IUD see sss see Scared facet rage Sovaes oReeadas estas anne +r t = (ae i UNIVERSITY OF NAIROBI COLLEGE OF HEALTH SCIENCES wey 4 Department of Obstetrics & Gynaecology > MBChB IV END OF TERM MCQ 24" March 2014 9.00-10.00 am INSTRUCTIONS There are 70 Multiple Choice Questions. Each Question has one correct answer which carries ‘one mark. A wrong choice will carry no mark. Circle one correct response. Any Question with more than one response will be invalidated. Attempt all Questions and put your Registration number on all.pages. A. L Anealthy sft 9in. tall, adult female is most likely to have a pelvic inlet that would be classified as . hich of the Towing Caldwell-Moloy types. yew1a artes \ A oti aod, Mrgle — sreca SI i sae e staged cnbnalsn es Ne he ® Patypeloi = ¢ let cuttroped le ET c. Anthropoid ~ 2: Lots Deal wait le € 9d, Gynecoid -9® Raitd erty pe'ad SIL ARE. fe. Triangular (ot) 2, The Inguinal canal in an adult female was opened surgically. Which of the following structures would normally-be found? ‘a. Acyst of the canal of Nuck b. Gartner's duct cyst Cooper's ligament — ; ligament and the ilioinguinal nerve * muscle /, an infant must pass through the maternal true pelvis. Which of the most s the characterise ofthe tru pelvis? lle Pes eh bab dln og e jdplane, and an outlet hh Wer ose Fa Lab ahbe praasas vaginetisc. thas an inlet made up of a double trianglé ~ +d. ttis completely ford by two fused bonese e. ities between the wings of the paired ileume @ The plane from the sacral promontory to the inner posterior surface of the pubic symphysis is an Lt agi Important dimension of the pelvis for normal delivery. What is the hame of this plane? a oss Haye wifee(Wem) va ce scenes eae AQ) ) © Diagonal conjugate - fan FST? «ald, eeger| [CE j 4 d, Biischial diameter a ie wv : ast Se e. Oblique diameter Aen, ne ust seriave de ; (S) The shape of the escutcheon may change with masculinization. The presence of a male = escutcheon in a female is one of the clinical signs of hirsutism or increased testosterone. What is the usual shape of the escutcheon in the normal female? a. Diamond shaped —m«b. te ® Triangular ‘ c. Oval 1. Circular. e. Heart shaped. 6. During the. performance of a’ pelvic examination, the area of the Bartholin’s ducts should be inspected. Where dotthe Bartholin’slands!open? py Into the midline of the posterior fourchette uadin Luba eva besechh bulbs poy b. Bilaterally, beneath the urethra < va ¢. Bilaterally, on the'inner surface of the labia majora Fy @ Betis into the posterior vaginal vestibule ne t pare Hh ache of & 'G e. Bilaterally approximately 1 cm lateral to the clitoris <3 veoh bile surfuce, 7. Apatient presents approximately 10 years postmenopausal with complaints of pressure vaginally and the sensation that something is falling out. When told she has a fallen uterus, she wonders if it is due to the damage from her round ligaments since she had a great deal of round ligament pain-during her pregnancies. Which of the following ligaments provide the mést support to the uterus in term of preventing prolapse? n/a, Broad ligament eonenes — Peet ult X, b. Round ligaments — Terminal, ab ye bode Limagor. ¢. Utero-ovarian ligaments oe @ Cardinal ligaments» e. Arcuate ligament. 8. When performing surgery; the position of important structure injury. What is the ureter’s relationship to the arteries in its course through the pelvis? should be well known to avoid a. Anterior to the internal iliac and uterine artery” @~* b. Posteriortto the iliac artery and anterior to the uterine artery, \e (2), Anterior to the uterine artery and posterior to the iliac artery” ) Z Posterior to the uterine artery and medial to the iliac artery =sl362 ©. Pasterior to the uterine artery and posterior to the hypogastric artery =, 6 During.a hysterectomy, vaginal bleeding may bea significant complication even after rem of the uteris, Such bleeding would most likely originate from which of the following arteries? @ Internal pudendal Superior hemorrhoidal Inferior mesenteric.” —+/;. d. Superior vesical e. Ovarian 10. Anterior vulvar cancer is most likely to spread primarily to which of the following lymph nodes? Inguinal t b. Para-aortic Obturator d. Femoral e. Ovarian 11. Which artery provides the main blood supply to the vulva @ Pudendal i Inferior hemorrhoidal ilioinguinal Femoral Inferior hypogastric 12. During delivery, which of the following muscles is most likely to be obviously torn? 18 a. Ischiocavernosus muscle a b. Bulbocavernosus muscle > ‘© Superficial transverse perineal muscle d.Levatorani muscle on fe. Coccygeus ; 13. Awoman has a radical hyseterectomy and pelvic lymphadenectomy for stage 1 carcinoma of the cervix. After surgery she comiplains that she cannot adduct her left leg and there.is afi absence of sensation on the tnedial aspect of her left thigh. What is the most likely explanation? ‘Injury to the obturator nerve - Femoralnerve injury > @ __¢, _Hematoma in the pouch of Douglas “Injury to the uterosacralnerve 9*"” : pudendal nerve ‘ ac ur about infertility. In your discussion about conception, tubal disease, Rade wi?hs oe ee sau reesenanennene > Eyer ee nae of . 15. The labaymajora are homologous to which male body part? : = sa PEM wre b. Testicle Foreskin herctagne- ‘Scrotum: = e "e. Gubernaculum testes 16. Worldwide, which of the following is the most common problem during pregnancy? a. Diabetes : : @ 2 Prescomone . Heartdisease d._ Urinary tract infection (UTI) Faron deficiency anemia e 17. A friend mentions to you she just had a positive pregnancy test and wonders if you can tell her when she is likely due. The LMP was June 30. Her expected date of confinement (EDC) is approximately which of the followin, “ a. March 23 2 aes) alt April 7 é ee Nea March 28 - =~ ® Ct ee oO eT d. April 23 cat amt 7% : @© March7 Vel 18. Using your knowledge of normal maternal physiology, which of the following would you employ ifa patient at 38 weeks became faint while lying supine on your exami n table? a. Aromatic ammonia spirit (smelling salt) ‘ : Turning the patient on her side 2 “Oxygen by face mask The most worrisome sign or symptom of potentially serious pathology in late pregnancy is which ‘the following than dates at her initial obstetric visit at 24 weeks’ EGA. She is “run” in the family. The best method to safely and reliablya. kraye of Sonnet : a DA rere ie ol cdence ht often oe gate rt crs tier ete erate ‘= 7 (yo) can substantaly reduce the risk of recurrence by taking periconceptional folic aid sultan. yi he recommended sos? ‘ © 04 me fost ofp sane dint i [ae 70 ; b. 0.8m~e @ SCS SA Hone orb - Pants 05 Lidalng @D sme - fats Ml bh ok of Fe meee of FU, PAT. = 22. A 19 year old woman without prenatal care (gravida 1, para 0) in the third trimester of pregnancy arrives in the emergency department. She has presented, because of headache and visual change. While being examined, she had a convulsion. You should do which of the following while waiting for the magnesium sulfate bolus to arrive from the labor and delivery department? a. Obtain an ultrasound to rule out molars pregnancy @® Prepare to perform an emergency cesarean delivery c. Give intravenous (IV) phenytoin ‘d= Protect the patient from self-harm @ e. Obtain a chest film 23. A patient.and her husband are extremely anxious about your suggestion that she be giver’ “ magnesium sulfate for seizure prophylaxis. In assuring he about the safety of the drug, you can. (per uz ereseclempes emphasize which of the following. ‘The drug:is rapidly excreted via the kidney * 7” b. Itisa mild: smooth-muscle constrictor and thus safe for the infusion The drug has narrow margin of safety so that we start off with @ lower dose in preeckamptics, and administer it by an IV pump: 4. Asa cehtral nervous system (CNS) stimulant it should not deprive her of the awareness of her delivery, unlike barbiturates @ The drug does not cross the placenta and thus should not affect her fetus/infant ience of diabetes in a patient 24, Which of the following histories might lead you to suspect the & now pregnant for the third time? a Spontaneous rupture of the m¢ preceding pregnancies. © ®> ee Games mice OY TY, Jaundice appeared in the last trimester of her second pregnancy receding infants were premature eee" garedemp Os intrauterine death occurred at 38 weeks’ gestation in her last pregnancy sntae occurred in the second pregnancy ‘old woman (gravida 3, para 2) uld you order? psbianes occurred during the second trimester in both. with suspected UTI. To obtain a urineb. Catheterization & Suprapabic tap 2 *d, 24 hour urine €. First morning void i h ¢%. An unconscious obstetric patient is admitted to the emergency department in the eighth mont been no of pregnancy with a BP of 60/20 mm Hg and a pulse of 120 per minute. Hf there has vaginal bleeding, which diagnosis may be excluded? ® Abrption placentae Ga be areal) b Placenta previa Bleeding « fale @ - ‘© Premature rupture of robmtends with septic shock . “AE Eclampsia : €. Amniotic fluid embolism - 27. A&B year old woman noted oss of fetal motion at 36 week's gestation by dates. FHTS were not heard at 40 weeks by dates when the patient was next seen. The uterus measured 30 cm from ‘symphsis to fundus. Which of the following tests would be valuable to perform at this time? @ Maternal serum estriol Hcabphla wrlhag cop 4 Gee aban, — ye AT Clotting screen @ —— © - fash bey 2 €Lecithin/sphingomyelin (1/5) ratio. eG or i3 4. Karyotype of amniotic cells ~ pefed e. Amniotic fluid creatinine dons 4 the ng Q28and 29 A 23 year old presents at 12 weeks gestation with persistent nausea and vomiting that progresses to constant retching. She has no fever or diarrhea, 28. What is your diagnosis.During pregnancy she is not at increased risk for a deep venous thrombo: peerieee/ ie creased risk for a deep thrombosis (DVT) as tong agg b. Low dose (8¥7ng) of aspirin should be taken during pregnancy afid postpartum, a She should be placed on prophylactic warfarin therapy since she is past the first trimester _@ She would benefit from prophylactic doses of low-molecular-weight heparin twice a day until 6 weeks postpartum. e. Since she has already had one DVT, she should be on therapeutic doses of subcutaneous heparin until after delivery when estrogen levels will fall r Q31 and 32 A.17 year old GIPO woman presents at 25 weeks gestation complaining of headache for the pi “hours, She has had regular prenatal visits going back to her first prenatal at 8 weeks’ gestation. A 20 week ultrasound redated her pregnancy by 2 weeks as it was 15 days earlier than her LMP dating. She has BP of 155/104 mm Hg. Sweonere< 34. Which of the following is the most important question to ask on history? a, Do youhave heartburn b. Do you have low back pi c. Ase you constipated o ‘Do you pain have in your right upper abdomen te e. Doyou have urinary frequency ay. oc 32: Which of the following would not help to determine her diagnosis? = a, Baseline or prepregnancy BP ¥ shel prepregnancy se } A aiawin levels te ee ¢. “Urine dip for protein E 4 @ cack porn fe. ASTand ALT 9” a prenatal visit at 34 weeks’ gestation. She complains of past 3 days. She has no headache and no visual changes. she has 2+ lower extremity pitting edema, and 3+ reflexes: * (A 26-year old GIPO woman presents for ‘some mild. nausea and vomiting over the Her BP is 142/83 mm Hg. On examination, bilaterally with four beats of clonus. A urinalysis dip has 1+ protein. low platelets, a normal hematocrit | The laboratory test results come back with elevated LFTS, n elevated LDH. What is her diagnosis? tus (TIDM) presents for a preconception visit. he ‘some challenges with glucose control during her > bs : edsubcutaneous ing Fecatarehen hire nctea(hpaciececcontrsifpertertrepo te use aie rancoe A pump. She has-no history of retinopathy, renal disease, heart disease, proteinuria, P neuropathy, or any other medical €hditions. On examination, she is 5" 8P is 128/76 mm He. 34. During your counseling, which of the following do you NOT mentign tha risk for during pregnancy? ee Preeclampsia Congenital abnormalities ; Breech presentation” d. Cesarean delivery i fe. Fetal macrosomia ,/ 76 lowing 35. You order a laboratory test and her HgbA,c returns at 11. You advise her which of the foll a. She should go ahead and start trying to get pregnant b, She should aggressively try to lower her HgbA.c to less than 9 to reduce the risk of preterm ze rth She should aggressively lower her HebAxc to less than 5 in order to reduce her risk of preeclampsia (GB She should aggressively lower her HgbAyc to less than 7 to reduce her risk of congenital anomalies e, She should go ahead and start tr with a HgbA,c target of less than 9 —_— 6. A 24 year old para 140 last delivery SVD presents at labour ward. She has 3 contractions every 10 minutes each lasting 30 seconds, fetal heart 130 beats per minute regular. Cervical dilation is noted to be 8 cm, no caput, no cord and no moulding. Liquor is noted to be meconium stained 16” tall and weighs 70kB. Her it she or her fetus is at ig to get pregnant, but also slowly reduce her blood glucoses, > grade Il. Your next course of action will b ag chwiavenss @ Start oxytoci™ or week van i “b. Give ergometrinex . ~~ ¢. Allow labour to progress yb aie LB cm Mek, « d._ Perform vacuum delivery immediately. rope nee ett - . e. Undertake emergency caesarean delivery patient in 2 stage, has-had 2 pushes but the fetal head is not emerging from the introitus ‘despite having crowned, you note she-has type | EGM. Fetal heart rate monitoring reveals “bradycardia after the last push. Your next course of action will be. disease in pregnancy goes into labour at 40 weeks. nas stable, fundal height term cephalic presentation 8and ceria dation of 3m, she has en on ls an goin during te ie ae ch ofthe folaying statement regarding het managements 4. Digonin shoul be stepped 1 Lasix should be stopped ae > Intravenous fluids should be commenced Ce ain ZU lee att Aa ave po 1 oe Elective vacuum delivery should be planned *“> to €. Emergency ¢/s should be undertaken rote a | 39. Regarding gestational diabetes mellitus, the best time to. screen for it during pregnancy is 1 a. Fourto six weeks b. Six weeks toTourteen weeks : ¢. Fourteen weeks to twenty weeks oe pal = D, Wenty weeks to twenty four weeks . Twenty four,weeks to twenty eight weeks / ‘40. Which of the following depicts prong | of PMICT _ 2 Piscordant couple where the postive male partner isput on ARV b. The use of ARV by a pregnant mother. 27ers 3 c. The use of elective caesarean section to avert verticaltransmission sonst seater Se @® the use of contraception by a HIV infected motifs” ® sare SRE The linkage of the HV infected mother after delivery to a HN care centre 41, A2B year old para 040 at 28 weeks gestation has been in the ward for the last one week with a Ng / diagnosis of preterm prelabour rupture of membranes which one of the following is an A, indication of immediate delivery gROK @® Arepeat white blood cell count of 5x 10’ with a baseline of 4X10? 7”? bb. Fetal heart rate of 150 b.p.m from a baseline of155 bpm ¢._ therease in the number of pads from 2 Initially to 3in 24hours d. Lower backache ‘ Lowerabdominal tenderness Chyviocxnbafs 2, 20 year old para 0+0 presents at 36 weeks gestation with complaints of drainage of clear fluid. Examination revealed a fundal height of 36 weeks, cephalic presentation, fetal heart 140 bpm 1b regular, cervix 3 cm dilated and clear liquor. Which one of the following, would be appropriate in her management. $7 sept 1D ov Insert prostaglandin pessary (€) Commence oxytocin drip tel 2 ‘Admister salbutamol aoe : inister indomethacin) é c/s a at 32 weeks gestation presents at labour ward 2 hours ago. In the process findings are normal pelvic & amination and a cervix 3m dilated. sfuse bleeding is noted, What wil be your next course of action,a (@ Take her for pelvic ultrasound ~ (© Take her for emergency caesareassection 44, When a patient has post-partum hemorrhage due to retained placenta, the management includes iS 2. Conservative management to wait for spontaneous expylsion b. Waiting for another 30 minutes for spontaneous expulsion Manual removal of placenta in theatre er~f&\ Affe sche TENS %@_ Injection of ergometrine to assist with expulsion = @. Injection of methyl F2a to assist with expulsion oo 45. A 36 year old para 3+0 (all term SVD) presents at 35 weeks gestation in labour. Ultrasound done 1 week previously revealed 1* twin cephalic & estimated fetal weight 2600 grams and 2" twin in breech.& estimated fetal weight of 2200 grammes. Pelvic examination revealed cervical dilatation of 5 cm, clear liquor, no cord palpated. How would you proceed in her management a. Start magnesium sulphate and betamethasone aM b. Undertake emergency caesarean delivery © © Do external cephalic versionfor the second twin and allow labour to proceed ‘d._ Deliver the first twin SVD then second twin through c/s _B> Allow labour to continue and aim at vaginal delivery for both babies 46. The following statements are true regarding laparoscopy EXCEPT &) ‘Accessory points creation has ess risk of visceral injury compared to primary points b. Laparoscopy gives 2 more panoramic view compared to laparotomy ¢. Monopolar diathermy is more risky than bipolar d. Veress needle has a safety spring load mechanism £rgonomics dictate'a higher table position compared to laparotomy 47. A126 year old presents with complaints of severe right abdominal pain that has become progressively worse since the onset of menses 3 years 280- The pain is no longer responding to NSAIDs. The next step in her management is ‘a. Take maximum dose of NSAID me, b. Refer her to a psychiatrist : ¢._ Start combined oral contraceptives 4 @ Obtain a pelvic ultrasound ‘e. Undertake laparoscopic evaluation | ge 48. indetermining if one is female 0. male physical sex a. Chiromosomal sex A b. Gonadal sex ay ~The internal sex organs “The external sex ld with a female body ‘true concernint encompasses the following EXCEPT feised asa gil wil always learn to consider herself female ‘gender and sex 10Meee tree that dre nurtured in one sex and discouragedintHeather Most individuals cléarly conform to the gender appropriate to their physical sex © Sex of assignment and rearing is never in confit with sexual self-dentifcation de A child with a female body will always be raised as a git) ©. Contradiction between, ones assumed gender and the physical sex resulting in complete PEG vibes RR ec fyeaes eters aaah 50. in human sexual dysfunction, which of he folowing statement is correct = re checticcienunction (<0) lero common thad paransle or eae . Organic eauses are the most common causes of s6BHdary erectile dysfunction o+4 c. Generally, management of sexual dysfunction involves replacement of welfare emotions with © lng. vels of 5’ GMP a emergency emotions WX (ED Phosphodiesterase 5 inhibitors mechanism of action is through increase of le @. None of the above 2 51. For a woman to be able to use lactation amenorrhoea method of contraception, the following 3 criteria should be fulfilled a. Baby less than.9 months old and exclusively breastfed with menses not haying resumed Baby less than 6 months old exclusively breastfed and the periods have ofenined . Baby if more than 6 months old exclusively breastfed and the period have resumed . Baby at least 6 months old started on complementary feeds and periods have not resumed e. Baby if less than 3 months old, exclusively breastfed and periods have resumed 52. Use of family planning methods influences population dynamics through effect on fertility viz: Delay in initiating childbearing b. Attainment of optimum birth intervals (1-2 years) Failure to attain desired family si d. Notlimiting size. e. No effect on perinatal, neonatal infant and under five mortality: - 53. A 46-year old is diagnosed to have endometrial cancer stage I. the most appropriate treatment will be a a. Total laparoscopic hysterectomy exe fut Ae b. Vaginal hysterectomy with bilateral salpingo-oophorectomy c. Administer tamoxifen Total’ abdominal hysterectomy, bilateral salpingoophrectomy, bilateral pelvic and paraoartic lymphaderectomy Supracervical abdominal hysterectomy and bilateral salpingoophorectomy woman is referred due to pelvic mass on u/s and elevated a-CA- is mobile. The most appropriate e. "54. A 70 year old postmenopausal 125, Further.examination revealed a readily palpable mass that ~ next step in her management will be ni Thoracentesis for staging uwSE NA ERR SAR taceteeeeresvees d. Laparoscopy for diagnosis ; oF €. Neoadjuvant chemotherapy Ga 20 year old para 0+0 presents with a 2 days history of fever and left lower quadrant abdominal pain one day after her menstrual period. A culture from endocervix grew neisseriagonorhoea What is a common sequlae of the above when treated is delayed: a, Cancer of the cervix 7 > Infertility T Urethra stricture 4. Uterine leiomyoma : €. Vaginal fistulae =7¥-venty 56, Which of the following conditions in HIV infected person suggests the greatest degree Of ienmunosuppression Qu Beer ce rie aes (BF Oral candidiasis Ty c. Generalized ee lymphadenopsthy é=xc¢ Recurrent upper respiratory tract infections i Skin rash he commonest cause of infertility in Kenya is due to a. Testicular varicocele b, Polycystic ovarian disease Mumps orchitis BF Falopien tube blockage e Agsonvone Pine te 58. A patient with a regular 28 day cycle is to me {SG for evaluation of het iad RR ahi ees . fx = sxeye exces the appropriate-day for evaluation one er Noe Seahes ah dla 2. bay1g\ it 3 Bes gota Gea Jroamab- b. Day 3% Le v7 ass ee : ot oP ie —rnen ce Day 9 di h ue 3. g ne dE Day KF Daye wea Cano» Se olny mass Ss Preqaanch’ e. Day 21 & ie Maralyn es a,Pelwic tendeiness 59, The following can be vsti fate symptoms arising from uterine fibroids EXCEPT a eee pupilarrarden events sO ee Danazol eu ie he come as. (eres 2 SARS ee sgieees c. eee ee moaned “cogent ‘Anabolic steroids # Bares ein ocae <& Y Combined oral contraceptives 60. Which of the following scenarios regarding uterine ( Subserosal at fundus“ b. Cornual intramural © © Fundal intramurab n fibroids is least likely to cause infertility