[SEM2] OB-GYNE Flashcards

Question

25. A 17-year-old female patient who has never had menses comes for evaluation. On examination, breasts and pubic hair are Tanner stage 1, and she possesses normal external genitalia. She is 55 inches tall with a webbed neck, wide-spaced nipples, and decubitus valgus. Your initial working diagnosis would be: A. Turner’s syndrome B. Polycystic Ovarian Syndrome C. Sheehan’s syndrome D. Klinefelter’s Syndrome

Answer 1

A. Turner’s syndrome High-Yield Rationale: A 17-year-old with primary amenorrhea, lack of sexual development (Tanner stage 1 breasts and pubic hair), short stature, webbed neck, wide-spaced nipples, and cubitus valgus is classic for 45,X (Turner’s syndrome). Why Not the Other Choices: 🔴 B. PCOS → Typically presents with normal-to-advanced breast development, often signs of hyperandrogenism, not primary amenorrhea with no puberty onset. 🔴 C. Sheehan’s syndrome → Postpartum pituitary necrosis; occurs after delivery with hemorrhage, not in an adolescent. 🔴 D. Klinefelter’s syndrome → A condition in males (47,XXY), not females.

Answer 2

B. Hyperandrogenism High-Yield Rationale: According to the Rotterdam criteria, two of the following three are needed for a PCOS diagnosis: 1️⃣ Oligo-ovulation or anovulation 2️⃣ Clinical or biochemical hyperandrogenism 3️⃣ Polycystic ovaries on ultrasound (>10 small peripheral cysts <1 cm in at least one ovary) Why Not the Other Choices: 🔴 A. Hyperprolactinemia → Not part of the formal PCOS definition (though it can cause menstrual irregularities, it’s a separate issue). 🔴 C. Hypothyroidism → Also can lead to menstrual disturbances, but it’s not one of the PCOS criteria. 🔴 D. Hypokalemia → Irrelevant to PCOS diagnostic criteria.

Answer 3

D. Primary Ovarian Insufficiency High-Yield Rationale: She is 38 years old with 6 months of amenorrhea and symptoms of estrogen deficiency (hot flashes, skin changes). Menopause is typically diagnosed after 12 consecutive months without menses, and its average onset is around 51 years. When such signs and symptoms occur <40 years, it is termed Primary Ovarian Insufficiency (also known as “premature menopause”). Why Not the Other Choices: 🔴 A. Menopause → By strict criteria, requires 12 months of amenorrhea and typically occurs ~age 51. She is only 38 and at 6 months of no menses. 🔴 B. PCOS → Characterized by hyperandrogenism, often with obesity or hirsutism. Does not typically present with hot flashes and low estrogen symptoms. 🔴 C. Hypothyroidism → Would more likely present with weight gain, fatigue, cold intolerance; does not typically cause vasomotor symptoms like hot flashes.

Answer 4

A. To immediately start aggressive thyroxine replacement, thus preventing long-term cognitive deficiencies in affected infants High-Yield Rationale: Newborn screening for congenital hypothyroidism is essential because early diagnosis and treatment with levothyroxine can prevent irreversible neurologic damage and impaired cognitive development. Why Not the Other Choices: 🔴 B. To immediately start the diagnostic work-up → You do want to confirm the diagnosis, but the main purpose is rapid detection and treatment to prevent disability. 🔴 C. To identify infants who will transmit the disease → Congenital hypothyroidism is not primarily screened to assess heritability. 🔴 D. To prevent mothers from breastfeeding → Breastfeeding is generally encouraged even if the mother has thyroid issues; no need to stop.

Answer 5

A. Hyperthyroidism High-Yield Rationale: She has clinical hyperthyroid signs (tachycardia, thyromegaly, difficulty sleeping) plus elevated T3 and T4 and low TSH. This clearly indicates hyperthyroidism in pregnancy (e.g., Graves’ disease). Why Not the Other Choices: 🔴 B. Subclinical Hyperthyroidism → Would show normal T3 and T4 with low TSH. 🔴 C. Hypothyroidism → Would have low T3 and T4 with high TSH. 🔴 D. Subclinical Hypothyroidism → Would have normal T3 and T4 with high TSH.

Answer 6

D. Subclinical Hypothyroidism High-Yield Rationale: Normal T3 and T4 but elevated TSH matches subclinical hypothyroidism. This can still have clinical consequences in pregnancy and often requires treatment to optimize maternal and fetal outcomes. Why Not the Other Choices: 🔴 A. Hyperthyroidism → Would show low TSH with high T3 and T4. 🔴 B. Subclinical Hyperthyroidism → T3 and T4 would be normal but TSH would be low. 🔴 C. Hypothyroidism → T3 and T4 would be low with TSH high.

Answer 7

C. Average risk 🧠 High-Yield Rationale: 📌 Risk factors for Gestational Diabetes Mellitus (GDM): 🟢 Maternal age ≥25 🟢 BMI ≥25 🟢 Family history of DM 🟢 Ethnicity (Asian, Hispanic, Black, Native American = higher risk) While she is: ✅ Filipino (higher-risk ethnicity) ✅ Has a positive family history ❌ But BMI is normal (20) and age is <25 🔍 So she falls under average risk. ❌ Why not the others: 🅰️ No risk – Incorrect; there is a family history 🅱️ Low risk – Reserved for very young, non-ethnic, no FHx, normal BMI 🅳 High risk – Requires multiple risk factors (e.g., obesity, history of GDM/macrosomia)

Answer 8

A. 50 grams oral glucose challenge test (OGCT) 🧠 High-Yield Rationale: 📌 For average-risk patients, GDM screening is done between 24–28 weeks using: 🟢 50g OGCT (non-fasting) 🟢 If result ≥140 mg/dL, proceed to 100g OGTT (diagnostic) ❌ Why not the others: 🅱️ Random blood sugar – Not reliable for GDM screening 🅲 75g OGTT – Diagnostic, not screening; used for high-risk or failed 50g test 🅳 Fasting blood sugar – Not enough as a standalone screening tool

Answer 9

B. Pregestational diabetes 🧠 High-Yield Rationale: 📌 GDM is diagnosed after 24 weeks AOG. 📌 Any abnormal glucose values in the 1st trimester → Pregestational Diabetes Mellitus (PGDM). Also, RBS ≥ 200 mg/dL = diagnostic of diabetes regardless of pregnancy. ❌ Why not the others: 🅰️ Normal – RBS 240 = definitely not normal 🅲 GDM – Not applicable before 24 weeks AOG 🅳 Other endocrinopathies – No evidence pointing to any other endocrine disorder

Answer 10

D. All of the above 🧠 High-Yield Rationale: 📌 Pregestational DM requires a multidisciplinary approach: 🍽️ Diabetic diet – cornerstone for glycemic control 🏃 Exercise – improves insulin sensitivity 💉 Insulin – DOC for glucose control in pregnancy (oral hypoglycemics are avoided) ❌ Why not individual options: 🅰️–🅲 Each plays a role, but none is sufficient alone

Answer 11

A. Fetal macrosomia 🧠 High-Yield Rationale: 📌 Maternal hyperglycemia crosses placenta → stimulates fetal insulin production, a potent growth factor. Result: 📈 Macrosomia (birthweight >4.0 or 4.5 kg) Other risks include: 🟢 Shoulder dystocia 🟢 Neonatal hypoglycemia 🟢 Congenital anomalies (especially in PGDM) ❌ Why not the others: 🅱️ Fetal death – Risk increases in uncontrolled GDM, but macrosomia is more common 🅲 Abortion – More associated with 1st trimester teratogenic exposure 🅳 Preterm delivery – Possible, but not the most likely

Answer 12

A. Pre-eclampsia 🧠 High-Yield Rationale: 📌 Poorly controlled pregestational diabetes increases the risk of pre-eclampsia, due to: 🟢 Endothelial dysfunction 🟢 Chronic hypertension 🟢 Vascular complications 📌 Target FBS in pregnancy: 🟢 Fasting: <95 mg/dL 🟢 2h postprandial: <120 mg/dL This patient’s readings are consistently above target, indicating uncontrolled diabetes. ❌ Why not the others: 🅱️ Hyperemesis gravidarum – Usually in the 1st trimester, not related to diabetes 🅲 Proliferative retinopathy – Complication of long-standing DM, but not most likely in pregnancy 🅳 Neuropathy – Chronic complication, not acute pregnancy-related concern

Answer 13

D. Sonography 🧠 High-Yield Rationale: 📌 Placenta previa = painless vaginal bleeding in 2nd/3rd trimester 📌 Transvaginal or transabdominal ultrasound is the gold standard to localize the placenta and confirm diagnosis. ❌ Why not the others: 🅰️ CT scan – Radiation risk, not indicated in pregnancy 🅱️ Doppler velocimetry – For fetal blood flow; not useful here 🅲 MRI – Helpful in placenta accreta, not for routine previa

Answer 14

C. Prompt removal of the uterus 🧠 High-Yield Rationale: 📌 This is Placenta Accreta, where placenta is abnormally adherent to the uterus. No cleavage plane, brisk hemorrhage, and inability to remove placenta → emergency. 🩺 Definitive treatment = Hysterectomy (to save the mother’s life). ❌ Why not the others: 🅰️ Manual removal – Risk of massive hemorrhage 🅱️ Leave in place – Used only if conservative fertility-preserving approach is considered and bleeding is controlled, not suitable here 🅳 Spontaneous expulsion – Not possible in accreta

Answer 15

D. Rupture of fetal vessels 🧠 High-Yield Rationale: 📌 Vasa previa presents with: 🟢 Sudden painless vaginal bleeding 🟢 Fetal distress (bradycardia) immediately after ROM 🧬 Rupture of fetal vessels traversing membranes (not protected by Wharton's jelly) → fetal exsanguination. ❌ Why not the others: 🅰️ Rupture of decidual arteries – Seen in placental abruption, not this context 🅱️ Dilatation of internal os – Not associated with sudden bleeding 🅲 Placental separation – Would have painful bleeding, not abrupt bradycardia

Answer 16

B. Clinical symptomatology 🧠 High-Yield Rationale: 📌 Placental abruption is a clinical diagnosis: 🟢 Painful bleeding 🟢 Tense uterus 🟢 Maternal shock 🟢 Fetal distress Even without overt bleeding (concealed type), symptoms + signs are diagnostic. ❌ Why not the others: 🅰️ Ultrasound – Low sensitivity for abruption; cannot rule it out 🅲 Fetal bradycardia – A sign, not sufficient for diagnosis 🅳 Pelvic exam – Contraindicated in bleeding; not diagnostic

Answer 17

A. Placenta accreta 🧠 High-Yield Rationale: 📌 Placenta accreta is a major concern in women with: 🟢 Multiple prior cesarean deliveries 🟢 Advanced maternal age 🟢 Anterior placenta or previa Accreta occurs when the placenta abnormally adheres to the uterine wall, risking massive hemorrhage during delivery. ❌ Why not the others: 🅱️ Uterine atony – Possible, but more linked to overdistension, prolonged labor, or oxytocin use 🅲 Consumptive coagulopathy – Seen in placental abruption or IUFD 🅳 Uteroplacental apoplexy (Couvelaire uterus) – Rare; seen in severe abruption

Answer 18

C. Uterine atony 🧠 High-Yield Rationale: 📌 The most common cause of postpartum hemorrhage is uterine atony (failure of the uterus to contract after delivery). Key signs: 🟢 Soft, boggy uterus 🟢 Heavy bleeding 🟢 No other findings (no lacerations, no retained placenta) ❌ Why not the others: 🅰️ Coagulopathy – Bleeding would be diffuse, not localized to the uterus 🅱️ Uterine rupture – Would present with abdominal pain, shock, not soft uterus 🅳 Retained secundines – Uterus usually firm, bleeding can be slower

Answer 19

B. Curettage 🧠 High-Yield Rationale: 📌 This is delayed postpartum hemorrhage, likely due to retained placental tissue. Open cervix, meaty tissues, and enlarged uterus are classic signs. 🩺 Management: Uterine evacuation via curettage. ❌ Why not the others: 🅰️ Uterotonics – Might help temporarily but won’t remove retained products 🅲 IV oxytocin – Same limitation as above 🅳 Antimicrobials – May be used if infection is present, but not definitive without evacuation

Answer 20

B. Genital tract laceration 🧠 High-Yield Rationale: 📌 Forceps delivery, especially breech or instrumental delivery, is associated with trauma-related postpartum hemorrhage: 🟢 Cervical tear 🟢 Vaginal lacerations 🟢 Perineal injury Bleeding despite a firm uterus suggests laceration. ❌ Why not the others: 🅰️ Atony of lower segment – Less likely; bleeding is traumatic, not atonic 🅲 Retained products – Less likely immediately post-delivery 🅳 Coagulopathy – Would not explain focal profuse bleeding post-instrumentation

Answer 21

B. Uterine inversion 🧠 High-Yield Rationale: 📌 Uterine inversion occurs when the fundus collapses and protrudes through the cervix or vagina. Key signs: 🟢 Fleshy mass at introitus 🟢 Absent fundal mass on abdomen 🟢 Hemorrhagic shock ❌ Why not the others: 🅰️ Pelvic organ prolapse – Chronic condition, not acute post-delivery 🅲 Vulvar hematoma – Presents as painful, bluish swelling, not a fleshy mass 🅳 Prolapsed submucous myoma – Rare postpartum; would have a history of fibroid

Answer 22

D. Several weeks after delivery 🧠 High-Yield Rationale: 📌 Although some hemodynamic changes begin to reverse soon after delivery, complete return to prepregnancy cardiovascular status takes several weeks—typically by 6 weeks postpartum. This includes normalization of: 🟢 Blood volume 🟢 Cardiac output 🟢 Stroke volume 🟢 Heart rate 🟢 Systemic vascular resistance ❌ Why not the others: 🅰️ 2 hours – Too early; only minimal changes occur 🅱️ 1 day – Cardiac output is still elevated postpartum 🅲 1 week – Some improvement occurs, but full normalization takes longer

Answer 23

C. Women who have undergone the Fontan Procedure 🧠 High-Yield Rationale: 📌 The Fontan procedure is used in single-ventricle physiology and results in: 🟢 Reduced cardiac output 🟢 Venous congestion 🟢 Impaired placental perfusion → IUGR ❌ Why not the others: 🅰️ Unrepaired VSD – Usually left-to-right shunt with preserved output unless large 🅱️ Arrhythmia + beta blockers – May slightly reduce fetal growth, but not a major IUGR risk 🅳 Pulmonary regurgitation – Well tolerated unless severe with right heart failure

Answer 24

D. Mechanical valve with full anticoagulation 🧠 High-Yield Rationale: 📌 Regional anesthesia (e.g., spinal, epidural) is contraindicated in: 🟢 Bleeding diathesis or full anticoagulation (↑ risk of spinal hematoma) 📌 Mechanical valve patients on therapeutic anticoagulation (e.g., warfarin or heparin) are at high bleeding risk → general anesthesia preferred. ❌ Why not the others: 🅰️ Severe pulmonary hypertension – Regional may still be used carefully to avoid large hemodynamic swings 🅱️ Severe aortic stenosis – Relative contraindication; regional may worsen hypotension but not absolute 🅲 Decompensated HF – Not an absolute contraindication; needs optimization first

Answer 25

B. Left axis deviation 🧠 High-Yield Rationale: 📌 During pregnancy: 🟢 Diaphragm elevation → heart shifts horizontally 🟢 Results in left axis deviation Other normal changes: sinus tachycardia, benign arrhythmias ❌ Why not the others: 🅰️ Sinus tachycardia – Common but must rule out anemia, infection, etc. 🅲 ST depression – Not normal; suggests ischemia 🅳 LBBB – Always abnormal and warrants further work-up

Answer 26

A. Eisenmenger syndrome 🧠 High-Yield Rationale: 📌 Eisenmenger syndrome = pulmonary hypertension with reversal of shunt (cyanotic) 🟢 Pregnancy is contraindicated 🟢 Mortality rate up to 40–50% Due to risk of sudden death, arrhythmia, thromboembolism ❌ Why not the others: 🅱️ Mitral stenosis – Risky but manageable 🅲 Aortic stenosis – Also risky but mortality < Eisenmenger 🅳 VSD – Repaired or small VSDs generally well tolerated

Answer 27

A. True 🧠 High-Yield Rationale: 📌 Cardiovascular stress peaks at mid to late pregnancy, especially: 🟢 Between 28–32 weeks (third trimester) 🟢 Intrapartum and early postpartum period Patients with congenital heart disease remain at risk for: 🟢 Arrhythmias 🟢 Decompensated heart failure 🟢 Thromboembolic events ❌ Why not B: Risk persists throughout pregnancy and even postpartum.

Answer 28

C. Systolic murmur 🧠 High-Yield Rationale: 📌 Due to increased blood volume and cardiac output, a systolic ejection murmur (grade 2/6 or less) is common and usually benign during pregnancy. Typically heard at the left sternal border ❌ Why not the others: 🅰️ Continuous murmur – Suggests PDA or AV malformation 🅱️ Diastolic murmur – Always pathologic 🅳 S3 gallop – May be present, but not classified as a murmur

Answer 29

C. Exaggerated splitting of the 2nd heart sound 🧠 High-Yield Rationale: 📌 Normal CV changes during pregnancy: 🟢 Increased blood flow → exaggerated S2 splitting 🟢 Heart displaced upward and leftward (not dextrorotated) ❌ Why not the others: 🅰️ Heart is dextrorotated – ❌ It’s actually left and upward shifted 🅱️ Pericardial effusion – ❌ Not a physiologic pregnancy change 🅳 None of the above – Incorrect since C is true

Answer 30

A. Systemic vascular resistance 🧠 High-Yield Rationale: 📌 Pregnancy is a low-resistance state due to: 🟢 Progesterone-mediated vasodilation 🟢 Increased blood flow to uterus/placenta → Results in ↓ systemic vascular resistance (SVR) despite ↑ CO ❌ Why not the others: 🅱️ Postpartum intravascular volume – Temporarily increases, not decreases 🅲 Cardiac output during parturition – Increases due to contractions and auto-transfusion from the uterus

Answer 31

D. Imperforate hymen 🧠 High-Yield Rationale: 📌 Imperforate hymen: 🟢 Congenital anomaly 🟢 Menstrual blood collects behind hymen → hematocolpos ± hematometra Presents after menarche with: 🟢 Pelvic pain 🟢 Primary amenorrhea 🟢 Bulging hymen 🟢 Distended uterus/vagina on imaging ❌ Why not the others: 🅰️ Atrophy of vaginal canal – Seen in postmenopausal women 🅱️ Synechiae – Refers to adhesions; unlikely at this age 🅲 Cervical stenosis – Usually acquired or post-surgical, rare at age 10

Answer 32

A. Myoma often increases in size 🧠 High-Yield Rationale: 📌 Estrogen and progesterone levels increase during pregnancy → stimulate the growth of uterine fibroids (myomas). 🟢 First and second trimesters: rapid growth common 🟢 Complications: pain, red degeneration, malpresentation ❌ Why not the others: 🅱️ Decreases in size – Uncommon; fibroids usually shrink after delivery 🅲 No change in size – Not typical during hormonal surges of pregnancy

Answer 33

D. Carneous 🧠 High-Yield Rationale: 📌 Red (carneous) degeneration is: 🟢 Most common degeneration of myoma during pregnancy 🟢 Caused by venous thrombosis and hemorrhagic infarction within the myoma 🟢 Presents as acute localized abdominal pain ❌ Why not the others: 🅰️ Hyaline – Most common overall, but painless 🅱️ Myxomatous – Rare; not linked with acute pain 🅲 Fatty – Extremely rare, not a typical complication in pregnancy

Answer 34

A. Intravenous leiomyomatosis 🧠 High-Yield Rationale: 📌 Intravenous leiomyomatosis: 🟢 Rare condition where benign smooth muscle cells infiltrate the venous system 🟢 Can extend into inferior vena cava or even heart chambers 🟢 Appears benign histologically but behaves aggressively ❌ Why not the others: 🅱️ Leiomyomatosis peritonealis disseminata – Multiple small nodules in peritoneum, not intravascular 🅲 Cellular leiomyomata – Variant of fibroid, more mitotically active but localized 🅳 Hereditary leiomyomatosis – Genetic disorder associated with cutaneous & uterine fibroids + renal cancer

Answer 35

D. Mature cystic teratoma 🧠 High-Yield Rationale: 📌 Mature cystic teratoma (dermoid cyst): 🟢 Most common benign ovarian tumor in young women 🟢 Contains elements from all 3 germ layers: ectoderm (hair, teeth), mesoderm, endoderm 🟢 Ultrasound: mixed echogenicity, calcifications, fluid, septa ❌ Why not the others: 🅰️ Endometrioma – Homogenous ground-glass appearance; lacks hair and calcifications 🅱️ Fibroma – Solid, hypoechoic; doesn’t match ultrasound findings 🅲 Theca lutein cyst – Bilateral, associated with high hCG (e.g., molar pregnancy)

Answer 36

D. Torsion of the pedicle 🧠 High-Yield Rationale: 📌 Torsion is the most frequent complication of mature cystic teratoma, due to: 🟢 Large size 🟢 Weight imbalance 🟢 Mobile nature of the cyst 🟢 Symptoms: sudden, severe lower abdominal pain ± nausea/vomiting ❌ Why not the others: 🅰️ Silent rupture – Rare; usually presents with peritonitis 🅱️ Reabsorption of fluid – Not typical for teratomas 🅲 Intraperitoneal bleed – Possible but less common than torsion

Answer 37

A. Iatrogenic implantation 🧠 High-Yield Rationale: 📌 Scar endometriosis (or scar endometrioma) occurs when endometrial tissue is implanted into the abdominal wall during uterine surgeries, especially C-sections or myomectomies. 🟢 Pain worsens during menstruation due to hormone-sensitive endometrial tissue 🟢 Imaging shows hypoechoic, heterogeneous mass near the scar ❌ Why not the others: 🅱️ Immunologic changes – Associated with theory of endometriosis pathogenesis, but not direct cause in scar cases 🅲 Lymphatic/vascular spread – Rare, and more common in deep pelvic or extrapelvic endometriosis 🅳 Retrograde menstruation – Explains pelvic endometriosis, not scar endometrioma

Answer 38

D. GnRH-a (Gonadotropin-Releasing Hormone agonist) 🧠 High-Yield Rationale: 📌 GnRH agonists suppress the pituitary-gonadal axis → decrease estrogen → pseudo-menopause: 🟢 Induces amenorrhea 🟢 Shrinks fibroids 🟢 Useful preoperatively ❌ Why not the others: 🅰️ COC (combined pills) – Regulates bleeding but doesn’t induce hypoestrogenism 🅱️ LNG-IUS – Local progesterone effect; doesn’t suppress systemic estrogen 🅲 SERM (e.g., raloxifene) – Estrogen agonist/antagonist; not potent enough to induce menopause-like state

Answer 39

D. Laparoscopy 🧠 High-Yield Rationale: 📌 Laparoscopy allows: 🟢 Direct visualization of endometriotic implants 🟢 Biopsy confirmation Gold standard because imaging may miss small, deep, or atypical lesions. ❌ Why not the others: 🅰️ Pelvic ultrasound – Good for endometriomas, but poor for small lesions 🅱️ MRI – Helpful in deep infiltrating endometriosis, but not first-line 🅲 CT scan – Poor soft tissue detail; not used for endometriosis

Answer 40

C. Greater than 12 months 🧠 High-Yield Rationale: 📌 Menopause = 12 consecutive months of amenorrhea without any other pathologic or physiologic cause 🟢 Average age: 51 years 🟢 Due to permanent ovarian follicle depletion ❌ Why not the others: 🅰️ >6 months – Could be oligomenorrhea, perimenopause 🅱️ <6 months – Too early to define as menopause 🅳 <12 months – Not yet considered menopause

Answer 41

C. Estrone 🧠 High-Yield Rationale: 📌 In menopause: 🟢 Ovaries stop producing estradiol 🟢 Estrone (E1) becomes the main estrogen, synthesized from adipose tissue via aromatization of androstenedione ❌ Why not the others: 🅰️ Estriol – Dominant during pregnancy 🅱️ Estradiol – Dominant in reproductive age 🅳 Any of the above – Only estrone dominates in menopause

Answer 42

A. Cognitive dysfunction 🧠 High-Yield Rationale: 📌 Common menopausal symptoms include: 🟡 Vasomotor symptoms (hot flashes, night sweats) 🦴 Bone demineralization ❌ Infertility due to ovarian failure Cognitive dysfunction is not a direct or universal effect of menopause, though some women report subjective memory issues. ❌ Why not the others: 🅱️ Vasomotor symptoms – Most common menopausal complaint 🅲 Bone loss – Estrogen deficiency → ↑ osteoclast activity 🅳 Infertility – A natural result of ovarian senescence

Answer 43

B. Results in an increase in LH 🧠 High-Yield Rationale: 📌 Menopause causes: 🟡 Loss of follicles → ↓ estrogen & inhibin → loss of negative feedback 🟢 Leads to ↑ FSH and LH ❗ But the increased LH is an effect, not a cause of menopause. ❌ Why not the others: 🅰️ Loss of ovarian follicular function – Primary cause of menopause 🅲 Chemotherapy – Can cause premature ovarian insufficiency 🅳 Genetic predisposition – Known risk factor for early menopause

Answer 44

B. Have osteopenia 🧠 High-Yield Rationale: 📌 WHO DEXA T-score classifications: 🟢 Normal: ≥ -1.0 🟢 Osteopenia: -1.0 to -2.5 🟢 Osteoporosis: ≤ -2.5 📉 T-score of -1.5 = osteopenia ❌ Why not the others: 🅰️ Osteoporosis – T-score not low enough 🅲 Normal – Cutoff is ≥ -1.0 🅳 Inconclusive – T-score is clear and diagnostic

Answer 45

D. Decrease in prostacyclin 🧠 High-Yield Rationale: 📌 Estrogen protects the cardiovascular system by: 🟢 Promoting vasodilation (via nitric oxide & prostacyclin) 🟢 Inhibiting platelet aggregation 🔻 Postmenopause = ↓ estrogen → ↓ prostacyclin → ↑ vasoconstriction & thrombosis risk ❌ Why not the others: 🅰️ Decrease in endothelin – Actually protective; endothelin is a vasoconstrictor 🅱️ Increase in nitric oxide – Protective, not harmful 🅲 Increase in prostaglandins – Non-specific; some PGs are vasodilatory, some vasoconstrictive

Answer 46

A. Estrogen only 🧠 High-Yield Rationale: 📌 If uterus is absent (post-hysterectomy): 🟢 No risk of endometrial hyperplasia or cancer ✅ Estrogen-only therapy is safe and preferred for symptom relief ❌ Why not the others: 🅱️ Estrogen-progesterone – Needed only if uterus is present 🅲 Progesterone only – Ineffective alone for vasomotor symptoms 🅳 Any of the above – Inappropriate since estrogen alone is safest post-hysterectomy

Answer 47

A. Breast cancer 🧠 High-Yield Rationale: 📌 Hormone therapy (HRT) is contraindicated in: 🟢 Hormone-sensitive cancers (e.g., breast, endometrial) 🟢 Active liver disease 🟢 Uncontrolled hypertension 🟢 History of thromboembolic events ❌ Why not the others: 🅱️ Active liver disease – Also contraindicated ✅ (but A is the most classic absolute contraindication) 🅲 Migraine with aura – Relative contraindication for COCs, not all HRT 🅳 Diabetes mellitus – Not an absolute contraindication if controlled

Answer 48

B. Tamoxifen 🧠 High-Yield Rationale: 📌 Bone resorption inhibitors: 🦴 Raloxifene, Droloxifene, and Tibolone all have anti-resorptive effects on bone ❌ Tamoxifen has partial agonist effect on bone in postmenopausal women, but it’s not primarily used to reduce bone resorption and may increase resorption in premenopausal women. ❌ Why not the others: 🅰️ Raloxifene – SERM used to treat osteoporosis 🅲 Droloxifene – Experimental SERM, similar to raloxifene 🅳 Tibolone – Has estrogenic activity on bone → ↓ bone loss

Answer 49

C. Lactate dehydrogenase (LDH) 🧠 High-Yield Rationale: 📌 For hypertensive disorders of pregnancy, check for organ dysfunction and hemolysis: 🧪 LDH → marker of hemolysis (part of HELLP) Uric acid, AST/ALT, platelet count, creatinine → also used ❌ Why not the others: 🅰️ Uric acid – Used but non-specific 🅱️ BUN – Can be checked but less sensitive than creatinine 🅳 Cholesterol/triglycerides – Not useful for hypertensive diagnosis in pregnancy

Answer 50

C. Gestational hypertension 🧠 High-Yield Rationale: 📌 Gestational hypertension = 🟢 BP ≥140/90 after 20 weeks AOG 🟢 No proteinuria or end-organ damage 🟢 Transient, resolves postpartum ❌ Why not the others: 🅰️ Preeclampsia with severe features – Needs organ damage or symptoms (e.g., headache with albuminuria or lab changes) 🅱️ Preeclampsia w/o severe features – Requires proteinuria 🅳 Chronic hypertension – Would require onset before 20 weeks

Answer 51

B. HELLP syndrome 🧠 High-Yield Rationale: 📌 HELLP = Hemolysis, Elevated Liver enzymes, Low Platelets 🟢 Anemia (Hb = 8) 🟢 Platelets <100,000 🟢 +++ proteinuria 🟢 Dark urine = hemolysis (bilirubin, hemoglobinuria) ❌ Why not the others: 🅰️ Preeclampsia with severe features – Overlaps, but the lab criteria make HELLP more specific 🅲 Chronic hypertension – Wouldn’t cause hemolysis or thrombocytopenia 🅳 Superimposed preeclampsia – Would present with chronic HTN + proteinuria; HELLP features

Answer 52

C. Eclampsia 🧠 High-Yield Rationale: 📌 Eclampsia = preeclampsia + seizure Key features: 🟢 BP ≥140/90 (here: 180/100 ✅) 🟢 Proteinuria (+++ ✅) 🟢 Seizure and LOC ✅ 🟢 Often triggered by stress (e.g., heat, light) ❌ Why not the others: 🅰️ Preeclampsia with severe features – No seizure component 🅱️ Electrolyte imbalance – Possible, but BP and proteinuria point to eclampsia 🅳 Seizure of unknown etiology – There's a clear obstetric cause

Answer 53

C. Immediate termination of pregnancy 🧠 High-Yield Rationale: 📌 Definitive treatment of preeclampsia is delivery, especially with severe features (e.g., BP ≥160/110, +++ proteinuria, end-organ damage). Gestational age ≥34 weeks? → Deliver. 🩺 Other measures are supportive. ❌ Why not the others: 🅰️ Magnesium sulfate – Prevents seizures ✅ but not definitive treatment 🅱️ Nicardipine drip – Used to control BP ✅ but supportive only 🅳 Steroids – For fetal lung maturity <34 weeks; this patient is 37 weeks

Answer 54

C. Plateauing of fetal weight estimates on at least 2 ultrasound tests 🧠 High-Yield Rationale: 📌 IUGR = fetal weight <10th percentile for gestational age 🩻 Most diagnostic: serial ultrasounds showing plateau or drop in fetal weight trajectory. Accurate, objective, and trackable over time ❌ Why not the others: 🅰️ Oligohydramnios – Common association, but not specific or diagnostic 🅱️ Fundic height lag – Initial clue, not definitive 🅳 Doppler ARED (Absent/Reversed End-Diastolic flow) – Indicates severity, not diagnosis

Answer 55

D. Contraction stress test

Answer 56

B. Brain-sparing phenomenon 🧠 High-Yield Rationale: 📌 Asymmetric IUGR = head > abdomen ratio due to redistribution of blood to vital organs, esp. the brain Occurs due to uteroplacental insufficiency Seen in late-onset IUGR ❌ Why not the others: 🅰️ Intrauterine infections – Cause symmetric IUGR 🅲 Congenital malformations – Usually cause symmetric IUGR 🅳 Oligohydramnios – Can accompany IUGR, not the cause

Answer 57

D. Arrest in descent 🧠 High-Yield Rationale: 📌 Macrosomia (estimated fetal weight ≥4,000–4,500g) can cause: 🟢 Cephalopelvic disproportion (CPD) 🟢 Failure to descend despite adequate contractions 📌 Arrest in descent is a classic intrapartum clue. ❌ Why not the others: 🅰️ Uncontrolled DM – Risk factor, not intrapartum clue 🅱️ Weight gain – Antepartum risk factor 🅲️ Arrest in dilatation – Nonspecific; can occur for many reasons

Answer 58

A. Outright cesarean section 🧠 High-Yield Rationale: 📌 In GDM, especially uncontrolled with estimated fetal weight ≥3.5–4.0 kg, cesarean delivery is preferred due to: 🟢 ↑ Risk of shoulder dystocia 🟢 Unfavorable cervix (Bishop 4 = poor candidate for induction) ❌ Why not the others: 🅱️ Cervical ripening/induction – Not recommended with unfavorable cervix & macrosomia 🅲️ Await until 39 weeks – Risk of fetal demise or shoulder dystocia 🅳 Antepartum testing – Helpful, but doesn’t replace delivery decision-making

Answer 59

A. No active intervention since the fetus is an abortus 🧠 High-Yield Rationale: 📌 Cutoff for viability: 🟢 Philippines & most guidelines: Viability starts at ≥24 weeks or ≥500g 🟢 <22 weeks or <500g → legally and clinically considered abortus 👉 Focus is on maternal care, not neonatal resuscitation ❌ Why not the others: 🅱️ CPR/intubation – Not indicated <500g 🅲️ Surfactant – Fetal lungs not responsive at 22 weeks 🅳 Incubator – Not considered viable

Answer 60

A. Await spontaneous passage of fetus 🧠 High-Yield Rationale: 📌 In cases of inevitable abortion with fetal cardiac activity, spontaneous expulsion is usually expected if: 🟢 The cervix is open and membranes ruptured 📌 Watchful waiting may avoid surgical risks. ❌ Why not the others: 🅱️ Progesterone – Used in threatened abortion, not here 🅲️ D&C – Not immediate indication when fetus is still viable and expulsion is expected 🅳 Medical curettage – Reserved for missed/incomplete abortions

Answer 61

C. Do dilation and curettage 🧠 High-Yield Rationale: 📌 Incomplete abortion with retained products of conception (RPOC) → best managed by uterine evacuation, especially if: 🟢 Active bleeding 🟢 Hemodynamic concerns 🟢 Ultrasound confirms RPOC (2cc) ❌ Why not the others: 🅰️ Spontaneous expulsion then D&C – Already passed tissue; now RPOC present 🅱️ Methylergometrine – Used for uterine atony, not first-line for RPOC 🅳 Progesterone – Used in threatened abortion, not applicable in RPOC

Answer 62

C. Uterine synechiae 🧠 High-Yield Rationale: 📌 Uterine synechiae (Asherman syndrome) results from: 🟢 Aggressive curettage damaging the endometrial basalis layer 🟢 Leads to intrauterine adhesions 🟢 Presents with secondary amenorrhea or infertility ❌ Why not the others: 🅰️ Uterine rupture – Seen in labor or previous cesarean scar, not from suction D&C 🅱️ Uterine perforation – Acute complication, not delayed like synechiae 🅳 Endometritis – Infection; not directly caused by overzealous scraping

Answer 63

A. Culdocentesis 🧠 High-Yield Rationale: 📌 Culdocentesis is a quick bedside procedure to diagnose hemoperitoneum: 🟢 Needle inserted through posterior vaginal fornix 🟢 Aspirates fluid from pouch of Douglas 🟢 Used in suspected ruptured ectopic pregnancy if no ultrasound available ❌ Why not the others: 🅱️ Amniocentesis – Fluid from amniotic sac 🅲️ Pericentesis – (Actually paracentesis) – Fluid from peritoneal cavity via abdomen 🅳 Peritoneal fluid cytology – A lab test, not a procedure

Answer 64

C. Diaphragmatic irritation 🧠 High-Yield Rationale: 📌 Blood from hemoperitoneum irritates the diaphragm, which shares innervation with the shoulder (C3–C5 phrenic nerve) → referred pain to shoulder ❌ Why not the others: 🅰️ Referred pain – True, but diaphragmatic irritation is the mechanism 🅱️ Peritoneal irritation – Too vague, not specific 🅳 None of the above – Incorrect because C is true

Answer 65

A. Administer methotrexate 🧠 High-Yield Rationale: 📌 Medical management with methotrexate is ideal if: 🟢 Hemodynamically stable ✅ 🟢 No rupture signs ✅ 🟢 Mass <3.5 cm ✅ 🟢 No fetal cardiac activity ✅ 🟢 β-hCG <5000 IU/L (assumed unless stated otherwise) ❌ Why not the others: 🅱️ Laparoscopy – Surgical option, reserved if methotrexate is contraindicated or fails 🅲️ Salpingostomy – Invasive, not first-line in stable cases 🅳 A and B only – Methotrexate alone is sufficient here

Answer 66

D. Reassure the patient that it is an acceptable side effect 🧠 High-Yield Rationale: 📌 Common GI side effects of methotrexate (especially in single-dose ectopic management) include: 🟢 Nausea 🟢 Vomiting 🟢 Diarrhea ✅ These are transient and self-limiting ❌ Why not the others: 🅰️ Leucovorin – Given for high-dose methotrexate toxicity, not routine ectopic cases 🅱️ Increase the dose – Would worsen toxicity 🅲️ Salpingostomy – Not needed unless methotrexate fails

Answer 67

A. Ampulla 🧠 High-Yield Rationale: 📌 The fallopian tube has 4 parts: 🟢 Infundibulum (with fimbriae) 🟢 Ampulla – 📍 Site of fertilization 🟢 Isthmus 🟢 Intramural/interstitial The ampulla is the widest and longest part, where fertilization usually occurs. ❌ Why not the others: 🅱️ Isthmus – Narrow, muscular, closer to uterus 🅲 Fimbriae – Collect oocyte, not where fertilization occurs 🅳 No difference – Incorrect; parts have distinct roles

Answer 68

B. Breech presentation 🧠 High-Yield Rationale: 📌 Leopold's maneuver clues: 🟢 Fundus (LM1): hard, round, ballotable → head 🟢 Pelvis (LM3): round, doughy → breech (buttocks) ➡️ Breech presentation ❌ Why not the others: 🅰️ Cephalic – Would have head at pelvis, not fundus 🅲 Fetal back on right – No data confirms this 🅳 Cannot be interpreted – Sufficient data is available

Answer 69

D. Send the patient home and advise on the signs and symptoms of labor 🧠 High-Yield Rationale: 📌 This is a case of false labor or early latent phase: 🟢 Mild, infrequent contractions 🟢 Cervix closed, long, soft ➡️ Discharge with advice is appropriate ❌ Why not the others: 🅰️ Ultrasound for presentation – Not needed, presentation is known 🅱️ Admit and monitor – Not in active labor 🅲 Immediate CS – Not indicated

Answer 70

B. Partial breech extraction 🧠 High-Yield Rationale: 📌 Partial breech extraction: 🟢 Spontaneous delivery of lower body 🟢 Assisted delivery of upper body using maneuvers This is typical in breech vaginal delivery where fetus delivers up to umbilicus then assistance is needed. ❌ Why not the others: 🅰️ Pinard's – Used to flex extended legs 🅲 Total breech extraction – Entire fetus delivered by traction only (e.g., in 2nd twin) 🅳 Spontaneous breech – Entirely without assistance

Answer 71

C. Loveset's 🧠 High-Yield Rationale: 📌 Loveset’s maneuver is used to deliver the shoulders, particularly when: 🟢 Nuchal arms are present 🟢 It involves rotating the fetus and sweeping the arm across the chest ❌ Why not the others: 🅰️ Pinard’s – For extended legs in breech 🅱️ Mauriceau – For after-coming head (flexion) 🅳 Pawlik’s – For abdominal palpation (not a delivery maneuver)

Answer 72

D. Experienced operator 🧠 High-Yield Rationale: 📌 Prerequisites for assisted vaginal delivery (forceps or vacuum) include: 🟢 Full cervical dilation 🟢 Ruptured membranes 🟢 Engaged fetal head 🟢 Known position 🟢 Empty bladder ✅ Experienced operator is critical to ensure safe application and minimize complications ❌ Why not the others: 🅰️ Breech presentation – Vacuum/forceps used for cephalic presentations only 🅱️ Intact bag of waters – Membranes must be ruptured 🅲️ Cervix 5 cm dilated – Not sufficient; must be fully dilated (10 cm)

Answer 73

A. Deliver the baby by vacuum extraction after careful explanation and consent 🧠 High-Yield Rationale: 📌 Indications for operative vaginal delivery include: 🟢 Prolonged second stage 🟢 Maternal conditions (e.g., hypertension) 🟢 Fetal head at low station (+4), cephalic, ruptured membranes → vacuum appropriate ❌ Why not the others: 🅱️ Cesarean – Not necessary if low station and all criteria for vacuum are met 🅲️ Augment labor – Not indicated if fully dilated and good contractions 🅳 No intervention – Delay could lead to fetal distress or maternal exhaustion

Answer 74

A. With contraction and good maternal expulsive effort 🧠 High-Yield Rationale: 📌 Traction timing must: 🟢 Synchronize with uterine contractions 🟢 Coordinate with maternal pushing ✅ This mimics the natural forces and reduces trauma ❌ Why not the others: 🅱️ Without contractions – Ineffective and increases risk of injury 🅲️ Brow presentation – Contraindicated for assisted vaginal delivery 🅳 When jaw is visible – That’s too late, baby is almost out already

Answer 75

B. Examine the mother's perineum for any trauma and examine the neonate for any trauma as well 🧠 High-Yield Rationale: 📌 After assisted delivery, it's essential to: 🟢 Check for maternal trauma (vaginal tears, cervical laceration) 🟢 Assess newborn for forceps injuries (facial bruising, cephalohematoma) ❌ Why not the others: 🅰️ Manual extraction of placenta – Not done unless indicated (e.g., retained placenta) 🅲️ Immediate cord clamping – Delayed clamping preferred unless contraindicated 🅳 Uterine massage – Routine postpartum care, but not specific to forceps use

Answer 76

D. Membranes intact 🧠 High-Yield Rationale: 📌 For safe forceps delivery, you need: 🟢 Consent 🟢 Adequate analgesia/anesthesia 🟢 Pediatric/neonatal support team ❌ Ruptured membranes are mandatory to assess fetal station and apply forceps safely. ❌ Why not the others: 🅰️ Consent – Legal and ethical requirement 🅱️ Anesthesia – Reduces maternal pain and facilitates procedure 🅲️ Neonatal support – Must be ready for potential complications