral arteries convert to uteroplacental
arteries in pregnancy)