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1. A 28-year-old patient complains of infertility. The patient has been married for 4 years, has regular sexual life and does not use contraceptives but has never got pregnant. Examination revealed normal state of the genitals, tubal patency. Basal body temperature recorded over the course of 3 consecutive menstrual cycles appeared to have a single phase. What is the most likely cause of infertility?

Explanation

2. A 28-year-old patient has been taken to a hospital for acute pain in the lower abdomen. There was a brief syncope. The delay ofmenstruation is 2 months. Objectively: the patient has pale skin, AP- 90/50 mm Hg, Ps- 110/min. Lower abdomen is extremely painful. Vaginal examination reveals uterus enlargement. There is positive Promtov’s sign. Right appendages are enlarged and very painful. Posterior vault hangs over. What is the most likely diagnosis?

Explanation

An ectopic pregnancy occurs when implantation takes place outside the walls of the uterus; in most cases it occurs in the fallopian tubes (tubal pregnancy). The patient presents with a history of missed periods for about 2 months (an early sign of pregnancy). Typical signs include pelvic and severe lower abdominal pain, mass present in the uterine appendage ( adnexa). Notice that on examination, the patient presents with enlarged and very painful uterine appendages on the right side which confirms a right-sided tubal pregnancy.

 Right ovary apoplexy refers to the rupture of the ovary, it presents with severe pain, bleeding into the abdominal cavity and signs of irritation of the peritoneum.

 

The inflammation of the uterine appendage, particularly on the fallopian tubes is the disease called Salpingo-Oophoritis. It develops when staphylococci, streptococci, colon bacilli, gonococci, tubercle bacilli or other pathogens enter into fallopian tubes and the ovaries.

3. A 58-year-old female patient came to the antenatal clinic complaining of bloody light red discharges from the genital tracts. Menopause is 12 years. Gynaecological examination revealed age involution of externalia and vagina; uterine cervix was unchanged, there were scant bloody discharges from uterine cervix, uterus was of normal size; uterine appendages were not palpable; parametria were free. What is the most likely diagnosis?

Explanation

4. Full-term pregnancy. Body weight of the pregnant woman is 62 kg. The fetus has the longitudinal position, the fetal head is pressed against the pelvic inlet. Abdominal circumference is 100 cm. Fundal height is 35 cm. What is the approximate weight of the fetus?

Explanation

 

In recent studies, the value of abdominal girth ( belly circumference) and fundal height ( length from the mother’s uterus to the top of the pubic symphysis) can be used in predicting the weight of a baby. This method is used in order to quickly determine low birth weight babies. It is done by multiplying  the belly circumference by the fundal height; giving you the predicted weight in grams (g), (divide by 1000 for the value in kg). Ie, 100x35= 3500g or 3.5kg.

5. A newborn’s head is of dolichocephalic shape, that is front to back elongated. Examination of the occipital region revealed a labour tumour located in the middle between the prefontanel and posterior fontanel. Specify the type of fetal presentation:

Explanation

6. A 30-year-old multigravida has been in labour for 18 hours. 2 hours ago the pushing stage began. Fetal heart rate is clear, rhythmic, 136/min. Vaginal examination reveals the completecervical dilatation, the fetal head in the pelvic outlet plane. Sagittal suture in line with obstetric conjugate, the occipital fontanel is near the pubis. The patient has been diagnosed with primary uterine inertia. What is the further tactics of labour management?

Explanation

UTERINE INERTIA  (“Failure to progress”, hypotonic uterine dysfunction) describes lack of progressive cervical dilatation and/or descent of the fetus.  It is such a condition in which uterine contractions strength, duration and frequency are inadequate, that’s why cervical effacement, dilation and fetal descending is slower than in normal labor. Since the baby’s head is already in the pelvic outlet plane and cant proceed further due to inadequate contractions, an outlet forceps is used in assisting delivery.

 

Cesarean session in cases of breech or fetal distress.

7. During her first visit to the prenatal clinic a pregnant woman was referred to other doctors for mandatory consultation. The patient was referred to:

Explanation

8. On the 2nd day of life a full term boy developed mild jaundice of skin and mucous membranes, the general condition of the child is normal. Blood test results: indirect hyperbilirubinemia 120 mmol/l. The child’s blood group is A(II) Rh(+), his mother’s blood group - B(III) Rh(+). What is the doctor’s tactics of choice?

Explanation

Notice that the Rh group of both mother and child are the same. This Proves that the increased unconjugated bilirubin is NOT due to Rh incompatibility. This baby is having PHYSIOLOGICAL JAUNDICE; a condition characterised by a high level of unconjugated bilirubin within the first week of life. Mild infant jaundice often disappears on its own within two or three weeks. Moderate and severe  cases are often treated with phototherapy, intravenous immunoglobulin etc. In this case, mild jaundice is experienced therefore, no  drug therapy is needed.
9. A 28-year-old patient complains of profuse, painful and prolonged menstruation. Before and after the menstrual period there is spotting lasting for 4-6 days. Vaginal examination reveals that the uterus is enlarged corresponding to 5-6 weeks of pregnancy, has limited mobility, is painful. Appendages are not palpable. On the 15th day of the menstrual cycle, the uterus was of normal size, painless. On account of stated problems and objective examination the patient has been diagnosed with internal endometriosis. Which drug should be used for the effective treatment of this patient?

Explanation

Endometriosis is a condition in which the tissues lining the endometrium grow outside the uterus in places such as the fallopian tubes, ovaries, etc. It is usually accompanied by intense pain, dysmenorrhea ( painful periods), painful intercourse, excessive bleeding - most of which are seen in the patient described above. Groups of drugs used in treatment of this pathology include: Hormonal contraceptives, Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists, progestin or combination hormonal contraceptive. 

Duphaston (dydrogesterone) is a progestin ( progesterone)  indicated in endometriosis, infertility, premenstrual syndrome etc 

Synoestrolum is a non steroidal estrogen indicated in breast and prostate cancer.

 

Parlodel (Bromocriptine) is used in hyperprolactinemia.

10. A 40 week pregnant secundipara is 28 years old. Contractions are very active. Retraction ring is at the level of navel, the uterus is hypertonic, in form of hourglass. On auscultation the fetal heart sounds are dull, heart rate is 100/min. AP of the parturient woman is 130/80 mm Hg. What is the most likely diagnosis?

Explanation

Hysterorrhexis is the violation of uterus integrity in any part during pregnancy or delivery ( the rupture of the uterus). hysterorrhexis during pregnancy can be explained by inconsistency of the presenting fetal part dimensions with the dimensions of the mother's pelvis. If there is an obstacle to fetus expulsion, rapid birth activity develops, the superior uterine segment contracts more and more,the fetus gradually moves into the thin-walled stretched inferior segment. It's super distension and rupture happen especially easily if the uterine neck has not moved behind the fetal head and is jammed between it and a pelvic wall. At that, the contraction ring reaches the level of the navel; the uterus acquires the form of an hourglass. If birth activity is pro- longed, super distension and thinning of the inferior reaches the highest level, its rupture takes place.

 

In the case where the rupture has already occurred, the clinical presentation is conditioned by uterine wall integrity violation, blood vessel rupture, hematoma/bloody appearance in the myometrium.

11. A baby was born by a young smoker. The labour was complicated by uterine inertia, difficult delivery of the baby’s head and shoulders. The baby’s Apgar score was 4. Which of the following is a risk factor for a spinal cord injury?

Explanation

 

Recall that the spinal cord is connected to the brain via the brainstem. During delivery, injury to the spinal cord/brainstem is likely to occur during expulsion of the head and shoulders of the baby. Apgar score refers to  a rapid method for assessing a neonate immediately after birth and in response to resuscitation. Elements of the Apgar score include color, heart rate, reflexes, muscle tone, and respiration. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score seven or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered great.

12. A 37-year-old patient complains of acute pain in the region of genitals, swelling of the labia, pain when walking. Objectively: body temperature is 38, 7oC, Ps- 98/min. In the interior of the right labia there is a dense, painful tumour-like formation 5,0x4,5 cm large, the skin and mucous membrane of genitals is hyperemic, there are profuse foul smelling discharges. What is the most likely diagnosis?

Explanation

Bartholin's glands are located at the openings of the vagina (left and right sides). The Bartholin’s glands are on each side of the vaginal opening. They’re about the size of a pea. They make fluid that keeps the vagina moist.

Acute bartholinitis is a disease usually seen in women in the period of genital activity. Its occurrence in a prepubertal child is an extremely rare event. Bartholinitis is an inflammation of Bartholin’s gland (large gland of vaginal vestibule). It may be caused by Staphylococcus, E.coli and N. gonorrhoeae.. There can be serous, serous-purulent, or purulent inflam­mation. It can manifest as acute, painful unilateral labial swelling, Dyspareunia, Pain with walking and sitting. 

 

Bartholinitis and bartholin cyst are used interchangeably but most cysts are caused by the blockade of the ductal path of the gland leading to an accumulation of its contents. Patients with cysts may present with painless labial swelling.

13. A 10 week pregnant woman was admitted to a hospital for recurrent pain in the lower abdomen, bloody discharges from the genital tracts. The problems turned up after ARVI. The woman was registered for antenatal care. Speculum examination revealed cyanosis of vaginal mucosa, clean cervix, open cervical canal discharging blood and blood clots; the lower pole of the gestational sac was visible. What tactics should be chosen?

Explanation

This is a case of retained product of conception which probably is an outcome of a missed abortion. Retained product of conception is a very common gynecological condition that you will definitely experience in your everyday Gynecological practice. She had acute respiratory viral infection (ARVI) which must have caused the abortion/miscarriage and presented with bloody discharge along with blood clots with no evidence of a live fetus, just the gestational sac was visible. In such conditions, a curettage or Manual Vacuum Aspiration (MVA) is done to get out the retained product of conception and the bleeding will stop.

Indication for curettage includes Abnormal uterine bleeding: irregular bleeding, menorrhagia, suspected malignant or premalignant condition, Retained material in the endometrial cavity, Evaluation of intracavitary findings from imaging procedures (abnormal endometrial appearance due to suspected polyps or fibroids),

 

Evaluation and removal of retained fluid from the endometrial cavity (hematometra, pyometra) in conjunction with evaluating the endometrial cavity and relieving cervical stenosis etc.

14. A multigravida at 39 weeks of gestation has been delivered to a hospital having a regular labour activity for 8 hours, the waters burst an hour ago. She complains of headache, seeing spots. AP is of 180/100mm Hg. Urine test results: protein - 3,3 g/l, hyaline cylinders. Fetal heart rate is 140/min, rhythmical. Vaginal examination reveals complete crevical dilatation, the fetal head is on the pelvic floor, sagittal suture is in line with obstetric conjugate, the occipital fontanel is under the pubis. What is the optimal tactics of labour management?

Explanation

An outlet forceps is used in assisting delivery when there is full cervical dilation with the fetal head reaching the perineal floor and the scalp is visible between contractions. This type of assisted delivery is performed only when the fetal head is in a straight forward or backward vertex position or in slight rotation (less than 45 degrees to the right or left) from one of these positions.

The patient in question is manifesting signs and symptoms of pre-eclampsia already: proteinuria 3.3g/L; elevated blood pressure 180/100mmHg; headache and seeing spots; pregnancy is already beyond 20 weeks of gestation. The fetus is still stable judging from the fetal heart rate of 140beats per min. So, with a full cervical dilation, the best option is to assist the delivery using an outlet forceps.

Full cervical dilatation indicates completion of the first stage of labor and if the head of the fetus has descended, then an assisted vaginal delivery can be pursued without much risk to both the mother and fetus.

 

With a full cervical dilatation (completion of the first stage of labor) and in the absence of fetal distress, a cesarean section will be unnecessary. Cavity forceps and Vacuum extraction can be used when the head of the fetus is still high up in the uterus (i.e. yet to descend) or in the case of a retained second twin in multiple gestation.

15. A patient complains of being unable to get pregnant for 5 years. A complete clinical examination gave the following results: hormonal function is not impaired, urogenital infection hasn’t been found, on hysterosalpingography both tubes were filled with the contrast medium up to the isthmic segment, abdominal contrast was not visualized. The patient’s husband is healthy. What tactics will be most effective?

Explanation

In vitro fertilization (IVF) is a complex series of procedures used to help with fertility or prevent genetic problems and assist with the conception of a child. During IVF, mature eggs are collected (retrieved) from ovaries and fertilized by sperm in a lab. Then the fertilized egg (embryo) or eggs (embryos) are transferred to a uterus. One full cycle of IVF takes about three weeks. IVF is the most effective form of assisted reproductive technology. The procedure can be done using your own eggs and your partner's sperm. Or IVF may involve eggs, sperm or embryos from a known or anonymous donor.

IVF is the best option if the woman has Fallopian tube damage or blockage. Fallopian tube damage or blockage makes it difficult for an egg to be fertilized or for an embryo to travel to the uterus. This is the case with this patient. The contrast medium got to the isthmic segment of the fallopian tube and wasn’t visualized in the abdominal cavity. This clearly indicates a blockage somewhere beyond the isthmic segment.

With this pathology, insemination with husband’s semen will not yield any result because the oocyte can’t travel to the uterus due to the blockage in the fallopian tube. In artificial insemination, sperm is placed in the uterus and conception happens otherwise normally. IVF involves combining eggs and sperm outside the body in a laboratory. Once an embryo or embryos form, they are then placed in the uterus. Research shows that IVF is just as effective as the ICSI (Intracytoplasmic sperm injection) procedure, where sperm is injected directly into an egg, when there is no male infertility factor.

16. A 22-year-old patient complains of amenorrhea for 8 months. Menarche occurred at the age of 12,5. Since the age of 18 the patient has a history of irregular menstruation. The patient is nulligravida. The mammary glands are developed properly, nipples discharge drops of milk when pressed. Gynecological study results: prolactin level is 2 times higher than normal. CT reveals a bulky formation with a diameter of 4 mm in the region of sella. What is the most likely diagnosis?

Explanation

Pituitary Gland produces: Growth hormone; Prolactin; Thyroid Stimulating Hormone (TSH); Adrenocorticotropic Hormone (ACTH); Gonadotropins (FSH, LH). A tumor in the pituitary gland can lead to overproduction of any of these hormones. However, these are the very common ones: 

-Growth Hormone: (Children - Gigantism; Adult - Acromegaly)

-TSH: Hyperthyroidism

-ACTH: Cushing disease

-Prolactin: Too much prolactin, a hormone that stimulates lactation and the secretion of progesterone, causes inappropriate secretion of breast milk, even in men. It can also cause osteoporosis, which is weakening of the bones; loss of sex drive; infertility; irregular menstrual cycles; and the inability to have an erection.

 

People with a pituitary gland tumor may experience the following symptoms or signs. Headaches; Vision problems (Bitemporal hemianopsia); Changes in menstrual cycles in women (amenorrhea); Erectile dysfunction, Infertility; Inappropriate breast growth or production of breast milk; Cushing’s syndrome; Acromegaly, the enlargement of the arms or legs and thickening of the skull and jaw caused by too much growth hormone.

17. A 38-year-old female patient complains about hot flashes and feeling of intense heat arising up to 5 times a day, headaches in the occipital region along with high blood pressure, palpitations, dizziness, fatigue, irritability, memory impairment. 6 months ago the patient underwent extirpation of the uterus with its appendages. What is the most likely diagnosis?

Explanation

 6 months ago the patient underwent extirpation (surgical resection) of the Uterus and its appendage (ovaries and fallopian tubes). Castration means loss of the gonads - testicles, ovaries. The loss could be by any means be it chemical, surgical or otherwise.

With the absence of the ovaries, there will be lack of female reproductive hormones - estrogen and progesterone which is synthesized in the ovaries normally. 

The absence of Estrogen especially will now create an artificial menopausal state manifesting with irritability, fatigue, hot flashes and feeling of intense heat. These are the symptoms seen in menopause due to lack of estrogen but we can now see it in this patient because the ovaries have been removed.

 

In menopause, the ovaries are present but they no longer produce adequate estrogen. However, in this case, the ovaries are out so Estrogen is not being produced.

18. 20 minutes after a normal delivery at 39 weeks a puerpera had a single temperature rise up to 38oC. Objectively: the uterus is dense, located between the navel and the pubis, painless. Lochia are bloody, of small amount. Breasts are moderately soft and painless. What is the optimal tactics?

Explanation

This condition is optimal for immediate postpartum and does not require immediate actions to be taken. Uterus is painless and located between the navel and pubis is normal. Bloody lochia observed immediate postpartum is normal. Breast is also painless.

 

The only abnormality here is the slightly elevated body temperature of 38*C which might be reactive as a result of the stress, shouting and crying during labour. Therefore, follow-up is the best tactic to employ in this situation.

19. A 55-year-old patient whose menstruation stopped 5 years ago complains of vaginal dryness, frequent and painful urination. Gynecologist revealed signs of atrophic colpitis. Urine analysis revealed no peculiarities. Which locally acting product will provide the proper therapeutic effect?

Explanation

Menopause is signalled by 12 months of complete cessation of menses. This patient is already 5 years into menopause. Menopause is characterized by significantly decreased female reproductive hormones especially Estrogen and Progesterone. Lack of Estrogen can manifest as vaginal dryness, osteoporosis and hot flashes. To remedy this situation, hormone replacement therapy can be utilized. Vaginal dryness is often treated with topical lubricants or oestrogen. Ovestin contains the female hormone - Estrogen and it can provide symptomatic relief in this condition.

Metronidazole, Tergynan, Meratin Combi, Dalacin are basically antibiotics used to treat gynecological infections. This patient, who is in menopause, is in need of hormone replacement and not antibiotics.
20. On the 10th day postpartum a puerperant woman complains of pain and heaviness in the left mammary gland. Body temperature is 38, 8oC, Ps- 94 bpm. The left mammary gland is edematic, the supero-external quadrant of skin is hyperemic. Fluctuation symptom is absent. The nipples discharge drops of milk when pressed. What is a doctor’s further tactics?

Explanation

Mastitis is inflammation of the breast tissue and can be broken down into lactational and non-lactational mastitis. Lactational mastitis is the most common form of mastitis. Lactational mastitis, also known as puerperal mastitis, is typically due to prolonged engorgement of milk ducts, with infectious components from the entry of bacteria through skin breaks. Patients can develop a focal area of erythema, pain, and swelling, and can have associated systemic symptoms, including fever. This occurs most commonly in the first six weeks of breastfeeding but can occur at any time during lactation, with most cases falling off after 3 months. Lactational mastitis is most commonly caused by bacteria that colonize the skin, with Staphylococcus aureus being the most common, in this case an antibiotic may be administered to fight the infection.

The first line of treatment is self-help remedies, such as ensuring that the breast is drained properly during feeds by breastfeeding regularly or expressing the milk. And after a feed, gently express any leftover milk.

 

Inhibition of lactation will complicate the condition. This is not a case of breast abscess. An abscess will be associated with pus discharge from the nipple, not drops of milk. Use a hot compress on the breast will not be enough to resolve the condition since there is a probability of an ongoing infection.

21. During self-examination a 22-year-old patient revealed a mammary tumour. Palpation revealed a firm, painless, mobile formation up to 2 cm, peripheral lymph nodes were not changed. USI results: in the superior external quadrant of the right mammary gland there was a big formation of increased echogenicity, sized 18x17 mm. The patient was provisionally diagnosed with fibroadenoma. What is a doctor’s further tactics?

Explanation

Fibroadenomas are typically present as firm, mobile, painless, and frequently multiple breast nodules. These tumors are common, benign breast tumors that usually affect women in second and third decades of life. Fibroadenomas are usually small and can be managed conservatively; however, a good percentage of these lesions will grow rapidly.

During pregnancy, fibroadenomas increase in size and may show lactational histologic changes. High concentrations of estrogen, progesterone, and prolactin promote the ductal growth and formation of tubuloalveolar structures. This may be a reason for the significant enlargement in this period.

 

Hence, it is recommended that it be removed prior to pregnancy.

22. A 49-year-old patient complains of itching, burning in the external genitals, frequent urination. The symptoms has been present for the last 7 months. The patient has irregular menstruation, once every 3-4 months. Over the last 2 years she presents with hot flashes, sweating, sleep disturbance. Examination revealed no pathological changes of the internal reproductive organs. Complete blood count and urinalysis showed no pathological changes. Vaginal smear contained 20-25 leukocytes in the field of vision, mixed flora. What is the most likely diagnosis?

Explanation

This patient actually presented with Climacteric syndrome; one of the neuroendocrine syndromes in gynaecology that occurs during the transitional period ( starts before menopause); it occurs as a result of the gradual decrease in ovarian function and is characterised by; hot flashes, insomnia, nervousness, irregular menstruation , sleep disturbance etc. The term Climacteric syndrome is usually used interchangeably with Menopausal syndrome  but note that, Menopause refers to the complete cessation of menstruation for 12 straight months

 

The result from the examinations carried out  revealed no pathological  changes - this rules out the option of  cystitis, trichomonas colpitis, vulvitis and bacterial vaginosis. 

23. 2 weeks after labour a parturient woman developed breast pain being observed for 3 days. Examination revealed body temperature at the rate of 39oC, chills, weakness, hyperaemia, enlargement, pain and deformity of the mammary gland. On palpation the infiltrate was found to have an area of softening and fluctuation. What is the most likely diagnosis?

Explanation

Mastitis is inflammation of the breast tissue and can be broken down into lactational and non-lactational mastitis. Lactational mastitis is the most common form of mastitis. Lactational mastitis, also known as puerperal mastitis, is typically due to prolonged engorgement of milk ducts, with infectious components from the entry of bacteria through skin breaks. Patients can develop a focal area of erythema, pain, and swelling, and can have associated systemic symptoms, including fever. This occurs most commonly in the first six weeks of breastfeeding but can occur at any time during lactation, with most cases falling off after 3 months. Lactational mastitis is most commonly caused by bacteria that colonize the skin, with Staphylococcus aureus being the most common. Risk factors for lactational mastitis include prior history of mastitis, nipple cracks and fissures, inadequate milk drainage, maternal stress, lack of sleep, tight-fitting bras, and use of antifungal nipple creams.

 

From the question stem, we can differentiate the different types of mastitis listed. On palpation, an INFILTRATE was found with an area of softening and fluctuation (PURULENT). We can boldly conclude it is purulent because lactational/puerperal mastitis is commonly caused by bacteria which will produce a purulent inflammation.

24. A puerpera breastfeeding for 1,5 weeks consulted a doctor about uniform breast engorgement. Breasts are painful. The body temperature is of 36, 6oC. Milk expressing is difficult. What is the most likely diagnosis?

Explanation

The key finding here is “Milk expressing is difficult” - this refers to a stagnation in the flow of milk in one or several ducts of the mammary gland leading to an enlarged and painful mammary gland; if not corrected, this leads to mastitis which is an inflammation (most often one-sided) of the mammary gland caused by pathogenic coccal flora (e.g. staphylococci).

This patient is yet to develop mastitis, however, if Lactostasis is not properly managed, it can result in Mastitis. Mastitis will be accompanied with fever, redness on the affected breast and pain. Of which this patient is afebrile and no redness stated in the question. 

It is important to treat blocked milk ducts so they do not progress to mastitis. Options include: 

-Making sure the baby is feeding well on the affected breast – offering the affected breast first can help. 

-The application of heat for a few minutes before a feed, gentle massage of the affected area during feeding, and cold packs after a feed and between feeds for comfort. 

-A change in feeding position. 

-Frequent drainage of the breast through feeding and expressing. 

 

If the blockage does not clear within 8 to 12 hours or you start to feel unwell, see your doctor.

25. Examination of a Rh-negative pregnant woman at 32 weeks of gestation revealed a four-time rise of Rh-antibody titer within 2 weeks, the titer was 1:64. In the first two pregnancies the patient had experienced antenatal fetal death due to hemolytic disease. What is the optimal tactics of pregnancy management?

Explanation

This question is talking about Rh incompatibility. This occurs when a Rhesus negative (Rh-) mother marries a Rh+ Man and they conceive a Rh+ child. Note: the mother must be Rh- and the child Rh+. The first child with Rh+ usually survives, but subsequently Rh+ fetus will be attacked by Rh antibodies in the mother which crosses the placenta to attack the fetal red blood cells causing hemolysis.

From the question, the patient already had 2 antenatal fetal deaths due to hemolytic disease. And in this pregnancy, it is observed that the Rh antibodies are beginning to rise (4 fold increase), therefore, another hemolytic disease is imminent.

The first Rh+ child usually survives because the mother is yet to develop the Rh antibodies. Usually, the Rh- mother will be exposed to these antibodies when the Rh+ antigens from the first child cross into her blood during delivery, or CS. In that case, the mother will develop Rh antibodies for any subsequent pregnancy that is Rh+.

Once this occurs, i.e. once a Rh- mother conceives a Rh+ child, she should receive RhoGAM at 28weeks of gestation and within 72hours after delivery. This will prevent the development of antibodies. However, if she did not receive the RhoGAM, she will develop the antibodies just as it is seen in this case and the best option is to deliver the fetus as soon as possible to prevent hemolytic reactions.

She’s already at 32weeks of gestation  and if she took RhoGAM @28weeks, the antibodies will not rise. It’s medically wrong to leave the pregnancy till 37 weeks because there is a high chance the antibodies must have risen to a considerable level to cause massive hemolysis in the developing fetus before getting to 37 weeks of gestation. Ultrasound would not have any impact in this case.

There is no need waiting for another 2 weeks to screen for Rh antibodies. From the history, there are 2 confirmed cases of hemolytic disease in the past, she’s Rh- and the Rh antibodies are already increasing. 

Anti-Rh immunoglobulin is effective when given to a Rh- mother @ 26-28 weeks of gestation and within 72hours after delivery of the first child that is Rh+. 

 

The best management is to deliver the child while the fetus is still alive and hemolytic reaction is yet to start. At 32weeks, the mother should receive Corticosteroids to help the fetal lungs develop and deliver the fetus as soon as possible.

26. A 50-year-old female patient complains of aching pain in the lower abdomen. She has a history of normal menstrual cycle. At the age of 40, the patient underwent a surgery for gastric ulcer. Examination findings: abdomen is soft, in the hypogastrium there is a well-defined nodular tumor of limited mobility. Vaginal examination findings: the cervix is clean, of cylindrical shape. Body of the uterus cannot be palpated separately. On both sides of the uterus palpation reveals tight tumors with an uneven surface. The tumors are immobile andl fill the whole pelvic cavity. What is the most likely diagnosis?

Explanation

 

Krukenberg tumor (also referred to as carcinoma mucocellulare) is a form of metastatic tumor that occurs in females. It is a malignancy present in the ovary that metastasized from the stomach ( primary site). Notice that from anamnesis, this woman underwent a surgery for gastric ulcer and on examination, a well defined tumor of limited mobility is found in the hypogastrium; these findings indicate a tumor in relation to the stomach. This tumor has likely travelled ( metastasised) to the region of the uterine cavity forming a krukenberg tumor. Note that the primary site of this malignancy can also be the colon, lungs and breast.

27. A 21-year-old female patient consulted a gynecologist about itching, burning, watery vaginal discharges with a fish like smell. Speculum examination revealed that the cervical and vaginal mucosa was of a normal pink color. Vaginal examination revealed no alterations of the uterus and appendages. Gram stained smears included clue cells. What is the most likely pathology?

Explanation

Clue cells are certain cells in the vagina (vaginal epithelial cells) that appear fuzzy without sharp edges under a microscope. Clue cells change to this fuzzy look when they are coated with bacteria. If clue cells are seen, it means bacterial vaginosis is present. 

 

Bacterial Vaginosis causes fishy smelling discharge; in this condition, the vagina is not inflamed, itching is rare but vaginal pH > 5.5, hence an alteration of bacterial flora +/- overgrowth. Causative agents include Gardenella vaginosis, mycoplasma hominis etc.

28. A 26-year-old secundipara at 40 weeks of gestation arrived at the maternity ward after the beginning of labor activity. 2 hours before, bursting of waters occurred. The fetus was in a longitudinal lie with cephalic presentation. Abdominal circumference was 100 cm, fundal height - 42 cm. Contractions occurred every 4-5 minutes and lasted 25 seconds each. Internal obstetric examination revealed cervical effacement, opening by 4 cm. Fetal bladder was absent. Fetal head was pressed against the pelvic inlet. What complication arose in childbirth?

Explanation

Recall that labor physiologically is divided into 3 stages;

In the first stage the cervix opens to full dilation to allow the head to pass through  The second stage is from full dilation to delivery of the fetus. The third stage lasts from delivery of the fetus to delivery of the placenta. Labor often lasts between 12 and 14 hours – or longer – for first-time mothers, but is usually shorter in subsequent births.

The 1st stage—is the longest stage of labor, and is divided into three separate phases:

The early ( latent) phase-  averaging 8 1 ⁄2 h in nulliparas and 5 h in multiparas; duration is considered abnormal if it lasts > 20 h in nulliparas or > 12 h in multiparas.

Active labor (the active phase)-  here, the cervix dilates to 7cm.  On average, the active phase lasts 5 to 7 h in nulliparas and 2 to 4 h in multiparas. The cervix should dilate 1.2 cm/h in nulliparas and 1.5 cm/h in multiparas.

Transition. The cervix dilates from 7 centimeters to 10 centimeters. This is usually the shortest stage of labor, but is often the most unpleasant.

If a woman\'s “water ―breaking” occurs in the first stage before/ until the active phase, it is called early amniorrhea.

In Primary uterine inertia, uterine contractions fail to be initiated while in the secondary form, uterine inertia ceases in between labor ( before completion)

29. A 28-year-old female patient has been admitted to the gynecology department for abdominal pain, spotting before and after menstruation for 5 days. The disease is associated with the abortion which she had 2 years ago. Anti-inflammatory treatment had no effect. Bimanual examination findings: the uterus is enlarged, tight, painful, smooth. Hysteroscopy reveals dark red holes in the fundus with dark blood coming out of them. What diagnosis can be made on the grounds of these clinical presentations?

Explanation

30. A woman at 30 weeks pregnant has had an attack of eclampsia at home. On admission to the maternity ward AP- 150/100 mm Hg. Predicted fetal weight is 1500 g. There is face and shin pastosity. Urine potein is 0, 66o/oo. Parturient canal is not ready for delivery. An intensive complex therapy has been started. What is the correct tactics of this case management?

Explanation

A Cesarean Section is a surgical procedure whereby an incision is made on the anterior abdominal wall and uterus to affect the delivery of fetus(es), placenta and membranes after the age of viability. It can be an Emergency or Elective Cesarean Section. The major difference between both is Emergency - Unplanned, while Elective - Planned during the antenatal period.

Indications for Emergency CS:

 
  • Maternal Indications: Eclampsia; Cephalopelvic disproportion; prolonged obstructed labor

  • Fetal Indications: Fetal distress in first stage of labor; Abruptio placenta; Cord prolapse; Multiple gestation with malpresentation of the leading twin.

31. A pregnant 26-year-old woman was admitted to a hospital for abdominal pain and bleeding from the genital tract. Bimanual examination revealed that uterus was the size of 9 weeks of pregnancy, the cervical canal let a finger through. Fetal tissues could be palpated in the orifice. There was moderate vaginal bleeding. What is the tactics of choice?

Explanation

 

This patient is most likely experiencing a Missed Abortion which is defined as the retention of dead product of conception for 4 weeks or more. Notice that the size of the uterus resembles that of a 9 week pregnancy and fetal tissues can be palpated from the cervical orifice accompanied by bleeding.  The appropriate tactics of choice is to evacuate the fetal tissue through vaginal or suction evacuation.

32. A 36-year-old female presented to a gynecological hospital with a significant bleeding from the genital tract and a 1-month delay of menstruation. Bimanual examination revealed soft barrel shaped cervix. Uterus was of normal size, somewhat softened. Appendages were unremarkable on both sides. Speculum examination revealed that the cervix was cyanotic, enlarged, with the the external orifice disclosed up to 0,5 cm. Urine hCG test was positive. What is the most likely diagnosis?

Explanation

hCG is positive plus amenorrhea (absent menses for 1 month) in a woman of reproductive age clearly indicates pregnancy. hCG can be detected as early as 1-2 weeks of gestation - this is what is tested in urine pregnancy test kits.

 

On Bimanual examination, Uterus (womb) is without changes, appendages (i.e. fallopian tubes, ovaries) are also unremarkable but the question clearly states that the cervix is barrel-shaped, cyanotic, and enlarged. This shows that the embryo was probably implanted in the cervix, hence, Cervical pregnancy.

33. An 18-year-old girl complains of breast pain and engorgement, headaches, irritability, swelling of the lower extremities. These symptoms have been observed since menarche and occur 3-4 days before the regular menstruation. Gynecological examination revealed no pathology. Make a diagnosis:

Explanation

Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc. 

 

Neurasthenia is a condition that is characterized especially by physical and mental exhaustion usually with accompanying symptoms (such as headache and irritability), is of unknown cause but is often associated with depression or emotional stress, and is sometimes considered similar to or identical with chronic fatigue syndrome.

34. A 25-year-old female presented to a women’s welfare clinic and reported the inability to get pregnant within 3 years of regular sexual activity. Examination revealed increased body weight, male pattern of pubic hair growth, excessive pilosis of thighs, dense enlarged ovaries, monophasic basal temperature. What is the most likely diagnosis?

Explanation

Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain male pattern pubic hair growth, excessive hair on the thighs etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation; 

Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc.
35. A puerperant is 28 years old. It’s the 3rd day post-partum after a second, normal, term delivery. The body temperature is of 36, 8oC, Ps- 72/min, AP- 120/80 mm Hg. Mammary glands are moderately engorged, the nipples are clean. Abdomen is soft, painless. The fundus is 3 fingers’ breadth below the navel. Moderate bloody lochia are present. What diagnosis can be made?

Explanation

The postpartum physiological changes are those expected changes that occur to the woman's body after childbirth, in the postpartum period. These changes mark the beginning of the return of pre-pregnancy physiology and of breastfeeding.

Involution, a part of postpartum physiology, is the term given to the process of reproductive organs returning to their prepregnant state. Immediately following the delivery, the uterus, and the placental site contracts rapidly to prevent further blood loss. 

After birth, the fundus of the uterus contracts downward into the pelvis one centimeter each day. After two weeks the uterus will have contracted and returned into the pelvis. Hence, the 3 finger’s breadth below the navel on the 3rd day postpartum.

The lochia is the vaginal discharge that originates from the uterus, cervix, and vagina. The lochia is initially red and consists of blood and fragments of decidua, endometrial tissues, and mucus and lasts 1 to 4 days. The lochia then changes color to yellowish or pale brown, lasting 5 to 9 days, and is composed mainly of blood, mucus, and leukocytes. Finally, the lochia is white and contains mostly mucus, lasting up to 10 to 14 days.

The lactogenesis or milk secretion starts the third or fourth day postpartum making the mammary glands engorged.

 

Subinvolution of the uterus is seen after childbirth, when the uterus does not return to its normal size. But a fundus 3 finger’s breadth below the navel on the 3rd day postpartum clearly indicates a physiologic process taking place.

36. A puerperant is 32 years old, it’s her first childbirth, term precipitate labor, the III period is unremarkable, the uterus is contracted, tight. Examination of the birth canal revealed a rupture in the left posterior vaginal wall that was closed with catgut. Two hours later, the patient complained of a feeling of pressure on the anus, pain in the perineum, minor vaginal discharges, edema of the vulva. These clinical presentations are indicative most likely of:

Explanation

 

Precipitate labor  occurs when the duration of the entire labor process is below 3 hours. It involves the rapid and spontaneous expulsion of the fetus. Major complication of this case involves laceration of the cervix, vagina and/or the perineum. These lacerations can lead to hemorrhaging and further hematoma of the cervix, vagina or perineum. Notice that this patient experienced the rupture of the posterior vaginal wall that led to bleeding. Although this rupture was closed by catgut, the collection of blood (  hematoma ) in the pelvic cavity led to the presented symptoms of pressure on the anus, pain in the perineum, vaginal discharge etc. 

37. A 31-year-old female patient complains of infertility, amenorrhea for 2 years after the artificial abortion that was complicated by endometritis. Objectively: examination of the external genitalia revals no pathology, there is female pattern of hair distribution. According to the functional tests, the patient has biphasic ovulatory cycle. What form of infertility is the case?

Explanation

This patient has had a previous abortion that was complicated by Endometritis. Endometritis is inflammation of the inner lining (endometrial layer) of the uterus. But she is presently bothered about her inability to conceive and the question is concerned about the origin/organ of primary focus.

Amenorrhea is the absence of menstruation. If a woman doesn’t see her menses, she can’t conceive (infertility). 

On examination: 

  • ‘the external genitalia reveals no pathology’ i.e. the vagina, cervix are normal.

  • ‘there is a female pattern of hair distribution’ - this is a function of Estrogen and this shows her secondary sexual characteristics are present. Estrogen is produced primarily in the ovaries, and adipose tissue. This indicates that the ovary is functioning normally.

  • ‘the patient has biphasic ovulatory cycle’ - biphasic ovulatory cycle is possible due to the effects of Progesterone and Estrogen. (NB: a monophasic ovulatory cycle indicates a problem with the ovary or the Hypothalamic-Pituitary Axis). These two hormones are elevated at different times during the normal ovulatory cycle and they indicate an adequate functioning of the Hypothalamus-Pituitary-Ovarian Axis. The Hypothalamus releases Gonadotropin Releasing Hormone to stimulate the Pituitary to release Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) - FSH and LH then act on the Ovary to produce Estrogen and Progesterone respectively producing the effect of the biphasic ovulatory cycle.

 

Therefore, since all other pathways and organs involved are functioning properly, we can conclude that the primary focus is the Uterus.

38. A 19-year-old primiparous woman with a body weight of 54,5 kg gave birth at 38 weeks gestation to a full-term live girl after a normal vaginal delivery. The girl’s weight was 2180,0 g, body length - 48 cm. It is known from history that the woman has been a smoker for 8 years, and kept smoking during pregnancy. Pregnancy was complicated by moderate vomiting of pregnancy from 9 to 12 weeks pregnant, edemata of pregnancy from 32 to 38 weeks. What is the most likely cause of low birth weight?

Explanation

Cigarette smoke contains about 4000 toxic chemical compounds that exert direct effect on cell proliferation and differentiation in the placenta and the fetus. Maternal smoking may lead to intrauterine growth restriction, spontaneous abortion, premature descent of placenta, premature rupture of membranes, premature birth, and sudden death syndrome in the newborn.

 

The abnormal development of placental vascularization leads to placental insufficiency, which further reduces the nutrient and trace exchange between maternal circulation and fetal circulation. These changes cause maternal and fetal complications which can result in intrauterine growth restriction manifesting as low birth weight. Low birth weight, according to the World Health Organization is any birth weight of an infant less than 2,500g regardless of gestational age.

 

Vomiting in the first trimester between 9 - 12 weeks of pregnancy and 3rd trimester edema are fairly normal and physiological changes during pregnancy. There are no signs of proteinuria or elevated blood pressure so we can rule out Preeclampsia. The woman’s age and weight has nothing to do with the birth weight as long as the baby gets the necessary nutrient. Moreso, the weight of 54.5kg is okay for the woman.

39. A 23-year-old primigravida at 39 weeks gestation has been admitted to the maternity ward with irregular contractions. The intensity of uterine contractions is not changing, the intervals between them stay long. Bimanual examination reveals that the cervix is centered, soft, up to 1,5 cm long. There is no cervical dilatation. What diagnosis should be made?

Explanation

The Preliminary stage of labor is characterized by: 

  • Irregular contractions

  • No structural changes in the uterus

  • Usually lasts 6-8 hours 

The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third combined. The first stage of labor has been divided into three phases: a latent phase, an active phase, and a transition phase. During the latent phase there is more progress in effacement ( stretching and thinning) of the cervix and little increase in descent. During the active phase and the transition phase there is more rapid dilation of the cervix and increased rate of descent of the presenting part.

The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The second stage takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.

The third stage of labor lasts from the birth of the fetus until the placenta is delivered. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born.The duration of the third stage may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits

The fourth stage of labor arbitrarily lasts approximately 2 hours after delivery of the placenta. It is the period of immediate recovery, when homeostasis is reestablished. It serves as an important period of observation for complications, such as abnormal bleeding. 

 

Notice that this patient presents with irregular contraction and no cervical dilation.

40. On the 10th day postpartum a puerperant woman complains of pain and heaviness in the left breast. Body temperature is 38, 8oC, Ps- 94 bpm. The left breast is edematic, the supero-external quadrant of skin is hyperemic. Fluctuation symptom is absent. The nipples discharge drops of milk when pressed. What is a doctor’s further tactics?

Explanation

 

This patient most likely has an infection around the left mammary gland; this expresses itself by the increased temperature, hyperemia in this region and edema. The doctor’s tactics should be to firstly administer an antibiotic  to curl the infection. Recall that this woman is currently breastfeeding; expression of breastmilk refers to manually squeezing out the breast milk for storage and to feed the baby later. This procedure should be carried out in order to prevent the baby from coming in contact with the infected area. The option of opening and drainage of the mammary gland will be carried out in case of purulent discharge from the breast.

41. During the breast self-exam a 37-year-old female patient revealed a lump in the lower inner quadrant of her left breast. Palpation confirms presence of a mobile well-defined neoplasm up to 2 cm large. Peripheral lymph nodes are not changed. What is the way of further management?

Explanation

Since physical examination revealed a neoplastic formation on the left breast, further investigation ought to be carried out in order to know the specific type of formation. These investigations include an ultrasound and a needle aspiration biopsy. Only after confirming the specific diagnosis can we begin to administer the right procedure to follow ( therapeutic or surgical).
42. A 25-year-old female has a self-detected tumor in the upper outer quadrant of her right breast. On palpation there is a painless, firm, mobile lump up to 2 cm in diameter, peripheral lymph nodes are not changed. In the upper outer quadrant of the right breast ultrasound revealed a massive neoplasm with increased echogenicity sized 21x18 mm. What is the most likely diagnosis?

Explanation

 Fibroadenomas are typically present as firm, mobile, painless, and frequently multiple breast nodules. These tumors are common, benign breast tumors that usually affect women in second and third decades of life. Fibroadenomas are usually small and can be managed conservatively; however, a good percentage of these lesions will grow rapidly.

During pregnancy, fibroadenomas increase in size and may show lactational histologic changes. High concentrations of estrogen, progesterone, and prolactin promote the ductal growth and formation of tubuloalveolar structures. This may be a reason for the significant enlargement in this period.

 

43. A 49-year-old female patient complains of itching, burning in the external genitals, frequent urination. The symptoms have been present for the last 7 months. The patient has irregular menstruation, once every 3-4 months. Over the last two years she has had hot flashes, sweating, sleep disturbance. Examination revealed no pathological changes of the internal reproductive organs. Complete blood count and urinalysis showed no pathological changes. Vaginal smear contained 20-25 leukocytes per HPF, mixed flora. What is the most likely diagnosis?

Explanation

This patient actually presents with Climacteric syndrome; one of the neuroendocrine syndrome in gynaecology that occurs during the transitional period ( starts before menopause); it occurs as a result of the gradual decrease in ovarian function and is characterised by; hot flashes, insomnia, nervousness, irregular menstruation , sleep disturbance etc. The term Climacteric syndrome is usually used interchangeably with Menopausal syndrome  but note that, Menopausal syndrome refers to the cessation of menstruation for 12 straight months

 

The result from the examinations carried out  revealed no pathological  changes - this rules out the option of  cystitis, trichomonas colpitis, vulvitis and bacterial vaginosis. 

44. On admission a 35-year-old female reports acute abdominal pain, fever up to 38, 8oC, mucopurulent discharges. The pati-ment is nulliparous, has a history of 2 artificial abortions. The patient is unmarried, has sexual contacts. Gynecological examination reveals no uterus changes. Appendages are enlarged, bilaterally painful. There is profuse purulent vaginal discharge. What study is required to confirm the diagnosis?

Explanation

 

The absence of uterine changes on gynecological examination helps rule out the option of Hysteroscopy and curettage of the uterine cavity. Notice the presence of profuse purulent discharge from the vagina coupled with acute abdominal pain and fever- these are indicative of an infectious process; a bacterioscopic and a bacteriological examination of the purulent discharge should be carried out inorder to identify the causative agent and administer the right treatment.

45. A 20-year-old female consulted a gynecologist about not having menstrual period for 7 months. History abstracts: early childhood infections and frequent tonsillitis, menarche since 13 years, regular monthly menstrual cycle of 28 days, painless menstruation lasts 5-6 days. 7 months ago the patient had an emotional stress. Gynecological examination revealed no alterations in the uterus. What is the most likely diagnosis?

Explanation

 Primary Amenorrhea: absence of menses by age 14 with the absence of secondary sexual characteristics or by age 16 with normal secondary sexual characteristics.

Secondary Amenorrhea: cessation of menstruation for at least 6 months or at least three of the previous cycle intervals. 

Algomenorrhea  refers to menstrual pain/ cramps. Spanomenorrhea refers to an increase in the length of time between periods while cryptomenorrhea refers to the obstruction in menstrual flow. 

 

Notice that this patient experienced Menarche ( first menstrual flow ) at age 13- this rules out the option of Primary amenorrhea. The absence of menstrual period for 7 months  indicates secondary amenorrhea.

46. A 48-year-old female has been admitted to the gynecology department for pain in the lower right abdomen and low back pain, constipation. Bimanual examination findings: the uterus is immobile, the size of a 10-week pregnancy, has uneven surface. Aspirate from the uterine cavity contains atypical cells. What diagnosis can be made?

Explanation

The result from the bimanual examination and uterine aspirate helps us put a diagnosis here. Notice that the uterus( not the Cervix or colon)  is enlarged, immobile and present with atypical cells on aspiration. These atypical cells in most cases indicate a carcinogenic process. Hysterocarcinoma also refers to endometrial cancer.

Chorionepithelioma is a malignant tumor which arises in connection with pregnancy at the site of the placental implantation.

47. A 45-year-old woman came to the maternity clinic with complaints of periodical pains in her mammary glands that start 1 day before menstruation and stop after the menstruation begins. Palpation of the mammary glands detects diffuse nodes predominantly in the upper outer quadrants. What is the most likely diagnosis?

Explanation

48. A 46-year-old woman came to the maternity clinic with complaints of moderate blood discharge from the vagina, which developed after the menstruation delay of 1.5 months. On vaginal examination: the cervix is clean; the uterus is not enlarged, mobile, painless; appendages without changes. Make the diagnosis:

Explanation

49. A woman is 40 weeks pregnant. The fetus is in the longitudinal lie and cephalic presentation. Pelvic size: 26-29-31-20. Expected weight of the fetus is 4800 gram. The labor contractions has been lasting for 12 hours, within the last 2 hours they were extremely painful, the parturient woman is anxious. The waters broke 4 hours ago. On external examination the contraction ring is located 2 finger widths above the navel, Henkel-Vasten sign is positive. Fetal heart rate is 160/min., muffled. On internal examination the uterine cervix is fully open, the head is engaged and pressed to the entrance into the lesser pelvis. What is the most likely diagnosis?

Explanation

50. A 17-year-old girl has made an appointment with the doctor. She plans to begin her sex life. No signs of gynecological pathology were detected. In the family history the patient’s grandmother had cervical cancer. The patient was consulted about the maintenance of her reproductive health. What recommendation will be the most helpful for prevention of invasive cervical cancer?

Explanation

51. An infant has been born at the 41st week of gestation. The pregnancy was complicated with severe gestosis of the second semester. The weight of the baby is 2400 g, the height is 50 cm. Objectively: the skin is flabby, the layer of subcutaneous fat is thin, hypomyotonia, neonatal reflexes are weak. The internal organs are without pathologic changes. This newborn can be assessed as a:

Explanation

Norms;  gestation period- 280 days or 40 weeks up to 42 weeks

              birth weight- 3-3.5kg ( 3000-3500g)

             Body length- 45-55cm

The baby in question underwent a full term gestation period (41 weeks) but is underweight ( 2500g). This underweight is due to complications that occurred during gestation as stated “The pregnancy was complicated with severe gestosis of the second semester”. We can therefore conclude that the baby who had a full term gestation had some intrauterine growth restrictions.

A premature infant is one which is born before 37 weeks of gestation.

 

A post mature infant is one born after 42 weeks of gestation.

52. The pregnancy is full term. The body weight of the parturient woman is 62 kg. Fetus is in a longitudinal lie, the head is engaged to the pelvic inlet. Belly circumference is 100 cm. Uterine fundus height is 35 cm. What body weight of the fetus can be expected?

Explanation

 

In recent studies, the value of abdominal girth ( belly circumference) and fundal height ( length from the mother’s uterus to the top of the pubic symphysis) can be used in predicting the weight of a baby. This method is used in order to quickly determine low birth weight babies. It is done by multiplying  the belly circumference by the fundal height; giving you the predicted weight in grams (g), (divide by 1000 for the value in kg). Ie, 100x35= 3500g or 3.5kg.

53. A 22-year-old woman, gravida 1, para 0 arrived with complaints of sharply painful contractions that occur every 4-5 minutes and last for 25-30 seconds. Amniotic fluid did not burst. The fetus is in transverse lie, fetal heartbeats are not affected. Contraction ring is acutely painful, located obliquely at the umbilicus. What is the most likely diagnosis?

Explanation

 

Uterine rupture is a birth complication in which the muscular wall of the uterus tears during pregnancy or childbirth. The term ‘Gravida’ refers to the number of times a woman has gotten pregnant. ‘Para’ refers to the number of births a woman has had after 20weeks of gestation.  increasingly severe abdominal pain that persists between contractions is a major sign of an impending uterine rupture; it is usually accompanied by maternal agitation. In the case of an already ruptured uterus, Hemoperitoneum is most likely to be seen, it is accompanied by a sharp pain during inspiration ( a tearing sensation)

54. A 16-year-old girl has primary amenorrhea, no pubic hair growth, normally developed mammary glands; her genotype is 46 ХY; uterus and vagina are absent. What is your diagnosis?

Explanation

Testicular Feminization syndrome also called Complete androgen insensitivity syndrome is a genetic anomaly in which an XY fetus has a defect in androgen receptors leading to a feminine appearance. Usually presents with an absent uterus and fallopian tubes, a rudimentary vagina, scanty or no pubic hair growth, normal and functioning testes etc Genotype 46XY.

 

Mayer-Rokitansky-Kuster-Hauser syndrome is also called Mullerian Agenesis. A failure in the development of the mullerian duct which leads to uterus, cervix agenesis and vaginal hypoplasia. Secondary sexual characteristics are normal in such individuals because Ovaries do not develop from the mullerian duct.

55. 6 hours ago the waters of a 30-year-old gravida 1, para 0, burst; her preliminary period was pathologic and lasted for over 2 days; the term of pregnancy is 39 weeks. No labor activity is observed. Fetal head presents above the pelvic inlet. Fetal heartbeats are 142/min., clear and rhytmic. On vaginal examination the uterine cervix is not dilated. What further tactics should the doctor choose?

Explanation

56. A newborn has Apgar score of 9. When should the infant be put to the breast?

Explanation

An apgar score is a test used in assessment of the health of a newborn child. In this test, the skin colour, pulse rate, irritability, muscle tone and respiration are checked and scored individually between 0-2. A score of 7 and above means the baby is normal, 4-6 is fairly low, 3 below refers to a critical condition; immediate actions to restore the child’s health should be taken. For a baby with normal response, he/she should be taken immediately to the mother to be breastfed.
57. A 23-year-old woman came the the gynecologist with complaints of blood smears from her genital tracts that have been observed for a long time. Her menstruation has been delayed for 8 weeks. Examination shows the uterine body to be enlarged up to 14 weeks of pregnancy. US detected a vesicular mole. What tactics should the doctor choose?

Explanation

 

From the question, we can pick out; A delayed menstruation for an 8 week period, an enlarged uterine body- These signs of pregnancy are backed up with an ultrasound. The US presents a Vesicular mole ( grape like mole) also called a Hydatidiform mole or molar pregnancy.  This occurs when a non-viable fertilised egg ( an egg without a maternal nucleus) gets implanted into the walls of the uterus. For treatment, the doctor should evacuate the uterus either through suction  or surgically by uterine curettage ( using a special equipment to scrape out uterine tissue).

58. The gynecology unit received a patient with uterine bleeding that started 6 hours after induced abortion at the term of 11-12 weeks. Objectively the skin is pale, pulse is 100/min., blood pressure is 100/70 mm Hg. On vaginal examination the uterus is painless, its enlargement corresponds to the 10th week of pregnancy; uterine cervix is dilated enough to let in one finger, there are fragments of the fertilized ovum. What actions should be taken next:

Explanation

Recall that Curettage is simply using an instrument (curette) to scrape out tissues especially in the uterus.  Indications for this procedure include:

  • Abnormal uterine bleeding: irregular bleeding, menorrhagia, suspected malignant or premalignant condition

  • Retained material in the endometrial cavity

  • Evaluation of intracavitary findings from imaging procedures (abnormal endometrial appearance due to suspected polyps or fibroids)

  • Evaluation and removal of retained fluid from the endometrial cavity (hematometra, pyometra) in conjunction with evaluating the endometrial cavity and relieving cervical stenosis

  • Office endometrial biopsy insufficient for diagnosis or failed due to cervical stenosis

  • Endometrial sampling in conjunction with other procedures (eg, hysteroscopy, laparoscopy).

 

The above patient presented with uterine bleeding and presence of fertilized ovum fragments- these are indications for a Curettage.

59. A woman came to the general practitioner with complaints of fatigability, significant weight loss, weakness, and loss of appetite. She has been presenting with amenorrhea for the last 8 month. One year ago she gave birth to a live full-term child. Blood loss during delivery was 2 liters. The woman received blood transfusion and blood components. What is the most likely diagnosis?

Explanation

 

Notice that the woman in question gave birth about a year ago and experienced a severe blood loss during delivery; this is the leading cause of sheehan’s syndrome. Sheehan’s syndrome is one of the major causes of hypopituitarism in females; it is due to pituitary infarction as a result of postpartum hemorrhage.  fatigability, significant weight loss, weakness, and loss of appetite all include associated symptoms.

60. A 22-year-old woman complains of itching and profuse discharge from her genital tracts. The condition developed 10 days ago after a sexual contact. Bacterioscopy of a discharge sample detected trichomonads. What drug should be prescribed for treatment in this case?

Explanation

 “ Bacterioscopy of a discharge sample detected trichomonads”- Trichomonads refer to a group of protozoans that possess about 3-6 flagellas. Examples include Trichomonas vaginalis, buccalis etc. 

Metronidazole is an antiprotozoal and antibiotic drug. It is indicated in several pelvic inflammatory diseases, bacterial vaginosis and protozoal diseases such as giardiasis,trichomoniasis etc. Most suitable treatment for the diseases caused by Trichomonads.

Ampicillin and Erythromycin are antibiotics; they are sometimes used in combination with anthelmintics/ antiprotozoal drugs for treatment of protozoal infections.

 

Acyclovir and valacyclovir are both antiviral drugs and are indicated in diseases such as herpes.

61. A multigravida on the 38th week of her pregnancy complains of increased BP up to 140/90 mm Hg, edema of the shins for 2 weeks. In the last month she gained 3.5 kg of weight. Urine analysis: protein - 0.033 g/L. Make the diagnosis:

Explanation

Preeclampsia, a pregnancy-specific condition in which hypertension develops after 20 weeks of gestation in a previously normotensive woman. It is characterized by hemoconcentration, hypertension, and proteinuria. The following are the differences between a mild and severe Preeclampsia: 

 

MIld Preeclampsia

Severe Preeclampsia

BP reading of 140/90 mm Hg twice, 4-6 hr apart

Proteinuria of 0.3 g/L in a 24 hr specimen or >0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart

Dependent edema, some puffiness of eyes, face, fingers; pulmonary edema absent

Output matching intake, ≥30 ml/hr or <650 ml/24 hr

Rise to >160/110 mm Hg on two separate occasions 4-6 hr apart with pregnant woman on bed rest

Proteinuria of >0.5 g/L in 24 hr

Generalized edema, noticeable puffiness; eyes, face, fingers; pulmonary edema possibly present

<20 ml/hr or <400 ml to 500 ml/24 hr

62. A 20-year-old woman, gravida 2, para 1 has been in labor for 4 hours. Her condition is satisfactory. Moderately painful contractions occur every 3 minutes and last for 35-40 seconds. The waters have not burst yet. The fetus is in longitudinal position. Fetal heartbeats are 136/min., clear and rhytmic. Major segment of the fetal head is engaged to the pelvic inlet. Vaginal examination shows smooth cervix of 6cm, amniotic sac is intact, sagittal suture is in the left oblique diameter, occipital fontanel is on the right near the symphysis pubis. What stage of the labor is it?

Explanation

The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. divided into three phases: a latent phase, an active phase, and a transition phase. During the latent phase there is more progress in effacement (stretching and thinning) of the cervix and little increase in descent. During the active phase and the transition phase there is more rapid dilation of the cervix and increased rate of descent of the presenting part.

The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. It takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.

The third stage of labor lasts from the birth of the fetus until the placenta is delivered.

 

The presented cervix is 6cm ( dilated to an extent), Major segment of the fetal head is engaged to the pelvic inlet - indicating either an active or transition phase.

63. It is the 3rd day after the normal term labor; the infant is rooming-in with the mother and is on breastfeeding. Objectively: the mother’s general condition is satisfactory. Temperature is 36.4oC, heart rate is 80/min.,BP is 120/80 mm Hg. Mammary glands are soft and painless; lactation is moderate, unrestricted milk flow. The uterus is dense, the uterine fundus is located by 3 fingers width below the navel. Lochia are sanguinoserous, moderate in volume. Assess the dynamics of uterine involution:

Explanation

Involution is the term used to describe the physical reduction in size of the uterus and cervix after parturition. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. At 6 weeks it weighs 50-60 g. 

 

Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

64. A 30-year-old woman complains of milk discharge from her breasts and no menstruation for the last 5 months. One physiologic childbirth was 4 years ago. There are no maldevelopments of mammary glands. Bimanual examination revealed diminished uterus and normal sized ovaries. MRI-scan shows no brain pathologies. Thyroid stimulating hormone is within normal limits. Serum prolactin is high. What is the most likely diagnosis?

Explanation

 

The woman presents with milk discharge from the breast and a high level of serum prolactin. The function of prolactin  is to stimulate the production of breast milk and occurs normally in females after childbirth; It also disrupts normal menstruation cycle in females as seen in the described patient. Note that the results of the MRI of the brain showed no pathology thereby ruling out the options of pituitary adenoma and sheehan syndrome.

65. A 25-year-old woman during self-examination detected a tumor in the upper external quadrant of her right mammary gland. On palpation: painless, dense, mobile growth 2cm in diameter is detected in the mammary gland; no changes in the peripheral lymph nodes are observed. On US of the mammary glands: in the upper external quadrant of the right mammary gland there is a space-occupying lesion of increased echogenicity 21х18 mm in size. The most likely diagnosis is:

Explanation

An adenoma is a benign epithelial tumor from the epithelium of the glands and glandular organs e.g. breast, thyroid gland, ovaries etc. A fibroadenoma is a benign nodular proliferation and not a true neoplasm (cancer); it presents as a mobile lump in the breast of young women. Breast cysts are fluid filled cavities common in females approaching menopause

 
66. A 45-year-old woman underwent one year ago mastectomy followed by chemo and radiation therapy. She now complains of dyspnea at rest and temperature up to 37.2oC. Her general condition is severe acrocyanosis is observed. The right side of her chest practically does not participate in respiration. Percussion reveals a dull sound below the 3rd rib; auscultation detects acute weakening of the respiratory sounds. Pleural puncture on the right has yielded a large amount of hemorrhagic exudate. What complication has developed in the patient?

Explanation

 

Realise that the woman had a mastectomy followed by chemo- and radiation therapy which implies she had a carcinogenic history. A current case of increased temperature, dyspnea even while at rest, non participation of the right side of chest during respiration, coupled with the result from percussion and auscultation indicate Pleuritis/ pleurisy of the right lung. Pleuritis is an inflammation of the lining of the lung. It can be as a result of a viral infection, lung cancer, pneumonia etc. The current case of pleuritis is most likely a complication of the previously mentioned carcinogenic issue.

67. A 45-year-old woman came to the maternity clinic with complaints of periodical pains in her mammary glands that start 1 day before menstruation and stop after the menstruation begins. Palpation of the mammary glands detects diffuse nodes predominantly in the upper outer quadrants. What is the most likely diagnosis?

Explanation

A fibrocystic mastopathy is a benign condition of the breast, it is the most common disorder of the female breast. Fibrocystic change is characterised  by hyperplastic overgrowth of components of the mammary unit, i.e lobules, ductules and stroma. In this condition, there are 4  characteristic features namely: Fibrosis (an increase in the amount of collagen rather than true growth of fibrous tissue), Adenosis ( an increase in the number of lobules and in the size of existing lobules), Cyst formation ( cyst are lined by flattened epithelium derived from lobal ductal unit and are filled with watery fluid) and Fibrocystic changes ( most commonly epithelial hyperplasia).

A mastitis is simply an inflammation of the mammary gland.

 
68. A woman complains of temperature increase up to 39oC, sharp pains in her lower abdomen, and sanguinopurulent discharge from her genital tracts. From her case history it is known that 6 days ago she underwent illegal abortion. Objectively her blood pressure is 100/60 mm Hg, pulse is 110/min. Abdominal rigidity, rebound tenderness (Bloomberg’s sign), and painful palpation of the lower abdomen are observed. On bimanual examination the uterus is enlarged up to 7 weeks of pregnancy, painful, and soft; posterior vaginal fornix overhangs. Make the diagnosis:

Explanation

Pelviperitonitis is the inflammation of the peritoneum ( serous membrane) surrounding the fallopian tubes and uterus. Observe that the patient presents with signs of peritonitis which includes; painful palpation of the abdomen, rebound rigidity ( a positive shotkin- blumberg sign) and abdominal rigidity. The disease is mostly as a result of a bacterial infection of the female genital tract that spread lymphogenously or hematogenously. The Disease begins sharply, is characterized by high temperature of a body (38 — 39 ° above), deterioration in the general state, severe pains in the bottom of the stomach, increase of pulse, abdominal distention etc.

 

An adnexitis is the inflammation of the uterus and its appendages ( ovaries and fallopian tubes).

69. A 55-year-old woman came to a gynecologist with complaints of leukorrhea and bloody discharge from the vagina after 5 years of menopause. Anamnesis states no pregnancies. Bimanual examination: the uterus and uterine appendages are without changes. During diagnostic curettage of the uterine cavity the physician scraped off enchephaloid matter. What is the most likely diagnosis in this case?

Explanation

70. A 24-year-old pregnant woman on her 37th week of pregnancy has been delivered to a maternity obstetric service with complaints of weak fetal movements. Fetal heartbeats are 95/min. On vaginal examination the uterine cervix is tilted backwards, 2 cm long, external orifice allows inserting a fingertip. Biophysical profile of the fetus equals 4 points. What tactics of pregnancy management should be chosen?

Explanation

A biophysical profile is a prenatal test used to check the well being of a baby. It involves using an ultrasound in evaluating the fetal heart rate, breathing, movement ,muscle tone and amniotic fluid level combined with a non-stress test for checking the fetal heart rate. Points are allocated for every measurement taken. This test is recommended for pregnant women at high risk of complications and a tendency of pregnancy loss. In most cases, a low biophysical profile score might indicate an early or immediate child delivery.

Note that the score of the above profile is 4 (indicating an immediate delivery).

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71. During regular preventive gynecological examination a 30-year-old woman was detected to have dark blue punctulated ”perforations” on the vaginal portion of the uterine cervix. The doctor suspects endometriosis of the vaginal portion of the uterine cervix. What investigation method would be most informative for diagnosis confirmation?

Explanation

A colposcopy is a simple procedure used to look at the cervix, the lower part of the womb at the top of the vagina ( Colposcopy is like a microscope put near the vagina to allow more detailed examination of the cervix). It's often done if cervical screening finds abnormal cells in your cervix. Under the guidance of colposcopy, a piece of the lesion will be removed (called a biopsy) and sent to the laboratory for detailed examination.

 

A hysteroscopy is used in detecting pathologies involving the Uterus. Curettage is a procedure used in removing tissues from the uterine cavity.

72. A postparturient woman, who has been breastfeeding for 3 weeks, made an appointment with the doctor. For the last 6 days she has been feeling unwell, complains of body temperature of 38-39oC, general weakness; within the last 2 days she developed pain and redness in the area of her right mammary gland. Examination revealed her mammary gland to be significantly enlarged and deformed; breast tissue fluctuations and lymphadenitis are observed. What type of mastitis is the most likely?

Explanation

73. On the 9th day after childbirth the obstetric patient developed high fever up to 38oC. She complains of pain in the right mammary gland. The examination revealed the following: a sharply painful infiltrate can be palpated in the right mammary gland, the skin over the infiltrate is red, subareolar area and nipple are swollen and painful. What is your diagnosis?

Explanation

 

A breast abscess is a localised collection of pus in the breast tissue. It is usually caused by a bacterial infection. It is characterised by the presence of a lump on palpation (painful infiltrate can be palpated), swollen and painful nipple. In mastopathy, we observe changes such as swellings, nodules, cysts etc, it is hormone dependent. In cancer, there will be increased proliferation of atypical tissues.

74. A 32-year-old pregnant woman at the term of 5-6 weeks was vaccinated against influenza along with her whole family. At that time she was not aware of her pregnancy. The pregnancy is wanted. The woman needs an advice from the family doctor regarding the maintenance of her pregnancy, namely whether there is a risk of fetal malformations because of received vaccination. What advice should the doctor give in this case?

Explanation

 

An inactivated influenza vaccine is reliably used as a form of prophylaxis from the influenza infection; optimal terms for vaccination are october-november. Influenza vaccination is indicated in children with: chronic bronchopulmonary diseases, cardiovascular diseases, hemolytic anemias, diabetes mellitus, chronic kidney and liver diseases, HIV infection etc. Note that the flu vaccine is safe during pregnancy. The inactivated Influenza vaccine can be given to pregnant women during any trimester.

75. A 17-year-old girl has made an appointment with the doctor. She plans to begin her sex life. No signs of gynecological pathology were detected. In the family history there was a case of cervical cancer that occurred to the patient’s grandmother. The patient was consulted about the maintenance of her reproductive health. What recommendation will be the most helpful for prevention of invasive cervical cancer?

Explanation

Notice that from family history, there was a case of cervical cancer. Cervical cancer occurs in the cells of the cervix- the lower parts of the uterus that connects to the vagina. This malignancy is mostly caused by an infection by Human papilloma virus ( HPV 16 & 18 ). Since there is a family history, the chances of occurrence is very high therefore, vaccination against HPV is the best possible preventive/prophylactic measure.

 

HPV vaccines eg. Gardasil are recombinant vaccines administered as prophylaxis against Genital warts, cervical cancers; they target HPV strains 6, 11, 16 and 18.

76. A 28-year-old woman has been delivered to a hospital with acute pain in the lower abdomen. There was a brief syncope. The delay of menstruation is 2 months. Objectively: the patient has pale skin, BP- 90/50 mmHg, Ps- 110/min. Lower abdomen is extremely painful. Vaginal examination reveals uterus enlargement. Promtov’s sign (pain during bimanual gynecological examination) is positive. Right uterine appendages are enlarged and very painful. Posterior vault hangs over. What is the most likely diagnosis?

Explanation

An ectopic pregnancy occurs when implantation takes place outside the walls of the uterus; in most cases it occurs in the fallopian tubes ( tubal pregnancy). The patient presents with a history of missed periods for about 2 months ( an early sign of pregnancy). Typical signs include pelvic and severe lower abdominal pain, mass present in the uterine appendage ( adnexa). Notice that on examination, the patient presents with enlarged and very painful uterine appendages on the right side which confirms a right-sided tubal pregnancy.

 Right ovary apoplexy refers to the rupture of the ovary, it presents with severe pain, bleeding into the abdominal cavity and signs of irritation of the peritoneum.

 

The inflammation of the uterine appendage, particularly on the fallopian tubes is the disease called Salpingo-Oophoritis. It develops when staphylococci, streptococci, colon bacilli, gonococci, tubercle bacilli or other pathogens enter into fallopian tubes and the ovaries.

77. A parturient woman complains of pain in her mammary gland. In the painful area there is an infiltration 3x4 cm in size with softened center. Body temperature is 38,5oC. What is the most likely diagnosis?

Explanation

 

Acute suppurative mastitis is a bacterial infection of the mammary gland. It occurs mostly in pregnant or postpartum women; due to lactation, the nipples present with some erosions and are increased in size making it easier for bacterial entrance. This infection is characterised by the production of purulent exudates.

78. A 29-year-old woman came to a gynecologist with complaints of irritability, tearfulness, headache, nausea, occasional vomiting, pain in the heart area, tachycardia attacks, memory impairment, meteorism. These signs appear 6 days before menstruation and disappear the day before menstruation or during its first 2 days. On vaginal examination: the uterus and uterine appendages are without alterations. What diagnosis is the most likely?

Explanation

 

Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc.

79. A primigravida at the term of 20 weeks complains of pain in her lower abdomen, smearing blood-streaked discharge from the genital tracts. Uterine tone is increased, fetus is mobile. On vaginal examination: the uterus is enlarged according to the term, uterine cervix is shortened to 0,5 cm, external cervical orifice is open by 2 cm. What is the most likely diagnosis?

Explanation

 

Abortion refers to the termination of a pregnancy before 22 weeks of gestation or before 500 grams of fetal weight. Early arbortion occurs before 12 weeks of gestation while late abortion takes place between 12-22 weeks. The above patient experiences an increased uterine tone, pain, bleeding, shortened cervix all of which are indicating a risk of abortion accompanied with hemmorhage. An incomplete abortion is observed when there is retention of some of the products of conception in  the uterus eg the placenta.

80. Vaginal examination reveals the head of the fetus, which fills the posterior surface of symphysis pubis and hollow of the sacrum. The lower edge of symphysis pubis, ischiadic spines, and sacrococcygeal joint can be palpated. Where in the lesser pelvis is the fetal head situated?

Explanation

81. A 30-year-old multigravida has been in labour for 18 hours. 2 hours ago the pushing stage began. Fetal heart rate is clear, rhythmic, 136/min. Vaginal examination reveals complete cervical dilatation, the fetal head in the pelvic outlet plane. Sagittal suture is in line with obstetric conjugate, the occipital fontanel is near the pubis. The patient has been diagnosed with primary uterine inertia. What is the further tactics of labour management?

Explanation

UTERINE INERTIA  (“Failure to progress”, hypotonic uterine dysfunction) describes lack of progressive cervical dilatation and/or descent of the fetus.  It is such a condition in which uterine contractions strength, duration and frequency are inadequate, that’s why cervical effacement, dilation and fetal descending is slower than in normal labor. Since the baby’s head is already in the pelvic outlet plane and cant proceed further due to inadequate contractions, an outlet forceps is used in assisting delivery.

 

Labour stimulation will occur in situations such as post-datism, premature rupture of membranes etc. Cesarean session in cases of severe preeclampsia, eclampsia, breech or fetal distress.

82. A 20-year-old woman on the 10th day after her discharge from the maternity ward developed fever up to 39oC and pain in her left mammary gland. On examination the mammary gland is enlarged, in its upper outer quadrant there is a hyperemic area. In this area a dense spot with blurred margins can be palpated. The patient presents with lactostasis and no fluctuation. Lymph nodes in the right axillary crease are enlarged and painful. Specify the correct diagnosis:

Explanation

 

Realise that the patient’s breasts are swollen, hyperemic and painful on palpation and this occurs a few days after discharge from the maternity ward; this is a case of lactational mastitis which refers to a woman’s breast becoming swollen, red and painful during lactation. It occurs due to breast trauma, (poor milk drainage (as seen in this case ‘lactostasis’) etc.

83. A 46-year-old woman came to a maternity clinic with complaints of moderate blood discharge from the vagina, which developed after the menstruation delay of 1,5 months. On vaginal examination: the cervix is clean; the uterus is not enlarged, mobile, painless; appendages without changes. Make the diagnosis:

Explanation

 A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism.

 

The dysfunctional uterine bleeding can appear at any age. Depending on the time of their onset, juvenile bleeding (at child age and in period of pubescence), bleeding of reproductive period, climacteric bleeding are classified. DUB are the manifestations of initial stages of neuroendocrinological diseases, especially of blood diseases. Realise that from physical examination the cervix is clean, the uterus is not enlarged and shows no pathologic changes.

84. A 30-year-old woman complains of amenorrhea that lasts for 2 years after she has given birth, loss of hair and body weight. The labor was complicated with hemorrhage caused by uterine hypotonia. Objectively the patient is of asthenic type, her external genitalia are hypoplastic, the uterine body is small in size and painless. No uterine appendages can be detected. What is the most likely diagnosis?

Explanation

 

Notice that the woman in question gave birth about a year ago and experienced a severe blood loss during delivery; this is the leading cause of sheehan’s syndrome. Sheehan’s syndrome is one of the major causes of hypopituitarism in females; it is due to pituitary infarction as a result of postpartum hemorrhage.  fatigability, significant weight loss, weakness, and loss of appetite all include associated symptoms.

85. A 28-year-old woman complains of increased intervals between menstruations, up to 2 months, and hirsutism. Gynecological examination revealed the following: ovaries are enlarged, painless, and dense; no alterations of the uterus. US of the lesser pelvis: ovaries are 4-5 cm in diameter, with numerous enlarged follicles on the periphery. X-ray of the skull base: sellar region is widened. What is the most likely diagnosis?

Explanation

Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation; the result of ultrasound, confirms the polycystic ovary pathology.

Algodysmennhorhea is characterised by painful menstruation or menstrual cramps during menstruation.

 

Premenstrual syndrome is a group of symptoms females usually  experience a week or two before menstruation.

86. A 37-year-old woman complains of acute pain in the genital area, swelling of the labia, pain when walking. Objectively: body temperature is 38,7oC, Ps- 98/min. In the interior of the right labia there is a dense, painful tumor-like formation 5,0x4,5 cm in size, the skin and mucous membrane of genitals are hyperemic, there is profuse foul-smelling discharge. What is the most likely diagnosis?

Explanation

Bartholin's glands are located at the openings of the vagina (left and right sides). The Bartholin’s glands are on each side of the vaginal opening. They’re about the size of a pea. They make fluid that keeps the vagina moist.

Acute bartholinitis is a disease usually seen in women in the period of genital activity. Its occurrence in a prepubertal child is an extremely rare event. Bartholinitis is an inflammation of Bartholin’s gland (large gland of vaginal vestibule). It may be caused by Staphylococcus, E.coli and N. gonorrhoeae.. There can be serous, serous-purulent, or purulent inflam­mation. It can manifest as acute, painful unilateral labial swelling, Dyspareunia, Pain with walking and sitting. 

 

Bartholinitis and bartholin cyst are used interchangeably but most cysts are caused by the blockade of the ductal path of the gland leading to an accumulation of its contents. Patients with cysts may present with painless labial swelling.

87. The left hand of a newborn is extended in all its joints, stretched along the torso, and pronated in the forearm. Active movements of the shoulder joint are retained. The hand is flattened, atrophied, cold to touch, hangs passively. Grasping and Babkin’s reflexes are absent at the affected side. Hemogram indicators are normal. Make the most likely diagnosis:

Explanation

 

An obstetrical paralysis is a form of paralysis that occurs during birth due to an injury to the nerves of the brachial plexus. Observe that the proximal parts of the baby’s arm are with no defect and this pathology affects the distal arm ‘The hand is flattened, atrophied, cold to touch, hangs passively. Grasping and Babkin’s reflexes are absent at the affected side’. This indicates an obstetrical paralysis affecting the distal area of the arm.

88. A 14-year-old girl has been delivered to a gynecological department with complaints of profuse blood discharge from her genital tract for 2 weeks. Anamnesis: menstruation since 13, irregular, painful, profuse; the last one was 2 months ago. Objectively: pale skin and mucosa, BP- 100/60 mm Hg, Hb- 108 g/l. The abdomen is soft and painless on palpation. Rectal examination revealed no pathologies of reproductive organs. What condition is it?

Explanation

Notice that the patient above experiences abnormal blood discharge with no reproductive organ pathology; this indicates a case of Dysfunctional Uterine bleeding ( juvenile form- since it occurs at child age and in period of pubescence). A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism. In hypo menstrual syndrome, light or scanty menstrual flow is experienced.
89. A man came to an urologist with complains of painful urination, discharge from urethra. The patient has been suffering from this condition for a week. Objectively: hyperemic urinary meatus, edema, purulent discharge. Microscopy of smears detected gram negative bacteria. Specify the diagnosis:

Explanation

 

Results from the microscopy of smears coupled with the complaints of painful urination and discharge indicates an infection by Neisseria gonorrhoeae ( a gram negative diplococci). The result from the bacteria smear presentation rules out the options of Chlamydia, candida and trichomonas. The infection is an acute one since the individual has only experienced it for about a week.

90. A 35-year-old woman has gained 20 kg weight within a year with the normal diet. She complains of chills, sleepiness, shortness of breath. The patient’s mother and sister are corpulent. Objectively: height - 160 cm, weight - 92 kg, BMI- 35,9. Obesity is uniform, there are no striae. The face is amimic. The skin is dry. The tongue is thickened. Heart sounds are muffled. HR- 56/min, BP- 140/100mm Hg. The patient has been suffering from amenorrhea for 5 months, has constipations. TSH- 28 mcIU/l (norm is 0,32-5). Craniogram shows no pathology. What is the etiology of obesity?

Explanation

91. A multigravida at 39 weeks of gestation presenting with regular labour activity for  8 hours has been delivered to a hospital; the waters broke an hour ago. She complains of headache, seeing spots. BP is 180/100 mm Hg. Urine test results: protein - 3,3 g/l, hyaline cylinders. Fetal heart rate is 140/min, rhythmical. Vaginal examination reveals complete cervical dilatation, the fetal head is on the pelvic floor, sagittal suture is in line with obstetric conjugate, the occipital fontanel is under the pubis. What is the optimal tactics of labour management?

Explanation

An outlet forceps is used in assisting delivery when the fetal head has reached the perineal floor and its scalp is visible between contractions. This type of assisted delivery is performed only when the fetal head is in a straight forward or backward vertex position or in slight rotation (less than 45 degrees to the right or left) from one of these positions.
92. An 18-year-old woman complains of pain in her lower abdomen, profuse purulent discharge from the vagina, temperature rise up to 37,8oC. Anamnesis states that she had a random sexual contact the day before the signs appeared. She was diagnosed with acute bilateral adnexitis. On additional examination: leukocytes are present throughout all vision field, bacteria, diplococci with intracellular and extracellular position. What is the most likely agent in the given case?

Explanation

 

The options of N. Gonorrhoeae, S. Aureus, Trichomonas and chlamydia can all lead to an Adnexitis which refers to a disease of the female genital organs that causes inflammation of the uterus, ovaries and fallopian tubes. Note that on further examination, , diplococci with intracellular and extracellular position were found- this characteristic is typical for N. gonorrhea which is a gram negative diplococci.

93. A 6-year-old girl came to a general practitioner with her mother. The child complains of burning pain and itching in her external genitalia. The girl was taking antibiotics the day before due to her suffering from acute bronchitis. On examination: external genitalia are swollen, hyperemic, there is white deposit accumulated in the folds. The most likely disgnosis is:

Explanation

Candidal vulvovaginitis is also known as vaginal thrush or vaginal yeast infection. It is characterised by very severe vaginal itching, burning sensation while urinating, pain during sex, hyperemic vagina and a thick white vaginal discharge. It occurs due to excessive growth of vaginal candida. Note that Trichomoniasis secretion is usually yellowish-green in colour
94. A 22-year-old woman complains of amenorrhea for 8 months. Anamnesis states that menarche occured at the age of 12,5. Since the age of 18 the patient has a history of irregular menstruation. The patient is nulligravida. The mammary glands are developed properly, nipples discharge drops of milk when pressed. Hormone test: prolactin level is 2 times higher than normal. CT reveals a bulky formation with diameter of 4 mm in the region of sella. What is the most likely diagnosis?

Explanation

Notice that the result of the CT shows a bulky mass in the sella; anatomically, the pituitary gland is located in the sella turcica of the sphenoid bone and a bulky formation of such diameter in this location indicates the presence of a tumour. Furthermore, Prolactin levels are twice the normal; this hormone is produced from lactotrophs present in the anterior pituitary gland. The increased production is mostly as a result of the tumour.

 

Lactational amenorrhea is observed in breastfeeding mothers; the period after child birth in which the lactating mother doesn't menstruate.

95. A 14-year-old girl came to a general practitioner with complaints of weakness, loss of appetite, headache, rapid fatigability. Her last menstruation was profuse and lasted for 14 days after previous delay of 2 months. Objectively: the skin is pale, heart rate is 90/min., BP is 110/70 mm Hg, Hb is 88 g/l. Rectal examination: the uterus and its appendages are without changes, no discharge from the genital tracts. What complication occurred in the patient?

Explanation

From anamnesis, we see that the patient experienced a prolonged Menstrual cycle characterized by profuse blood discharge; the current state of the patient (pale skin, fatigue etc) is due to the amount of blood already lost. A post hemorrhagic anemia is a condition in which a person loses lots of hemoglobin and RBCs due to blood loss. It is usually seen in cases of trauma, severe injuries etc.

 

In Somatoform Autonomic dysfunction, the symptoms are presented by the patient as if they were due to a physical disorder of a system or organ that is largely or completely under autonomic innervation and control, i.e. the cardiovascular, gastrointestinal, respiratory, and  urogenital systems.

96. Examination of a Rh-negative pregnant woman at 32 weeks of gestation revealed a four-time rise of Rh-antibody titer within 2 last weeks; the titer is 1:64. The first two pregnancies resulted in antenatal fetal death due to hemolytic disease. What is the optimal tactics of pregnancy management?

Explanation

 

Rh Antibody Titre test is done to determine the type and quantity of antibodies in the blood. Rh antibodies are likely to rise during pregnancy. Depending on the level of other antibodies these antibodies could cause hemolytic problems in the baby and need to be monitored. It is usually repeated several times during pregnancy (at 32, 36, & 38 weeks). A low titer (less than 1:16) may not pose any problem for the baby.  any test from 1:64 or higher, is indicative of incompatibility. Notice that the patient has previously had 2 fetal deaths from this incompatibility, to save the current situation, an early delivery should be induced.

97. A woman is on the 32nd week of her second pregnancy. She complains of fever, chills, nausea, vomiting, lumbar pain, and dysuria. Costovertebral angle tenderness is present on both sides. Urine analysis: pyuria, bacteriuria. Blood test: leukocytosis. What is the most likely diagnosis?

Explanation

Gestational pyelonephritis is a urinary tract infection that occurs in pregnant women. It is caused by bacteria that is why on blood analysis, we see leukocyturia. It is also accompanied by signs of pyelonephritis which include dysuria, lumbar pain, fever etc

 

Cystitis is an inflammation of the bladder, characterised by frequent urge to urinate, blood in urine, pain during intercourse etc. Pyelitis is an inflammation of the renal pelvis.

98. A pregnant woman is 28 years old. Anamnesis: accelerated labor complicated by the II degree cervical rupture. The following two pregnancies resulted in spontaneous abortions at the terms of 12 and 14 weeks. On mirror examination: the uterine cervix is scarred from previous ruptures at 9 and 3 hours, the cervical canal is gaping. On vaginal examination: the cervix is 2 cm long, the external orifice is open 1 cm wide, the internal orifice is half-open; the uterus is enlarged to the 12th week of pregnancy, soft, mobile, painless, the appendages are without changes. What diagnosis would you make?

Explanation

Realise that this patient is experiencing cervical changes that are more advanced in respect ( corresponding) to the duration of pregnancy. The word ‘gaping’ indicates that the walls of the cervix is weak and from vaginal examination, we observe the dilation and effacement of the cervix. Note that these changes are not due ( In a normal pregnancy, dilation and effacement occurs in response to uterine contractions). These changes in the cervix are typically seen in a condition termed ‘cervical weakness’ or ‘cervical insufficiency’ ie., cervical dilation and effacement occurring in preterm pregnancy. 

A cervical pregnancy usually terminates during the first trimester and occurs when implantation takes place in the cervix.

 

Incipient abortion is a form of spontaenous abortion. It refers to the non induced fetal death before 20 weeks of gestation.

99. A 26-year-old secundipara at 40 weeks of gestation arrived at a maternity ward after the beginning of labor activity. The bursting of waters occurred 2 hours prior. The fetus was in a longitudinal lie with cephalic presentation. Abdominal circumference was 100 cm, fundal height - 42 cm. Contractions occurred every 4-5 minutes and lasted 25 seconds each. Internal obstetric examination revealed cervical effacement, opening by 4 cm. Fetal bladder was absent. Fetal head was pressed against the pelvic inlet. What complication arose in the childbirth?

Explanation

Recall that labour physiologically is divided into 3 stages; 

In the first stage the cervix opens to full dilation to allow the head to pass through  The second stage is from full dilation to delivery of the fetus. The third stage lasts from delivery of the fetus to delivery of the placenta. Labor often lasts between 12 and 14 hours – or longer – for first-time mothers, but is usually shorter in subsequent births.

The 1st stage—is the longest stage of labor, and is divided into three separate phases:

The early ( latent) phase-  averaging 8 1 ⁄2 h in nulliparas and 5 h in multiparas; duration is considered abnormal if it lasts > 20 h in nulliparas or > 12 h in multiparas.

Active labor (the active phase)-  here, the cervix dilates to 7cm.  On average, the active phase lasts 5 to 7 h in nulliparas and 2 to 4 h in multiparas. The cervix should dilate 1.2 cm/h in nulliparas and 1.5 cm/h in multiparas.

Transition. The cervix dilates from 7 centimeters to 10 centimeters. This is usually the shortest stage of labor, but is often the most unpleasant. 

If a woman's “water ―breaking” occurs in the first stage before/ until the active phase, it is called early amniorrhea. 

 

In Primary uterine inertia, uterine contractions fail to be initiated while in the secondary form, uterine inertia ceases in between labor ( before completion)

100. A 26-year-old woman, who gave birth 7 months ago, has been suffering from nausea, morning sickness, somnolence for the last 2 weeks. The patient breasfeeds; no menstruation. She has been using no means of contraception. What method would be most efficient in clarification of the diagnosis?

Explanation

101. A 30-year-old parturient woman was delivered to a maternity hospital with full-term pregnancy. She complains of severe lancinating pain in the uterus that started 1 hour ago, nausea, vomiting, cold sweat. Anamnesis states cesarean section 2 years ago. Uterine contractions stopped. Skin and mucous membranes are pale. Heart rate is 100/min., BP is 90/60 mm Hg. Uterus has no clear margins, is sharply painful. No heartbeat can be auscultated in the fetus. Moderate bloody discharge from the uterus can be observed. Uterus cervix is 4 cm open. Presenting part is not visible. The most likely diagnosis is:

Explanation

102. A parturient woman is 23 years old. Internal obstetric examination shows the uterine cervix to be completely open. Fetal bladder is absent. Cephalic presentation is observed in the plane of the small pelvic outlet. Sagittal suture is at the longitudinal section of the small pelvic outlet, small fontanel is situated closer to the uterus. What cephalic position will the newborn have during birth in this case?

Explanation

103. During the dynamic observation of a parturient woman in the second stage of labor it was registered that the fetal heart rate decreased to 90-100/min. and did not normalize after contractions. Vaginal examination revealed the complete cervical dilatation, the fetal head filling the entire posterior surface of the pubic symphysis and sacral hollow; the sagittal suture was in the anteroposterior diameter of the pelvic outlet, the posterior fontanelle was in front under the pubic arch. What plan for further labour management should be recommended?

Explanation

104. A 27-year-old sexually active woman complains of numerous vesicles on the right sex lip, itch and burning. Eruptions regularly appear before menstruation and disappear 8-10 days later. What is the most likely diagnosis?

Explanation

Herpes simplex viruses are enveloped double stranded linear viruses. HSV-1 is also known as oral herpes ( gingivostomatitis, keratoconjunctivitis etc) while HSV-2 is known as genital or neonatal herpes. The clinical presentation of genital herpes include  pain, itching, dysuria, vaginal and urethral discharge, tender lymphadenopathy, appearance of herpes vesicles on the  external genitalia, labia majora, labia minora, vaginal vestibule - for women and glans penis, the prepuce, the shaft of the penis, and sometimes on the scrotum, thighs, and buttocks- for men.

Primary syphilis usually presents with a localized painless hard chancre on the genitals.

Cytomegalovirus is also known as human herpes virus-5, it is usually seen in immunocompromised patients and infected cells have characteristic ‘ owl's eye’ intranuclear inclusions.
105. A 35-year-old woman addressed a gynecological inpatient department with complaints of regular pains in her lower abdomen, which increase during menstruation, and dark-brown sticky discharge from the genital tracts. On bimanual examination: the uterine body is slightly enlarged, the appendages are not palpated. Mirror examination of the uterine cervix reveals bluish spots. What diagnosis is most likely?

Explanation

106. A baby was born by a young smoker. The labour was complicated by uterine inertia, difficult delivery of the baby’s head and shoulders. The baby’s Apgar score was 4. Which of the following is a risk factor for a spinal cord injury?

Explanation

107. A 25-year-old woman complains of menstruation retention lasting for 3 years. The patient explains it by a difficult childbirth complicated with profuse hemorrhage, weight loss, brittleness and loss of hair, loss of appetite, depression. Objective examination reveals no pathologic changes of uterus and uterine appendages. What pathogenesis is characteristic of this disorder?

Explanation

Gonadotropin ( luteinizing hormone and follicle stimulating hormone) are hormones that act on the gonads and stimulate the production of sperm ( in males) and ovaries ( in females). LH stimulates the Leydig cells of the testes and the theca cells of the ovaries to produce testosterone (and indirectly estradiol), whereas FSH stimulates the spermatogenic tissue of the testes and the granulosa cells of ovarian follicles, as well as stimulating production of estrogen by the ovaries. Follicle stimulating hormone stimulates the growth of the ovarian follicles thereby enhancing ovulation and menstruation. This patient has problems relating to menstruation and childbirth; a reduction in FSH is most likely the reason behind these changes.

 

Estrogen is the primary female sex hormone produced in the ovaries and a little from the placenta. It is responsible for puberty changes in females. Progesterone is also a sex hormone, produced from the corpus luteum in the ovaries, just like estrogen, it is involved in changes during pregnancy, menstruation, embryogenesis etc. Note that from examination, there were no pathologic changes of uterus and uterine appendages; this statement rules out the option of estrogen and progesterone ( if these hormones were responsible, there will be a change in uterine appendages eg in the ovaries).

108. A 26-year-old woman has attended maternity center complaining of her inability to become pregnant despite 3 years of regular sex life. Examination revealed the following: increased body weight; male-type pubic hair; excessive pilosis of thighs; ovaries are dense and enlarged; basal body temperature is monophasic. The most likely diagnosis is:

Explanation

Also called Stein- Leventhal syndrome, Ovarian sclerocytosis is the process of ovarian regeneration, accompanied by the formation of small cystic formations up to 1 cm in size. It usually occurs in patients with polycystic ovarian syndrome. Key findings include; infertility, male pattern hair distribution, weight loss, hormonal disbalance, bilateral enlargement of the ovaries, violation of menstrual cycle etc. 

Adrenogenital syndrome ( congenital adrenal hyperplasia) is a condition characterized by the enlargement of the adrenal gland coupled with the excess production of androgens (sex hormones).

 

Premenstrual syndrome usually occurs just before a woman’s menses and is characterised by emotional, physical and behavioural changes.

109. A woman addressed a gynecologist on the 20th day of puerperal period with complaints of pain in the left mammary gland, puruent discharge from the nipple. Objectively: Ps- 120/min., body temperature is 39oC. The left mammary gland is painful, larger than the right one, the skin there is hyperemic; in the upper quadrant there is an infiltrate 10x15cm in size with soft center. Blood test: ESR-50 mm/hour, leukocytes - 15, 0 · 109/l. What would be the treatment tactics?

Explanation

In the left mammary gland, we observe the presence of purulent discharge, and presence of a mass. From the above description, this woman should be  taken to the surgical department for the drainage of the purulent content and removal of the infiltrate/ mass. A conservative treatment will not be possible at this stage because of the present size of the infiltrate.

 
110. A patient with fibromyoma of uterus sized up to 8-9 weeks of pregnancy consulted a gynaecologist about acute pain in the lower abdomen. Examination revealed pronounced positive symptoms of peritoneal irritation, high leukocytosis. Vaginal examination revealed that the uterus was enlarged corresponding to 9 weeks of pregnancy due to the fibromatous nodes, one of which was mobile and extremely painful. Appendages were not palpable. There were moderate mucous discharges. What is the optimal treatment tactics?

Explanation

From vaginal examination, we observe the presence of a very large fibroid mass that causes the enlargement of the uterus and is responsible for the severe pain the woman is experiencing and the mucous discharge. Coupled with the positive symptom of peritoneal  irritation (which indicates peritonitis), this patient is in need of an urgent surgical procedure.
111. An 18-year-old woman complains of pains in her lower abdomen, purulent discharge from the vagina, temperature rise up to 37, 8oC. Anamnesis states that she had random sexual contact the day before the signs appeared. She was diagnosed with acute bilateral adnexitis. On additional examination: leukocytes in the all field of vision, bacteria, diplococci with intracellular and extracellular position. What agent is most likely in the given case?

Explanation

 

All of the above listed options can lead to an Adnexitis which refers to a disease of the female genital organs that causes inflammation of the uterus, ovaries and fallopian tubes. Note that on further examination, , diplococci with intracellular and extracellular position were found- this characteristic is typical for N. gonorrhea which is a gram negative diplococci.

112. During a regular check-up of a 50-year-old woman a tumor was detected in her right mammary gland. The tumor is 5 cm in diameter, dense, without clear margins. The skin over the tumor resembles lemon rind, the nipple is inverted. The lymph node can be palpated in the axillary region. What diagnosis is most likely?

Explanation

 

From physical examination, there is a dense tumor ‘without clear margins’ in the right mammary gland - this description is typical for breast cancer. Signs of breast cancer include; presence of lumps in the breast, change in size and shape of the breast, skin depression in the affected area, swollen lymph nodes etc.

A breast lipoma is a non-cancerous tumor (benign) tumor composed of adipose ( fatty) tissues with a thin fibrous capsule around it. These types of tumors have clear margins. 

A lacteal cyst is also called galactocele; usually seen shortly after lactation and is characterised the presence of a milk filled  cavity

113. A maternity patient breastfeeding for 1,5 weeks has attended a doctor. She considers the onset of her disease to be when proportional breast engorgement occurred. Mammary glands are painful. Body temperature is 36, 6oC. Expression of breast milk is hindered. The most likely diagnosis is:

Explanation

They key finding here is “ the expression of breastmilk is hindered” - this refers to a stagnation in the flow of milk in one or several lobes of the mammary gland leading to an enlarged and painful mammary gland; if not corrected, this leads to mastitis ( is an inflammation (most often one-sided) of the mammary gland caused by pathogenic coccal flora (most often by staphylococci)).
114. 13 months after the first labor a 24-year-old patient complained of amenorrhea. Pregnancy ended in Caesarian section because of premature detachment of normally positioned placenta which resulted in blood loss at the rate of 2000 ml due to disturbance of blood clotting. Choose the most suitable investigation:

Explanation

The menstrual cycle is regulated by a group of hormones namely; follicle stimulating hormones, luteinizing hormones (both referred to as the major gonadotropins); other hormones include the female sex hormones estrogen and progesterone. From the above listed options, estimation of the gonadotropin rate will be the suitable investigation in finding the reason behind the amenorrhea.

FSH- is activated by the gonadotropin releasing hormones from the hypothalamus. FSH is produced in the anterior lobe of the pituitary gland  and its production is increased in the first half of the menstrual cycle. It stimulates the recruitment and maturation of oocytes. 

 

LH- is also released by the anterior lobe of the pituitary and initiates ovulation.  Ovulation takes place 36 hours after the LH surge. 

115. A 24-year-old primipara was hospitalised with complaints of discharge of the amniotic waters. The uterus is tonic on palpation. The position of the fetus is longitudinal, it is pressed with the head to pelvic outlet. Palpitation of the fetus is rhythmical, 140 bpm, auscultated on the left below the navel. Internal examination: cervix of the uterus is 2,5 cm long, dense, the external opening is closed, light amniotic waters are discharged. Point out the correct component of the diagnosis:

Explanation

The above patient is experiencing a preterm/prelabor rupture of membrane. Refers to the escape/leakage of amniotic fluid from the ruptured fetal membrane. It can be Preterm (occurs after 28 weeks of gestational age and before 37 weeks) or Term ( occurs after 37 completed weeks of gestational age, including post-term cases occurring after 40 weeks). From the above listed signs, the antenatal discharge of amniotic fluid is the key in diagnosis because in this case, it indicates the woman is about to enter the first stage of labor.
116. A primagravida with pregnancy of 37-38 weeks complains of headache, nausea, pain in epigastrium. Objectively: the skin is acyanotic. Face is hydropic, there is short fibrillar twitching of blepharons, muscles of the face and the inferior extremities. The stare is fixed. BP- 200/110 mm Hg; sphygmus is of 92 bpm, intense. Respiration rate is 32/min. Heart activity is rhythmical. Appreciable edemas of the inferior extremities are present. Urine is cloudy. What medication should be administered?

Explanation

 

The patient in perspective is pregnant and thus drug selection should be done carefully. Dibazolum is contraindicated in pregnant and lactating mothers while Papaverine has not been cleared as a safe drug to administer during pregnancy. Droperidol is a drug that has sedative, tranquilizing and antipsychotic effects and is marked safe to use during pregnancy. Notice that the patient experiences twitching of the facial muscles, Droperidol can act as a relaxant in this case coupled with having an anti nausea effect.

117. A 25-year-old female patient complains of marked weakness, sleepiness, blackouts, dizziness, taste disorder. The patient has a history of menorrhagia. Objectively: the patient has marked weakness, pale skin, cracks in the corners of her mouth, peeling nails, systolic apical murmur. Blood test results: RBC- 3, 4 · 1012/l, Hb- 70 g/l, colour index - 0,75, platelets - 140 · 109/l, WBC- 6, 2 · 109/l. What is the most likely diagnosis?

Explanation

 

From anamnesis, we see that the patient has a history of menorrhagia; the current state of the patient (pale skin, fatigue etc) is due to the amount of blood already lost. A post hemorrhagic anemia is a condition in which a person loses lots of hemoglobin and RBCs due to blood loss. It is usually seen in cases of trauma, severe injuries etc. A chronic form is seen in patients with moderate or prolonged occurrence of bleeding eg, gastric ulcers, menorrhagia, hemophilia etc while an acute form is seen in short term events such as trauma.

118. A 59-year-old female patient attended a maternity welfare clinic with complains of bloody discharge from the genital tracts. Postmenopause is 12 years. Vaginal examination revealed that external genital organs had signs of age involution, uterus cervix was not erosive, small amount of bloody discharge came from the cervical canal. Uterus is of normal size, uterine appendages are unpalpable. Fornices were deep and painless. What method should be applied for the diagnosis specification?

Explanation

Diagnostic dilation and curettage is typically employed to assess endometrial histology. Indications include; Abnormal uterine bleeding, biopsy and sampling, Evaluation and removal of retained fluid from the endometrial cavity, etc.

 

For many gynecologic procedures, such as removal of an ectopic pregnancy, treatment of endometriosis, ,ovarian cystectomy and hysterectomy, laparoscopy has become the treatment of choice. Colposcopy is a procedure in which a colposcope is used in examining the vagina, cervix and vulva. Culdoscopy is used in examining the rectouterine pouch and organs of the pelvis.

119. After examination a 46-year-old patient was diagnosed with left breast cancer T2N2M0, clinical group II-a. What will be the treatment plan for this patient?

Explanation

TNM stands for tumor, node and metastasis respectively, Tumour describes the size of the tumour (area of cancer). T1 means that the tumour is 2 centimetres (cm) across or less.T2 means that the tumour is more than 2 centimetres but no more than 5 centimetres across, T3 means the tumour is bigger than 5 centimetres across while T4 is even bigger in size, it is further divided into various stages.

Node (N) describes whether the cancer has spread to the lymph nodes.

NX means that the lymph nodes can't be assessed (for example, if they were previously removed). N0 means there are no cancer cells in any nearby nodes. N1 means cancer cells are in the lymph nodes in the armpit but the nodes are not stuck to surrounding tissues.
120. A 28-year-old woman has bursting pain in the lower abdomen during menstruation; chocolate-like discharges from vagina are observed. It is known from the anamnesis that the patient suffers from chronic adnexitis. Bimanual examination revealed a tumour-like formation of heterogenous consistency 7х7 cm large to the left from the uterus. The formation is restrictedly movable, painful when moved. What is the most probable diagnosis?

Explanation

 

Endometrial cyst or endometrioma also called chocolate-like cyst is a form of endometriosis ( a condition in which the lining of the uterus ie., the endometrium grows outside the uterus). They are characterised by fluid filled cavities usually dark brown or chocolate in color; this color feature is gotten from old menstrual blood. Recall that a cyst is a fluid formed cavity and from bimanual examination, the cavity was found from which the chocolate like discharge can be traced. Note that follicular cysts are painless and harmless and usually resolve on its own.

121. A woman consulted a therapeutist about fatigability, significant weight loss, weakness, loss of appetite. She has been having amenorrhea for 8 months. A year ago she born a full-term child. Haemorrhage during labour made up 2 l. She got blood and blood substitute transfusions. What is the most probable diagnosis?

Explanation

 

Notice that the woman in question gave birth about a year ago and experienced a severe blood loss during delivery; this is the leading cause of sheehan’s syndrome. Sheehan’s syndrome is one of the major causes of hypopituitarism in females; it is due to pituitary infarction as a result of postpartum hemorrhage.  fatigability, significant weight loss, weakness, and loss of appetite all include associated symptoms.

122. A 20-year-old parturient woman has the I labor stage. The pregnancy is full-term. Labors occur every 3 minutes and last for 55 seconds. Fetus presentation is polar, the head is pressed to the small pelvis entrance. Heart rate of the fetus is 150/min, distinct and rhythmic. Vagina examination: uterus cervix is smoothed out; mouth of the womb is 2 cm open; fetal bladder is intact; the head is presented over the I plane of small pelvis; moderate mucous-bloody discharge is observed. What phase of the I labor stage is it?

Explanation

The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third combined. The first stage of labor has been divided into three phases: a latent phase, an active phase, and a transition phase. During the latent phase generally ranges from the onset of labor until 3 or 4 cm of dilation and is characterised by slow cervical changes. The Active phase follows the latent phase and expands until 10cm or more of dilation and is characterised by fast cervical changes. 

The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The second stage takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.

The third stage of labor lasts from the birth of the fetus until the placenta is delivered. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born.The duration of the third stage may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits

The fourth stage of labor arbitrarily lasts approximately 2 hours after delivery of the placenta. It is the period of immediate recovery, when homeostasis is reestablished. It serves as an important period of observation for complications, such as abnormal bleeding.

 
123. On the 10th day postpartum a puerperan woman complains of pain and heaviness in the left mammary gland. Body temperature is 38, 8oC, Ps- 94 bpm. The left mammary gland is edematic, the supero-external quadrant of skin is hyperemic. Fluctuation symptom is absent. The nipples discharge drops of milk when pressed. What is a doctor’s further tactics?

Explanation

 

This patient most likely has an infection around the left mammary gland; this expresses itself by the increased temperature, hyperemia in this region and edema. The doctor’s tactics should be to firstly administer an antibiotic  to curl the infection. Recall that this woman is currently breastfeeding; expression of breastmilk refers to manually squeezing out the breast milk for storage and to feed the baby later. This procedure should be carried out in order to prevent the baby from coming in contact with the infected area. The option of opening and drainage of the mammary gland will be carried out in case of purulent discharge from the breast.

124. An Rh-negative woman with 32-week-long term of pregnancy has been examined. It was observed that Rh-antibodies titer had increased four times within the last 2 weeks and was 1:64. First two pregnancies ended in antenatal death of fetus caused by hemolytic disease. What tactics of pregnancy management should be chosen?

Explanation

Rh Antibody Titre test is done to determine the type and quantity of antibodies in the blood. Rh antibodies are likely to rise during pregnancy. Depending on the level of other antibodies these antibodies could cause hemolytic problems in the baby and need to be monitored. It is usually repeated several times during pregnancy (at 32, 36, & 38 weeks). A low titer (less than 1:16) may not pose any problem for the baby.  any test from 1:64 or higher, is indicative of incompatibility. Notice that the patient has previously had 2 fetal deaths from this incompatibility, to save the current situation, an early delivery should be induced.

 
125. A 48-year-old patient was delivered to a hospital in-patient unit with uterine bleeding that occurred after the 2-week-long delay of menstruation. Anamnesis states single birth. Examination of the uterine cervix with mirrors revealed no pathologies. On bimanual examination: uterus is of normal size, painless, mobile; uterine appendages have no changes. Discharge is bloody and copious. What primary hemostatic measure should be taken in the given case?

Explanation

Indication for fractional curettage includes Abnormal uterine bleeding: irregular bleeding, menorrhagia, suspected malignant or premalignant condition,Retained material in the endometrial cavity, Evaluation of intracavitary findings from imaging procedures (abnormal endometrial appearance due to suspected polyps or fibroids),

 

Evaluation and removal of retained fluid from the endometrial cavity (hematometra, pyometra) in conjunction with evaluating the endometrial cavity and relieving cervical stenosis etc. This patient presents with uterine bleeding, the word ‘copious’ means the discharge is abundant ( plenty in quantity).

126. A 30-year-old woman complains of irregular copious painful menstruations, pain irradiates to the rectum. Anamnesis states 10-year-long infertility. On bimanual examination: uterus is of normal size; uterine appendages on the both sides are corded, with rectricted mobility, painful; there are dense nodular painful growths detected in the posterior fornix. A doctor suspects endometriosis. What method allows to verify this diagnosis?

Explanation

127. A 30-year-old woman complains of infertility during her 10-year-long married life. Menstruations occur since she was 14 and are irregular, with delays up to a month and longer. Body mass is excessive. Hirsutism is observed. On bimanual examination: uterine body is decreased in size; ovaries are increased in size, dense, painless, and mobile. The most likely diagnosis is:

Explanation

 

Polycystic ovarian syndrome (Stein–Leventhal syndrome) is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation; the result of bimanual examination, confirms the polycystic ovary pathology.

128. A woman, primagravida, consults a gynecologist on 05.03.2012. A week ago she felt the fetus movements for the first time. Last menstruation was on 10.01.2012. When should she be given maternity leave?

Explanation

129. A 28-year-old parturient complains about headache, vision impairment, psychic inhibition. Objectively: AP-200/110 mm Hg, evident edemata of legs and anterior abdominal wall. Fetus head is in the area of small pelvis. Fetal heartbeats is clear, rhythmic, 190/min. Internal examination revealed complete cervical dilatation, fetus head was in the area of small pelvis. What tactics of labor management should be chosen?

Explanation

130. A secundipara has regular birth activity. Three years ago she had cesarean section for the reason of acute intrauterinen hypoxia. During parodynia she complains of extended pain in the area of postsurgical scar. Objectively: fetus pulse is rhythmic - 140 bpm. Vaginal examination shows 5 cm cervical dilatation. Fetal bladder is intact. What is the tactics of choice?

Explanation

131. A 27-year-old woman presents at the maternity welfare centre because of infertility. She has had sexual life in marriage for 4 years, doesn’t use contraceptives. She hasn’t get pregnant. On examination: genital development is without pathology, uterine tubes are passable, basal (rectal) temperature is one-phase during last 3 menstrual cycles. What is the infertility cause?

Explanation

132. A 25-year-old woman complains of profuse foamy vaginal discharges, foul, burning and itching in genitalia region. She has been ill for a week. Extramarital sexual life. On examination: hyperemia of vaginal mucous, bleeding on touching, foamy leucorrhea in the urethral area. What is the most probable diagnosis?

Explanation

133. A 40 week pregnant secundipara is 28 years old. Contractions are very active. Retraction ring is at the level of navel, the uterus is hypertonic, in form of hourglass. On auscultation the fetal heart sounds are dull, heart rate is 100/min. AP of the parturient woman is 130/80 mm Hg. What is the most likely diagnosis?

Explanation

134. A 25-year-old female patient complains about having amenorrhea for 3 years. She associates it with difficult labour complicated by massive hemorrhage. She also complains of loss of weight, hair fragility and loss, lack of appetite and depression. Objective examination reveals no pathological changes of uterus and its appendages. What is the desease pathogenesis?

Explanation

135. A 28-year-old female patient complains of having haemorrhage from the genital tracts for 1 month. 6 months ago she had natural delivery and gave birth to a girl weighing 3100 g. Objectively: the uterus is enlarged to 9-10 weeks, mobile, painless, of heterogenous consistency. Examination reveals vaginal cyanosis, anaemia and body temperature rise up to 37, 8oC. There is a significant increase in hCG concentration in the urine. What is your provisional diagnosis?

Explanation

136. During self-examination a 22-year-old patient revealed a mammary tumour. Palpation revealed a firm, painless, freely mobile formation up to 2 cm, peripheral lymph nodes were not changed. USI results: in the superior external quadrant of the right mammary gland there was a big formation of increased echogenicity, sized 18x17 mm. The patient was provisionally diagnosed with fibroadenoma. What is a doctor’s further tactics?

Explanation

137. A 54-year-old female patient consulted a doctor about bloody discharges from the genital tracts after 2 years of amenorrhea. USI and bimanual examination revealed no genital pathology. What is the tactics of choice?

Explanation

138. A 68-year-old patient consulted a doctor about a tumour in her left breast. Objectively: in the upper internal quadrant of the left breast there is a neoplasm up to 2,5 cm in diameter, dense, uneven, painless on palpation. Regional lymph nodes are not enlarged. What is the most likely diagnosis?

Explanation

139. 10 minutes after delivery a woman discharged placenta with a tissue defect 5х6 cm large. Discharges from the genital tracts were profuse and bloody. Uterus tonus was low, fundus of uterus was located below the navel. Examination of genital tracts revealed that the uterine cervix, vaginal walls, perineum were intact. There was uterine bleeding with following blood coagulation. Your actions to stop the bleeding:

Explanation

140. A 24-year-old female patient complains of acute pain in the lower abdomen that turned up after a physical stress. She presents with nausea, vomiting, dry mouth and body temperature 36, 6oC. She has a right ovarian cyst in history. Bimanual examination reveals that uterus is dense, painless, of normal size. The left fornix is deep, uterine appendages aren’t palpable, the right fornix is contracted. There is a painful formation on the right of uterus. It’s round, elastic and mobile. It is 7х8 cm large. In blood: leukocytosis with the left shit. What is the most likely diagnosis?

Explanation

141. A parturient woman is 23 years old. Vaginal obstetric examination reveals full cervical dilatation. There is no fetal bladder. Fetal head is in the plane of pelvic outlet. Sagittal suture is in mesati pellic pelvis, anterior fontanel is closer to pubes. The fetal head diameter in such presentation will be:

Explanation

142. A 26-year-old woman complains of having bloody discharges from the genitals for the last 14 days, abdominal pain, general fatiguability, weakness, weight loss, fever, chest pain, obstructed respiration. 5 weeks ago she underwent an induced abortion in the 6-7 week of gestation. Objectively: the patient is pale and inert. Bimanual examination revealed that the uterus was enlarged up to 8-9 weeks of gestation. In blood: Hb - 72 g/l. Urine test for chorionic gonadotropin gave the apparently positive result. What is the most likely diagnosis?

Explanation

143. A 28-years-old woman complains of nausea and vomiting about 10 times per day. She has been found to have body weight loss and xerodermia. The pulse is 100 bpm. Body temperature is 37, 2oC. Diuresis is low. USI shows 5-6 weeks of pregnancy. What is the most likely diagnosis?

Explanation

144. A full-term baby was born with body weight of 3200 g, body length of 50 cm, Apgar score - 8-10 points. What is the optimum time for the first breast-feeding?

Explanation

145. A 22-year-old female patient complains of dull pain in her right iliac area that she has been experiencing for a week, morning sickness and gustatory change. She has a histrory of menstruation delay for 3 weeks. Objectively: AP-80/50 mm Hg, pulse is 78 bpm, body temperature is 37oC. Bimanual examination reveals that uterus is enlarged, soft, mobile and painless. Uterine appendages are palpable on the right, there is a dense, elastic and moderately painful formation 3x4 cm large. What is the most likely diagnosis?

Explanation

146. A 32-year-old gravida complains of episodes of unconsciousness, spontaneous syncopes that are quickly over after a change of body position. A syncope can be accompanied by quickly elapsing bradycardia. There are no other complications of gestation. What is the most likely reason for such condition?

Explanation

147. An ambulance delivered a 21-year-old woman to the gynaecological department with complaints of colicky abdominal pain and bloody discharges from the genital tracts. Bimanual examination revealed that uterus was soft,   enlarged to the size of 6 weeks of gestation, a gestational sac was palpated in the cervical canal. Uterine appendages weren’t palpable. Fornices are free, deep and painless. Discharges from the genital tracts are bloody and profuse. What is the most likely diagnosis?

Explanation

148. On the fifth day after a casual sexual contact a 25-year-old female patient consulted a doctor about purulent discharges from the genital tracts and itch. Vaginal examination showed that vaginal part of uterine cervix was hyperemic and edematic. There was an erosive area around the external orifice of uterus. There were mucopurulent profuse discharges from the cervical canal, uterine body and appendages exhibited no changes. Bacterioscopic examination revealed bean-shaped diplococci that became red after Gram’s staining. What is the most likely diagnosis?

Explanation

149. A parturient woman is 25 years old, it is her second day of postpartum period. It was her first full-term uncomplicated labour. The lochia should be:

Explanation

150. A pregnant woman was delivered to the gynecological unit with complaints of pain in the lower abdomen and insignificant bloody discharges from the genital tracts for 3 hours. Last menstruation was 3 months ago. Vaginal examination showed that body of womb was in the 10th week of gestation, a fingertip could be inserted into the external orifice of uterus, bloody discharges were insignificant. USI showed small vesicles in the uterine cavity. What is the most likely diagnosis?

Explanation

151. A primigravida is 22 years old. She has Rh(-), her husband has Rh(+). Anti-bodies to Rh weren’t found at 32 weeks of pregnancy. Redetermination of antibodies to Rh didn’t reveal them at 35 weeks of pregnancy as well. How often should the antibodies be determined hereafter?

Explanation

152. A 14-year-old girl complains of pain in vaginal area and lower abdomen that last for 3-4 days and have been observed for 3 months about the same time. Each time pain is getting worse. Objectively: mammary glands are developed, hairiness corresponds to the age. The virginal membrane is intact, cyanotic and protruded. She has never had menstruation. She has been diagnosed with primary amenorrhea. What is the reason of amenorrhea?

Explanation