#1

24 y/o, admitted to emergency gynecoklogical service unit for hypogastric pain, fever 38.6.
During examination, patient reports regular menstrual cycle without dysmenorrhea. Last
menses 2 wks ago, she uses OCs for 2 years. Lower abdominal pain started 4 days ago with
gradual intensification. The patient doesnt complain about GI disturbances or constipation,
she has taken paracetamol for fever. She's married, non smoker, without history of STDs.
The physical exam reveals bp 110/75, pulse 84, temp 38,6. On abdominal examination the
patient records tenderness in the lower quadrant at superficial palpation. External genetalia
intact without lesions. Speculum exam reveals mucopurulent discharge from the cervix in a
moderate amount. Bimanual examination reveals tender uterus and adnexa and cervical
motion tenderness, anteverted uterus normal size.
- PID
-dx: USG
- management: catch clamydia and give antibiotics (ciftriaxone, doxycycline)

#2
32 y/o, transported to medical emergency department for heavy vaginal bleeding during the
last 30 mins. Hx: 6 pregnancies including 2 C-sections 2 spontaneous abortions and 2
medical abortions. Gestational age of the current pregnancy 33wks from the last menstrual
period. The vaginal bleeding occurs spontaneously at rest during sleep without pain. In the
context of some irregular uterine contractions. Clinical examination reveals bp 110/60 pulse
110 temp 36,8. Abdominal palpation didnt reveal any tenderness and pain. The uterus is
normal in tonus, fetus in transversal line, FHR was 190-200. Vaginal speculum shows active
abundant bright red bleeding coming from endocervix.
- pregnancy 33wks hemorragic placenta previa
- management: emergency c-section

#3
Nulliparous, gave birth to a babygirl weighing 3500g at 39wks, 6 days after birth she
complained of hypogastric pain, fever 38, fatigue, loss of appetite. Clinical examination bp
110/70 pulse 98 temp 38,7. Obs examination reveals an enlarged uterus, painful at palpation
and mobilization. Uterine fundus2cm below the umbilicus, lochia abundant bloody and foul
smelling
- Puerperal infection endometritis
-tx: antibiotics

#4
35 y/o 3rd pregnancy at 38wks gestation delivered a boy weighing 4200g (macrosomic
fetus). She had 2 normal births in 2008 and 2013. More than 10mins after the baby's birth,
there was an abnmormal bleeding with fresh red blood. Uterus is relaxed and soft. The
uterine fundus goes beyond the umbilicus, external manuevers dont determine any signs of
placenta seperation.
- Uterine atony

#5
She had one spontaneous abortion in the 1st trimester 2 years ago without uterine
curretage. Last normal menstrual cycle 2 months ago, does not use contraceptives,
pregnancy is desired. Discontinued contraceptive pills 6 months ago. Urinary pregnancy test
performed a month ago is +ve. The patient reports abundant dark color painless heavy
vaginal bleeding for the last few hours. Signs of pregnancy presents, nausea vomiting.
Clinical examination bp 120/70 pulse 84, temp 37,4. Abdomen at palpation soft tender and
painful, vaginal examination reveals few black bloody streaks from endocervix. Speculum
exam cervix with characteristics of pregnancy, bimanual vaginal exam non-tender uterus,
uterine fundus height is 16, the cervix is long and closed. Absence of parauterine masses,
douglas space the posterior vaginal fornix is painless. The pelvic USG determined multiple
intrauterine hypoechogenic vesicular-like images, snowstorm pattern
- Molar pregnancy
-management: evacuation of the uterus & monitoring of betaHCG (bcz risk of
choriocarcinoma

#6
28 y/o, coming to gynecologist complaining of secondary amenorrhea for the past 4 years,
menarche at 12 y/o. Regular meses, had 1st intercourse at 19, started contraceptives and
after stopping, she has amenorrhea 5 years, persistent headache during the last year.
Physical exam height 165 weight 60kg without signs of hirsutism. Breast examination
determines bilateral galactorrhea.
- Hyperprolactinemia, PRL to exclude prolactinoma
-tx: gabergolin, or surgery

#7
45 y/o, 3 gestations 3 deliveries, admitted to gynecological ward with heavy vaginal bleeding
for 3 wks, Hx: last menses was abundant with clots 6 wks ago and lasted for 9 days.
Gynecological hx: cryotherapy for cervical moderate dysplasia 10 years ago and leiomyoma
diagnosed 3 years ago. Obs hx: 3 c-sections and tubal ligations. Stabilization: does not take
any medications, doesn't smoke or use alcohol. Physical exam bp 110/70, temp 36.7,
speculum exam healthy clean uterine cervix, bleeding from cervical os. On pelvic
examination an enlarged non-tender mobile uterus with an irregular contour, no adnexal
pathology.
- Leiomyoma AUB (AUB-L)
- dx: blood count, USG, perform curettage

#8
42 y/o, submitted to gyno ward on november 28 with a 6wks pregnancy and heavy uterine
bleeding that became more abundant after speculum exam without any abdominal cramps.
Because of non-specific vaginal bleeding, the patient was consulted by gynecologist 5 days
earlier, appreciated betaHCG 8800 after 48hrs 9100 (should double normally). On clinical
exam bp 110/90, hr 100. Vaginal exam appreciated an enlarged cervix with a barrel
appearance. Uterus of normal size, no adnexal pathology, and free fornixes.
- Cervical ectopic pregnancy
-dx: USG - management: curretage, methotrexate, hysterectomy for elderly women
#9
29 y/o, admitted to gyno department with acute abdominal pain, localized in the right iliac
region, and AUB. Hx: delay of menses, clinical signs of pregnancy nausea and vomiting.
Clinical exam: pale, hr106, bp 90/60, temp 37,2. Abdominal palpation determines
hypogastric pain, signs of acute abdomen. Gynecological exam normal uterus size, painful
during mobilization, painful douglas pouch (douglas cry), in the region of right adnexa mobile
painful formation (like a tumor) 30-40mm, positive pregnancy test.
- Interrupted Tubal ectopic pregnancy (probably ruptured bcz of acute pain)
dx: USG exam intra-abdominal fluid and enlarged adnexa

#10
20 y/o, 32wks pregnancy, presents for routine obs visit, she has no medical problems, bp
was 115/75, now bp 150/96. urine dipstick shows ++ of protein, she complains of constant
headache and vision changes that arent relieved with painkillers, tonus of uterus not
increased, fetus longitudinal line, cephalic presentation , FHR 155-160 (mild tachycardia), on
bimanual exam cervix is not effaced, cervical os is closed. The patient is sent to the hospital
for further management, at the hospital her bp is 158/100, she's noted to have tonico-clonic
seizures.
- Severe preeclampsia that switched to eclampsia
-management: ABC(open airways, turn to left side, oxygen) magnesium & antihypertensive
drugs labetalol, C-section.

#11
19 y/o, gravida 1st pregnancy, at 12 wks, has vaginal bleeding, enlarged uterus (too big for
12wks preg). No fetal heart sound, USG shows villous, alot of vesicles.
- Molar pregnancy

#12
18 y/o, 2nd prenancy 1st delivery, presents to emergency department with non-severe
abdominal pain, vaginal spotting for the past days, her last menses 7wks ago. On
examination no fever normal bp normal pulse, her abdomen is tender, in left lower quadrant
with voluntary ...?, On pelvic examination she has a small anteverted uterus, no adnexal
masses, mild left adnexal tenderness, and mild cervical motion tenderness. Labs reveal
normal white blood count, Hb 10.5, betaHCG2300, USG reveals 10x5x6cm uterus and
normal appearing 1cm stripe and no gestational sac on fetal ...?. 2,8cm complex adnexal
mass is noted on the left
- Tubal pregnancy

#13
32 y/o , 2nd pregnancy, presents to labor&delivery 34wks of gestation complaining on
regular uterine contractions about every 5 mins for the past several hours. She has also
noticed that the passage of clear fluid per vagina. The external fetal monitoring
demonstrates a reactive fetal hr raising with regular uterine contractions occurring about
every 3-4mins. On sterile speculum exam the cervix is visually closed, a sample of ...?
amniotic fluid is seen in the vaginal wall with nitrazine positive, the patient has a termp of
38,8 pulse 102, bp 100/60, her fundus is tender uterus to palpation. The blood analysis
indicate leukocytes 19000, PET sonography indicates oligohydramnios, fetus size is
appropriate for gestational age, and cephalic presentation.
- preterm labor, preterm ROM 34wks of pregnancy, with infection chorioamnionitis
-treatment: clindamycin + gentamycin and then terminate the pregnancy by C-section

#14
30 years old woman, pregnant with twin gestation at 20th week of pregnancy, is evaluated
for vaginal bleeding and uterine contractions, ultrasound examination rules out the presence
of placenta previa, uterine contraction every 2-3 minutes an lasts for 60 seconds, tonus of
the uterus is not increased both fetus are in longetudinal line in cephalic presentation, sterile
speculm examination is negative for rupturemembrane , digital examination indicates that
the cervix is 2-3cm dilated and 50% effaced and the presentiong part of the first fetus is not
engaged.
Diagnosis: threatened preterm labor
Mangment: tocolysis(nifedipine 10-20mg orally , repeat after 30min if the contractions
continue and after that we switch to 10-20 mg every 6-8 hours for 48 hours , if nifedipine is
not effective we use atosiban or idomethacine) + corticosteriods(dexamethasone:four doses
6 mg every 12 hours, betamethasone: tow doses 12mg intramascular 24 hour apart.)

#15
40 years old ,34 weeks of pregnancy ,she had a normal vaginal dilevery at 40 week 10 years
ago ,the baby weighted 2800 mg ,her hight is 158 cm and her weghit is 52kg, during the
present pregnancy , she has no complication, she gained 8 kg,her fundal hight is 30cm, at
previous visit at 24 and 30 week the fundal hight was 21 and 27 respectively.during ultra
sound examination estimated fetal weight is 8 percintile and amniotic fluid index is 60.
Diagnosis: small gestational age
Mangment : to monitor the growth of the fetus by serial ultra sound exam

#16
39 years old ,she is admitted to the delivery ward at 38 week of pregnancy with a blood
pressure 160/100 mmhg , her baseline blood pressue during the pregnancy was 140-
150/90-100mmhg , on arrival to labor and delivery the patient has persistent sever headache
and visual changes.irregular uterine contracions, cervix is 3 cm dilated and effacment 50%,
her blood presure repeated 170/105 mmhg .hematocrite:34%, platlets 190,transaminase
207, urine dipstick 3+
Diagnosis: sever preeclampsia superimposed on chronic hypertension

#17
At 35 weeks of pregnancy presnts to labor and delivery complaining of several days history
of anorexia malaise
She denies any headache or visual changes her fetal movement has been good during
uterine contractions b
In physical examination mildly jaundice and appears to be allittle confused
Her vital sign indicates a temperature 37.7 pulse of 70beats per min blood pressure 110/62
mmhg
Blood is drawn and wbc: 25000 Ht 42 platelets 51000 transaminase:287 and 350 glucose
7.8
Creatinine and urea increased ,fibroinogen 1.3 prothrombin 56 , urine dipstick +++, and large
ketones.
Diagnosis: acute fatty liver

#18
32 years old present s at 39 weeks of pregnany with ruptured membranes and 4 cm dilation
she has a history of two prior vaginal deliveries with her largiest child 3800g
Over the next two hours progress 7 cm of dilation, 2 hours later she remain in 7cm dilation,
she has 2 contraction in 10min lasting for 20-25 seconds.

Diagnosis: secondary arrest of dilation because it's on the active phase and it should be
lasting for at least 30 seconds.

#19
23 years old 40 weeks pregnancy present to the hospital with complains of contracrions
Occurring every 4 to8 min
And each lasting for approximately 1 min
She reports good fetal movement and denies any fluid leakage or vaginal bleeding
Continues CTG(cardiotocography) reveals contractions every 2-10 min {so it is irregular}.
The midwife said mild uterus on palpation, on examination the cervix is dilated 2cm, 50%
effaced , head of the fetus is not engaged, after 4hrs the patient was reexamined and the
same was observed about the dilation and effacement was noticed. Fetal heart rate was
rising to 140 bpm, acceleration was present but no deceleration.
Diagnosis: false labor because there's irregular contractions and no dynamic changes

#20
On post partum day 2 after vaginal delivery , 32 years old develops acute shortness of
breath and chest pain , her vvital signs are: BP120/80 pulse, 130/min respiratory, rate
32/min, temperature 37.6 she has new onset of cough she appears to be in mild distress,
lung examination reveals clear bases with no rales or rounchi , the chest pain is reproducible
with deep respiration pulse oximetry 88% ,
Diagnosis : pulmonary thromboembolism.

#21
35 years old gravida with a pap smear shows high grade squamous intraepithelial lesion of
the cervix (CIN3) , has inadequate colposcopy , cone biopsy of the cervix shows squamous
cell cancer that has invaded only 1mm beyond the basement membrane .
There are no evidence of lymphatic or vascular invasion, the margins of the cone biopsy are
free of disease .
Diagnosis: invasive cervical cancer stage 4
#22
presents to the gynecology complaining of hair growth on her face chest
she is obese , she also has had problems with acne last menstrual cycle 4 months ago,
on physical examination the patient has significant amount of coarse, dark hair on her face,
chest, and abdomen
on gynecological examination she has enlarged clitoris and 7 cm left adnexal Mass .

diagnosis: androgen-producing ovarian tumor, hyperandroginemia,signs of virilization.

#23
20 years old last mens period 5 days ago comes to the emergency room complaining of a 24
hour history of increasing pelvic pain .
this morning she experience anxious and a fever
she reports no changes in urine or bowel habits she has no nausea or vomiting her only
surgery was a laparoscopy performed last year for ectopic pregnancy
she reports regular menses and denies dysmenorrhea she is currently secual active
she has a new sexual partner and had sexual intercourse with him just prior to her last
menstrual period.
she denies a history of any abnormal pap smear or any sexual transmitted disease
urine pregnancy test is negative
urine analysis is normal , leukocytes 18000 temp 38.8
physical examination: abdomen is diffusely tender in the lower quadrant with rebound
guarding
bowel sounds present but diminished
bimanual examination reveals tender uterus and adnexal cervical motion tenderness
diagnosis: PID,pelvic peritonitis not the whole peritonium.

#24
18 years old consults for evaluation of disabling pain with her menstraul period , the pain has
been appeared since menarch and has been accompanied by nausea and headache
she is sexually active for 1 year and her partner use condoms as contraceptive methods
history is unremarkable
on pelvic examination she has a small anteverted uterus , no adnexal masses no
pathological vaginal discharge
diagnosis: primary dysmenorrhea
its better to do pregnancy test in such cases

#25
a mother brings her daughter to see your consultation
the daughter is 17 years old and has not started periods
she is 1.52 tall
she has no breast , on examination she has no pubic hair
by digital examination she has cervix and uterus,
the ovaries are not palpable .
as part of the workup serum FSH and LH are drawn , both are high
diagnosis: turner syndrome (hypergondatropic hypogonadism/ovarian amenorrhea)

#26
39 years old complains of severe progressive secondary dysmenorrhea,
and menorrhagia for the last 2 years.
speculum examination reveals a healthy and clean uterine cervix , mobile.
pelvic examination demonstrates a tender diffusely enlarged uterus, nonpalpable adnexa,no
adnexal tenderness and free vaginal fornixes .
results of endometrial biopsy are normal.
diagnosis: we suspect endometriosis,ultrasound or ct to rule out endometriosis
biopsy for final diagnosis.
treatment : OCPs,progestin, hypophysis inhibitors

#27
22 years old presents to the emergency
right side pelvic pain, a two day history of non-significant vaginal bleeding (spotting) and 15
days of menstrual delay
she had a history of appendectomy and recurrent genital infection
the patient has nasuea without other intestinal tract disturbances
bimanual pelvic examination reveals uterus that is smalleer than the assumed term of
gestation and painful right side adnexal mass.
douglus space painless,vital signs stable, BP 118/65 , pulse 85/min body, temp 37.2 ,
clinical examination is normal.
diagnosis : tubal pregnancy ( triad: pain , spotting , delay of menses)
treatment : methotrexate or laparoscopy

#28
21 years old woman presents to the emergency with acute abdominal pain
she reports 6 weeks mestrual delay .
{we have to exclude a pregnancy}
the presence of moderate vaginal bleeding
body temp 37.5
blood pressure 90/60
pulse 100
physical examination : abdomen is tender in the right lower quadrant with rebound and
voluntary guarding {so we have here >> acute abdomen}
bimanual exam: normal not enlarged uterus , mobilization of the uterus is painful, right side
adnexal mass, palpation of posterior fornix is very painful { douglas cry}
BHCG: 6258
diagnosis: acute abdomen with ruptured tubal pregnancy.
management: surgery with removal of the tube

#29
29 y\o 33w of pregnancy come to the emergency department with severe headache,
epigastric pain ,visual disturbances . During previous antepartum visit at 29 w of pregnancy
nothing was abnormal.
Clinical examination: SBP 170 DBP 110, weight 65kg ,51kg prior to pregnancy , weight
gain of 3 in the last one week ( rapid weight gain )
Obstetrical examination : uterus non tender , fundal height 25 cm , longitudinal lie of the
fetus, cephalic presentation , Fetal heart rate 145\150 , cervix 3cm long closed , urine
dipstick 3 glasses proteinuria
Urine analysis reveals 5.7 g\l proteinuria , ultrasound determines estimated fetal weight
below 8%
Amniotic fluid index 4 cm , uterine artery Doppler examination indicates bilateral --- diastolic
incision and decreased diastolic velocity , other Para clinical investigation fetal umbilical and
cerebral Doppler
Non stress CTG normal . DIAGNOSIS?
33 w pregnancy , severe preeclampsia , intrauterine growth restriction
Management: stabilization , corticosteroids , delivery CS

#30
25 y\o 33w of pregnancy come to the emergency department with severe headache,
epigastric pain
Clinical examination: BP 200\120 , 3 glasses proteinuria , fundal height 32 cm, longitudinal
lie of the fetus, cephalic presentation , ultrasound estimated fetal weight 15%, CTG, Doppler
Normal.
Diagnosis ?
Severe preeclampsia without IUGR

Consultation for a married couple who is trying to conceive a child for 5 years , they didn’t
use a method of contraception , 27 y\o woman have a history of acute salpingitis at the age
#31
of 20 , she has regular painless menstruation 28 -30 days apart , 3 years ago the patient
had a left side tubal pregnancy treated with methotrexate followed with salpingotomy , after
one year a right side tubal pregnancy treated by salpingectomy , her husband 29 y\o healthy,
his semen analysis reveals :
Volume 2ml , ph: 7.2 , total sperm count 120 million , 50% mobile , 40% mobile after 4 hours
80% viability , 60% normal .
Diagnosis ?
Secondary infertility , tubal factor

#32
20 y\o woman come to the gynecological consultation for absences of period for 6 months ,
her breast and pubic hair was developed at the age of 11.5 y\o the age on menarche was
13.5 y\o , between the age of 13.5-16.5 her periods were unpredictable usually coming every
3-4 months , at the age of 16 she started to take combined contraceptive pills , the pills were
discontinuous 6 months ago and she had no menstruation after stopping the pills.
Clinical examination : weight 67 kg ,height 169 BP 130\70 , moderate hirsutism , greasy hair
and skin .
Vaginal exam: no congenital anomalies , normal appearing clitoris, normal appearance of
cervical mucus .
Lab results: FSH 2.4 , LH 10 , testosterone 2.8 , androstenedione 18 , 6binding hormone
globulin 5
Diagnosis?
Secondary amenorrhea , polycystic ovarian syndrome
Main complaint : infertility
Management: clomiphene citrate if she want to be pregnant , if not to give contraceptive
drugs.

#33
20 y\o woman present at the emergency department with a history of 3 days pelvic pain that
increase in time and become more severe in the last 2 hours , a combined with nausea and
vomiting , the patient didn’t pass any medical or surgical history , she denies any urinary
symptoms
Clinical examination : BP 150\60 ,pulse 100 , T 37.4 c .
On physical examination : abdomen is diffusely tender in the left lower quadrant with
rebound and voluntary guarding , bowel sound present , there is normal appearing cervix on
speculum examination ,bimanual vaginal exam : not enlarged uterus , on the left side there
is a tender 7-8 cm mass with limited mobility , vaginal fornix is unpainful
FULL blood count : HB 130 , erythrocyte 3.2 , leukocyte 11.5 , 10% neutrophils, ESR 46 .
Ultrasound exam determines 7-8 cm adnexal mass left from the uterus with a granular
homogenous but hyperecogenic appearance without a shadow and no collection of
intraabdominal liquid , Doppler ultrasound doesn’t detect intratumral vascularization .
Diagnosis ?
Acute abdomen ovarian torsion

#34
30 y\o woman present to the emergency department with hypogastric pain , malaise , fever
39 for 4 days, she had an uncomplicated term vaginal delivery 10 days ago .
Clinical examination : Bp 110\70 , pulse 100, temperature 39 .
On physical examination : the abdomen is diffusely tender , over distended with rebound
and voluntary guarding diffusely, during the bimanual exam uterus is very painful , soft
around 15 weeks of pregnancy size ( increased) .
Discharge lochia abundant purulent , foul smelling , vagina fornix is painful
Blood analysis : Hb 94 , erythrocyte 2.9 , leukocytes 19.5 , 18% neutrophils , ESR 55
Diagnosis ?
Puerperal endometritis , peritonitis , sepsis .

#35
29 y\o woman , did CS 7 days ago for a rest of active phase of labor , 5 days ago of CS the
woman present at the department with fever 38, abdominal and lumbar pain .
Clinical and para clinical examination reveals heart rate 100, Bp 110\75, Tempreture 38 ,
abdomen at the palpation soft , but painful at the hypogastric region , the skin incision is
without erythema and without pain , there is no tenderness to palpation of costovertebral
angle in both sides, Breast soft without pain , speculum examination foul smelling bloody
vaginal discharge lochia , uterine fundus is soft at the Medline between the umbilicus and
the symphysis with tenderness on palpation , the Douglas is soft and painless .
Diagnosis ?
Puerperal endometritis after CS

#36
40 y\o woman was admitted to the gynecological department complains of light vaginal
bleeding ,spotting for 3 days and mild lumbar pain .
History : the patient performed transvaginal ultrasound 3 weeks ago and diagnosed
intrauterine pregnancy 6 weeks in evoloution , it’s the 3rd pregnancy , the 1st -two
pregnancies were spontaneous abortions at the 6 , 8 weeks of gestation , the first day of last
menstrual period was 10 weeks ago .
Clinical and para clinical exam : vital parameters normal , abdomen on palpation soft ,
painless , vaginal exam reveals cyanotic cervix , half opened cervical os , moderate bloody
discharge , at bimanual exam uterus corresponds to 7 weeks of pregnancy , painless no
adnexal masses.
Erythrocyte 3.6, Hb 110, leukocytes 13 , ESR 40 .
Diagnosis ?
Missed abortion, Recurrent pregnancy loss
Management : 3 options ,1)expectative: wait and monitor the signs of infection - wait for
recurrent abortion , 2)medical: Misoprostol , 3) surgical :aspiration or curettage .

#37
26 y\o comes to the gynecology clinic because the inability to become pregnant for 2 years ,
despite regular and un protective sexual intercourse , the gynecological history of
menarche occurred at 12 y\o , menses are regular every 28-30 days , for the last 2 years the
character of menstruation changed ,they last for 1-2 days and are reduced in flow without
pain , the patient had 3 surgical abortions , dilation and curettage , no pathologies after the
curettage , husband healthy , clinical and para clinical exam are normal ,normal developed
secondary sexual characteristics , gynecological exam , external genitalia without pathology
, cervix normal , uterine normal size , mobile no adnexal masses, the basal body
temperature is biphasic .

Diagnosis ?

Asherman syndrome , confirm the diagnosis with hysteroscopy and remove the adhesions

#38
48 y\o woman come to the gynecological clinic presents with intermenstrual bleeding ,
during the last 2 months , heavy menstrual bleeding over the last 4 months , menstrual
bleeding may last for 8-10 days , abundant flow, sometimes clots, no associated pain , the
patient is sexually active , have 3 children , barrier methods of contraceptive , the last pap
smear 2 years ago normal , she doesn’t take any medication , no relevant medical history .
Physically abdomen soft without particularities , speculum exam did not reveal cervical
lesion or current bleeding , bimanual gynecological uterus is painless , normal volume ,
regular surface , no adnexal masses , mucosal discharge from the genital tract .
HB 87, leukocytes 4.5 , platelets 400 . + ultrasound pic
Diagnosis ?
Endometrial polyp
Management: surgical removal by curettage or hysteroscopy ( gold standard)

#39
37 weeks and 6 days admitted to the hospital in labor, intrauterine contractions every 15 to
20 minutes. Obstetric history 3 vaginal births without complications, current pregnancy
occurred uneventful. Clinical examinations blood pressure and heart rate normal, fetal
presentation cephalic, bimanual exam cervical effaced, 5cm dilation of cervix and amniotic
membrane is intact. Fetal heart rate is 140. After 15 minutes during utrine contractions,
spontaneous rapture of amniotic membrane occurs with significant discharge of amniotic
fluid in the vagina, suddenly the patient becomes confused and disoriented, also showing
dyspneaa and anxiety, immediately afterwards the woman becomes unconscious, cyanotic,
do not react to painful stimulate. Blood pressure 90/40, heartrate 120, oxygen saturation 86,
respiratory rate 20, cardiac auscultation is normal , but lung auscultations reveals diffused
respiratory wheezing. Abdominal palpitations show intermittent utrine contractions, fetal
heartrate 80.
Diagnoisis : Amniotic fluid embolism and fetal distress

#40
26 years old presents to the gynecology clinic with complaints of amenorrhea for 8 months,
galactorrhea for 6 months and inability to conceive for 2yrs. Gynecological history the first
menstruation at 15, menstrual cycle has been rare and irregular until now, secondary sexual
characteristics normal, sexual life of 22, she and her husband used condoms for
contraception, last 2 years have had regular unprotected intercourse, the woman didn’t take
any hormonal contraception. Physical examination weight 90kg, height 165cm, without signs
of hirsutism. Breast examination reveals bilateral galactorrhea, without other pathology at the
palpation.
Secondary amenorrhea
Hyperprolactinemia
Galactorrhea
Primary infertility ( can’t conceive for 2yrs)
Obesity
Order MRI to exclude prolactinoma

#41
37yrs old pregnant woman present to the emergency department, 18 weeks gestation,
complains of fatigue, headache, insomnia and difficulty of breathing, periodic chest pain,
cold extremities. These symptoms are cleared after 10th weeks of gestation. Patient denies
any occurring diseases or allergies. The results of laboratory examination are in normal
limits. Clinical examinations blood pressure 150/100, pulse 90, respiratory rate 23, oxygen
saturation 96%, weight 82kg, height 157. At palpation abdomen is soft and painless, there's
no tenderness to palpation across the vertebral angles, there’s no dysuria. Uterus is soft,
normal tonus, height of the uterus 18 which corresponds to the term. There are edema on
the lower extremities to the knee. Family history father type 2 diabetes, , mother died after
myocardial infarction.
Pregnancy 18 weeks
Chronic hypertension
Obesity
Management: long term use methyldopa

#42
Patient 30 yrs old complains of primary infertility for 3yrs. Obstetric gynecological history
shortly after menarche that occurred at 16, she had irregular light rare menstruation. Last
menstrual bleeding one week ago, induced by progesterone administration. Clinical exam
body mass index is 30, acanthosis nigricans and hirsutism. Blood pressure 120/80, pulse 80,
lab tests FSH 2.4, LH 10, testosterone 2.8, anti-mullerian 7. Ultrasound exam the ovaries are
12cm square, multiple follicles more than 10.

Primary infertility
Anovulation
Poly cystic ovarian syndrome.

#43
19 yrs old presents to gyne clinic because she didn't have periods for the last 10 months.
She’s in high school now, actively practices sports, sexual active. She had the menarche at
age 14, had irregular menstrual during one year that became regular after that, she's 168cm
tall, and weights 43kg. There's no adnexal mass, hcg negative , prolacin normal, estradiol
decreased, FSH 0.3, LH 1.

Secondary amenorrhea
Hypogoandotropic hypothalamic anorexia

#44
27 yrs old gravida just delivered vaginal, her first pregnancy, 5270g, midwives gave 10 units
of oxytocin intramuscularly (active management), after 5 minutes the intact placenta was
delivered by gentle traction of umbilical cord. During inspection of genital tract, the second
degree of perineal laceration and 3cm right lateral vaginal wall observation is noticed, which
is attempted to be repaired, suturing is difficult because of risk of bleeding from the upper
angle of laceration, estimated blood loss at this moment around 600ml. Abdomen palpation
reveals soft uterine fundus, which is level 3cm above the umbilicus. Vital signs blood
pressure 125/70, pulse 120, temperature 36.7.

Early postpartum hemorrhage

Uterine atony
Management: stop bleeding by oxytocin 20 to 40 units in one litre of ringer, 60 drops per
minute, once the uterine becomes contracted you swap to 40 drops per minute, with
simultaneously uterine massage, tranexamic acid 1g in order to delay the development of
coagulopathy and to preserve coagulation factors.

#45
17yrs old girl was brought by ambulance to the emergency department because she has
collapsed at home and her clothes are in the blood, she has irregular menstruation without
dysmenorrhea and periodically she’s bleeding abundant during her periods. Last menstrual
period was 45 days ago. She doesn’t have any chronic illness, no allergies, doesn’t use
contraceptives, she's conscious but very pale, vital signs blood pressure 88/52, pulse 125,
temperature 37.7. Speculum examination reveals red bright blood coming from cervical os,
vaginal cervix are intact, bimanual examination determine normal uterus, non-tender,
regular, no adnexal mass. Pelvic ultrasound is unremarkable, pregnancy test is negative,
blood test haemoglobin 6.7, RBC 2.5, WBC 4.5, platelet 300.
Abnormal uterine bleeding
Hemorrhagic shock
Anaemia
Management: anovulatory bleeding, probably based on atresia of follicles, so to stop the
bleeding we will give estrogen intravenously for 24hrs or combined pills in young girls with
no pathology. For hemorrhagic shock (6.7 hb) we will give transfusion RBC and liquids
(crystalloid) because she’s hemodynamically unstable

#46
32yrs old woman has been trying unsuccessfully to conceive for the last 4yrs, she had
menarche at 14, regular menstruation , 30-32 days interval, without dysmenorrhea till age
25. Last 7rs she had pelvic pain and deep dyspareunia, that worsens overtime. Vitals
parameters are normal, abdomen soft, speculum examination vagina cervix normal, pelvic
examination retroverted normal sized uterus. Left adnexal mass, nodular tender uterus
sacral ligament, pelvic ultrasound 5cm left complex ovarian mass, CA125 is elevated.
Primary infertility
Endometriosis ( progressive pain, dyspareunia, tender uterus sacral ligament nodular and
ovarian mass, also elevated CA125)

#48
27yrs old woman has been trying to get pregnant for the last 2 years ,her first child was born
when she was 22yrs old, she used oral contraceptive for 3yrs after her pregnancy, do not
have any chronic illness or allergies. She had surgery for appendicitis 3yrs ago and PID
episode after that. Periods are regular 4 to 5 days, she denies smoking, alcohol and using
drugs. On examination she has a normal developed vulva, vagina without lesions, normal
cervix and uterus. The husband is healthy and spermograph is normal.

Secondary infertility of tubal origin.

To confirm it we do laparoscopy to see the patency of the tubes and remove the adhesions.

#49
29yrs old woman has been trying to get pregnant for the last 2yrs, she doesn’t have any
known chronic illness or allergies. Her periods are regular last for 4 to 5 days, 30 days
interval. Associated with dysmenorrhea, she denies alcohol, smoking and drug use. 168 is
the height and her weight is 63kg, vital signs is normal, on examination she has a developed
vulva, vagina and normal uterus cervix, no adnexal mass. Laboratory testing on day 3 is
normal, ovulation is confirmed by progesterone level in the second phase, she performed
hysterosalpinogram that shows normal uterine cavity, normal fallopian tubes. Husband 33yrs
old healthy with normal sperm count.

Primary infertility
Origin is unexplained infertility

#50
29yrs old woman and her 32yrs old husband have been trying to get pregnant for the last
2yr. She doesn't have chronic illness or allergies. Her periods are regular last for 4 to 5 days,
30 days interval assiocsted with dysmenorrhea. Both deny smoking, alcohol and drugs.
168cm and in weight 63kg. Vital signs are normal and in examination vulva vagina uterus
cervix are normal, no adnexal mass. The husband spermoanalysis reveal a volume 2.5mL,
total count is 0.1 sperm per ml, 10% forward progression and 30% normal morphology.
Primary infertility of Male origin
Severe oligospermiea
IVF for management

#51
33yrs old woman presents to gynecological office complaining of 5 months of amenorrhea,
she went under normal puberty development and had menarche at 12, with regular cycles
for 3 years. She's intensively practicing gymnastics. Clinical examinations vital parameters
normal, abdomen soft painless, tanner stage 4 development, axillary and pubic hair growth.
Theres no bleeding following progesterone challenging test. Laboratory tests are beta hCG
is negative, estradiol 110, prolactin 20, TSH 1.6, FSH 0.4 and LH 1.2
Secondary hypothalamic Hypogoandotropic amenorrhea

#52
17yrs old presents to gynecological clinic with primary amenorrhea, normal weight, normal
breast but not sexual hair. Gynecological examination reveals normal looking female
external genitalia but no uterus and vagina. Laboratory tests estradiol 150, FSH 2.3, LH 3,
testosterone 4.8, prolactin 17, TSH 2.6.
Congenital androgen insensitivity syndrome and primary amenorrhea.

#53
Patient 39 yrs old presents to gynecological clinic with 5 months of amenorrhea, hot flushes,
she is of normal weight and doesn’t have any somatic disorders. Beta hCG is negative,
prolactin normal, estradiol 120, FSH 9.3, LH 13, testosterone and TSH is normal..
Secondary amenorrhea and early menopause due to premature ovarian failure.

#54
15yrs old presents to gynecological clinic with primary amenorrhea, physical examination
reveals no secondary sexual development and short stature.
Turner syndrome.

#55
16yrs old presents to gynecological clinic because she never had menstruation, she doesn’t
have chronic illness, no drug allergy. She is in high school with excellent academic
performances, practices sport basketball and gymnastics. 178cm tall and weights 73kg.
Clinical examinations reveals vital signs normal, abdominal soft, painless, tanner STAGE 4.
On speculum examination shows short vagina, blind vagina, no cervix, no uterus. Ultrasound
reveals normal sized ovaries. Blood test negative hCG, prolactin normal, estradiol normal,
FSH normal, LH normal, testosterone normal.

Rokitansky-Kuster-Hauser syndrome also known as Mullerian agenesis

Management: plastic operation, elongation of vagina. We should also do karyotype.

#56
15yrs old came to gynecological clinic because she never had menstruation, she doesn't
have chronic illness and allergies. 168cm tall and weights of 63kg. She did not start sexual
life. Clinical examinations vital signs normal, abdomen soft, painless, no secondary sexual
characteristics, tanner STAGE 0, speculum examination normal vagina and cervix. Blood
tests negative hCG, normal prolactin, estradiol decreased, FSH 15.3, LH 18, TSH 1.7.
Primary amenorrhea hypergoandotropic
Karyotype 46XY
Swyer syndrome
Management: to remove the testes and give hormonal therapy.

#57
23yrs old presents to gynecological clinic complaining of increased vaginal discharge,
associated with pruritus, she had one pregnancy that ended up with full term delivery, she is
not using contraceptive, one week ago she got antibiotics for treatment of sinusitis.
Gynecological examination reveals hyperemia of vulva and vagina, whitefish grey clamping
vagina discharge, ph is 4.5, vaginal smear absence of glue.
Vaginal candidiasis
Management: anti-muctic drugs vaginally or locally. We do culture to see the sensibility,
vaginal candidiasis is not included in the list of sexual transmitted diseases since 2010 so
her partner doesn’t need to be treated because don’t develop these symptoms and when
they do is rare because of anatomy, only when its recurrent episodes of candidiasis lead to
treatment of the Male.

#58
36yrs old with 37 weeks of gestation presents to clinic for check up, complains of diminished
fetal movement, without uterine contractions. Obstetric history this is her 5th pregnancy ,
one delivery one year ago, she had one missed and two medical abortions . Physical exams
pulse 88, blood pressure 125/85, height 168cm, weight 66kg. External obstetric examination
normal tonus of uterus, longitudinal and cephalic presentation, uterine fundus 31cm, fetal
heartrate 132. Lab investigation rh positive, hb 100, leukocyte 11, thromboctyes 165.
Ultrasound single lied fetus, cephalic presentation, biparietal diameter corresponds to 34
weeks and two days, head circumference corresponds to 34 weeks and abdomen
circumference corresponds to 34 weeks and 1 day. Third degree placenta maturity and fetal
heartrate 143. Deepest vertical pocket amniotic fluid is 0.8cm.

Severe oligohydramnios less than 2cm associated with fetal growth restriction as a result of
reduced renal perfusion and urinary output. Also anaemia (iron deficiency)
Management: iron supplements, 37 weeks but corresponds to 34 so c section.

#59
18yrs old presents to clinic for her first anenatal visit with 36 weeks of pregnancy, she
doesn’t have any complains, current pregnancy is the first. Patient is heavy smoker for 4
years . Physical examination 120/80, 168cm, weight 65. External obstetric examination
normal tonus of uterus, longitudinal cephalic presentation of the fetus, fundal height 32cm.
Fetal movement is normal, auscultation of fetal heartrate 138. Lab investigation are normal,
ultrasound exam single lied fetus cephalic presentation corresponds to biparietal 34 weeks,
abdomen circumference to 34weeks, third degree placenta maturity, heartrate 132, deepest
vertical pocket of amniotic fluid is 5cm. Amniotic fluid index is 14cm, estimated fetal weight
2300g, normal end diastolic flow on umbilical artery.
Small for gestational age, we will monitor and deliver at full term.
#60
36yrs old woman with 36 weeks of pregnancy presents to the obstetric department by
referral note of the family doctor because of blood pressure of 150/90, and moderate
headache. Obstetric history first pregnancy, blood pressure has increased from the booking
visit of the 14th weeks. During the pregnancy she received antihypertensive methydopa, the
last ultrasound was performed at 20th week of pregnancy, no fetal malformations, physical
examination height 168cm, weight 105kg. External obstetric exams normal tonus of uterus,
longitudinal and cephalic presentation, fundal height 32. Fetal heartrate is normal, laboratory
investigation appear normal. Ultrasound exams shows amniotic fluid index normal, estimated
fetal weight 2300g, reduced end diastolic blood flow at umbilical artery.

Chronic hypertension
IUGR
Obesity
Management: c section

#61
Patient 21yrs old presented to family doctor for routine check up at 36 weeks of pregnancy,
this is the first pregnancy and don’t have any complains, fetal movement is fine, somatic
medical surgeries are unremarkable, physical examination blood pressure 150/100, pulse
normal, fetal heartrate normal, ,moderate legs edema, weight gain during pregnancy 18kg,
blood range positive, haemoglobin 104, RBC 10, thrombocytes 175, transaminases are
normal, urine protein 0.1.

Pregnancy 36 weeks
Gestational hypertension

#62
31yrs old present to a doctor for routine antepartum visit at 32 weeks, her first pregnancy
she doesn’t have any complains, somatic history surgical are unremarkable, blood pressure
150/100 on both arms, pulse normal, uterus tonus normal, fetal heart rate is 140, there are
moderate legs edema , she gained 18kg, urine analysis is 0.5g protein per litre.
Pregnancy of 32 weeks
Mild preeclampsia

#63
32yrs old patient at 38 weeks of pregnancy admitted to delivery with regular uterine
contractions every 3 minutes lasting for 35 seconds, obstetric history 2 spontaneous
abortions, one physiological full term birth 2yrs ago, a boy weighting of 3800g. Obstetric
examination reveals longitudinal cephalic presentation of fetus , cervix is fully effaced, 3cm
dilation, ultrasound exam was done at 32 weeks pregnancy and indicated a normal position
of placenta. After 4hrs of admissions oxytocin perfusion was inserted for uterine contractions
insufficiency. After one hour of oxytocin perfusion the patient developed frequent every
minute and very painful uterine contractions. Intense pain on the lower uterine segment,
maternal cardio respiratory parameters are normal, external obstetric examination reveals
hard uterus, don’t relax between contractions, external recording of fetal heartrate indicates
an irreversible severe bradycardia 60 to 80 per min, vaginal exams reveals cervical dilation
of 8cm, left occipital anterior presentation, scalp woman is overlapping each other, when its
gently pushed the overlap bone goes back easily (moulding degree 2).
Pregnancy 38 weeks
Hyper stimulation of uterus due to oxytocin, there is no break between contractions, risks are
uterine rupture and placenta detachment and fetal distress. Fetal and pelvic disproportionate
because the head is not engaged or can’t engage.
Management: emergency tocolysis intravenously and c section.

#64
29 years old , 38 weeks of gestationt , admitted to the dilvery ward with a blood pressure
150/100 mmhg,her base line blood pressure during pregnancy 120/60 mmhg , irregular
uterine contraction ,cervix 3 cm dilated, 50% effacet , repeated blood pressure 160/90mmhg
hematocrit 34%, platlets 160, transaminase normal , urine dipstick negative.
Diagnosis : gestational hypertenstion

#65

#66