Oral 2007

Topics involved :-
-APH
- DUB
- Abortion
- Vaginal Discharge
- Pap Smear
- IUCD
- Gestational DM
- PolyHydraminous
- Types Of Stitchs In Cervical Incompetence
- DDx Of HyperEmesis Gravidurum

Question 1
1-Thrombophilia ...... effects on pregnancy ?
2- Give 10 indications for laporoscope in OBS/Gyne ?

Answers :-
1- The contact between placenta and maternal circulation is crucial for the
success of pregnancy. Pro-thrombotic changes and thrombosis may interfere
with these processes leading to adverse pregnancy outcomes at any gestational
age preeclampsia, IUGR, placental abruption and some cases of fetal loss and
preterm labor .
2- it is used as therapeutic or diagnostic lap. Tubal sterilization, adhesiolysis, tt
of endometriosis, cystectomy, ectopic tt, hystrectomy, myeomectomy, ovarian
procedures, investigation for recurrent abortions,

Question 2

You are in your clinic , you have a pt complaining of a missed period, she tells
you that she is 8 wks pregnant :
1- what do you ask 4 booking ? (He wants you to start with Hx (detailed), P/E,
investigations )

Answers :-
Focused hX
- obs hx about LMP, EDD, PTL, PROM, IUGR, fetal death, macrosomic baby,
congenital anomalies, PP, PA, PET, GDM, PPH, DVT
-Gyne hx about fibroids, PID, endometriosis, OCP, Lactation, STD medical hx
about DM, HTN, SLE, DVT, thyroid..
surgical, social, past medical hx

Routine investigation for the booking visist:

CBC>> Hb, platelets., bld group and Rh,
Blood sugar anti body screening (kell)
Urine analysis and culx
Rubella titer
Hepatitis screening

Question 3

1- Epithelial lining of the vagina and the cervix ?

2- How to take a pap smear ?
3- wa7deh bel ER and just delivered her baby,,,and immediately sar 3endha
vaginal bleeding how to manage ? ( bedhom a7kelhom that we have to call for
help awwl eshy then try and deliver the placenta ,,,thats it :) )

Answers:-
1- The ectocervix (more distal, by the vagina) is composed of nonkeratinized
stratified squamous epithelium. The endocervix (more proximal, within the
uterus) is composed of simple columnar epithelium.The area adjacent to the
border of the endocervix and ectocervix is known as the transformation zone.
The vagina is St. Seq no keratinized

2- under good privacy the pnt is in lithiotomy position, bivalve speculum is used
to open the canal and then we have 2 methods to take samples:-
a. Conventional Pap—In a conventional Pap smear, samples are smeared
directly onto a microscope slide after collection.
b. Liquid based cytology—The Pap smear sample is put in a bottle of
preservative for transport to the laboratory, where it is then smeared on
the slide.

3- the labor still in progress and the pt. at the 3rd stage of labor, so it is managed
by active management of the 3rd stage of labor, giving oxytocine, and
controlled cord traction.

Question 4

1- OCPs... composition, mechanism of action ?

2- OCPs.... benefits other than contraception ?

Answers :-
1- Composition includes a combination of an oestrogen and progestogen
-MOA: Progestogen negative feedback decreases the pulse frequency of
gonadotropin-releasing hormone (GnRH) release by the hypothalamus, which
decreases the release of follicle-stimulating hormone (FSH) and greatly
decreases the release of luteinizing hormone (LH) by the anterior pituitary.
Decreased levels of FSH inhibit follicular development, preventing an increase
in estradiol levels. Progestogen negative feedback and the lack of estrogen
positive feedback on LH release prevent a mid-cycle LH surge. Inhibition of
follicular development and the absence of a LH surge prevent ovulation.
A secondary mechanisms of action of all progestogen-containing contraceptives
is inhibition of sperm penetration reduce the likelihood of implantation

2- Benefits : used to treat other medical conditions, such as polycystic ovary

syndrome (PCOS), endometriosis, adenomyosis, menstruation-related anemia
and painful menstruation (dysmenorrhea). In addition, oral contraceptives are
often prescribed as medication for mild or moderate acne.[122] The pill can also
induce menstruation on a regular schedule for women bothered by irregular
menstrual cycles or disorders where there is dysfunctional uterine bleeding. In
addition, the Pill provides some protection against breast growth that is not
cancer, ectopic pregnancy, vaginal dryness and menopause-related painful
intercourse.

Question 5
1- Types of abortion ?
2- how to differentiate complete from incomplete ?
3- management of incomplete ?
4- complications ?

Answers :-
1. threatened, missed , complete, inevitable , incomplete, septic
2. mainly by hx and exam.
in INCOMPLETE : of passing of some product of conception, severe
lower abdominal pain after bleeding, poor general condition dilated
cervix, uterine size correct or small of GA.
in COMPLETE: heavy vag, bleeding that has STOPPED MIN FATRA..
lower abd pain that has STOPPED MIN FATRA,, passage of all
conception.. with closed cervix and SMALL uterus for GA.. U.S shows
empty uterus
3. management of incomplete, CBC, blood grouping cross matching, resuscitate
the prn, oxytocin or ergometrin, Evacuation and curettage, post abortion
management
4. hemorrhage, complications of D&C, rh iso immunization, psychological
trauma

Question 6

In the delivery room :

1- How do you monitor the Mother, the fetus and progress of Labor ?
2- What is Bishop Score ?
3- What is Fetal distress ?
4- what are the types of deceleration & the cause of each ?
5- How to manage, if Fully dilated and if not ?

Answers:-
1- partogram
2- is a pre-labour scoring system to assist in predicting whether induction of
labour will be required, and its' parameters are:
Cervical dilation
Cervical effacement
Cervical consistency
Cervical position
Fetal station
3- the term fetal distress refers to the presence of signs in a pregnant woman
that suggest that the baby will be born unwell.
4- Early Deceleration: usually symmetrical, gradual decrease and return of the
FHR associated with a uterine contraction. A gradual FHR decrease is defined
as one from the onset to the FHR nadir of greater than or equal to 30 seconds. In
most cases the onset, and recovery of the deceleration are coincident with the
beginning, peak, and ending of the contraction, respectively . Physiological
cause
Late Deceleration: usually symmetrical gradual decrease and return of the FHR
associated with a uterine contraction. The deceleration is delayed in timing,
with the deceleration occurring after the peak of the contraction. In most cases,
the onset, nadir, and recovery of the deceleration occur after the beginning,
peak, and ending of the contraction, respectively. Due to uteroplacental
insufficiency
Variable Deceleration: abrupt decrease in FHR. The decrease in FHR is
greater than or equal to 15 beats per minute, lasting greater than or equal to 15
seconds, and less than 2 minutes in duration. When variable decelerations are
associated with uterine contractions, their onset, depth, and duration commonly
vary with successive uterine contractions.Due to cord compression
5- fully dilated > Instrumental delivery
not fully dilated > C/S

Question 7

Dysmenorrhea primary/secondary :
1- Difference between primary and secondary dysmenorrhea ?
2- Treatment ?

Answers:-
1.
Primary dysmenorrhea Secondary dysmenorrhea
-Onset within 6 months after -Onset in 20s or 30s, after relatively
menarche painless menstrual cycles in the past
-Lower abdominal/pelvic pain -Infertility
begins with onset of menses and -Heavy menstrual flow or irregular
lasts 8-72 hours -Low back pain bleeding
-Medial/anterior thigh pain -Dyspareunia
-Headache -Vaginal discharge
-Diarrhea -Pain may not be relieved by
-Nausea/vomiting nonsteroidal anti-inflammatory drugs
(NSAIDs)
** Risk factors for Primary
dysmenorrhea ** Risk factors for Secondary
Early age at menarche (< 12 y) dysmenorrhea
Nulliparity Fibroids
Heavy or prolonged menstrual flow Pelvic inflammatory disease
Smoking Tubo-ovarian abscess
Positive family history Ovarian torsion
Obesity Ovarian cysts
Endometriosis
Adenomyosis
Intrauterine device
2. For primary, we start with NSAIDs, secondary we can use Hormonal therapy,

Question 8

DVT in pregnancy :
1- DVT and heparin use ?
2- When to stop and convert on warfarin ?

Answers:
1- Long term therapy by Heparin :-Maintenance dose ( Best given by SC route -
the best is LMWH ,if not available HMWH can be used.
LMWH ; eg Clexane 40mg/once daily
HMWH ; 5000IU /twice daily
-As prophylaxis for thromboembolism during pregnancy
2- we use LMWH, in acute phase and during pregnancy in maintenance if it
occurred during pregnancy, but if after pregnancy for maintenance ,we can use
either warfarin or LMWH
In 36wks we stop warfarin and then continue with HMWH
Important .........Is either by subcutaneous heparin in maintenance dose or by
oral warfarin.
The best is :
If thromboembolism occurs during pregnancy – the best after acute phase
therapy for 2-3 months, is to give S/C heparin in the maintenance dose for the
rest of pregnancy ( in order to avoid side effects of warfarin during pregnancy)
& for 12 weeks postpartum of either S/C heparin or warfarin.
If thromboembolism occurs after delivery – S/C heparin in therapeutic dose for
4 weeks, then either S/C heparin in maintenance dose or oral warfarin , for 3
months.

Question 9

1-How can u decide which way to induce labour ?

2- what are the types of prostaglandins that we use ?
3- what are there trade names ?
4- what is the dose of oxytocin ? for induction ?
5- what the differential diagnosis of low abdominal pain in a female 25 y old
and uses IUCD ? (they wanted ovarian tortion, ovarian cysts comlications,
pelvic inflamatory disease, ectopic pregnancy and appendicitis)
6- what investigations u should do ? (CBC, B HCG, Ultrasound!!)
7- why Ultrasound ?

Answers :-
1- bishop score
2- dinoprostone (PG E2) or misoprostol
3- Cervidil, prostin E2, >> for PG E2 Cytotec>> for misoprostol
4- 0.5 to 2.0 mu/min, increments of 1.0 mu/min to doubling of the dose,
intervals of every 30 to 60 minutes, and a maximum dose ranging from 16
mu/min to 40 mu/min
5- they wanted ovarian torsion, ovarian cysts complications, pelvic
inflammatory disease, ectopic pregnancy and appendicitis
6- CBC, B HCG, Ultrasound, Urine analysis.
7- ultrasound helps in detecting cystic findings, pregnancy confirmation, renal
disorders, it is cheap, non invasive, with good specificity and sensitivity.

Oral 2008
The exam consists of 2 stations, it's like an OSCE exam, in each station the
doctor gives you a scenario and then he asks a question related to this case.

Questions:

*A pregnant lady presented with abdominal pain, how to approach this case?
(history,physical examination, investigations). The patient was found to have
HELLP syndrome.
*A question about hyperstimulation syndrome .
*A case of infertility, what are the points you ask about in history?
*A patient asks about oral contraception and IUCD; efficacy, complications,
indications…
Other topic that were asked :
*A case of vaginal discharge
*A case about instrumental delivery
*A case about amenorrhea
*Hypertensive disorders in pregnancy
*Gestational Diabetes
*Menorrhagia
*Thromboembolic disorders
*Miscarriage
*Ectopic pregnancy
*Contraception
*Ovarian CA
*PID
*Cesarean section
*Poly and Oligohydrominos

Oral 2010
There were 4 circuits , each circuit u enter 2 rooms , each room with 2 drs
my stations were

CIRCUIT 1
1. 42 year old female come to your office diagnosed with menorrhagia
1) defined menorrhagia ?
-menorrhagia is excessive bleeding in amount (>80ml) and/or duration (7 days)
at regular interval
2) what are the causes ?
-obs causes-molar,abortion,ectopic
-gyne causes-polyps,fibroid,laceration,infection(endometritis,cervicitis,PID)
-iatrogenic-IUCD,OCP,tamoxifen
-systemic-cancer,drug(anticoagulant),bleeding disorder,DM,thyroid disease
-DUB

3) what r u going to do for her ?

-CBC,TFT
-U/S
-endometrial biopsy

4) what line treatments you gonna offer for the pt if the biopsy showed
Edometrial Hyperplasia with atypia..
-hysterectomy

5) if she was 18 year old what other modalities of treatment ?

(mostly due to DUB,due to anovulatory cycle)
Non hormonal -anti PG (mefenemic acid)
-anti fibrinolytic (traxenamic acid)
Hormonal -POP
-COCP
-danazol,GnRH analogues

2. a 30's year old female known case of DM

1) counsel her in the per-conceptional visit ?
-take folic acid 3 month before conception
-HbA1c 6.5?
-modification of insulin dose during pregnancy?

2) indication for blood sugar testing in first visit ?

-presence of Dm symptoms(polyuriapolydipsis,polyphagiaketoacidosis,etc..)
-presence of risk factor-advanced age
-past h of DM in pregnancy,macrosomic baby,unexplained IUFD,congenital
anomaliesrecurrent misscarriage
-family hx of DM
-obesity
-hypertension
-recurrent infection
-polyhydramnion

3) complication of DM on both fetus and mother?

FETUS
-macrosomic
-delayed organ maturity(RDS)
-congenital malformation (CNS,CVS)
-caudal regression syndrome
-renal agenesis
-anal atresia
-IUFD,IUGR
-prematurity

MOTHER
-DM complications(DKA,hypoglycemia,retinopathy,neuropathy,peripheral
vascular,rec infection)
-polyhyramnions
-PET
-recurrent miscariage

4) they gave a scenario about 1 hr-OGTT value and what to do next, and
diagnostic 3 hr-OGTT value and what u call it ?
-50g1 hour glucose challenge test(GCT)
-100g, hours OGTT-for patient with abnormal GCT

----------------------------------------------------------------------

CIRCUIT 2
1. DVT :
1) symptoms and signs
-symptoms-pain and swelling in the leg
-signs-increase temp of leg,tender calf muscles,a difference>2cm in
circumference,positive homan?s sign

2) whats the most imp. sign which is SWELLING >3 cm

3) acute phase Tx and long term Tx you should mention the analgesia with your
Tx plan.
-acute phase tx-therapeautic dose of heparin(2 mg/kg/day in 2 diveded doses by
S.C route) for 2-3 days
-long term tx-S.C heparin or oral warfarin for 3 months postpartum

4) a pt with cardiac condition she is pregnant and on warfarin when to stop it

and when to start it again ?
- stop warfarin at 36 wks and start it again after delivery.

2. Dysmenorrhea
1) Primary Dysmenorrhea presentation.risk factors, Tx .
-reassurance,NSAID

2) secondary Dysmenorrhea give 4 causes ?

-endometriosis
-PID
-adenomyosis
-uterine fibroid
-ovarian cyst

3) Endometriosis presentation other than secondary dysmenorrhea ?(mention

4)
-deep dysparunea
-lower abdominal pain
-infertility
-low back pain
-irregular mense
-cyclical hematuria,rectal bleeding,surgical or umbilical pain,hemoptysis

4) whats the Tx options ? ((medical VS. surgical)) .

medical-NSAID,COCP(continuos use),danazol,GnRH analogues
surgery-TAH+BSO (definite tx)

----------------------------------------------------------------------

CIRCUIT 3
1. Interpretation of Pap smear of 25 year old lady that's showed HSIL?
1) what's the criteria of adequate pap smear how to do it?
-adequacy is presence of both endocervical cell(columnar) and ectocervical
cell(squamous cell)
-obtain ectocervical cell by spatula and endocervical cell by cytobrush.

2) serotypes of HPV and what other gynecological diseases caused by that

virus?
-high risk HPV (16,18,31,33,35,...)
-STD(abn vaginal discharge,..),genital wart

3) what do you see in colposcopy?

-acetowhite lesion
-mosaicism
-puntuation

2.hypertensive disorders in pregnancy.

----------------------------------------------------------------------
CIRCUIT 4

1. 28 wk pregnant dx with pyelonephritis

1- mention 4 clinical manifestations
 loin pain
 fever
 chills and rigors
 vomiting
 urinary bladder symptoms
 2- mention 2 findings on urinalysis
 > 10 WBC's in HPF
 > 5 RBC/s in HPF
 presence of bacteria

3- what's the most common micro-organism

 E. coli

4- what antibiotic to give and what's the route of administration

 2nd or 3rd gen of cephalosporin
 intravenous

5- how do you manage recurrent pyelonephritis in pregnancy (2 points)

 renal USS
 prophylactic antibiotics until delivery

6- mention 4 effects of pyelonephritis on the fetus

 miscarriage
 preterm labor
 IUGR
 IUFD

7- when does the effect of pregnancy on the renal system end?

 at 12 wk after delivery

2. Amenorrhea
1- define primary amenorrhea
-absence of menses at the age of 16 regardless of secondary sexual growth
-absence of secondary sexual growth by the age of 14

2- mention 4 possible causes for primary amenorrhea

-Hypothalamus-kallman syndrome,excessive stress,weight loss,exercise
-pituitary-pituitary adenoma,emprty sella syndrome
-Ovaries-gonadal dysgenesis(Turner,etc..),gonadal agenesis
-uterus-mullerian agenesis,androgen insensitivity syndrome
-outflow tract-imperforated hymen,transvaginal septum

3- 15 yr old female with primary amenorrhea and cyclical pain. what's the
most likely dx?
-imperforate hymen

4- what do you know about androgen insensitivity syndrome?

-XY46
-absence of androgen receptor or lack of responsiveness to androgen stimulus
-normal breast,no uterus
-no internal genitalia,female external genitalia
-gonad should be removed,risk of malignancy
 5- what are the clinical features that go with hypothalamic-pituitary-ovarian
axis failure?
-lack of pubertal growth( height,weight,breast)
-poor health
-loss of weight,appetite,stress
-headache,visual field defect,
-fatigue

6- P1, and 8 months amenorrhea.. mention 4 relevant points in the history

-previous cycle
-virilization symptoms
-symptom of increase prolactin,hypothyroidism
-hx of previous pregnancy and delivery,is there any complication(esp bleeding)
-symptom of menopause( hot flushes,vaginal dryness,etc..)
-symptom of excessive stress,weight loss,exercise
-familay history of similar problem

7- how is Asherman's syndrome dx?

-laparoscopy
----------------------------------------------------------------------
station 1:

1. assessment of gestational age, causes for large for gestational age at 14

weeks, multiple pregnancy, risk on the baby and mother...

2. OCP + IUCD
----------------------------------------------------------------------
station 1:

1) define labor?
-labor is defined as regular,painful,progressive uterine contraction leading to
cervical changes and decsend of presenting part

2) cervix dilated 2cm and length 1cm what is the stage of labor is this?
-latent phase of first stage of labour

3) how frequent would you like to do vaginal examination in the 1st stage of
labor? what is the length of the second stage of labor in a primigravida?
-Every 2 to 4 hour
-2 hours ( 3 hours with epidural)

4) give me 2 EARLY sign that would suggest obstructed labor?

-dry vagina
-edematous cervic
-caput,moulding
5) give me 2 things that would delay the second stage?
-secondary uterine inertia
-epidual anesth
-malposition
-narrow pelvis

6) what is the active management of the 3rd stage?

-oxytocin injection after delivery of ant shoulder
-controlled cord traction
-uterine massage

7) CTG with 2 abnormalities mention them? explain those findings?

-tachycardia and decelaration.
-fetal distress

station 2:

1) define primary infertility?

-infertility without any previous conception

2) what are the female factors that cause it?

-HPA-excessive weight loss,stress,exercise
-kallman syndrome
-pituitary diseases
-hyperprolactinemia
-ovualtory-POF,PCOS
-hormonal-thyroid disease,adrenal tumor
-tubal-chronic PID
-uterine-congenital anomalies,endometriosis,fibroid

3) what is the test to know the male factor?

-semen analysis

4) (semen analysis) what shall u advice the male to do before this test?
- 48 hours abstinence,examination within 2 hours

5) where is the best place for it?!!|(bathroom of hospital or home!)

6) what are the investigations for the ovulatory factors?

-Hormonal assay-day 21 serum progesteron
-day 2 LH,FSH,thyroid,prolactin,LH:fsh ratio
-endometrial biopsy
-u/s
-basal body temp

7) what are the normal parameters for normal semen analysis?

-count 15 million/ml
-motility A(rapid progressing),b(slowly),c(immotile),d(dead).
A>32%,a+b>15%
-morphology>4%
-Liquefaction time 20-30 min
-volume 1.5ml
----------------------------------------------------------------------
case 1 . PROM
case 2 . early pregnancy bleeding , ectopic , incomplete abortion & D & C
----------------------------------------------------------------------
first Station

1. about everything in Ovarian Ca.

1) Mention 2 DDX for ovarian mass.
-ovarian cyst(follicular,theca luteal,corpus luteal)
-benign mass(dermoid cyst,serous or mucinous cystadenoma)
-malignant mass(epi,germ cell,sex cord)
2) mention 4 non specific symp for Ov. CA .
-irregular mense
-abdominal enlargement,ascites,bloating
-pelvic fullness,dysparunea
-vaginal bleeding
-urinary,bowel symptoms
3) mention 2 test .
-U/S
-tumor maker
4) Mention 3 hormone Secreting tumor
-granulosa-theca cell tumor
-androgen-secreting tumor
5) Mention 2 complications ...etc

Second Station.

1) 35 wk P3+0 Abd pain + V. Bleeding --> DDX ...

-placenta previa
-placenta abruption
-vasa previa
-show
-local causes
-unknown cause
2) how to differentiate between Placenta abruptio and Previa ??
-placenta previa-painless causeless vaginal bleeding,danger more on
mother,malpresentation,prematurity,C/S
-placenta abruption-painful vaginal bleeding,tender uterus,both harmed,fetal
distress,hypoxia,VD
3) Hx, Ex, complication ?
-PV contraindicated in placenta previa?
4) DIC .. fetal .. how to manage ...etc
-RBC,FFP,cryo,platelet
5) what are the causes of abruptio ..
-PET
-overdistended uterus
-PROM
-trauma
-previous AP
-multipara,advanced maternal age
-short cord
-smoking
-idiopathic
6) mention 5 DDX of abdominal pain in Pregnancy --> Abruption ... pre term
labor ..medical causes, surgical then dr fayez 2ali ..(it was last oral for me)
sho r2yak tetla3 min 3endi o tetkharaj :D i said yalla .. so he told me Allah
m3ak :D.

----------------------------------------------------------------------
type 1 diabetic patient advice her what to do before getting pregnant?
take folic acid 3 month before conception
-HbA1c 6.5?
-modification of insulin dose during pregnancy?

U/S finding in 1 trimester and 2 and what u should look for same patient OCP
other uses, how do they work.
----------------------------------------------------------------------
external:
1)types of abortion
-complete,incomplete,inevitable,threatened,missed,septic

2)how to differentiate complete from incomplete

-complete-severe abd pain,heavy vaginal bleeding with passage of vesicle,then
stop,closed os,empty uterus
-incomplete-severe abd pain,heavy vaginal bleeding and passage of
vesicles,persist,opened os,uterus SGA

3)management of incomplete
-resuscitation
-oxytocin drug
-E&C
-post abortion management

4)d & c kit,complications

-perforation,cervical,vaginal injury,infection,bleeding,adhesion,cervical
incompetence
----------------------------------------------------------------------
dr maher m3ai6a :
1) indication of CS dr 2ymen qatawna
FETAL
-fetal distress
-malpresentation
-cord prolapse,vasa previa
-active HIV,Herpes
-macrosomic

MATERNO-FETAL
-failure to progress
-APH(PA,AP)
-conjoined twin
-perimortem
-placenta accreta

MATERNAL
-repeated C/S (1 classical C/S,>2 LSCS)
-contracted pelvis
-obstructive tumor
-abdominal cerclage
-reconstructive surgery(rupte,myomectomy,colporrhaphy)
-medical condition(cardiac,pulomonary,etc..)

2)side effect and C/I of COCP

-side effect-mood changes,nause,vomiting,weight gain,breast
tenderness,spotting
-C/I-pregnancy,VTE,focal migraine,old age,lactating,active liver
disease,CVS,smoking,unidentified menorraghia,estrogen dependent neoplasm

----------------------------------------------------------------------
Dr Issa & Dr. Fida2a:
32 wk pregnant lady came with leaking fluid, differential
-vaginal dicharge , PROM, Stress incontinence
then management of PROM
-admission,hydration,bedrest,tocolytic,dexamethasone
Do u advise her to breastfeed her baby? Why?
----------------------------------------------------------------------
External examiner:
a hypertensive patient came to the clinic, she's planning to get pregnant and is
concerned her hypertension might affect her baby,
1)talk to her about possible fetal and maternal complications and things she has
to do to have a smooth pregnancy

FETAL COMPLICATION
-IUGR,IUFD
-oligohydramnion
-abruptio placenta
-preterm labour
-fetal distress
-abnormal doppler study

MATERNAL
-headache
-seizure
-visual defect
-pul edema
-RUQ pain
-renal problem
>take antihypertensive drug(methyldopa during pregnancy),salt restriction,fish
oil supplement,vitamins,low dose aspirin(in high risk of developing PET)
2)mention 3 clinics u would like to transfer her to
-nephro, ophthalmo, and cardio

Doc Mu3taz: 65 year old lady came to ur clinic, menopause 15 years ago,
she started having spotting, take a history and mention an important
investigation u would like to order (hysteroscopy and D&C).
----------------------------------------------------------------------
Dr. Ma ba3rafha:
Define labor and mention its stages
-labour is defined as regular,painful,progressive uterine contraction which lead
to cervical dilatation and decend of presenting part
-4 stages

Dr. Rama7i:
Primary amenorrhea, Hx, DDx. And if she has turner, give HRT, ask for IVU
(uro anomalies), and echo (cardiac anomalies),fertility(egg donor)
----------------------------------------------------------------------
Dr. Asma and other Dr. !!!
Thrombophilia ...... effects on pregnancy
-recurrent miscarriage
-preterm labour
-IUGR,IUFD
-PET
10 indications for laproscope in OBS/Gyne
-endometriosis
-PID
-adhesion
-pelvic congestion
-uterine mass
-ovarian mass
-hysterectomy
-myomectomy
-tubal blockage
-endometrial ablation
-bladder support surgery
-uterine suspension
definition Of Normal Vaginal delievery.
----------------------------------------------------------------------
Dr. Dabbas & Dr. Afram
most common presentation of endometrial CA pre & post menopausal
-menorrhagia,PCB,irregular mense,PMB
cause of death in endometrial, ovarian & cervical CA
efrad enak kont fe el s7ra o ma fe 3ndak pregnancy test, y3ni mn el a5er beddo
el
Sx of pregnancy mechanism of nausea & vomiting in pregnancy ...HCG
u r an obstetrician and the resident called u and told u that he has a patient with
labor pains,,, what does labor pains mean.
----------------------------------------------------------------------
Dr maher ma3ay6a..
abdominal pain in a 26 yr old non-pregnant female.. approach Dr qatawneh
pregnancy over IUCD management..
-----------
Dr Fawwaz 5aza3leh and Dr Majed Bata
how can u decide which way to induce labour?? it is Bishop score !!!
what are the types of prostglandins that we use??? what are there trade
names????? PGE2 (prostin)
what is the dose of oxytocin?? for induction
-12ml/hour (2ml/10 min) in 500 ml NS,then doubling every 20 min

what the deferential diagnosis of low abdominal pain in a female 25 y old and
uses IUCD? -they wanted ovarian tortion, ovarian cysts comlications, pelvic
inflamatory disease, ectopic pregnancy and appendicinetis
what investigations u should do?
-CBC, B HCG, Ultrashound!!
why will u use ultrasound??
-to know location of IUCD,to detect any masses
----------------------------------------------------------------------
External examiner....
1. Prerequisites for instrumental delivery...
-enganged
-fully dilated cervix
-term
-known position and presentation
-ROM
-emptied bladder
-effective uterine contraction

2. Late decelerations, definition, drawing, Management...

-drop in FHR after onset of contraction. Due to fetal distress,hypoxia
-management-o2,stop oxytocin,roll patient to the left,further monitoring for
vital sign,good hydration with IV fluid,immediate C/S
Dr.Mo'ataz....
1. OCPs... composition, mechanism of action...
-estrogen and progesterone,POP
-estrogen-centrally acting(inhibit ovulation)
Progesterone-peripheral action(thicken cervical mucus,thinning of endometrial
lining)
2. OCPs.... benefits other than contraception...
-COCP-treat menorrhagia,PMS,irregular mense,endometriosis,functional
ovarian cyst,reduce risk of endometrialCA, ovarian CA,PID,ectopic pregnancy
-POP-in lactation,old age,all contraindication of COCP
----------------------------------------------------------------------
Dr. Issa Semreen & Dr. Feda2:
in the delivery room How do you monitor the Mother, the fetus and progress of
Labor?
-mother( by vital sign,palpation for uterine activity)
-fetus( CTG)
-progress of labour(dilatation,engagement)
What is Bishop Score?-pre labor scoring system to assist in predicting whether
induction of labor will be required.consist of:
-cervical dilatation
-cervical length
-cervical consistency
-cervical position
-station
What is Fetal distress?what are the types of deceleration & the cause of each?
and How to manage, if Fully dilated and if not?
Early decelaration-head compression
Late deceleration-fetal hypoxia
Variable deceleration-cord compression
----------------------------------------------------------------------
Infertile couple ..
How to investigate both ..
-female
Ovulatory factor-hormonal assay(day21 progesterone,day2
FSH,LH,tyroid,prolactin),endometrial biopsy,basal body temp,U/S
Tubal,uterine factor-HSG,hysteroscopy,laparoscopy
-male-semen analysis
Criteria of NL seminal fluid analysis and sample collection optimal conditions ..
-count 15 million/ml
-motility A(rapid progressing),b(slowly),c(immotile),d(dead).
A>32%,a+b>15%
-morphology>4%
-Liquefaction time 20-30 min
-volume 1.5ml

Preterm Rupture Of Membranes ..

----------------------------------------------------------------------
Dr Kameel + Dr Aldabas:
infertility history + investigations bartograph : ta3reefoh bishop score..
----------------------------------------------------------------------
doctor majed ba6a and fawwaz 5aza3leh :
epithelial lining of the vagina and the cervix how to take a pap smear wa7deh
bel ER and just delivered her baby,,,and immediately sar 3endha vaginal
bleeding how to manage? bedhom a7kelhom that we have to call for help awwl
eshy then try and deliver the placenta ,,,thats it :)))
----------------------------------------------------------------------
*Dr. Maher Ma3ay6a
Endometriosis
*Dr. Ayman 8a6awneh:
You are in your clinic, you have a pt complaining of a missed period, she tells
you that she is 8 wks pregnant... what do you ask 4 booking? He wants you to
start with Hx (detailed), P/E, investigations.....

Oral 2011
Station 1:
about ovarian cancer
pt 59 yrs menopause since 7 yrs, presented with abdominal distention, on
u/s has bilateral ovarian mass
Q1) u/s features of malignant ovarian cyst
>>septation, multilocular, bilateral, abdominal mts, ascites,..
Q2) what investigation will u ask for her to cofirm ur dx
>>CT/MRI,tumor marker
Q3) who to know if this pt have benign or malignant cyst
>> by risk malignancy index
Q4) about RMI
>> menopausal state*u/s features * level of ca-125
Q5) if RMI was 500 what means
>> malignant cyst
Q6) which stage is the pt
>> advanced stage
Q7) what is the tt
>> surgery & chemotherapy
Q8) what is 5yr survival
>>10-30%

Station 2:
about instrumental delivery
Q1) indications for instrumental delivery
>> prolonged 2nd stage, maternal distress require short 2nd stage (eg:cardiac
problem), fetal distress in 2nd stage
Q2) 7 prerequisites for instrumental delivery
>> fully dilated cervix,enganged,term,ROM,known position and
presentation,empty bladder,effective uterine contraction
Q3) complications of forceps on mother
>> perineal lacerations, pelvic nerve injury,PPH,infection
complications on fetus
>>skull fracture,cephalhematoma,ICH,facial nerve palsy,trauma to
face,eyes,scalp,asphyxia
Q4) conditions u must use forceps not vacuum
>> preterm, face,breech presentation

Station 4 :
Q1)define normal vaginal delivery
criteria of of NVD
-alive baby
-singleton
-full term
-no NICU,no complication,normal birth weight
-no induction of labour,not assisted by forceps,vacuum

CTG components
-fetal heart heart
-acceleration
-deceleration
-variability
-maternal contraction

define acceleration
-transient increase in fetal heart rate of 15 bpm or more lasting for 15 sec

define deceleration
- transient decrease in fetal heart rate below baseline of 15 bpm or more lasting
for 15 sec

the causes of failure to progress .

-ineffective uterine contraction
-Malpresentation,malposition
-CPD

Q2)
causes for menorraghia
-obs causes-molar,abortion,ectopic
-gyne causes-polyps,fibroid,laceration,infection(endometritis,cervicitis,PID)
-iatrogenic-IUCD,OCP,tamoxifen
-systemic-cancer,drug(anticoagulant),bleeding disorder,DM,thyroid disease
-DUB

options for treatment

Non hormonal-anti PG (mefenemic acid)
-anti fibrinolytic (traxenamic acid)
Hormonal-POP
-COCP
-danazol,GnRH analogues
Surgical-endometrial ablation
-hysterectomy

side effects for mini pills ( progesteron only ) .

-bloating,weight gain
-acne,hirsutism
-post pill amenorrhea
-continuos spotting,PMS,irregular menses
-breast tenderness
-long term-osteoporosis,functional ovarian cyst

And other Question was about ovarian cancer .

Station 5:
60 yo woman post menopausal present with abd. Distention
Q1) what is the likely dx:
-Ovarian Ca.
Q2) What are 5 parameters you look for on US?
-Multilocularity, cystic vs solid, size, bilateral, ascitis.
Q3) What is the most important diagnostic test?
-ca-125.
Q4) What is RMI?
-Risk of Malignancy Index
Q5) How do you calculate RMI?
-ca125 x menopausal score x US score.
Q6) If RMI is 500 what is it most likely and what is its grade
-malignant,grade(3 or 4)
Q7) what is the tt?
-TAH+BSO + chemo and radio.
Q8) What is the survival rate?
-10-30%

Station 6:
Q1) Give 5 indications for instrumental delivery?
-Maternal exhauston
-maternal medical indication to shorten 2nd stage of labor
-Prolonged second stage of labor
-After coming head
-fetal distress.

Q2) Give prerequisites?

- Ruptured membrane
-dilated cervix
-engaged head
-effective contractions
-known position
-empty bladder
-effective utrine contraction
-good analgesia
-exp doctor
Q3) Give immediate complicatons maternal and fetal for forceps
complications of forceps on mother
>> perineal lacerations, pelvic nerve injury,PPH,infection
complications on fetus
>>skull fracture,cephalhematoma,ICH,facial nerve palsy,trauma to
face,eyes,scalp,asphyxia
Q4) Finally give contraindications for vacuum?
-Prematurity, breech or face presentation, or not fulfilling any of the
prerequisites

Station 7:
if a pt came after a C/S with vaginal discharge (not bleeding)
Q1) wt is the Dx?
-PPH
Q2) what are the types?
-Primary & Secondary
Q3) wt are the risk factors for each type?
-primary-5Ts (uterine atony,trauma,RPOC,coagulopathy,uterine inversion)
-secondary- infection,(RPOC)
Q4) what to do at 3rd stage of labor to decrease PPH?
-oxytocin
-CCT(controlled cord traction)
-uterine massage
Q5) it was about cervical tear ?
-manage by continuos,interlocking sutures

Station 8:
showed me a paper with 5 photos of instruments on it
Q1) asked about there names? they were:
-Curette, Cervical Dilators, Uterine Sound, Speculum,
Q2) what are they used for (asked for 2 uses)?
-D&C,insertion of IUCD
Q3) what are the early and late complications of D&C?
-early-perforation,bleeding,cervical and vaginal injury,abdominal cramping
-late-adhesion,infection,cervical incompetence,bleeding

Station 9:
Q1) Name the following instruments (pic):
A- Sims Speculum B- Endometrial curret C- Hegar dilators D- Tenaculum E-
Uterine Sound
Q2) Name 2 procedures in which u would use all or some of them:
- D& C (or E&C)
- IUCD insertion
Q3) Name two steps u would take before u do D&C:
-empty bladder
- bimanual exam
>5 steps while standing-lithotomy position
Sterilization
Draping
empty bladder
bimanual examination
>5 steps while sitting-expose by sims speculum
-catch ant cervic by tenaculum
-acsess direction and depth by uterine sound
-dilate cervix by hager dilator
-evacuate the uterus and take biopsy by curette

Q4) Name 3 long-term complications of D&C:

-Infection
-Asherman's synd
-cervical incompetence
Q5) Name two immediate complications of IUCD insertion:
-perforation
-bleeding

Station 10:
A case of a pt who underwent CS and came 1 week later with vaginal
bleeding.
Q1) Dx ?
-2ndary PPH
Q2)Most probable cause?
-Infection
Q3)What is primary PPH?
-vaginal bleeding in the first 24 hours following NVD or CS. ( he was looking
for something more to add )
Q4)How much blood lost in each?
-NVD- 500cc (mainly 1st 6 hrs) CS- 1000cc (after 24 hrs - 6 wks)
Q5)Most common cause in primary PPH?
-Uterine atony Retained products of conception
Q6)Risk factors for uterine atony
-overdistention abd: multiple gest, multiparous, polyhydraminous, etc..
Q7)Name 4 steps you would do in such pts to decrease the risk of bleeding: (hl2
hoon i answered ino active managemnet of 3rd stage and named them but i
discovered ino the next Q is asking abt them) , so i dont know maybe u should
say: put an IV line, take blood for XM (he nodded when i added this)
Q8)Name 2 steps in the active management of labor:
-use of uterotonics (oxytocin) when delivery of the ant shoulder
-controlled cord traction
Q9) If the cause was a cervical tear, what would be the presentation and
findings?
-bright red blood (i thnk)
-contracted uterus

Station 11:
Preterm labour.
Q1) 7 risk factors of PTL
-infection
-overdistended uterus
-APH(esp placenta abruption)
-Previous preterm
-PROM
-intercurrent illnes(UTI<STD<GBS,etc..)
-trauma
-cervical incompetence

Q2) 3 dDx of PTL( ~acute abd pain)

-placental abruption
-chorioamnitis
-complicated fibroid(red degeneration0
-UTI,gastroenteritis
-constipation

Q3) 2 benefits of tocolytics

-give time for lung amturity
-more time to transfer to specialized care)
Q4) 2 type of steroid used in PTL
-betamethasone (better for neurological development), dexamethasone
Q5) What's the mechanism of action of steroid to promote lung maturity?
-induce production of lung surfactant
Q6) What's the optimal time that we can benefit most from steroids?
-28-32wks

Station 12:
Cervical Intraepithelial Neoplasm
Q1) What's the role of smear cytology in management of cervical cancer?
-For screening
Q2) What's the name of the smear? the types of Pap's smear?
-Pap’s smear (conventional,liquid based)
Q3) What causes cervical neoplasm? types of HPV?
-persistent high risk HPV infection
-16(most common),18,31,33,35,
Q4) 3 modalities of treatment of ASCUS
-expectant management
-ablation
-incision( if persist more than 2 years)
Q5) 3 indications to do cone incision
-colposcopy is unsatisfactory
-ECC positive for high grade lesion
-punch biopsy shows microinvasive carcinoma
-any discrepancy b/w pap smear and punch or colposcopy

Station 13
post menopausal with ascitis + bilateral ovarian masses
Q1) most probable dx
-ovarian cancer
Q2) US maligancy signs ?
- Multilocularity, cystic vs solid, size, bilateral, ascitis.
Q3) RMI
- ca125 x menopausal score x US score.
Q4) suppose RMI is 500 ? how to treat?
-TAH+BSO + chemo
Q5) prognosis ?
-around 30 percent bcz of late stage
Oral 2012

Question 1
A 16 year old female patient complaining of severe pain during menstruation
that disable her to go her school :

1- What do you call this complain?

2- What are the types of dysmenorrhea ?
3- What is the different between these types?
4- How do you approach this patient ?
5- What is the cause of pain in primary dysmenorrhea ?
6- What type of dysmenorrhoea most likely she has ?
7- What investigation you will request ?
8- And Why ?
9- How do you manage her ?
10- By which drugs ?
11- What is the most effective drug in primary dysmenorrhoea ?

Answers:-
1- Dysmenorrhoea .
2- Primary and secondary .
3- Primary is physiologic and secondary is associated with organic disorder .
4- Hx and PE Hx of pain, and associated symptoms .
5- Prostaglandin release, myometrium ischemia , and OVULATION (Dr. was
looking for this) .
6- Primary .
7- Nothing .
8- It is physiologic .
9- Relieve her symptoms .
10- Pain killer, anti-spasmodic drugs .
11- Combined oral contraceptive pills .

Question 2
A pregnant in her 27th wk of gestation presented to the clinic with SOB her Hb
is 7 :
1- Take a proper Hx ?
2- What's you Dx ?
3- How to confirm IDA ?
4- How to differentiate between IDA and Thalasemia by Hx ?

Answers :-
1-Ask about sign and symptom of anemia...ask about iron supplement...ask
about ?
2-IDA
3-cbc...ferritin and iron level
4-ask about splenectomy....family hx....bd transfusion

Question 3
A 25 year Female presents with vaginal bleeding after intercourse :
1- How do you approach her ?

Answers:-
Notes: the case was about Cervical Ectropion. Don’t forget to ask about using
combined contraceptive through your history & Pap smear too. Also if you are
asked about what kind of patient we use brush type pap smear not the spatula
one? The answer is Postmenopause woman because the transformation zone
goes inside due to estrogen deficiency. I was asked too about the mechanism of
ecropion formation .
Question 4
Vaginal discharge :

1- Approach(Hx,PE, Ix)

Answers:-
Main point from history
1) Patient Profile : Age, parity, marital status ,If married -ask duration
2)Analysis of vaginal discharge - amount, colour, w/o malodorous smell,
consistency either like cottage cheese
3)Associated symptom - itching ,pelvic pain, vaginal bleeding
4)Past obstetric - previous first trimester miscarriage(BV is a risk factor for this)
5)Past gynaecological
-menstrual cycle (duration, amount, w/o dysmenorrhea )
-past hx of STD, PID
-sexual intercourse activity (early age of first intercourse ,sex during
menses, oral sex, with new/multiple partner, sex with female partner )
-vaginal douching
-contraceptive method (IUD, pill, vaginal spermicides)
6)Past medical , surgical & drug
-Undiagnosed/ uncontrolled DM
-prolonged used of steroid
- Antibiotic
7)Social
-Habit of wearing tight cloth, panty hose

Examination
-excoriation of vulva
-erythematous with patches of adherent cottage cheese like discharge
Investigation
1)wet mount (0.9% normal saline )
pus and clue cell : suggestive of BV
pseudohyphae/hyphae with budding of yeast : candida vaginitis
flagellated trichomonas : trichomonas vaginalis

2)Whiff test (10% KOH)

malodorous fishy smell : BV

Question 5
Antenatal Care :
1- Define booking visit ?
2- What should u do in booking visit ?
3- After NVD low risk mother and everything is fine , what u are going to tell
her
4- What do u know about breast feeding ?
Answers:-
1-First visit to antenatal clinic
2- Take full history
-Do full physical examination (general & obstetric examination & sometimes
pelvic examination is done when indicated ; speculum & DVE)
-Ultrasonic estimation of EDD (CRL in 1st trimester , BPD,HC,AC, & FL in
2nd trimester )
-Routine Lab test (Hb, Platelet count, Blood group & Rh, urine analysis ,Blood
sugar , Hepatitis screening )
** There is a few test that routinely done but according to which country you
work at such as VDRL(venereal disease research laboratory test for syphilis),
HIV screening and pap smear
3- To have regular check up once per month till GA: 27th w ,twice per month
(GA : 28- 36th w) and weekly visit starting from 36th w gestation.

4- 3 advantages of breast feeding :

(1) Ideal food for newborn , inexpensive and usually in good supply
(2) Nursing accelerates the involution of uterus
(3) Has immunologic advantages for baby
- Breast milk consist of two components which are colostrum( secreted 2nd day
after delivery, its content mostly protein, fat, minerals, secretory IgA) and
mature milk (secreted after 3-6 day after delivery mainly consist of
protein,lactose, water, fat )
- Breast milk is unique compared to cow’s milk because it contents major
protein which are synthesized by human (casein, lactalbumin & β-
lactoglobulin), also a source of omega-3 fatty acid
- 3 complications of breast feeding
(1) Cracked nipple
(2) Mastitis
(3) Drug passage to newborn

Question 6
APH :
1- (define, Hx, exam) ?
2- What about the vaginal examination ? if no or contraindicated he asked ,
WHY ?
3- When to deliver this pt ?

Answers :-
1-Definition APH : Vaginal bleeding occurring after 24 weeks gestation
-History :
Patient profile : Age, parity , blood group, Rhesus
Analysis of bleeding : Duration, amount, color, clots
Association : abdominal pain, back pain, uterine contraction, vaginal
discharge, fetal movement
Symptoms of anemia : drowsiness, postural changes, palpitation, fainting
History of current pregnancy :-
 LMP
Booking visit , regular ANC
Hx of early pregnancy bleeding,polyhdramnios, ROM
Previous documentation of placental site
Past obstetrical Hx : previous APH, C/S , IUGR baby
Past gynaecological hx : uterine anomaly
Past medical, surgical & drug Hx :
Chr illness - HTN, bleeding tendency
Hx of blunt abdominal trauma
Anticoagulant , aspirin used
-Physical examinations :
General condition & VS
BP & pulse(lateral &standing position)
Pallor
Sign of shock (restless, cold, clammy extremities, poor skin
perfusion
Abdominal examination
SFH
Tenderness, tightness, uterine contractions, fetal part (couvelaire
uterus)
2- PV is C/I before ruling out placenta previa
3- Deliver this pt when she is at 37th gestation (placenta previa ) , in active
bleeding, fetal distress

Question 7
A case of primary PPH
1- What's the cause ? "step by step you'll reach a cervical tear"
2- How to Mx ?

Answers :-
1-Causes of primary PPH (4T & UI)
Tone -uterine atony
Trauma - on maternal genital area
Tissue - retained placenta
Thrombosis
Uterine Inversion
2-Management
-Uterine Atony
✓ Rapid continuous Oxytocin infusion (40-80 u IV in 1L NS)
✓ Massage the uterus till the medication taken start working
✓ If still atonic with placental site bleeding >Ergonovinemaleate/
Methylergonovine IM
-Genital trauma
✓ Surgical evacuation
✓ Search for the bleeding artery & ligation
(absorbable continuous interlocking stitch )
-Retained product of conception
 ✓ In profuse bleeding : manual rapid removal of placenta & check for
complete removal of placenta
✓ If there is no bleeding : wait 30 minutes to allow spontaneous
separation
✓ If there is suspected missing placental pieces, do exploration &
removal
-Uterine Inversion
✓ Immediate IV volume expansion with crystalloid (pt rapidly goes
into shock)
✓ After stable, remove placenta & replace the uterus
✓ If failed, give IV nitroglycerin (100mcg)
✓ Replace again (Johnsons method/balloon pressure)& once
replaced, give oxytocin infusion
✓ Surgical intervention needed if all attempt failed

Question 8
HRT:
1- Definition ?
2- Types ?
3- Use of each type ?
4- Symptoms of menopause how to Mx ?

Answers :-
1-Definition of HRT : postmenopausal hormone therapy which is recommended
for short term management of moderate to severe vasomotor flushes.
2-Types :
Combined, continuous conjugated estrogen and progesterone
Un-opposed estrogen ( hystrectomised pt)
3-Uses : for short term menopausal symptoms & disease prevention
4- Symptoms of menopause
Short term : Hot flashes, insomnia, labile mood, anxiety, loss of
concentration, poor memory, joint aches, dry itchy skin, hair changes,
decreased sexual desire
Intermediate : urogenital atrophy, vaginal dryness and soreness, stress
incontinence, recurrent UTI , skin collagen loss, urogenital prolapse,
dyspareunia
Long term (disease ) : osteoporosis, dementia, cardiovascular disease ,
colon cancer---

Question 9
A 25 yr old primigravida complaining of spotting vaginal bleeding ( threatened
abortion ) :
1- Hx ?
2- Ddx ?
3- Investigations ?
Answers :-
1-History
Patient Profile : age, parity, marital status, occupation
History of current pregnancy
-LMP (sure of date, regular, amount, duration,contraceptive,
lactating)
-Parity
-How pregnancy was diagnosed
-Spontaneous / assisted pregnancy
-Symptoms of pregnancy (subsiding/exaggerated)
Analysis of complaint(bleeding)
-onset, duration, pattern, amount, color
-Severity (symptoms of anemia, impact of life)
-Passage of tissue or vesicles
-Relieving and aggravated factors (sexual intercourse)
-Associated with abdominal pain (analyze SOCRATES)
-Other associated symptoms : Dizziness, SOB, LOC, fever, vaginal
discharge, dyspareunia, urinary Sx, constipation,PCB
Review of system
-Thyroid symptoms (GTN mimic hyperthyroidism)
Past obstetric hx
-Each pregnancy delivery date, GA at delivery, type (CS/NVD)
outcome, APH/PPH complication, duration of lactation
-Hx of abortion (documentation, GA, place, fetal anomalies,
post abortion bleeding or infection, induced/spontaneous abortion
Past gynaecological hx
-contraceptive used(IUCD/tubal ligation)
-Hx of PID, IVF, tubal reconstruction
-Hx of ectopic pregnancy
-PCB, dyspareunia
-Last pap smear done
Past medical & surgical Hx
-Chr illness : DM, hypothyroid, bleeding disorder
-Hx of pelvic surgery
-Blood transfusion
Drug Hx
-warfarin, heparin, aspirin
Family hx
-Hx of endometrial , cervical, ovarian CA
Social hx
-smoking
-alcohol
2-Differential diagnosis
Obstetrical causes
-Miscarriage
-Ectopic pregnancy
-Molar pregnancy
 Gynaecological causes
-vaginal laceration, infection, cervical polyp, fibroid
Systemic causes
-Drugs induced
-Bleeding disorders
-Cancer
3-Investigations
-Ultrasound ( TVUS/TAUS)
-Biochemical evaluation - CBC(Hb), serum β-hCG, Progesterone

Question 10
Ectopic pregnancy and postmenopausal bleeding

Question 11
Station about Threatened abortion & Rh iso ?

Question 12
Case 30 wk gestation came with abdominal pain :
1- how do u approach Hx ?
2- differential ?
3- what r the possible causes of PTL in the Hx ?
4- On P/E, if large what is the cause other than multiple and poly ?
5- What next ?
6- Is it necessary to do PV, and can't it be enough to assess the cervical changes
with the speculum ?

Answers:-
1- Hx, PE and Investigations
2- Differential Dx :
Obstetric cause - Labor, abruptio placenta , chorioamnionitis, severe
polyhdramnios
Gynaecological cause - Complicated ovarian cyst, Red degeneration of
fibroid
Surgical cause - Acute appendicitis, cholecystitis, pyelonephritis, gastritis
Medical cause - UTI, IBS , FMF, sickle cell crisis,
3- Multiple pregnancy, polyhydraminos, chorioamnionitis, previous PTL,
previous abortions,
4- Fibroid .
5- Pelvic exam inspection speculum and PV .
6- ?

Question 13
What do u know about cervical smear ? "everything"

Question 14
1- Approach to 41 wks pregnancy , hx, examination ,what to do what u found
on US
2- Every thing about induction of labor ?
3- Everything about breech presentation ?
4- Everything about ECV ?

Question 15
Atrophic endometritis :
1- Approach to 60 year female 10 years postmenopause with vaginal bleeding ?
2- After taking hx , examination , us , what is ur treatment ?
3- What type ?
4- What COCP?
5- What do u call this type of COCP ?

Answers:-
1- History
Patient Profile
Analysis of complaint
-Duration
-Amount of bleeding(#pad soaked)
-Previous similar attacks
-Relation to sexual activity
-Associated : pelvic pain, vaginal discharge, urinary complaints
weight loss
Gynaecological hx
-Age of menopause
-Last cervical smear done
-Previous gynaecological operations
-IUCD
Past medical, surgical & drug Hx
-Hx of breast cancer
-Use of HRT , tamoxifen , anticoagulant
-Examination
General - malignancy sign (cachexia, lymphadenopathy , abdominal
masses, ascitis, lower limb edema )
Pelvic
Inspection of vulva & urethra
Speculum examination of cervix & vagina (local causes& sign of
atrophic vaginitis which include dryness,pallor, thin appearance
of mucosa & loss of mucosal rugae )
Bimanual examination of uterine size & adnexal masses
-Investigations
U/S : to assess endometrial thickness , if >4mm is suspicious
Hysteroscopy guided endometrial biopsy (thickness>4mm)
Cervical smear
2- HRT.
3- Combined, continuous conjugated estrogen (0.625mg) &
medroxyprogesteroneacetate(MPA 2.5mg) because she still has her uterus .
4- Monophasic .
5- Non bleeding

Question 16
Stations about :
1. placenta abruption
2. ectopic pregnancy
3. Contraception

Question 17
1-What's the definition of ectopic pregnancy ?
2- What are the risk factors ?
3- What are the commonest sites ?
4- How you treat it (surgically & medically) ?
5- Compare between the 3 surgical procedures ?
6- What's menorrhagia ?
7- What's the differential diagnosis ?
8- What's endometriosis?
9- How they present usually ?
10- What's adenomyosis ?
11- What's fibroids ?
12- The commonest site of fibroids to cause menorrhagia ?
13- How do you treat fibroids medically ?

Answers :-
1- Definition of ectopic pregnancy : Pregnancy that is implanted outside the
uterine cavity
2- Risk factor of ectopic pregnancy
Tubal abnormalities (diverticulae, false passages,endosalphingitis)
Assisted reproduction
Endocrine disorders
Use of Contraceptive (minipill, IUCD, tubal ligation)  failure
Previous hx of ectopic pregnancy
Hx of PID, endometriosis
3- Commonest site of ectopic pregnancy : Right ampulla of fallopian tube
4- Treatment :
Medical therapy : Methorexate (criteria : size< 4cm, β hCG serum<
5000mIU/ml, no fetal heart beat,reliable for follow up )
Surgical therapy : Laparoscopy
5-
6- Definition of menorrhagia : Subjectively as excessive, prolonged and regular
menstrual blood loss and objectively as MBL of 80ml or more.
7-Differential diagnosis of menorrhagia
Dysfunctional Uterine Bleeding (60%)
Organic menorrhagia (40%)
-Genital causes
 • Uterine : submucosal fibroid, endometrial
hyperplasia/CA
• Adenomyosis/ endometriosis
• PID
• Cu releasing IUCD
• Theca & granulose cell tumours of ovary
-Systemic causes
• Thyroid disorder : Myxedema
• Drugs : AntiCoagulant, aspirin, tamoxifen
• Blood disorder : ITP, def of coagulation factors, Von-
Willebrand’s disease, Glanzman disease
• Liver failure
8-Definition of endometriosis : Presence of endometrial tissue outside
endometrial cavity
9-Presentation of endometriosis
Often discovered incidentally .
According to site :
Female reproductive tract
-infertility
-dysmenorrhea
-lower abdominal and pelvic pain
-dyspareunia
-accident to endometriotic cyst
-low back pain
-menstrual irregularity
Urinary tract
-Cyclical hematuria/dysuria
-ureteric obstruction
GI tract
-Dyschezia
-cyclical rectal bleeding
-intestinal obstruction
Surgical scar & umbilicus
-cyclical pain & bleeding
Lungs
-Cyclical hemoptysis
-haemopneumothorax
10-Definition of adenomyosis : Endometrial glands deep within the
myometrium
11- Definition of fibroid - Leiomyomas are well-circumscribed benign uterine
tumors
12-Commonest site of fibroid causing menorrhagia : Submucosal fibroid
13-Medical treatment of fibroid : LHRH analogue (short term )

Question 18
3rd stage of labor :
1- How would you give the oxytocin?
2- How long it takes to start its action?
3- Give it WITh or AFTER delivery of the anterior shoulder ?

Answers :-
1- 10IU of Oxytocin ,IM
2-Within 3-5 minutes
3-AFTER

Question 19
Pregnant 32 weeks, presented with abdominal pain :
1- How would u approach her?
**answers similar to Question 12**

Question 20
HELLP syndrome : (all things from presentation till treatment)
1- options of treatment for 31 wks with HELLP syndromes ?

Answers :-
1-Management :
Stabilization & delivery regardless of GA
Dexamethasone ; 10mg IV every 12hours
Transfusion if platelets are 20,000(C/S) or 50,000(vaginal delivery)

Question 21
Vaginal discharge : ( history+exam+investi+treatment )
7 year old female with vaginal discharge :
1- Ddx ? ( F.B , infections but NOT candida )
2- Tx ? (antibiotic + estrogen )
**Answers are similar to Question 4**

Question 22
Hypertensive disorders in pregnancy

Question 23
About OCP & IUCD

Question 24
Early pregnancy bleeding

Question 25
PROM

Question 26
Indication of CS ?
 Answers :

Fetal Materno-Fetal Maternal

Category III Fetal Heart Failure to progress in Repeated CS

Rate Tracing
Scalp pH <7.2 , severe
bradycardia
Malpresentation
(Breech, transverse,
Brow..etc)
Cord prolapse and Vasa
Previa
Human Immunodeficiency
Virus
Active herpes virus
Congenital anomalies
Macrosomia
>5 kg in nonDiabetic
>4.5 kg in Diabetic
labor:
Arrest of descent or
dilatation
Placental Abruption
Placenta Previa
Conjoined twins
Perimortem
Placenta Accreta
Esp Classical CS
>1 low transverse
Contracted pelvis
Obstructive tumors
Abdominal cerclage
Reconstructive surgery ie.
Rupture, myomectomy,
colporrhaphy
Medical conditions (e.g.,
cardiac, pulmonary)

Question 27
A hypertensive patient came to the clinic, she's planning to get pregnant and is
concerned her hypertension might affect her baby :
1- Talk to her about possible fetal and maternal complications ?
2- Things she has to do to have a smooth pregnancy ?
3- Mention 3 clinics you would like to transfer her to ?

Answers:-
1-
Fetal complications Maternal complications
-oligohydramnios -eclamptic seizure
-Fetal distress -ICH
-IUGR -pulmonary edema
-Abruptio placenta -myocardial dysfunction
-IUFD -acute renal failure due to vasospasm
-proteinuria > 4-5g/d
-hepatic swelling w/o liver dysfunction
-DIC
2-After she conceives:
Routine ANC for BP assessment & protein in urine
Should be counselled to seek care urgently if she has any symptoms of
preeclampsia
PET profile (platelet count, 24 h urine collection, LFT, KFT ) if pt shows
symptoms or signs of preeclampsia
3- nephro, ophthalmo, and cardio(for ventricular hypertrophy)

Question 28
65 year old lady came to your clinic, menopause 15 years ago, she started
having spotting :
1- take a history ?
2- mention an important investigation you would like to order ?

Answers:
1- History
Patient Profile
Analysis of complaint
-Duration
-Amount of bleeding(#pad soaked)
-Previous similar attacks
-Relation to sexual activity
-Associated : pelvic pain, vaginal discharge, urinary complaints
weight loss
Gynaecological hx
-Age of menopause
-Last cervical smear done
-Previous gynaecological operations
-IUCD
Past medical, surgical & drug Hx
-Hx of breast cancer
-Use of HRT , tamoxifen , anticoagulant
2- Investigations : Ultrasound ,hysteroscopy guided biopsy, cervical smear

Question 29
Primary amenorrhea :
1- Hx ?
2- DDx ?
3- If she has turner,what will you give her ?
4- what is the most 2 important investigation ?

Answers :
1-History :
Patient Profile : Age, occupation(athlete)
Developmental hx : Childhood growth & development, Ht & wt chart,
Age at thelarche
Gynaecological hx :
 -Age at menarche / LMP / Duration / flow
- Cyclical symptoms : to r/o outflow obstruction
(breast tenderness, mood changes, lower abdominal pain, bloating)
-Sexual hx
-Menopausal symptoms
Systemic Review
-General : wt changes
-Focused :
1)Hypothyroidism : lethargy,wt gain,cold intolerance
2)Hyperandrogenism : hirsutism, acne, virilism
3)Hyperprolactinemia : galactorrhea
4)Kallmann syndrome : anosmia
Past medical & surgical Hx : chr illness, medications, previous operations
Family hx : Age at menarche/premature menopause
Social hx : Exercise & diet
Psychological hx : Stressful events

2-Differential Diagnosis :
Anatomical cause : Vaginal agenesis, Vaginal septum, Imperforate
hymen, Mullerian agenesis
Hormonal cause : Complete androgen insensitivity, gonadal dysgenesis
(Turner syndrome) ,Hypothalamic pituitary insufficiency
3- HRT .
4- IVU (uro anomalies) , and echo (cardiac anomalies).

‫يون ج ِهلَت‬
ُُ ‫ع‬ ُ ِ ّ‫داخلي في ما الن‬
ُ ‫اس‬
ُُ‫فو َجدت‬ َ ‫بصيرا بالفُؤا ُِد ربّي‬
ُُ ‫سافر ال ُح‬
‫زن أيّها يا‬ ُُ ‫دَمي في ال ُم‬
‫دعني‬, ‫أسيرا يكون لن فقلبي‬
‫معي ربّي‬, ُ‫إذن أخشى الذي ف َمن‬
‫ِن ربّي مادام‬ ُُ ‫التدبيرا يُحس‬
‫قرآنه في قال قد الذي وهو‬
‫ونَصيرا هاديًا ِب َربّك وكفى‬