1.

placenta Previa 33 wks, bleeding mild but feels heavies vitally stable, contracting 3/10 ctg
reactive:
A-Tocholytic+steroid
B-Cs
Explanation:
No tocolytic for patient bleeding.
Women should also be advised to seek immediate medical attention if contractions or vaginal bleeding occur, given

the potential for severe bleeding and need for emergency cesarean delivery

Other Up to date
●We do not administer tocolytic drugs to actively bleeding patients.

●Anti-shock garments have been used to restore adequate blood pressure in pregnant/postpartum women

who are hemodynamically unstable due to severe bleeding in low resource settings [18-20]. However, these

devices have not been used when the fetus was viable and there is no information on their effect on

uteroplacental blood flow and the fetus.

●Tranexamic acid is generally not administered before delivery because it freely crosses the placenta.

However, it has been recommended for treatment of antepartum, intrapartum, and postpartum bleeding

related to several inherited bleeding disorders [21]. Fetal/neonatal harm has not been reported, but data are

limited.

Outcome — Most women who initially present with symptomatic placenta previa respond to supportive therapy, as

described above, and do not require immediate delivery [22-26]. In observational series, 50 percent of women with a

symptomatic previa (any amount of bleeding) were not delivered for at least four weeks [23,25,26]. Even a large

bleed does not preclude conservative management. In one series, 50 percent of women whose initial hemorrhagic

episode exceeded 500 mL were successfully managed with aggressive use of antepartum transfusions and had a

mean prolongation of pregnancy of 17 days [22].

Indications for delivery — Cesarean delivery is indicated for:

●Active labor.

●A nonreassuring fetal heart rate tracing unresponsive to resuscitative measures. (See "Management of

intrapartum category I, II, and III fetal heart rate tracings", section on 'In utero resuscitation'.)

●Severe and persistent vaginal bleeding such that maternal hemodynamic stability cannot be achieved or

maintained.

●Significant vaginal bleeding after 34 weeks of gestation – Because the neonatal benefits from avoiding

preterm delivery decrease with advancing gestational age, whereas maternal risks from persistent or recurrent

bleeding probably increase, we feel the balance of fetal benefit versus maternal risk favors delivery in women

with significant vaginal bleeding after 34 weeks. The gestational age threshold and amount of bleeding

considered significant are matters of clinician judgment. The decision to deliver these pregnancies is made on
 a case-by-case basis while observing the patient's course on the labor unit. Delivery should not be delayed to

administer antenatal corticosteroids [10].

Magnesium sulfate — We suggest a course of magnesium sulfate therapy for neuroprotection in patients with

preterm (24 to 32 weeks) placenta previa in whom a decision has been made to deliver within 24 hours, but not

emergently. Emergency delivery because of maternal or fetal status should not be delayed to administer magnesium

sulfate. (See "Neuroprotective effects of in utero exposure to magnesium sulfate".)

Anesthesia — (See "Anesthesia for the patient with peripartum hemorrhage", section on 'Placenta previa'.)
-------------------------------------------------------------------------------------------------------------------------
2.Pregnant patient with history of dysuria progress to pyelonephritis which of the following
facilitate this condition?
A) decrease level of glucose in urine
B) Smooth muscle relaxant in the ureter
C) decrease GFR
D) increase urine acidity"

3. Postpartum hemorrhage case, all uterotonic treatment given

Bp 90/40, P 125 What to do:
A. barky Balloon à it is the first choice after the uterotonic but patient vitally unstable.
B. Hysterectomy
C. B lynch
D. tranexamic acidà it uses when the medical management failed in the first 3 hours causes
significant mortality reduction.
Explanation:
It is incomplete question; you should know the complete scenario with the type of delivery the
amount of EBL and other signs and symptoms so go down to the table àif patient considered
hemodynamically stable àtranexamic acid then bakery balloon (ACOG à Tranexamic acid can
be used for postpartum hemorrhage not responding to other medical options. It should
typically be administered within 3 hours of the time of delivery)
Up to date
-BLOOD LOSS >500 ML AT VAGINAL DELIVERY OR >1000 ML AT CESAREAN DELIVERY BUT <1500 ML WITH
ONGOING EXCESSIVE BLEEDING — These patients are generally hemodynamically stable, but may have mild
tachycardia (heart rate ≥110 beats/min), mild hypotension (systolic blood pressure 80 to 85 mmHg), fall in oxygen
saturation (O2 sat <95 percent), and/or lightheadedness, before initiation of therapy.

Patients with blood loss >1500 mL with ongoing excessive bleeding require all of the above, and consideration of
the following:
•Laboratory tests to evaluate blood loss and coagulopathy (see 'Laboratory evaluation' above)
•Placement of an intrauterine balloon for tamponade, after excluding cervical and vaginal lacerations, retained
placenta, uterine inversion, and uterine rupture (see 'Perform uterine tamponade in patients with atony or lower
segment bleeding' above)
•Transfusion of red cells and correction of coagulopathy (see 'Transfuse red blood cells, platelets, plasma' above
and 'Correct clotting factory deficiencies' above)
•Selective arterial embolization if less invasive measures fail, the patient is hemodynamically stable, and volume
and blood product replacement can compensate for the rate of blood loss (see 'Consider uterine or hypogastric
artery embolization' above)
•Resuscitative endovascular balloon occlusion of the aorta by appropriately trained personnel can decrease the
amount of bleeding distal to the occluded site and provide a window of opportunity for resuscitation and definitive
hemorrhage control. (See 'Consider resuscitative endovascular balloon occlusion of the aorta' above.)
●Patients with blood loss >1500 mL and ongoing excessive bleeding refractory to medical and minimally invasive
interventions require consideration of all of the above, and should receive oxygen to maintain oxygen saturation
>95 percent and receive normothermic fluids and blood to avoid hypothermia. Acidosis should be corrected using
bicarbonate, if necessary. Aortic compression is a temporizing measure to reduce blood flow to the uterus and
thus provide time to initiate and continue other measures. These interventions may be indicated in some patients
with less blood loss as well. (See 'Blood loss >1500 mL with ongoing excessive bleeding refractory to medical and
minimally invasive interventions' above.)
●Laparotomy is indicated in patients with massive bleeding and those who are unstable after the initial
interventions described above since it is unlikely that ongoing replacement of blood products will match blood loss
in these patients. Ideally, the clinician should correct hemostatic defects prior to laparotomy, but surgery should
not be delayed if bleeding cannot be controlled promptly. (See 'Consider laparotomy' above.)

4. Scenario of a patient had a forceps delivery with episiotomy repaired post-delivery 12 hours
she’s unable to void what is the most common cause of this issue:
A. Epidural analgesia —>effect will last up to 8hr.
B. vulvovaginal edemaà can be correct as the OVD cause outlet obstructions.
C. vulvovaginal hematoma ànothing in the history indicated that she is having hematoma.
D. bladder over Distention
Explanation:
I took also Urogyne consultant opinion.
there is similar question in true learn.
A consistent risk factor associated with postpartum urinary retention is operative vaginal delivery.
Explanation
Urinary bladder function can be impacted during labor; distention of the bladder can hinder descent of the fetal
presenting part and lead to subsequent bladder hypotonia and infection.
Most women resume normal voiding before discharge from the hospital; however, approximately 1 in 200 women
experience postpartum urinary retention. Several risk factors have been proposed and studied – operative vaginal
delivery consistently has a strong association with postpartum urinary retention.
Answer A: Advanced maternal age has not been demonstrated to be a risk factor for postpartum urinary retention.
Answer B: Primiparity is likely a risk factor for urinary retention, but operative vaginal delivery is most associated.
Answer D: Perineal lacerations have been proposed as a risk factor for urinary retention, but operative vaginal
delivery is most associated.
Answer E: Spontaneous labor is not a risk factor for urinary dysfunction.
5. Twin peak sign the division in which days occur?
Twin peak or lambda sign occurs when there is upward or downward projection of placental
tissue where the chorion and amnion interface between 2 amniotic sacs —>this indicates Di-Di
twins, division will occur in day 1-3 after fertilization.
6. Patient after vaginal delivery you noticed labial lesion of active HSV, she gave history of HSV
which was in the past, what is the risk of fetal HSV infection? (Repeated Q 2021)
A. 5%--> it should be 0-3% but I choose the lowest value
B. 20%
C. 30%
Explanation:
It is recurrent HSV so àAnswer is < 1% in bergella
In RCOG 0-3% so just look for any 1 of them available in the answers
à for primary episode of HSVà25-50%

Bergella

MRCOG
7. 38 weeks severe oligo, congenital absence of hand
A- isotretinoin
B- Potter’s syndrome
C- amniotic band
8.Di Di 36 weeks, 1st cephalic,
what is safer?
A- planned vaginal delivery.
B- Planned cesarean
C- Planned cesarean for 2nd if breech

ACOG
9.A case of pregnant with previous history of DVT diagnosed with homogeneous factors V
What to give? (Repeated Q 2021)
A) therapeutic low molecular weight heparin during pregnancy and postpartum
B) Prophylactic low molecular weight heparin during pregnancy and postpartum
Explanation
it is high risk thrombophilia. The answer depends on if there is previous history of 1 DVT
àprophylactic.
or previous 2 DVT àtherapeutic
10. The endometrial sample shows a crowded cell with (description of complex
hyperplasia with atypia) with atypia. what is her risk to develop endometrial cancer? (Repeated
Q 2019)
a. 1%
b. 3 %
C. 9%
D. 29 %
Answer: D
11. Risk of having stroke in pregnancy : (Repeated Q 2020)
A. 1st trimester
B. 2nd trimester
C. 3rd trimester
D. Postpartum
Answer: D

12. Which of the following is critical level of bile acid: (Repeated Q 2020)
A.10 mmol
B.20 mmol
C.30 mmol
D.40 mmol
Answer: D

13. Case of recurrent pregnancy loss (3 first trimester) what is the percentage of chromosomal
anomaly?
A.30%
B.50%
C.70%
Up to date
D.100
Explanation:
Here as I understood from the question the % of the embryos with chromosomal anomalies in RPL
 But if the question about the chromosomal anomalies in the parents who is having RPL the % is only 2-5%
-from true learn:
in 50–75% of couples with recurrent pregnancy loss (RPL), no etiology is determined.
RPL is defined as ≥2 failed clinical pregnancies and a clinical pregnancy is a pregnancy documented by
ultrasonography or histopathological examination. It is estimated that <5% of women will experience 2
consecutive miscarriages and only 1% experience 3 or more.
Suspected Causes of Recurrent Pregnancy Loss

Cause Contribution to RPL (%) Recommended Screening

• Balanced reciprocal translocations

Cytogenetic 2–5%

• Lupus anticoagulant
• Anticardiolipin IgG or IgM antibody
Antiphospholipid antibody syndrome 8–42%, mean 15%
• Anti-β2-glycoprotein I

• Hysterosalpingography
Anatomic 1.8–37.6%, mean 12.6% • Sonohysterography

• Prolactin
• TSH
Hormonal or metabolic --
• Hemoglobin A1c

• None
Infectious --

Aneuploidy — The risk of aneuploidy increases as the number of previous miscarriages increases [83]. The relationship between

the karyotype of the abortus and risk of RPL requires further study to better define which abnormalities are likely to be recurrent.

In some series, having one chromosomally abnormal spontaneous abortion appeared to increase the risk of a subsequent loss

associated with a chromosomal abnormality [84-87]. As an example, one study reported that the frequency of an abnormal

karyotype in a second abortus after a first aneuploid or euploid abortus was 70 and 20 percent, respectively [84]. Another study

involving preimplantation genetic diagnosis reported 532 of 764 embryos (70 percent) were abnormal in couples with RPL versus

97 of 215 embryos (45 percent) among controls [85]. In addition, an increased rate of aneuploid embryos has been demonstrated

in young women with previous aneuploid conceptions [88].

However, these findings were not validated in other series [77,89,90]. As an example, in one study, there was no increased risk of

chromosome abnormality in the next pregnancy if the prior abortus had a trisomy that was always lethal in utero or when the

Up to
date
parental karyotypes were normal [89]. The aneuploid losses in this study, and others, may have been associated, in part, with the

older age of the mothers, rather than solely a nonrandom risk in a predisposed couple.

14."In Pre employment checkup women, found to have 5 x 6 CM dermoid cyst?

A) immediate OR immediate surgery
B) rescan in 4-6 months
C) tumor marker"
Explanation
In Acog she mentioned to remove the cyst if symptomatic or large (to prevent torsion) or
suspicious for malignancy or growing.
Here it is asymptomatic but might be consider large, so we will go with surgical removal, also its
is doesn’t need to be immediate, so if you have another option with surgical removal without
immediate which indicate it is emergency better to choice that one
Surgery — Surgery may be recommended in the following situations:
●A cyst is causing persistent pain or pressure or may rupture or twist. Up to
●A cyst appears on ultrasound to be caused by endometriosis and is removed for date
fertility reasons.
●Large cysts (>5 to 10 cm) are more likely to require surgical removal compared with
smaller cysts. However, a large size does not predict whether a cyst is cancerous.
●If the cyst appears suspicious for cancer (based on tests) or if you have risk factors for
ovarian cancer.
●If the suspicion for ovarian cancer is low but the cyst does not resolve after several
ultrasounds, you may choose to have it removed after a discussion with your health care
provider. However, surgical removal is not usually necessary in this case.
Surgery to remove ovarian cyst — If surgery is needed to remove an ovarian cyst, the
procedure is usually done in a hospital or surgical center. Whether the surgery involves
removing only the cyst or the entire ovary depends upon your age and what is found
during the procedure.
ACOG

Williams
gyne
15."Commonest organism to cause sub clinical endometritis:
A. Klebsiella
B. staph
C. Chlamydia
D. Pepto-streptococcus
Explanation
The answer is chlamydia (sure)
Mentioned in William Ob, chapter 37, 26th edition (Chlamydial infections have been implicated
in late-onset, indolent metritis)

Up to date

16.A pregnant patient presented with preterm prelabor rupture of membrane then she
developed maternal fever &fetal tachycardia. What is the most likely causative organism?
a. E.coli
b. Staph aureus
c. Bacteroids
d. Group A -beta hemolytic streptococci
Explanation
The m/c in uptodate to cause chorioamnionitis in pprom is uroplasma uraetycium 45 % but it is
not one of the answers here.

MICROBIOLOGY — IAI is typically polymicrobial, often involving vaginal or enteric flora (table 2 and table 3). Two-thirds of
women with IAI have at least two isolates per specimen of amniotic fluid.
Regardless of gestational age, genital mycoplasmas (Ureaplasma and Mycoplasma species) are the most common isolates [26].
Anaerobes (including Gardnerella vaginalis), enteric gram-negative bacilli, and group B Streptococcus are other frequent
pathogens. Anaerobes appear to be more frequently involved in preterm IAI than term IAI [27].
Genital mycoplasmas are the most frequent organisms detected in cases of culture-confirmed chorioamnionitis and are highly
prevalent (>70 percent) in the lower genital tract. For this reason, some authors attribute their isolation from patients with IAI
to contamination or colonization from the lower tract rather than a true infection. However, as data accrue, there is increasing
support for their pathogenicity, including induction of a robust inflammatory response with clinical consequences for both
mother and neonate [26,28].
If the scenario was about purpureal endometritis, then the answer is à group A b hemolytic
streptococcus

17.Scenario about a patient who's 2 weeks post hysterectomy and A/p repair
What complication can occur?
A. Dyspareunia
B. Stress incontinence
C. Urge incontinence
D. Vault prolapse.
Explanation
The answer is stress incontinence.
Also, urogyne consultant answered the same.
18."A case of 30 GA came to ER in labor pain PV examination showed 3CM and membrane
bulging maternal vital in normal range, fetal heart 190 bpm, wbc s 16
After starting antibiotic what next?
A) allowed to progress
B) cesarean section
C) Start induction
Explanation
To diagnose as chorioamnionitis we need maternal fever, but her it is preterm labor with 3cm
and bulging membrane and nonreassuring ctg + signs of infections (high wbcs) so it is
contraindicated to use tocolytic but if there is answer to allow progress +dexa and magnesium
sulfate it will be better answer

Contraindications — Tocolysis is contraindicated when the maternal/fetal risks of prolonging pregnancy or the risks
associated with these drugs are greater than the risks associated with preterm birth. Established contraindications
to labor inhibition include [4]:
●Intrauterine fetal demise
●Lethal fetal anomaly
●Nonreassuring fetal status
●Preeclampsia with severe features or eclampsia Up to date
●Maternal hemorrhage with hemodynamic instability
●Intraamniotic infection
●Medical contraindications to the tocolytic drug
Known or suspected fetal pulmonary maturity is not an absolute contraindication to tocolysis, as preterm birth is
also associated with nonpulmonary morbidities.
Contraindications to use of specific drugs are reviewed below in the discussions of specific tocolytics.
19."A case of patient in labor after after receiving Pethidine CTG showed prolonged
deceleration patient requested epidural analgesia what is your advice?
A) after next PVàthe only suitable answer (as it incomplete scenario and options)
B) Contra indicated due to low platelet ( plt was 123) à CI if plt was less than 80
C) it is possible after the first category CTG"ànot the answer because it is also recommended
in category 2 ctg as shee might need cs so decrease the need for GA

Up to date
20."A case of patient with previous intra-abdominal surgery complaining of moderate to mild
abdominal pain ultrasound showed irregular mass with minimal ascites (history suggestive of
intraperitoneal inclusion cyst… I don’t think so ..) ?! What is the next step?!
A) MRI
B ) surgery
C ) CTà if ct cap it will be a better answer
D) rescan after 4 week "
Explanation
Mass is subspinous for malignancy, so we need to do first CT cap to r/o mets then surgical
management. But the question is vague and incomplete. And It is not suggestive of
intraperitoneal inclusion cyst as written it is suspicious for malignancy

21."Patient with polycystic ovary she will undergo ovarian drilling what is the outcome?
(Repeated Q 2019)
A) improved ovum Quality
B) decrease level of FSH and LH"àthe right answer decrease androgens which later causes
stimulation to pituitary to increase fsh
C) increase AMH
D)form ovarian adhesions
Explanation
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 5747291/
it causes reduces secretion of androgens by 40% which results in increased.
FSH and LH secretion from the pituitartry

22.A pregnant patient 17 weeks has a vulvar lesion and Treponema Pallidum hemagglutination
test is positive. What is the most appropriate treatment?
The correct answer is Penicillin. Up to date
Explanation
Preferred regimen: penicillin — Penicillin is the gold standard for the treatment of syphilis in
both pregnant and nonpregnant individuals. No clinically relevant penicillin-resistant strains of
T. pallidum have been identified to date. Penicillin therapy in pregnancy is effective for treating
maternal disease, preventing transmission to the fetus, and treating established fetal disease.
Because penicillin is considered the only appropriate treatment of syphilis during pregnancy,
pregnant women with penicillin allergy should be desensitized and treated with penicillin. (See
'Patients with immediate type allergic reactions to penicillin' below.).
23.A 23-year-old a sexually active patient comes to Gynecology clinic compiling of vaginal
discharges and lower pelvic pain. A pelvic exam showed cervical motion tenderness and cervical
discharges. What is the recommended treatment according to CDC?
a) Azithromycin 2 gm as a single dose. àshe is pid needs also doxycycline.
b) ?
c) ?
 Up to date
d) doxycycline 100 mg bid for 7 days àshould be 14 days
Explanation
Not complete answers
Outpatient therapy — Patients with mild or moderate PID are suitable candidates for
outpatient therapy since clinical outcomes are equivalent with inpatient or outpatient therapy.
(See 'Efficacy of inpatient versus outpatient therapy' above.)
First-line regimens — The CDC recommends any of the following outpatient regimens, with or
without metronidazole (500 mg twice a day for 14 days) [1]:
●Ceftriaxone (250 mg intramuscularly in a single dose) plus doxycycline (100 mg orally twice a
day for 14 days)
●Cefoxitin (2 g intramuscularly in a single dose) concurrently with probenecid (1 g orally in a
single dose) plus doxycycline (100 mg orally twice a day for 14 days)
●Other parenteral third-generation cephalosporins, such as cefotaxime (1 gram intramuscularly
in a single dose) or ceftizoxime (1 gram intramuscularly in a single dose) plus doxycycline (100
mg orally twice a day for 14 days)
Of the cephalosporins listed, ceftriaxone has the overall best activity against gonococcal
infection. We prefer ceftriaxone plus doxycycline in patients with mild to moderate PID.
Metronidazole should be added for patients with Trichomonas vaginalis or in those women
with a recent history of uterine instrumentation.
Alternative agents
The long half-life of azithromycin, its concentration intracellularly, and its activity against
Chlamydia offers the potential for an easier dosing schedule than twice-daily doxycycline. Small
clinical trials suggest clinical efficacy although data on microbiological cures are not available:
●A double-blind randomized controlled trial compared the efficacy of a single intramuscular
injection of ceftriaxone followed by either doxycycline (100 mg twice daily for two weeks) or
azithromycin (1 gram once per week for two weeks) in 120 women with mild PID [25]. The
azithromycin and doxycycline arms were found to be equivalent in clinical cure rates. The study
limitations include the subjective nature of the measured outcome, limited microbiologic data
and the small sample size.

24."Patient diagnosed with chlamydia what is the recommended treatment according to the
CDC?
A) doxycycline 100 mg daily for 7 days
B) azythromycin 1 g po

Up to date

Explanation
cHLAMYDIA TREATMENT — Treatment of chlamydia is the same for women and men. For most
infections, experts recommend a one-time antibiotic treatment that is taken by mouth,
azithromycin. Azithromycin is safe to take during pregnancy.
Anyone who is allergic to azithromycin (or erythromycin) can take another antibiotic,
doxycycline, but this must be taken twice daily for 7 days. It is important not to have sex during
this treatment. Doxycycline is not used in pregnant women because of the risk of harm to
developing teeth and bones in the fetus.
Some people who are infected with chlamydia may also be infected with gonorrhea. Thus,
testing for gonorrhea is sometimes done at the same time as chlamydia testing. If the patient
has both infections, additional treatment for gonorrhea will be needed. (See "Patient
education: Gonorrhea (Beyond the Basics)".)
Sexual partner treatment — Treatment is important for you and anyone you have had sex with
recently (the last 60 days, or the last person you had sex with), whether or not he or she has
symptoms or has a negative test for chlamydia. This is because not all infections cause
symptoms, and because the test might not detect a recent infection, which could have been the
source of your infection. Your doctor or nurse might ask you to tell your sexual partner(s) to be
treated. In some cases, your doctor or nurse may give you a prescription for both you and your
partner.
You should not have sex until one week passes after both you and your partner have completed
treatment. It is possible to be infected with chlamydia more than once, and the most common
reason for this is failure to treat sexual partners.
If you take the recommended treatment, you will not need to be tested in the short term (1 to
2 months) to make sure that the chlamydia is gone unless you continue to have symptoms. If
symptoms do recur or occur for the first time after you are treated you should see your doctor
or nurse again.
However, anyone with chlamydia should have another test for chlamydia three to six months
after their diagnosis, because many people (as many as 25 percent in some studies) are re-
infected from untreated sexual partners.

25. A patient delivered vaginal after deinfibulatuon and she asked you to do reinfibuoation.
What is the most appropriate response? (Repeated Q 2021)
a) Refer her to another physician who will the reinfibulation.
b) Tell the patient that reinfibulation is not recommended. -->it is a crime
c) Agree to the patient’s request and do the reinfibulations
d) ?
26. A pregnant patient was found to have an umbilical cord with single uterine artery. What is
the best next step? (Repeated Q 2019)
a) Do amniocentesis
b) Ultrasound for growth scan
c) Offer genetic counselling
d) ?

27. A 30 year-old pregnant underwent a C-section and it happens that the bladder got injured.
At what stage of the Cesarean section the bladder was injured? (Repeated Q 2021)
a) During opening the sheath
b) During the peritoneal entry
c) During lower uterine segment incision to lower down the bladder flap
d) ?
Explanation
Incomplete scenario and options
28. A patient who has complaints of urgency, frequency, nocturia and multiple visits to
bathroom to urinate. On Physical examination: You noticed a small opening through the upper
lateral side of the vagina in which some fluid comes through. What is the best next step to
confirm the diagnosis? (Repeated Q 2021)
a) CT scan pelvisàthe gold stander test ct with contrast
b?
c) Intravenous peyelogram (IVP). --> it is to check the ureter
d) Carmine dye in bladder and tampons à it is clinical test
Explanation
Best next step àdye test in the clinic if you are not sure of diagnosis.
If the question to identify the location àcystourethroscopy

Cystourethroscopy would be the most helpful next step in this patient, to locate a vesicovaginal
fistula.
Vesicovaginal fistula is a connection between the bladder and vagina, with hysterectomy being
the leading cause of vesicovaginal fistula formation in the United States. Fistulas between the
urinary tract and vagina typically result in painless urinary leakage from the vagina. Intermittent
leakage, particularly when positional, can be a sign of ureterovaginal fistula, whereas
continuous urine loss is more characteristic of vesicovaginal fistulas.
Vesicovaginal fistula may be identified with multiple methods including visualization of dyes or
laboratory evaluation. However, locating it is the next step for surgical evaluation and
exploration.
Cystourethroscopy directly visualizes the abnormality, and can assess the bladder for residual
injury, surgical materials and the number of intravesical fistula orifices. Very small fistulas will
be difficult to appreciate on bimanual or speculum examinations. Dye studies alone are not
sufficient to completely evaluate the number and location of urogenital fistula. The intravenous
pyelography (IVP) is less useful for noting any disruption in ureteral integrity, because it may
miss ureteral leakage that is immediately adjacent to the trigone when dye filling the bladder
obscures a small leak. Small amounts of dye may not show up on conventional radiography, and
puddling may result from ureteral or bladder leakage, or both. When a normal renal unit is seen
on IVP, but the ureter is never visualized, complete transection preventing accumulation of dye
in the ureter must be considered. A recent study of obstetric vesicouterine fistula
demonstrated that pelvic magnetic resonance imaging (MRI) may be more sensitive than IVP or
computed tomography (CT).
Answer A: Bimanual exam will not appreciate smaller fistulas.
Answer C: Dye tests are helpful in assessing whether or not a fistula is present, but are not
sufficient to completely evaluate the number and location of urogenital fistulas. Dyed sterile
fluid (e.g., sterile infant formula, or indigo carmine or methylene blue mixed with saline, where
available) may be instilled into the bladder through a bladder catheter. In combination with the
use of blue dye in the bladder, use of oral phenazopyridine (e.g., pyridium) will distinguish a
fistula communicating between the vagina and ureter (orange urine) from located in the
bladder (blue urine).
Answer D: The intravenous pyelography (IVP) is less useful for noting any disruption in ureteral
integrity, because it may miss ureteral leakage that is immediately adjacent to the trigone when
dye filling the bladder obscures a small leak. Small amounts of dye may not show up on
conventional radiography, and puddling may result from ureteral or bladder leakage, or both.
When a normal renal unit is seen on IVP, but the ureter is never visualized, complete
transection preventing accumulation of dye in the ureter must be considered. A recent study of
obstetric vesicouterine fistula demonstrated that pelvic magnetic resonance imaging (MRI) may
actually be more sensitive than IVP.
Answer E: Speculum examination may not identify fistulas. For more mature fistulas, it may be
difficult to visualize the vaginal orifice. Very small fistulas may be difficult to visualize due to
size and also the anatomy of the vagina (e.g., fornices are difficult to examine).

29. 45 years old female with menorrhagia and the endometrial biopsy (a picture was attached)
shows endometrial hyperplasia with atypia.
What is the most appropriate management? (Repeated Q 2021)
a) Hysterectomy
b) Mirena IUCD

30. A 32 year-old female para 3 who completed her family and does not wish to get pregnant
again. She complains of heavy menstruation. What is the best treatment option?
a) Endometrial ablation
b) Hormonal IUD
Up to date
c) D&C
d)
Explanation
Because he mentioned that she completed her family, it is like he is guiding us to endometrial
ablation ,and the comparison between mirnea and ablation is mentioned clearly in up to date
is according to future fertility desire
Levonorgestrel IUD versus surgical treatments — A systematic review of six randomized trials
and a subsequent randomized trial found that women with menorrhagia who were treated with
either the LNg52/5 or endometrial ablation had similar reductions in menstrual blood loss at 6,
12, and 24 months, as well as similar improvements in quality of life [23,63].
In a study of 236 patients with HMB which followed women for 10 years after they were
randomized to placement of a LNg52/5 or hysterectomy, 46 percent of women initially
randomized to IUD placement ultimately underwent hysterectomy. Overall, costs were lower
among women randomized to the IUD while health-related quality of life and psychosocial well-
being were similar in the two groups [64]. In the same trial, 10-year follow-up reported that
women in the IUD group had significantly lower rates of stress urinary incontinence (34 versus
48 percent) and usage of medications for urinary incontinence (1 versus 12 percent) [65].
The decision to use the LNg52/5 or endometrial ablation depends upon a patient's preferences
regarding treatment factors such as plans for fertility and contraception, convenience, and risks
of anesthesia. The LNg52/5 is a reversible contraceptive. Pregnancy is contraindicated after
endometrial ablation, but the procedure may not prevent pregnancy; thus, women will need to
continue to use contraception following ablation. The LNg52/5 is placed in an office setting and
requires no or local anesthesia. Endometrial ablation can also be done in an office by surgeons
who are appropriately equipped but is often performed in an operating room under general
anesthesia. If successful, endometrial ablation is performed once, while the LNg52/5 needs to
be replaced regularly.
Women finished with childbearing

1.Endometrial ablation — Endometrial ablation is a minimally invasive option for treatment of

heavy or prolonged uterine bleeding when medical therapy fails or in women who do not want
to use chronic medical therapy [66]. Pregnancy is contraindicated after endometrial ablation,
but contraception is still required. As described above, endometrial ablation and the LNg52/5
have equivalent efficacy in reducing menstrual blood flow in women with HMB. (See
'Levonorgestrel IUD versus surgical treatments' above and "An overview of endometrial
ablation".)
2.Uterine artery embolization — Uterine artery embolization is an option for women with
uterine leiomyomas. The safety of pregnancy after this procedure has not been established;
therefore, it is usually reserved for women who are not contemplating future childbearing. (See
"Uterine leiomyomas (fibroids): Treatment with uterine artery embolization".)
3.Hysterectomy — Hysterectomy represents definitive treatment for uterine bleeding. This
procedure has a high rate of patient satisfaction because it is curative, is frequently performed
after medical management has failed, is not associated with drug-related side effects, and does
not require repeated procedures or prolonged follow-up. On the other hand, hysterectomy has
a risk of perioperative complications and, depending on the operative approach, a prolonged
recovery. (See "Choosing a route of hysterectomy for benign disease".)

31. A 52 year-old female comes to the clinic complaining of tiredness and abdominal bloating
with a decrease in her BMI from 40 to 30 kg/m2 and she noticed her clothes are getting looser
than before. She also has mild vaginal bleeding. What is the best next step?
a) Tumor markers àno tumor marker for endometrial cancer
b) CT abdomen and pelvis à after diagnosing there is a cancer we do CT cap to see if there are
mets
c) MRI pelvis
d) Ultrasound pelvis with endometrial biopsy
Explanation
Signs of cancer decrease weight, and with vaginal bleeding the only abnormality we will go to
us with EMB

32. A 82 year-old brought by her granddaughter in a wheelchair complaining of Urinary

incontinence. During vaginal exam she has pelvic organ prolapse (I forgot the degree). She is
diabetic and hypertensive, and the anesthesiologist classified her as ASA score 4.
What is the best management for this patient? (Repeated Q 2021)
a) Le fort surgery
b) Pessary
c) ?
d) ?
Explanation
She is ASA 4 so not fit for surgery we will go with conservative management.

33. A pregnant who is 22 weeks came to Labor and Delivery with abdominal pain and the
amniotic membrane is bulging. What is the next best step in management?
a) Tocolysis
b) Expectant management àpreviable preterm labor
C) Emergency C-section Up to date
d)?
Explanation
General principles — Women in the early phases of acute preterm labor, when cervical dilation is not advanced,
are optimum candidates for tocolytic therapy [3]. Tocolysis is indicated when the overall benefits of delaying
delivery outweigh the risks. In a practice bulletin, the American College of Obstetricians and Gynecologists opined:
"Interventions to reduce the likelihood of delivery should be reserved for women with preterm labor at a
gestational age at which a delay in delivery will provide benefit to the newborn. Because tocolytic therapy is
generally effective for up to 48 hours, only women with fetuses that would benefit from a 48 hour delay in delivery
should receive tocolytic treatment" [4].
Inhibition of acute preterm labor is less likely to be successful as labor advances to the point that cervical dilation is
greater than 3 cm. Tocolysis can still be effective in these cases, especially when the goal is to administer antenatal
corticosteroids or safely transport the mother to a tertiary care center [3-6]. (See 'Treatment goals' below.)
Lower and upper gestational age limits
●Lower limit – The minimum gestational age at which inhibition of preterm labor is a reasonable intervention is
controversial, and largely based on expert opinion. The authors would give tocolytics to a woman less than 22
weeks of gestation if she has a self-limited condition that could cause an acute episode of preterm labor but is
unlikely to cause recurrent preterm labor. As an example, we would attempt to inhibit contractions related to an
appendectomy or acute pyelonephritis at 20 weeks of gestation in the absence of maternal sepsis [7,8].
In the United States, a workshop comprised of obstetric and pediatric experts suggested 220/7ths weeks as the
lower limit for consideration of tocolysis if antenatal steroids were concurrently administered [9], given this
gestational age is at the limit of viability and corticosteroid effectiveness. The American College of Obstetricians
and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommend not administering
tocolysis before 24 weeks of gestation, but consider its use at 23 weeks based on individual circumstances [10].
(See "Periviable birth (Limit of viability)" and "Antenatal corticosteroid therapy for reduction of neonatal
respiratory morbidity and mortality from preterm delivery", section on 'Gestational age at administration'.)
●Upper limit – There is more consensus about the upper gestational age limit for treatment of preterm labor. We
agree with ACOG and SMFM that 34 weeks of gestation defines the threshold at which perinatal morbidity and
mortality are too low to justify the potential maternal and fetal complications and costs associated with inhibition
of preterm labor and short-term delay of delivery [4,11].

34. A picture of hysteroscopy attached. what is the most common complication of this
procedure? (Repeated Q 2019)
a) Uterine perforation
b) Uterine bleeding
c) Cervical laceration
d) ? "
35.Pregnant lady 8 week of gestation with history of penicillin allergy diagnosed with UTI which
of the following is the treatment? (Repeated Q 2021) but here they specified first trimester
pregnancy.
A) ampicillin à she is allergic
B) nitrofurantoinàbetter to avoid in first trimester if there is safer antibiotic
Up to date
C) metronidazole ànot prefeed treatment of uti
Explanation
Nitrofurantoin is frequently used during pregnancy, although some potential concerns exist.
Nitrofurantoin has been associated with birth defects in case control studies [76,77], but these
findings should be interpreted with caution as multiple comparisons involving small numbers of
affected exposed infants may have led by chance to the observed associations. In a prospective
study of pregnant women with asymptomatic bacteriuria, there were no congenital birth
abnormalities reported among the 40 women who received nitrofurantoin compared with 2
among the 208 women who received placebo or no antimicrobial treatment [8]. The safest
course is to avoid using nitrofurantoin in the first trimester if another antibiotic that is safe and
effective is available. Nitrofurantoin has also been reported to cause hemolytic anemia in the
mother and fetus with G-6PD deficiency [78]. The risk of hemolytic anemia is estimated to be
only 0.0004 percent of cases, but its use should be avoided near term for this reason.
36. scenario (25 y PG 12 w…. NT 4mm) what will do for early diagnosis:
A. Urgent referral MFM for CVS
b. Urgent referral MFM for amniocentesis
C. NIPT for trisomy 21
D. Reassuring
Explanation
NT >3 is high (it is screening test ) so we need diagnostic test àCVS can be done from 10 to 13
weeks so we can do it in this question, while amniocentesis between 15-20 weeks
Why not nipt?àWomen who want to maximize the amount of genetic
information they can obtain about their fetus should consider an invasive
diagnostic test (amniocentesis, CVS) with chromosomal microarray analysis.
Screening using cfDNA is targeted at detecting trisomy 21, 18, or 13 and sex
aneuploidies and is not diagnostic.

Postdiagnostic evaluation — After a diagnosis of increased nuchal translucency, post-diagnostic

evaluation includes:

●Genetic counseling, including options for fetal genetic testing

●Fetal anatomic survey at the time of nuchal translucency measurement and at 18 to 22 weeks
of gestation
●Fetal echocardiography at 18 to 20 weeks of gestation Up to date
●Periodic assessment of fetal well-being
Genetic studies — For women who have had increased nuchal translucency identified as part of
Down syndrome screening, either chorionic villus sampling (CVS) or amniocentesis for definitive
diagnosis is offered. Offering secondary screening with a cell-free DNA test of maternal blood is
also supported by the American College of Obstetricians and Gynecologists and the Society for
Maternal-Fetal Medicine for these women who initially screen positive. (See "First-trimester
combined test and integrated tests for screening for Down syndrome and trisomy 18", section
on 'Screen-positive first-trimester combined test results'.)
In some cases, it is reasonable to offer diagnostic genetic studies after measurement of nuchal
translucency without performing the full combined test (ie, measurement of biochemical
markers and consideration of maternal age). The optimum nuchal translucency threshold for
proceeding directly to an invasive diagnostic test is unclear. Absolute thresholds of 3.0 to 4.0
mm have been suggested, given the relatively high risk of Down syndrome at this level [13,38-
40].
In our practice, we use a threshold ≥3 mm for offering immediate CVS. In a large observational
study, 92 percent of patients with a nuchal translucency measurement ≥3 mm will screen
positive on the combined test and be offered invasive testing [39]. Offering prompt invasive
testing based on nuchal translucency alone shortens the time between the positive screen and
obtaining a definitive diagnosis. Some clinicians use a threshold of ≥3.5 mm, which corresponds
with the 99th percentile in populations at high risk of aneuploidy, regardless of crown-rump
length [20].
We offer microarray genetic analysis to all patients undergoing invasive genetic studies. In a
2015 systematic review of pooled data from 17 studies and 1696 pregnancies, the incremental
yield of genomic microarray over conventional G-banded karyotyping was 4 percent among
fetuses with isolated increased nuchal translucency and 7 percent among fetuses with
increased nuchal translucency associated with abnormalities diagnosed by first-trimester
ultrasound [41]. The most common pathogenic copy number variants detected by microarray
were 22q11.2 deletion, 22q11.2 duplication, 10q26.12q26.3 deletion, and 12q21q22 deletion,
and approximately 1 percent were variants of uncertain significance.

These findings should be considered by patients with increased nuchal translucency who
choose to undergo secondary cell-free DNA screening. Since cell-free DNA screening only
detects trisomy 21, trisomy 18, trisomy 13, and sex chromosome aneuploidies, not performing
an invasive procedure for more detailed genetic testing will fail to detect some genetic causes
of increased nuchal translucency.

37. infibulation immediate post-partum ask for repair: (Repeated Q 2021)

A. Infibulation is recommended.
B. Infibulation is discouraged.
C. Appointments after 6 w for repair
….?
38.thermal ureter injury at pelvic brim level (Repeated Q 2021)
A. End to end anastomosis.
B. Insert stent
C. Re implantation in bladder
….?

39. A 30-year-old pregnant 37 weeks with severe itching on palms and soles. liver profile
normal and bile acids were not included.
What is the best management?
1) Expectant management
2) Immediate C-section
c) ? Up to date
d)?
Explanation
It is incomplete question with incomplete options, the main idea if she is diagnosed as icp (see
diagnosis down) and she is 37 week or more she needs to deliver but by IOL if no
contraindication so we can’t let her with expectant management and no need for cs.
ICP is characterized by pruritus and an elevation in serum bile acid levels, typically developing in
the second and/or third trimester and rapidly resolving after delivery. Pruritus, which may be
intolerable, is often generalized but predominates on the palms and the soles of the feet and is
worse at night. (See 'Clinical findings' above.)
●The diagnosis of ICP is based upon the presence of pruritus associated with elevated total
serum bile acid levels, elevated aminotransferases, or both, and the absence of diseases that
may produce similar laboratory findings and symptoms. Severe cholestasis is defined as bile
acids over 40 micromol/L, and accounts for about 20 percent of cases. (See 'Diagnosis' above.)

deliver most women with ICP at 36+0 to 36+6 weeks of gestation or upon diagnosis if ICP is
diagnosed at ≥37+0 weeks of gestation, without performing an amniocentesis to check fetal
pulmonary maturity prior to delivery.
delivery — No special considerations related to delivery are required in women with ICP.
Continuous fetal monitoring during labor is indicated, given increased frequency of fetal death
and non-fatal asphyxial events [66,68]. Labor induction does not necessarily lead to an
increased risk of cesarean delivery compared with expectant management.

40. "Case of complicated delivery. Now patient suspected to have PE. That is the next?
Repeated Q 2021)
A) CBC
B) chest x ray
C) CT angio
D) ECG"

41.What is the tumor marker for yolk sac tumor?

AFP
42.Side effect of bleomycin?
pulmonary fibrosis
43.Professionalism q, scenario about breaking bad news, what is the first step?
A-establish rapport with the patient and if she wants someone to attend with herà(setting)
B-Provide information. à(knowledge)
C-Assess her knowledgeà(perception)
D-Empathy (my answer A based on SPIKES)

44."19 years old complaining of premenstrual abdominal pain affecting her school?
A) mefemenic acid
B) OCP
D) SSRI"
46. Osteoporosis wants medication that can be taken monthly?
Answer: Ibandronate Up to date
Osteoporosis – Although we previously recommended estrogen as a first-line choice for
prevention and treatment of osteoporosis, we now recommend bisphosphonates. However, in
the occasional patient with persistent menopausal symptoms who cannot tolerate first- and
second-line therapies for osteoporosis, estrogen may be a reasonable option.
47.Indication for Endocarditis prophylaxis:
A. VSD
B. prosthetic valve
C. defect already repaired in childhood.
D. aortic root > 4 mm

48.
The same picture But the question was what is the treatment?
Penicillin is the drug of choice for all stages of syphilis. Although alternative drugs have been
utilized for the treatment of syphilis in HIV-seronegative patients, there are very limited data on
the efficacy of these agents in the HIV-infected patient [89-93]. (See "Syphilis: Treatment and
monitoring", section on 'Penicillin as the treatment of choice'.)
The specific formulation of penicillin varies with the stage of syphilis. Long-acting benzathine
penicillin given by intramuscular administration can be used for most stages of disease;
however, intravenous therapy should be used for the treatment of ocular, otic, and central
nervous system disease (table 1). In addition, patients with ocular syphilis should be
comanaged with an ophthalmologist.
49. You are delivering a breech baby vaginally and the head got stuck, your next step
A. symphysiotomy
B. Duchene incision
C. cesarean delivery

Scopology
50. Picture of vasa previa in labor, what is the mode of delivery:
51.Patient diagnosed as POI given HRT for symptomatic treatment developed ovarian cyst
multiloculated 7 cm persistent, her ca 125 normal for a premenopausal aged women, what’s
your next step:
A. referral to gyne oncology àknow RMI
B. unilateral saloingoophrectomy à it is fertility preservation option for the diagnosed ovarian
cancer.
C. TAHBSO àit is part of the treatment of ovarian cancer.
D. tumor markers and serial ultrasound
Explanation
It is incomplete question we need to know the age and other features but with the present
scenario I will go with expectant management.

A hypoechoic, thin-walled cyst is a simple cyst. Simple cysts are very likely to be benign in any age group
and resolve spontaneously. Expectant management is an option in patients with benign adnexal masses
such as simple ovarian cysts.

However, if there is any suspicion for malignancy, if the cyst is greater than 10 cm, or if the adnexal mass
is causing symptoms, surgical intervention is warranted. Endometriomas and hydrosalpinges can cause
issues with fertility and surgical intervention is indicated in those instances.

Characteristics suspicious for malignant ovarian masses include:

ACOG
• wall thickening or septations measuring > 3 mm in width
• papillary excrescences
• solid components.

Fertility preservation should be paramount in adolescent patients and premenopausal patients who have
not completed childbearing. This patient desires to maintain fertility and likely has a simple cyst with
minimal symptoms. Gynecologic oncology referral is not warranted unless there is suspicion for
malignancy.

Observation with repeat ultrasound in 6 months is the treatment of choice for asymptomatic simple
cysts and benign-appearing masses measuring up to 10 cm because there is < 1% chance of
malignancy, even in postmenopausal women.

Ultrasound Findings Associated with Malignant vs Benign Adnexal Masses

Benign Malignant

• Unilocular • Irregular solid mass

• Solid components < 7 mm • Presence of ascites
• Presence of acoustic shadows • 4+ papillary structures
• Smooth multilocular < 10 cm • Irregular, multilocular solid tumor > 10 cm
• No Doppler flow • High Doppler flow
.
52.Ectopic pregnancy bhcg of 2000 with Free fluid in the pelvis with peptic ulcer disease on
treatment, how you will treat her ectopic: : (Repeated Q 2021)
A. methotrexate à Contraindicated if peptic ulcer.
B. salpingostomy
C. serial bhcg and observation àfor expectant bhcg should be 200 or less.
Explanation
You should know the indications for expectant and medical and surgical management +the
contraindications of methotrexate use àgo back to 2021 exam

53.Full term unbooked patient given analgesia for labor pain her ctg for the last 90 minutes
showed minimal variability, what your next step:
No options):
Explanation
Normal sleep pattern 20-60 minàif no improvement resuscitation
If she received opioid decreased variability is normal for 1-2 hours,

Loss of variability without decelerations — FHR variability results from oscillatory input by the
parasympathetic nervous system. The new onset of minimal variability (amplitude 0 to 5 bpm)
may occur for several reasons, including [62-64]:

●Fetal sleep cycle - These cycles generally last approximately 20 minutes, but may persist for as
long as one hour. When the fetal sleep cycles are over, moderate variability should return.
●CNS depressants - The most common medications that decrease variability are opioids and
magnesium sulfate. The effect of maternal opioids on FHR variability generally lasts no more
than two hours.
●Fetal hypoxemia
If the FHR pattern had been normal and there are no decelerations, a reasonable approach to
the assessment and management of new onset minimal fetal variability is to make a

Up to
date
presumptive diagnosis of a fetal sleep cycle or the effect of recently administered maternal
medications. Both of these causes warrant expectant management. It is also prudent to
attempt to induce accelerations with scalp stimulation, as the presence of accelerations is
strong evidence of the absence of fetal acidemia at that time [20]. A maternal fluid bolus,
repositioning, and/or maternal oxygen administration are appropriate adjunctive measures
(table 2B), especially in settings in which a benign etiology is less certain, such as coexistent
pregnancy complications associated with uteroplacental insufficiency.

Long-standing loss of variability can be related to congenital or acquired anomalies of the CNS
or heart, or to very preterm gestation [

I think this is the question.

Persistent minimal to absent variability should be concerning for fetal acidemia.

ExplanationBaseline variability changes with fetal sleep and over the course of labor.
During a labor course, it can change from moderate to minimal; however, periods of
minimal variability should be transient. If minimal variability is noted, potential causes
include administration of opioids, magnesium sulfate, fetal sleep cycle, absence of fetal
cortex (ie, anencephaly), or fetal acidemia. If variability changes are thought to be from
opioids, this should improve typically within 1–2 hours. If the variability improves within
20–60 minutes then likely a fetal sleep cycle was occurring. If persistent minimal or
absent variability is noted, then resuscitative measures should be deployed.
When normal fetal heart rate (FHR) variability is present, regardless of what other FHR
patterns are present, the fetus does not have cerebral tissue acidemia because the
fetus can centralize oxygen and the fetus is physiologically compensated. If hypoxia
persists, the fetus will no longer be able to compensate and may have progressive
hypoxia. When this occurs, then fetal heart rate variability decreases until eventually it is
gone. If minimal variability persists with the absence of accelerations, there should be
concern for fetal acidemia.
Answer B: Minimal to absent variability has been ongoing for 4 hours making a sleep
cycle, or response to any opioid unlikely. Given the lack of response to appropriate fetal
resuscitation methods and that vaginal examination shows the patient to be remote
from delivery, a cesarean delivery would be advisable.
Answer C: If there is absence of maternal hypoxia, oxygen administration is not shown
to improve fetal heart tracing and should not be used.
Answer D: There is no evidence to support the administration of glucose to improve
fetal heart tracing.
Answer E: The question stem provides enough information. The patient has had
minimal to absent variability despite interventions, and there was a negative scalp
stimulation test, which is concerning for fetal acidemia. Vaginal examination reveals the
patient is remote from delivery, making cesarean delivery the most feasible option.

54.Primigravida, fully dilated, head is in OA position pushing for the last 3 hours, fetal head
station @ +2, what your next step:
A. allow her to push for an additional hour.
B. cesarean section
C. operative vaginal delivery

55. Patient with triplets’ pregnancy, how to reduce her risk in current pregnancy: (repeated Q
2021)
A. aspirin
B. cerclage
C. progesterone supplement
56. Patient with triplet’s pregnancy asking about first trimester screening for aneuploidy what
to offer: (repeated Q 2021)
A. NT measurement
 Scopology

57.

Scopology

58.
 ‫‪Williams‬‬
‫‪gyne‬‬

‫‪Answer is B it was pre ovulatory estrogen it will cause farming effect.‬‬

‫‪59. Hx of molar pregnancy and the patient took a medication and she has fits. What is the most‬‬
‫? ‪likely drug‬‬
‫‪methotrexate‬‬

‫ﺑﺎﻟﺗوﻓﯾق ﻟﻠﺟﻣﯾﻊ ‪..‬ﺗﺟﻣﯾﻊ اﻻﺳﺋﻠﮫ ﻛﺎن ﻧﺎﻗص ﺣﺎوﻟت اﻓﮭم اﻟﻣطﻠوب ﺑﺎﻟرﻏم ﻣن اﻟﻧواﻗص ‪،‬وﺗﺣري ادق اﻟﻣﺻﺎدر ‪،‬واﻟﺑﺣث ﻋن‬
‫اﺳﺋﻠﮫ ﻣﺷﺎﺑﮭﮫ ﻓﺎﺗﻣﻧﻰ ان ﺗﻛون إﺟﺎﺑﺎت ﻣوﻓﻘﮫ‪،‬و ﻛﺗﺑت ﻓﻲ اﻟﺷرح اﻻﺣﺗﻣﺎﻻت اﻟﻣﻣﻛﻧﮫ ﻻﺗﻧﺳوﻧﻲ ﻣن ﺻﺎﻟﺢ دﻋﺎﺋﻛم وواﻟدي‬