26.

When performing a hysterectomy, the surgeon must be aware that at its closest portion to the
cervix, the ureter is normally separated from the cervix by which of the following distances?
a. 0.5 mm
b. 1.2 mm
c. 12 mm
d. 3 cm
e. 5 cm
LANGE : A surgeon has a little more than a 1-cm space between the cervix and the ureter when
performing
a hysterectomy. Just lateral to the cervix is a high-risk area for injury to the ureter during
gynecologic
surgery. The importance of dissecting away the bladder, staying close to the cervix, and not
placing
clamps too far laterally or inserting wide sutures is apparent. At times, it is necessary to dissect
enough
to allow visualization of both ureters prior to ligation of the uterine arteries.

A 32-year-old G3P2002 woman presents for routinr prenatal care at 37 weeks. Her pregnancy is
complicated by Rh-negative status, depression, and a history of LSIL Pap smear with normal
colposcopy in the first trimester. Today she reports good fetal movement and denies leaking
fluid or contrarctions. During your examination you measure the fundal height at an appropriate
37 weeks, and find fetal hearts tones located in the upper aspect of uterus. A bedside ultrasound
reveals frank breech presentation

27. Which of the following is the next best step in management of this patient ?
a. Schedule a cesarean delivery at 39 weeks
b. Return visit in 1 week to reseassess fetal
position c. Schedule an external cephalic version
d. Offer a trial of vaginal breech delivery
e. Offer emergency cesarean delivery
Blueprint
Given her gestational age prior to 39 weeks, it would be best to try an
external cephalic version. If unsuccessful, a second trial of version at 39
weeks with epidural or spinal anesthesia should be offered. If the version
is successful prior to 39 weeks, the patient is followed expectantly with
routine prenatal care. If the version is accomplished after 39 weeks, she
may be induced at that time. If the version is unsuccessful on second
attempt with anesthesia, delivery by cesarean section is recommended.
External cephalic versions carry the risk of cord compression and
placental abruption. It is critically important to monitor the fetus for a
period of time after the procedure. Occasionally, an emergent delivery is
indicated by cesarean following a trial of version due to nonreassuring
fetal testing. If the patient declines a trial of version, she should be
 scheduled for an elective cesarean section after 39 weeks’ gestation. In a
select population, trial of vaginal breech delivery can be attempted but
requires stringent criteria be met.

28. Prior to discharging the patient from labor and delivery triage after her successful external
cephalic version, which of the following should you do first ?
a. Schedule induction for 39 weeks
b. Palce abdominal binder to help hold fetus in cephalic presentation
c. Prescribe
tocolytic d. Give
RhoGAM
d. Check fetal position with ultrasound
Blueprint
Because the patient is Rh negative, she should receive a dose of
RhoGAM prior to discharge. External cephalic version carries the risk of
placental abruption and also the possibility of maternal exposure to fetal
blood through disruption in the placental interface. In Rh-negative
mothers, this could lead to formation of antibodies against Rh factor if the
fetus is Rh positive. In future pregnancy with an Rh-positive fetus,
maternal antibodies can cross the placenta and destroy fetal blood cells,
resulting in anemia and fetal hydrops. A dose of RhoGAM can prevent
this problem. Other risk factors of external cephalic version include fetal
distress, failed rotation, and need for urgent cesarean section. Induction is
generally scheduled at 39 to 40 weeks, and abdominal binders are
commonly used to prevent the fetus from returning to breech
presentation, but these are not the best answers. There is no role for use of
tocolytics at this stage of pregnancy. Lastly, rechecking the fetal position
is possible and reasonable, especially if the mother describes a large fetal
movement, but it is not necessary or the best answer choice.

29. Which of the following findings would deter you from offering this patient a trial of breech
delivery
?
a. Frank breech presentation
b. Fetal weight of 3200 g
c. Complete breech
presentation d. Fetal weight of
4100 g
d. Footling presentation
Blueprint
Fetal weight of 4,100 g is a relative contraindication to offering a trial of
breech delivery. The criteria recommended to offer a trial of breech labor
include an adequate pelvis as determined by pelvimetry and imaging
(generally X-ray, CT, or MRI), frank or complete breech, a flexed fetal
head, and estimated fetal weight of 2,500 to 3,800 g. Relative
contraindications to offering a vaginal breech trial of labor include weight
greater than 3,800 g, nulliparity, and incomplete breech, such as footling
breech presentation.

30. Preterm rupture of the membranes is most strictly defined as spontaneous rupture at any time
prior to which of the following ?
a. A stage of fetal viability
b. Second stage of labor
c. 32 weeks of gestation
d. 37 weeks of gestation
d. Onset of labor
Lange

31. 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. In 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
blueprint

32. On examination you attempt to determine the presentation of the fetus. Which of the following
presentations and position would be the most favorable to achieve vaginal delivery ?
a. Breech
b. Transverse
c. Vertex with occiput
posterior d. Vertex with occiput
anterior
d. Vertex with occiput transverse
In most cases of vertex presentation, the back of the baby's head (called the occiput) is toward
the front (anterior) of the mother's pelvis. This presentation is called occiput anterior, and is
considered the best position for a vaginal delivery.

33. The patient is 5 cm dilated with regular contactions. However on the CTG you find several variable
decelarations. What is the pathophysiology of variable declarations ?
a. Normal labor
b. Head compression
c. Cord compression
d. Maternal chronic anemia
e. Uteroplacental insufficiency
34. She pushes the head to the perineum and your deliver the head and the shoulders without
complication. The cord is clamped and the placenta delivered. You examined 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 sphingter

You are providing prenatal care to a 22-year-old G1P0 woman at 16 weeks GA by LMP. She has
had a relatively smooth pregnancy without complication thus far. At 5950 and 215 lb she has
obese BMI, otherwise without medical or surgical history. She presented to prenatal care at 14
weeks and so missed first-trimester screening. She undergoes the quad screen and has an
elevated level of maternal serum alpha-fetoprotein (MSAFP)

35. Given the elevation in MSAFP her pregnancy is at increased RISK for which the following ?
a. Gestational
diabetes b.
Gastroschisis
c. Down syndrome
d. Klinefelter syndrome
e. All of the above
 Blueprint
Elevated MSAFP can be seen in a variety of pregnancy complications. It
is primarily used to screen for NTDs such as spina bifida,
meningomyelocele, or anencephaly. It is also elevated in pregnancies that
are not dated as far along as they should be, have abdominal wall defects
such as omphalocele or gastroschisis, and have placental abnormalities
like previa or accreta. MSAFP is decreased in Down syndrome and has
no relationship with Klinefelter syndrome.

36. You discuss the potential meaning of the elevated MSAFP. After a long conversation, the patient
decides to undergo her second trimester ultrasound. The ultrasound reveals a myelomeningcele.
Which of the following is true and may be used in counseling ?
a. This is generally a lethal anomaly
b. Delivery must be by cesarean to protect the baby
c. Fetal surgery includes laser therapy
d. Fetal surgery has been shown to improve some outcomes
e. Fetal surgery is experimental and has no known benefits
Blueprint
Myelomeningocele, a common form of spina bifida, is not usually lethal,
but leads to long-term morbidity in a large majority of affected children.
In order to reduce the morbidity, a recent prospective trial of closure of
the defect while the fetus was still in utero was conducted. The study
demonstrated improvement in several outcomes including ambulation at
30 months of age. Laser is used for in utero ablation of connecting vessels
in the setting of twin-to-twin transfusion syndrome, not in
myelomeningocele repair. Some providers recommend cesarean delivery
for fetuses with NTDs. This is not a uniform recommendation and is not
accompanied with much evidence in favor of its practice.

37. The increased incidence of this finding is a associated with which of the following medications
when used in pregnancy ?
a. Valproic acid
b. Lithium
c. Fluoxetine
d. Prednisone
e. Acetaminophen
Blueprint
NTDs are increased in the setting of diabetes and women with seizure
disorders. The latter is thought to be associated with the use of several
antiepileptic drugs, including carbamazepine and valproic acid. Lithium is
associated with Ebstein anomaly, a displacement of the tricuspid valve.
Fluoxetine and several other SSRIs have been associated with an increase
 in fetal cardiac anomalies. Prednisone does not cross the placenta.
However, it can lead to hyperglycemia, which may, in turn, cause fetal
effects. It is important to have women on prednisone in pregnancy check
blood glucose values. Acetaminophen has not been associated with any
fetal anomalies.

38. In a subsequent pregnancy, prevention of reccurence would include :

a. Low-dose aspirin
b. Low molecular weight heparin
c. Prenatal vitamin taken twice per
day d. 4 mg folic acid
d. Increased dietary calcium
Blueprint
Folic acid supplementation has been shown to decrease the risk of NTDs.
Folic acid has been added to grains in the United States, which has led to
lower rates of NTDs. There is 0.4 mg of folic acid in standard prenatal
vitamins. However, in high-risk patients, the recommendation is currently
to take 10 times that dose, or 4 mg/day. Further work delineating the dose
response and threshold effect still needs to be done. Low-dose aspirin has
been shown to slightly reduce the risk of preeclampsia, and both low-dose
aspirin and LMWH have been used in women with known
thrombophilias. Low dietary calcium intake has been shown to be
associated with preeclampsia, but intervention trials are equivocal on the
potential benefits.

A 32-years-old woman is 36 weeks pregnant in first pregnancy with DCDA (dichorionic

diamniotic) twins and is being reviewed in the antenatal clinic. A recent obstetric growth scan
confirm both fetuses are normally grown. Both twins are longitudinal lie and cephalic
presentation. She has no other complicating medical or obstetric disorders. She is deciding
between planned vaginal or elective cesarean modes of delivery.

39. Which one of the following is correct in relation to the counseling she will receive ?
a. About 10% of twin pregnancies result in spontaneous birth before 37 weeks
60 in 100 twin pregnancies result in spontaneous birth before 37 weeks
b. Continuing twin pregnancies beyond 38 weeks increases the risk of fetal
death
However, delaying delivery to 38 weeks gestation led to an additional
8.8 deaths per 1,000 due to an increase in stillbirths. When twins shared a
placenta, the risk of stillbirth appears to be higher than the risk of
neonatal death once babies go beyond 36 weeks gestation, the study found.
c. Maternal antenatal corticosteroids are routinely recommended for all twin pregnancies
A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks
and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days, including for
those with ruptured membranes and multiple gestations.
 d. Offer elective birth from 37 weeks after a course of maternal corticosteroids has been
administered
e. There is strong evidence to show cesarean delivery as safer for mother and fetuses than
vaginal mode of delivery

40. Which of the following statements about twinning is true ?

a. The frequencies of monozygosity and dizygosity are the same
b. Division after formation of the embryonic disk results in conjoined twins
Bottom: If separation occurs after the formation of the embryonic disc, the amnion has
already formed, and will lead to a monoamniotic, monochorionic pregnancy. Incomplete
fission at this stage or later will result in conjoined twins).
c. A dichorionic twin pregnancy always denotes dizygosity
The scientific terms to describe twin type or zygosity, are monozygotic (identical)
or dizygotic (fraternal). Dizygotic twins, which form from two separate zygotes,
will always develop separately, with two individual placentas, sacs, and chorions.
d. Twinning causes no appreciable increase in maternal morbidity and mortality over singleton
pregnancy

41. You are following a 38-year-old G2P1 at 39 weeks in labor she has had one prior vaginal delivery
of a 3800-g infant. One week ago, the estimated fetal weight was 3200 g by ultrasound . over the
past 3 hours her cervical examination remains unchanged at 6 cm. fetal heart rate tracing is
reactive. An intrauterine pressure catheter (IUPC) reveals two contractions in 10 minutes with
amplitude of 40 mm Hg each. Which of the following the best management for this patient ?
a. Ambulation
b. Sedation
c. Administration of oxytocin
d. Cesarean section
e. Expectant
Normal montevidio kontraksi regular : 200 mmHg  kasus ini kurang  diberi oksitoksin

42. A primipara is in labor and an episiotomy is about to be cut. Compared with a midline
episiotomy, which of the following is an advantage of mediolateral episiotomy.
a. Ease of repair
b. Fewer breakdowns
c. Less blood loss
d. Less dyspareunia
e. Less extension of the incision
Pretest
Midline episiotomies are easier to repair, and have a lower incidence of surgical breakdown, involve less pain, and
lower blood loss. However, the incidence of extensions of the incision to include the rectum is higher for midline
episiotomies compared with mediolateral episiotomies. Mediolateral episiotomies lead to more pain, blood loss, and
dyspareunia. Regardless of technique, attention to hemostasis and anatomic restoration is the key element of a
technically appropriate repair.

43. A 24-year-old primigravid woman, at term, has been in labor for 16 hours and has been dilated
 to 8 cm for 3 hours. The fetal vertex is in the right occiput posterior position, at +1 station, and
molded. There have been mild late decelarations for the pas 30 minutes. Twenty minutes ago,
the fetal scalp pH 7.27;it is now 7.20
For above clinical description, select the most appropriate procedure
a. External version
b. Internal version
c. Midforceps relation
d. Low transverse cesarean section
e. Classic cesarean section
Molding  CPD. pH acidosis  asfiksia. Late deselerasi  uteroplasenta insufisiensi
LSCS

44. A 27-year-old G2P1 at 38 weeks gestation was admitted in active labor at 4 cm dilated;
spontaneous rupture of membranes occurred prior to admission. She has had one prior
uncomplicated vaginal delivery and denies any medical problems or past surgery. She reports an
allergy to sulfa drugs. Currently, her vital signs are normal and the fetal heart rate tracing is
reactive. Her prenatal record indicates that her Group B streptococcus (GBS) culture at 36 weeks
was positives. What is the recommended antibiotic for prophylaxis during labor ?
a. Cefazolin
b. Clindamycin
c. Erythromycin
d. Penicillin
e. Vancomycin
Blueprint
Pilihan : golongan ampicillin atau gentamycin

45. Variable decelerations are caused by which fetal situation ?

a. Hypoxia
b. Academia
c. Cord compression
d. Head compression – early
Sudah dibahas

46. With increasing gestational age, the fetal heart rate baseline undergoes which of the following
trends ?
 a. Increase
b. Remains unchanged
c. Variability changes become more closely tied to activity changer
d. Decreases
It is generally assumed that fetal heart rate variability increases with gestation, reflecting
prenatal development of the autonomic nervous ...

47. Fetal bradycardia typically may result from which of the following ?
a. Maternal fever - takikardi
b. Fetal head compression
c. Maternal atropine use - takikardi
d. None of the above
Head compression  early deselerasi.

48. A 20-year-old G1 at 38 weeks gestation presents with regular painful contactions every 3
to 4 minutes lasting 60 seconds. On pelvic examination, she is 3 cm dilated and 90%
effaced; an amniotomy is performed and clear fluid is noted. The patient receives
epidural analgesia for pain management, the fetal heart rate tracing is reactive. One
hour later on repeat examination, her cervix is 5 cm dilated and 100% effaced. Which of
the following is the best next step in her management ?
a. Begin pushing
b. Initiate Pitocin augmentation for
protracted labor c. No intervention; labor is
progressing normally
d. Perform cesarean delivery for inadequate cervical effacement
e. Stop epidural infusion to enhance contractions and cervical change
Awal buka 3, 1 jam kemudian buka 5. FHR reaktif  normal

A 63-year-old G4 P4 woman presents to your office with a chief complaint of vaginal

spotting. She reports an isolated episode 1 week prior to presentation that consisted of
scant vaginal bleeding. She denies any associated symptoms including pelvic pain,
pressure, or early satiety. She also denies any family history of gynecologic malignancy.
Her past medical history in significant for morbid obesity, hypertension and
inflammatory bowel disease.

49. What is the most likely

diagnosis ? a. Athrophic
endometrium
b. Endometrial cancer
 c. Endometrial polyp
d. Ovarian cancer
e. Adenomyosis
About 90% of asymptomatic postmenopausal women with endometrial thick-ness <7
mm resulted in an atrophic endometri-
Jika ada gejala penurunan BB dll  mungkin bisa ca endo

50. After obtaining a thorough history and performing a physical examination (including a
pelvic exam), what is the next best step in evaluation ?
a. CA 125
b. MRI
c. Cervical cytology
d. Transvaginal ultrasound and possible endometrial
e. Mammography
Sonographic endometrial thickness: a useful test to predict atrophy in patients with
postmenopausal bleeding. An Italian multicenter study. Ultrasound Obstet ...

Kalua ada histeroskopi  pilih histeroskopi