SEMESTER VI

A 28-year-old P0010 woman presents to the emergency department with abdominal pain since the past day. She
reports a 1-week history of nausea with occasional vomiting. She has noticed some breast tenderness as well. She
denies dysuria, vaginal bleeding, or any bowel symptoms. She reports that her last period was 4 weeks ago, but was
lighter than normal. She has been using condoms for contraception. On arrival, her vital signs include a temperature
of 37°C, BP of 117/68, pulse rate of 78 beats per minute, and respiratory rate of 16 breaths per minute.
Cardiovascular and respiratory examinations are normal. She notes some suprapubic abdominal discomfort with
palpation, but she does not have rebound tenderness or guarding. A speculum examination reveals a closed cervix
without bleeding. A pelvic examination is mildly uncomfortable and reveals a normally sized, anteverted uterus, and
palpably normal adnexa. A urine pregnancy test is positive.

1. What is the test you should order first?

a. Type and cross
b. CBC
c. Quantitative level of β-hCG
d. Pelvic ultrasound
e. Urine gonorrhea and chlamydia testing

2. The quantitative β-hCG level is 1,300 mIU/mL. The patient reveals that this was an unplanned, but desired
pregnancy. What follow-up recommendations do you give this patient?
a. Make an appointment with her primary OB/GYN for an initial prenatal visit
b. This is likely an ectopic pregnancy and she should proceed with methotrexate therapy
c. She should undergo urgent laparoscopy for evacuation of an ectopic pregnancy
d. She should return in 48 hours for a repeat β-hCG
e. She has likely had a SAB and does not need further follow-up

3. The patient returns 48 hours later per your recommendations. She reports that her abdominal pain is worse
and is left-sided. Yesterday, she also had a small amount of vaginal bleeding that has since subsided. She has
not been lightheaded, short of breath, or had palpations and she has been able to tolerate food and drink
without difficulty. Her vital signs remain stable. You repeat a β-hCG and the level is now 1,700 mIU/mL. A pelvic
ultrasound reveals a left adnexal mass and nothing in the uterine cavity. What is the most common site of an
ectopic pregnancy?
a. Ampulla
b. Ovary
c. Fimbriae
d. Isthmus
e. Cervix

4. You explain to the patient that she most likely has an ectopic pregnancy that requires treatment. She would
like to avoid surgery. You draw a type and screen, CBC, and complete metabolic panel. Her blood type is O
positive, antibody negative. Her hemoglobin is normal as are her liver enzymes. What is your next
recommendation?
a. Her vaginal bleeding suggests an inevitable abortion and she does not need further treatment at this time
b. Her abdominal pain is concerning and she must undergo urgent laparoscopy for evacuation of the ectopic
pregnancy
c. This is a desired pregnancy, she should return in 48 hours to continue to follow the β-hCG level
d. She should proceed with methotrexate therapy
e. She should proceed with mifepristone and misoprostol therapy

5. What additional recommendation would you make at this time?

a. The patient should receive RhoGAM
b. She should return in 48 hours for a follow-up test of β-hCG level
c. She should return in 96 hours for a follow-up test of β-hCG level
d. She should return in 1 week for a follow-up test of β-hCG level
e. She should return in 48 hours for a follow-up ultrasound
A 34-year-old G3P0020 woman presents to the office at 8 weeks’ gestation for her first prenatal visit. This is a
planned and desired pregnancy. Her obstetric history is significant for one prior elective termination and one SAB. It
took her and her partner just over 1 year to conceive this pregnancy. She is afebrile, normotensive with a normal
pulse. Pelvic examination reveals a 7- to 8-week-sized uterus with normal adnexa. Her cervix is closed and there is
no vaginal bleeding. An office ultrasound is performed and an IUP is seen with a crown–rump length consistent with
7 weeks and 2 days gestation. Unfortunately, no fetal heart beat is seen.

6. What is your diagnosis?

a. Incomplete abortion
b. Threatened abortion
c. Ectopic pregnancy
d. Missed abortion
e. Inevitable abortion

7. You offer the patient either medical or surgical management. She opts for medical management and takes
mifepristone in the office with the plan to take misoprostol the next day. The following evening, you receive a
call that the patient has presented to the emergency department with heavy vaginal bleeding. Her vital signs
are as follows: temperature, 37°C; BP, 90/52; pulse rate, 100 beats per minute; respirations, 16 breaths per
minute; and 100% oxygen saturation on room air. Pelvic examination reveals active bleeding from an open
cervical os. Pelvic ultrasound reveals partial retention of fetal products. What is your new diagnosis?
a. Incomplete abortion
b. Threatened abortion
c. Ectopic pregnancy
d. Missed abortion
e. Inevitable abortion

8. The emergency department team obtains IV access and draws blood for a CBC, type and screen and quantitative
β-hCG level. An IV fluid bolus is given. Her hematocrit is 30.6%, she is RH positive, and the β-hCG is pending.
What is your next step in the management of this patient?
a. Reassure that patient and send her home
b. Proceed with dilation and curettage
c. Administer RhoGAM
d. Administer vasopressors
e. Transfer the patient to the ICU

9. The patient stabilizes and is discharged. She follows up in your office 1 week later and wants to know why she
had a miscarriage as well as her risk of future miscarriages. Which of the following is not true?
a. As much as 80% of first-trimester SABs are due to abnormal chromosomes
b. The most common chromosomal abnormality is autosomal trisomy
c. Ninety-five percent of the chromosomal abnormalities are due to errors in paternal gametogenesis
d. Her risk of a third miscarriage is 25% to 30%
e. Because of her advancing age, she should consider evaluation for recurrent pregnancy loss, starting with
parental karyotyping

A 31-year-old G1P0 woman at 39 weeks and 4 days presents to labor and delivery unit, with regular contractions
occurring every 3 to 5 minutes. Her contractions last 30 to 90 seconds. She not sure if she’s been leaking any fluid
from her vagina. You take her history and conduct a physical examination.

10. ROM would be supported by which of the following?

a. Nitrazine paper remaining orange when exposed to fluid in the vagina
b. A negative fern test
c. An ultrasound with a normal AFI
d. A negative tampon test
e. Speculum examination with evidence of pooling in the vagina
11. You determine her membranes have ruptured and admit her for active management of labor. The first stage
of labor
a. includes an active and latent phase
b. begins when the cervix has completely dilated
c. is considered prolonged if its duration is longer than 2 hours in a nulliparous woman
d. begins with the onset of Braxton Hicks contractions
e. is commonly associated with repetitive early and variable decelerations

12. On examination you attempt to determine the presentation of the fetus. Which of the following presentations
and positions would be most favorable to achieve a vaginal delivery?
a. Breech
b. Transverse
c. Vertex with occiput posterior
d. Vertex with occiput anterior
e. Vertex with occiput transverse

13. The patient dilates without difficulty to 10 cm and the second stage of labor begins. She is pushing effectively,
but during contractions you notice decelerations on fetal heart tracings. Which of the following would be most
concerning?
a. Isolated early decelerations
b. Repetitive variable decelerations that resolve quickly after each contraction
c. Repetitive early decelerations and variable decels
d. Repetitive late decelerations and loss of variability between contractions
e. Absence of decelerations

14. She pushes the head to the perineum and you deliver the head and shoulders without complication. The cord
is clamped and the placenta delivered. You examine her for lacerations. A second-degree laceration
a. involves the anal mucosa
b. is commonly associated with buttonhole lacerations
c. involves the mucosa or the skin only
d. will heal well without repair
e. extends into the perineal body, but does not involve the anal sphincter

A 16-year-old female presents to your office with her mother, who is concerned that she is pregnant. Over the last
3 months, the patient and her mother have noticed a swelling in her lower abdomen. The patient notes a sensation
of fullness, and occasional left lower pelvic pain. The patient reports that she does have a male partner, but they
have not yet been sexually intimate. She reports irregular menses over the last 6 months, but
thought it was secondary to stress. She has noted increased hair over her chin and breasts, and her acne seems to
have worsened and spread onto her chest and back, whereas it used to be only on her face. Her mother
attributes this to “normal puberty stuff.” She is otherwise healthy, with no other known medical problems or prior
surgeries. She is normotensive, and vital signs are normal. On physical examination, you notice a few
dark colored hairs over her upper lip, and several beneath her chin. Her breast development is normal. Pelvic
examination reveals a prominent, enlarged clitoris, and bimanual examination reveals a 17-cm, mobile, smooth
left adnexal mass. An in-office urine pregnancy test is negative.

15. What set of laboratory tests would you first perform to aid in your diagnosis?
a. Serum testosterone and DHEA-S
b. TSH, free T4
c. 24-hour urine collection for metanephrines
d. Plasma aldosterone and renin

16. Your laboratory tests confirm your suspicions, and you perform a pelvic ultrasound, which reveals a 15 × 16 ×
17 cm3 solid left ovarian mass. Which of the following is the most likely diagnosis?
a. Polycystic ovary syndrome
b. Sertoli-Leydig cell tumor
c. Luteoma of pregnancy
 d. Cushing syndrome

17. You opt to proceed with excision of her left adnexal mass. What procedure do you recommend?
a. Total abdominal hysterectomy, bilateral salpingo-oophorectomy and staging procedure
b. Total abdominal hysterectomy, bilateral salpingo-oophorectomy with intraoperative frozen section
followed by staging
c. Laparotomy, left ovarian cystectomy and possible oophorectomy with intraoperative frozen section
d. Neoadjuvant chemotherapy

A 28-year-old patient is in your office to discuss the possibility of getting pregnant. As part of her history, you take
thorough menstrual history. She states that she had menarche at age 12 years. Initially, her menses was irregular,
but since she was 14 years, her menses has been every 30 days and last for 5 days. She uses four to five tampons a
day and denies dysmenorrhea.

18. The menstrual cycle is divided into which two phases when describing the endometrium?
a. Follicular and secretory phases
b. Follicular and luteal phases
c. Proliferative and luteal phases
d. Proliferative and secretory phases
e. Atrophic and menstrual

19. Which of these structures does NOT produce progesterone?

a. Placenta
b. Endometrium
c. Corpus luteum
d. Follicle
e. Adrenal cortex

20. The patient comes back to your office, and she is pregnant. What hormone does the developing trophoblast
produce?
a. Human chorionic gonadotropin (hCG)
b. Progesterone
c. Androstenedione
d. Luteinizing hormone (LH)
e. Estrogen

A 58-year-old G3P3003 Caucasian, postmenopausal woman comes to your office. She has been menopausal since
age 50 years. She has a negative past medical and surgical history. She took hormone replacement for about 2 years
but stopped due to concerns of an increased risk of cancer that she heard about from friends. Prior to the onset of
menopause, she had a history of normal and regular menses. She has had annual GYN care with you and has never
been diagnosed with cervical dysplasia. Her last Pap smear with HPV was obtained last year, and both were negative.
She has recently become sexually active with a new partner and has noted some spotting with intercourse. She also
reports some intermittent spotting when she wipes and occasional mild low abdominal cramping over the past 2 to
3 months. She complains of a general feeling of vaginal dryness and does have pain and dryness with intercourse.
She has no other complains what so ever.

21. Her most likely diagnosis is:

a. endometrial cancer
b. cervical cancer
c. genitourinary syndrome of menopause
d. bleeding disorder
e. uterine fibroids

22. On examination, she has normal appearing external female genitalia. She has a normal appearing rectum, and
a fecal immunoassay test is negative for blood. On speculum examination, she has pale, thin vaginal epithelium
 without lesions, blood, or discharge. Her cervix is pale and stenotic but without lesions. A bimanual examination
reveals a small, nontender mid-position uterus, with no adnexal masses. The most appropriate testing includes:
a. endometrial biopsy (EMB)
b. transvaginal ultrasound
c. sexually transmitted infection (STI) testing (gonorrhea and chlamydia)
d. all of the above
e. none of the above

23. You perform an examination testing for gonorrhea and chlamydial infection as well as perform an EMB. In
addition, you order a pelvic ultrasound. Sexually transmitted disease (STD) testing is negative. Her EMB returns
with inactive, atrophic endometrium, negative for hyperplasia, endometrial intraepithelial neoplasia (EIN), or
malignancy. Her transvaginal ultrasound reveals a normal appearing uterus with evidence of a 2-cm
intracavitary lesion, consistent with an endometrial polyp. Ovaries are normal; there is no free fluid present in
the peritoneal cavity. The next most appropriate step in the management of this patient is:
a. reassurance and follow up in 1 year
b. reassurance and follow up ultrasound in 1 year
c. outpatient hysteroscopy D&C with polypectomy
d. treat the urogenital atrophy with systemic or vaginal estrogens and follow up in 3 months
e. no additional follow up is indicated

24. A 39-year-old woman presents to your emergency department with complaints of irregular vaginal bleeding
for the past 1 year. Upon evaluation of her surgical history, she tells you she had a D&C outside of the country
for an “abnormal pregnancy” about 1 year ago. She has had no follow-up since then and has not been
sexually active since her procedure. On review of systems, she tells you she has been coughing up blood for
the past 1 week. Physical examination reveals old blood in the vaginal vault. Your laboratory data are
significant for a serum β-hCG of 112,000 mIU/mL. The most likely diagnosis is:
a. Complete molar pregnancy
b. Partial molar pregnancy
c. Metastatic persistent GTD
d. Placental site trophoblastic tumor
e. Ectopic pregnancy

25. A 37-year-old woman presents to your office with a 3-month history of intermenstrual bleeding and
intermittent pelvic pain. She is sexually active and reports one new sexual partner in the last year. She uses
condoms for contraception. A pelvic ultrasound is found to be normal. Subsequently, an endometrial biopsy
is performed. The biopsy specimen shows leukocytic infiltrate with plasma cells. Which of the following is the
most appropriate course of action?
a. Doxycycline 100 mg orally twice daily for 14 days
b. Insertion of a levonorgestrel intrauterine system (LNG-IUS)
c. Hysteroscopy
d. Total abdominal hysterectomy
e. Cefoxitin 2 g IV every 6 hours

26. A 36-year-old G4P4004 woman comes to you for contraceptive advice. She had a intrauterine device (IUD)
placed last year; however, it was noted to be perforated, so it was removed. She does not want another IUD.
She asks if she is a candidate for the birth control pill. Her medical history is significant for a history of DVT
during her last pregnancy. She has a BMI of 42 and Type II diabetes mellitus controlled with an oral agent. She
has occasional tension headaches relieved with nonsteroidal anti-inflammatory drugs (NSAIDs). She is a
nonsmoker, and otherwise has had only uncomplicated vaginal deliveries and no surgeries. Which of the
following is an absolute contraindication to starting combined oral contraceptive pills in this patient?
a. Age greater than 35 years
b. History of DVT
c. Diabetes mellitus
 d. History of tension headaches
e. Obesity
27. A common complication of both epidural and spinal anesthesia includes:
a. Maternal hypotension
b. Maternal hyperventilation
c. Fetal tachycardia
d. Tetanic uterine contractions
e. Chorioamnionitis

28. Which of the following is not a sign of active labor?

a. Bloody show
b. Palpable contractions
c. Nausea and vomiting
d. Fever and chills
e. Maternal pain

29. A 24-year-old G1P0 at 28 weeks 5 days’ gestation presents to routine prenatal care with complaint of
increased discharge today. She first noticed it after going to the bathroom. When she stood up she felt as if a
little urine continued to leak out. Throughout the afternoon, she has continued to feel like water is leaking
from the vagina. There is no vaginal bleeding or abdominal pain. The discharge is clear and odorless. Her
pregnancy has been otherwise uncomplicated. Which of the following is the first step in evaluating this
patient?
a. Amnio dye test/tampon test
b. Ultrasound to check for Amniotic Fluid Index (AFI)
c. Sterile speculum examination
d. AmniSure test
e. Amniocentesis to rule out chorioamnionitis

30. Oral fluids and food are often delayed following major gynaecological surgery. Which gastrointestinal
complication is improved by early postoperative feeding?
A. Abdominal distension
B. Incidence of diarrhoea
C. Need for nasogastric tube placement
D. Recovery of bowel function
E. Rectal bleeding

31. Which type of ureteric injury is most commonly reported at laparoscopy?

A. Crush
B. Laceration
C. Ligation
D. Thermal
E. Transection

32. During laparoscopic pelvic surgery, which visceral structure is most likely to be damaged?
A. Aorta
B. Bladder
C. Ileum
D. Rectum
E. Ureter

33. An 18-year-old nulliparous girl presents as a gynaecological emergency with severe left-sided pelvic pain,
tachycardia and vomiting. A pregnancy test is negative. An ultrasound scan is performed in the emergency
department, which appears to demonstrate a left adnexal cyst. In theatre, a laparoscopy is performed which
 shows an ovarian torsion that has twisted three times on its pedicle. The left tube and ovary appear purple
and congested.
What is the most appropriate surgical management?
A. Convert to laparotomy and perform a left salpingooophorectomy
B. Laparoscopic left salpingo-oophorectomy
C. Untwist the tube and ovary and perform a laparoscopic ovarian cystectomy
D. Untwist the tube and ovary and perform a oophoropexy
E. Untwist the tube and ovary, drain the ovarian cyst and leave the tube and ovary in situ

34. A healthy 54-year-old lady is due to attend the outpatient postmenopausal bleeding hysteroscopy clinic.
Which medication should she be advised to consider taking prior to her attendance at the clinic?
A. Benzodiazepines
B. non-steroidal anti-inflammatory agents (NSAIDs)
C. Opioids
D. Paracetamol
E. Prostaglandins

35. A 62-year-old is due to undergo a hysteroscopy due to a thickened endometrium detected as part of her
investigations for postmenopausal bleeding.
Which medication should be used to ‘prime’ the cervix prior to the hysteroscopy?
A. Mifepristone
B. Misoprostol
C. No medication required
D. Non-steroidal anti-inflammatory
E. Vaginal oestrogen

36. With respect to instrumentation of the uterus, which operation has the highest risk of perforation?
A. Division of intrauterine adhesions
B. Outpatient hysteroscopy
C. Postpartum suction evacuation for haemorrhage
D. Second generation endometrial ablation
E. Surgical termination of pregnancy

37. What is the most frequently encountered complication of suction evacuation of the uterus for first trimester
miscarriage?
A. Haemorrhage
B. Pelvic infection
C. Perforation
D. Retained products of conception
E. Significant Cervical Injury

38. A morbidly obese woman is due to undergo a total laparoscopichysterectomy for endometrial cancer.
type of complication is more common compared to traditional open hysterectomy in this situation?
A. Bowel injury
B. Hernia
C. Infection
D. Urinary tract injury
E. Venous thrombosis

39. Recently, the prevalence of HPV-related VIN has increased significantly and consequently the incidence of
vulval cancer in young women is rising.
What are the most common HPV serotypes found in vulval cancers?
A. HPV 5 and 8
B. HPV 6 and 11
C. HPV 16 and 18
D. HPV 31 and 33
E. HPV 58 and 59
40. An 84-year-old patient who had a previous history of vaginal hysterectomy presents with a stage 3 vault
prolapse. The patient has limited mobility and has previously had difficulty with the use of vaginal pessaries.
What is the most appropriate treatment option?
A. Abdominal Sacrocolpopexy
B. Colpocliesis
C. Physiotherapy
D. Sacrospinous fixation
E. Transvaginal repair with mesh

41. 55-year-old patient presents with a history of urinary symptoms of urgency, increased frequency and
nocturia. The patient states that she does not have symptoms of hesitancy and feels as though she empties
her bladder completely.
What would be the first line of management?
A. Cystoscopy
B. Neuromodulation
C. Reduce caffeine intake and start anticholinergic medication
D. Ultrasound scan to rule out pelvic pathology
E. Urodynamics

42. A patient is undergoing a vaginal hysterectomy for uterine prolapse and at the end of the procedure it is
noted that the vault of the vagina descends to 3 cm above the hymenal ring.
What should be considered in order to prevent further descent of the vault in the future?
A. McCall culdoplasty
B. Moschowitz-type operation
C. No further action
D. Sacrospinous fixation
E. Suturing the cardinal and uterosacral ligaments to the vaginal cuff

43. A 38-year-old patient is suffering with stress incontinence. Her BMI is 32 kg/m2 and the patient is interested
in lifestyle management for her incontinence.
What is the most important lifestyle change that you would
recommend?
A.Avoidance of caffeinated drinks
B. Exercise
C. Reduction of alcohol intake
D. Reduction of fluid intake
E. Weight loss

44. Vasectomy failure rate is quoted as approximately 1 in 2000 (0.05%) after clearance has been given. By how
many months postprocedure should the vasectomy be considered a failure if motile sperm are still observed
in a fresh semen sample?
A. 3 months
B. 4 months
C. 5 months
D. 6 months
E. 7 months

45. More and more women are leaving childbearing to a later age. What is the most common reason given by
women for making this choice?
A.Availability of reliable contraceptives
B. Career concerns
C. Financial reasons
D. Finding a suitable partner
E. Other causes
46. At what gestational age is chorionic villus sampling (CVS) usually performed?
A. 8–10+0 gestation
B. 8–13+6 gestation
C. 10–11+0 gestation
D. 11–13+6 gestation
E. 12–14+6 gestation

47. What is the mode of action of bisphosphonates?

A. Calcitonin antagonist
B. Decreased bone resorption
C. Increased bone formation
D. Inhibition of release of parathyroid hormone
E. Vitamin D agonist

48. In otherwise uncomplicated preterm labour, evidence suggests that use of tocolysis delays delivery by how
long?
A. 24 hours
B. 48 hours
C. 72 hours
D. 7 days
E. 14 days

49. What type of headache is associated with a dural puncture?

A. Fronto–occipital location
B. Occipital location
C. Temporal location
D. Temporal with non-focal neurology
E. Thunderclap

50. A woman who is taking antipsychoticmedication is contemplating pregnancy.

Why is Lithium not the drug of choice?
A. Risk of cardiac defects in the fetus
B. Risk of constipation in the fetus
C. Risk of gestational diabetes
D. Risk of maternal hypertension
E. Possible risk of neonatal persistent pulmonary hypertension
Kunci jawaban
1) C
2) D
3) A
4) D
5) C
6) D
7) A
8) B
9) D
10) E
11) A
12) D
13) D
14) E
15) A
16) B
17) C
18) D
19) B
20) A
21) C
22) D
23) C
24) C
25) A
26) B
27) A
28) D
29) C
30) D
31) E
32) B
33) E
34) B
35) C
36) C
37) D
38) D
39) C
40) B
41) C
42) A
43) E
44) E
45) B
46) D
47) B
48) D
49) A
50) A