Nagy's favorite questions

Question: First stages after conception and how many cells?

Zygote → cleavage → morula → blastocyst → implantation.

Cell number: zygote = 1 cell → 2-cell stage → 4-cell stage → 8-cell stage → morula = about 16-32 cells → blastocyst = about 100 cells.

O2. Obstetric and gynecologic evaluation

Question: Routine exams

Colposcopy, cytology, bimanual exam, breast exam.

Question: History taking

Previous operations, medication allergies, obstetric anamnesis, illnesses/drugs, first day of last menstrual period.

Question: Naegele's rule

If cycles are regular and 28 days: LMP + 7 days - 3 months. Example: 20 Sept → 27 June.

O3. Endocrinology of pregnancy and parturition

Question: Hormone responsible for starting onset of labor

Fetal cortisol.

Question: List hormonal changes in pregnancy

Increased prolactin, hCG, oxytocin, cortisol/ACTH and total thyroid hormone; free T3/T4 and TSH remain unchanged in the examiner note; increased BMR.

O5. Human genome and genetic testing

Question: Which patients would you send for genetic testing?

High-risk patients, previous pregnancy with aneuploidy or other abnormalities; diabetes/HbA1c was specifically mentioned in the source.

O6. Physiologic changes in pregnancy - cardiovascular/respiratory

Question: Physiological changes in pregnancy, CV changes

Heart rate, cardiac output and plasma volume increase.

O7. Physiologic changes in pregnancy - renal/hormonal

Question: Physiologic changes in pregnancy, renal system, hormonal changes

Increased renal blood flow and GFR; decreased serum creatinine.

Question: Physiological changes of thyroid during pregnancy

Increased hCG may function as TSH; TBG increases; free thyroid hormones and TSH stay the same in the examiner note; total thyroid hormone increases.

Question: Appendicitis/GI diagnosis issue in pregnancy

Leukocytosis and constipation may occur physiologically and can imitate disease symptoms.

O8. Hypertensive disorders, eclampsia, HELLP

Question: Definition of preeclampsia/eclampsia

After the 20th gestational week.

Preeclampsia: BP > 140/90 mmHg + proteinuria > 300 mg/24 hours.

Eclampsia: tonic-clonic seizures / unexplained generalized seizures in a patient with preeclampsia.

Question: Definition of gestational hypertension

BP over 140/90 measured two times 4 hours apart, or BP over 160/110 measured one time.

Question: What does HELLP stand for?

Hemolysis, elevated liver enzymes, low platelet count.

Question: HELLP: definition, how much thrombocytopenia

Mississippi classification: M3 <150 G/L, M2 <100 G/L, M1 <50 G/L.

Question: When can we see thrombocytopenia in pregnancy?

HELLP syndrome, DIC, TTP and HUS.

Question: Superimposed preeclampsia

Chronic hypertension before 20 weeks; after 20 weeks develops >300 mg/day proteinuria.

Question: Antihypertensives contraindicated in pregnancy

Propranolol, ACE inhibitors, ARBs, diuretics.

O9. Signs and symptoms of pregnancy

Question: Signs of pregnancy

Presumptive: Chadwick sign = bluish discoloration of cervix/vagina due to pelvic vascular engorgement, around week 6.

Probable: positive urine pregnancy test, uterine enlargement, breast engorgement, Piskacek sign, Goodell sign, Hegar sign.

Positive: fetal heartbeat, recognition of fetal movement.

O10. Pregnancy care and counseling

Question: Prenatal care

Starts before conception.

Question: Vitamin supplements

Preconception: folic acid up to 6 weeks before, 400 microgram/day.

2nd trimester: low-dose iron and iodine 250 microgram/day.

Question: Advice during pregnancy

No alcohol or drugs; proper diet; seatbelt.

Question: Advice about smoking

Advise cessation; smoking causes vasoconstriction of vessels and can cause fetal IUGR.

Question: Would you recommend physical exercise, especially during 1st and 2nd trimester?

Physical exercise can be recommended if there is no obstetric contraindication.

O11. Pregnancy and cardiovascular diseases

Question: Which classification would you use for pregnant women with cardiovascular disease?

New York Heart Association (NYHA) classification.

Question: Which NYHA stage is contraindication to pregnancy?

Absolute contraindication: stage IV. Relative contraindication: stage III.

Question: Which CV disease is highest risk/most dangerous in pregnancy?

Postpartum dilated cardiomyopathy.

O12. Pregnancy and diabetes mellitus. Gestational diabetes

Question: Gestational diabetes

Screen all pregnancies at 24-28 weeks.

Fasting glucose <5.6 mmol/L → healthy.

Fasting glucose 5.6-7.0 mmol/L → do OGTT.

Fasting glucose >7.0 mmol/L on two separate measurements → DM.

Question: OGTT

75 g glucose fasting test.

0 min <7.0 mmol/L; 120 min <7.8 mmol/L.

<7.8 mmol/L → impaired fasting glucose (IFG); 7.8-11.1 mmol/L → impaired glucose tolerance (IGT); >11.1 mmol/L → DM.

Question: Who should you screen for DM?

Everyone should be screened at week 24-28.

Question: Patient with type 1 diabetes

Do not do OGTT. Monitor blood glucose and HbA1c.

Poorly controlled diabetes: offer abortion according to examiner note.

Risk for baby: congenital malformations, IUGR, hypoglycemia.

O13. Pregnancy and kidney diseases. UTI

Question: Problem with UTI during pregnancy

Ascending infection → premature birth, PROM, low birth weight and increased perinatal mortality.

Question: Why are urinary tract infections not wanted in pregnancy and how do they ascend?

Asymptomatic bacteriuria can ascend; complications include premature labor, PROM and low birth weight.

O14. Pregnancy and gastrointestinal disorders

Question: Appendicitis in pregnancy, difficult to diagnose why?

Leukocytosis may occur in pregnancy.

Question: What is difficult with GI disorders in pregnancy?

Pregnancy may imitate symptoms such as leukocytosis and constipation.

Question: What do you do in a patient with asymptomatic gallstones?

Wait and do elective cholecystectomy after pregnancy.

O15. Pregnancy and hematologic disorders

Question: When can we see thrombocytopenia in pregnancy?

HELLP syndrome, DIC, TTP and HUS.

O16. Spontaneous abortion

Question: Spontaneous abortion

History: pain + bleeding. Diagnosis: cervix, ultrasound, hCG.

Question: Definition of abortion

Induced abortion: medical or surgical termination before 24th gestational week.

Spontaneous abortion: non-induced embryonic or fetal death or passage of products of conception before 24th gestational week.

Question: Sign of missed abortion

Retained fetus in the uterine cavity during routine prenatal care; risk of DIC.

O17. Preterm labor and delivery

Question: Preterm labour - what drugs do you give?

Betamethasone and antibiotic prophylaxis.

Question: Contraindications to tocolysis

Obstetric: severe abruption, ruptured membranes, chorioamnionitis.

Fetal: lethal anomaly, fetus already dead, fetal jeopardy.

Maternal: eclampsia, advanced dilation.

O18. Intrauterine growth restriction

Question: Types of IUGR

Symmetric = fetal causes; asymmetric = maternal/placental causes.

Question: Does chromosomal abnormality cause symmetrical or asymmetrical IUGR?

Symmetrical, because it is a fetal cause.

Question: What is important to determine with suspected IUGR?

Compare with previous ultrasound to distinguish wrong gestational dating from true IUGR.

Question: When diagnose IUGR in fetus / what look for during US?

Around gestational week 30-32 in examiner note; assess head circumference, abdominal circumference, limb length and compare with same sex/gestational age.

Question: Common factor and difference between SGA and IUGR

Both are below the 10th percentile; SGA may be physiological, IUGR is pathological.

O20. Dystocia from abnormal presentation/position

Question: Dystocia caused by abnormal presentation and position of the fetus

Persistent occipitotransverse or occipitoposterior position; breech.

Question: Why can breech position cause dystocia?

More complications: cord prolapse, decreased fetal oxygen supply, head entrapment, fetal brain/skull injury; head does not gradually mold as in cephalic presentation.

O21. Dystocia from fetal structure or maternal pelvis

Question: Dystocia with normal position and presentation causes?

Macrosomia, shoulder dystocia, maternal pelvic alterations; think 3 Ps: power, passage, passenger.

Question: Dystocia - maternal causes?

Cephalopelvic disproportion, pelvic shape, trauma.

Question: Fetal causes of macrosomia

Maternal diabetes, maternal obesity, genetics, gestational age >40 weeks.

O22. Stages of delivery - first and second stage

Question: Stages of birth - 1st and 2nd stages

1st stage: onset of labor, longest stage; latent to 3 cm, active 3-10 cm.

2nd stage: baby, 30-90 min; propulsive phase and expulsion phase.

Question: How often does a doctor or nurse check on a woman in 2nd stage?

Continuously.

Question: When do membranes rupture?

First stage, late; or earliest 1 hour before labor starts.

Question: How to treat 1-2 stage of labor

External Leopold, internal CTG, blood pressure for preeclampsia, and infection check such as GBS.

Question: Drugs used in 1st and 2nd stage of labour

Oxytocin and analgesia/anesthesia according to indication.

O23. Third and fourth stage of labor

Question: Stages of birth - 3rd and 4th stages

3rd stage: placenta, 5-30 min, separation and expulsion of placenta/membranes.

4th stage: recovery, 2 hours after placenta; increased bleeding risk, repair lacerations, RhoGAM.

Question: Signs that placenta has detached in 3rd stage

Fresh blood from vagina; umbilical cord lengthens outside vagina; fundus rises and uterus becomes firm/globular.

Question: Placenta longer than 30 minutes outside hospital

No-touch technique; do not do uterine massage unless in hospital with OB-GYN specialists because of risk of placental retention and PPH.

Question: Timing of each stage

Stage 1: longest. Stage 2: 30-90 min. Stage 3: shortest, 5-30 min. Stage 4: recovery, 2 hours.

O24. Obstetric anesthesia

Question: Types of anesthetics used in C-section

Spinal, epidural for vaginal delivery, intratracheal narcosis for emergency C-section.

Question: Anesthesia for a C-section

Spinal.

O25. Induction and augmentation of labor

Question: Induction and augmentation of labor - medications

Oxytocin and intravaginal prostaglandin E2.

Other methods: artificial rupture of membranes/amniotomy, membrane sweep and balloon catheter.

O26. Cephalopelvic disproportion

Question: Maternal-fetal indication for C-section

Cephalopelvic disproportion and failed induction of labor.

Question: What fetal parameters help determine potential CPD?

Biparietal diameter about 10 cm and head circumference.

Question: What maternal parameters help determine potential CPD?

Pelvic size/shape and maternal height; short height increases dystocia risk.

O27. Breech presentation

Question: Which breech malpresentation can be delivered vaginally?

Frank breech was accepted; complete breech was also mentioned in the source.

O28. Malpresentations

Question: What malpresentation requires C-section?

Transverse lie.

Question: Types of transverse lie

Left-right, facing up-down, backwards-forwards as examiner explained.

Question: What fetal position enables vaginal delivery of twins?

Only if the first fetus is in proper position; no breech, not even frank according to examiner note.

O29. Premature rupture of membranes

Question: What is PPROM and causes?

Preterm premature rupture of membranes; causes include ascending vaginal and cervical infections.

Question: Problem with PROM

Infections, abnormal presentation, placenta-related complications and preterm birth risk.

Question: Prophylaxis meds in PPROM and for what

Antibiotics: 48 h IV ampicillin + erythromycin, then oral amoxicillin + erythromycin.

Corticosteroids before 34 weeks for lung maturity. IV magnesium sulfate before 32 weeks. Chorioamnionitis: ampicillin + gentamicin.

O30. Placenta previa

Question: Placenta abruptio / placenta previa

Use hands to palpate uterus. Previa: painless, CTG normal.

Question: Placenta previa types and complications

Types: total, partial, marginal, low-lying.

Complications: fetal malpresentation, vasa previa, PPROM, IUGR.

Question: What type of delivery in placenta previa?

C-section.

O31. Multiple gestation

Question: Multiple gestation: how differentiate dizygotic from monozygotic twins?

If twins are different sex, boy and girl = dizygotic.

O32. Placental abruption

Question: Placenta abruptio / placenta previa

Abruptio: painful, hard uterus → C-section.

Question: How diagnose placental abruption / first examination?

Physical exam; feel hypertonic/rock-hard uterus.

Question: Differentiate placental abruption and previa

Emphasis is rock-hard uterus in abruption, not pain alone.

O33. Amniotic fluid disorders

Question: Polyhydramnios/Oligohydramnios - AFI cutoffs

Oligohydramnios <6 cm; polyhydramnios >24 cm.

Question: How measure AFI?

Four-quadrant measurement: measure deepest pocket in each quadrant and add them together.

Question: Cause of oligohydramnios

Decreased fetal urine production, e.g. renal agenesis.

O34. Postpartum hemorrhage

Question: Post-partum haemorrhage

4 Ts: tissue = retained placenta; trauma = vaginal lacerations; thrombin = coagulopathy/DIC; tone = uterine atony after excluding other causes.

Question: Stopping uterine bleeding

Young: progesterone to preserve fertility. Old: D&C.

O35. Birth canal lesions and uterine rupture

Question: Uterine rupture - physical diagnosis

Loss of fetal station; pain changes from contractions to diffuse abdominal pain.

Question: Worrying sign in prolonged labour

Sudden sense of relief after straining a lot can suggest uterine rupture.

Question: Birth canal lesions

Know perineal tear degrees; worst outcome is complete continuity between vaginal opening and anal canal.

Question: Degrees of perineal tears

1st: perineal mucosa. 2nd: perineal mucosa and muscles, needs suturing. 3rd: external anal sphincter. 4th: internal anal sphincter and rectal mucosa.

Question: Why repair the cervix?

For possible future pregnancies.

O36. Bacterial and parasitic infections in pregnancy

Question: Toxoplasma - how can you get it?

Household pets/cats.

Question: How diagnose fetus infected with Toxoplasma?

Do amniocentesis and check viral DNA/genome as written in examiner note.

Question: Treatment of toxoplasmosis

Affected women during pregnancy: spiramycin.

Infected fetus: pyrimethamine and sulfadiazine.

Question: Advice to avoid toxoplasmosis

Avoid cat litter/contact if possible; wash hands; avoid raw meat and unpasteurized milk.

Question: Syphilis treatment

Penicillin G 2.4 million units.

O37. Viral infections in pregnancy

Question: How diagnose fetal viral infection?

Amniocentesis and look for viral genome.

O38. IUFD and postterm pregnancy

Question: How diagnose intrauterine death?

Ultrasound.

Question: Connection between IUFD and postterm pregnancy

Postterm pregnancy is associated with increased perinatal mortality.

O39-O40. Detection of fetal jeopardy during pregnancy and labor

Question: Suspected IUGR

Compare to previous ultrasound to distinguish incorrect dating from true growth restriction.

Question: What a normal CTG looks like

Baseline FHR 110-160/min, moderate variability, accelerations may be present, no recurrent pathological decelerations.

Question: Fetal indication for C-section

Non-reassuring fetal heart rate/bradycardia.

O41. Prenatal diagnosis

Question: Why is cordocentesis done nowadays?

To give transfusions.

Question: Which patients send for genetic testing?

High-risk patients and previous pregnancy with aneuploidy/abnormalities.

O43. Licit and illicit drug use in pregnancy

Question: BP drugs you CAN give in pregnancy

Labetalol, nifedipine, alpha-methyldopa.

Question: Name drugs you can't give during 1st trimester

Antiepileptics, ACE inhibitors, folic-acid inhibitors, coumarin.

Question: Antihypertensives contraindicated in pregnancy

Propranolol, ACE inhibitors, ARBs, diuretics.

O44. Obstetrical examinations

Question: Leopold maneuvers

1. Fundal grip: palpate fundus/upper abdomen, fundal height, breech/cephalic.

2. Umbilical grip: localize fetal back.

3. Pelvic grip: fetal presenting part above inlet.

4. Pawlik/second pelvic grip: face woman's feet, locate brow, assess flexion.

Question: Maneuver used in malpresentation - author name

Leopold.

Question: Obstetric examination: Leopold and bimanual pelvic exam, what can you feel?

Lie, presentation, position, fetal back, presenting part, engagement/flexion and pelvic/cervical findings.

O45. Ultrasound diagnosis during gestation

Question: US in pregnancy

0 scan 6-7 weeks: chorionic/gestational sac, heart rate, intra-/extrauterine location, twins.

I scan 11-13 weeks: congenital malformations, nuchal translucency for Down syndrome, neural tube defects, biometrics.

II scan 18-20 weeks: congenital malformations, genetics.

III scan 30-31 weeks: IUGR, late congenital malformations.

IV scan 36-38 weeks: fetal presentation, fetal weight, delivery information.

O46. Physiologic puerperium

Question: Puerperium

Period beginning immediately after birth and extending for about 6 weeks.

Question: Physiologic puerperium duration

6 weeks.

O47. Pathologic puerperium

Question: Pathological puerperium extragenital causes

Mastitis, UTI, thrombophlebitis, atelectasis.

O49. Hemolytic disease / Rh isoimmunisation

Question: Rh isoimmunization

Mixing of maternal and fetal blood can occur with placental abruption, bleeding during pregnancy and during labor.

Question: Stage 4 recovery

RhoGAM belongs in postpartum recovery when indicated.

O50. Newborn respiratory problems / resuscitation

Question: Respiratory resuscitation - whole cascade and compressions

Place newborn in warm environment and stimulate breathing.

If after 30 s HR <100, gasping or no breathing → positive-pressure ventilation.

If HR remains low after 60 s → consider endotracheal intubation.

If HR remains low despite adequate ventilation for 30 s → chest compressions 3:1.

If HR remains low despite ventilation and compressions → IV epinephrine.

O51. Congenital malformations

Question: Main congenital GI malformations

Omphalocele, gastroschisis, anal atresia.

O52. Cesarean section indications and technique

Question: Indications for C-section

Maternal-fetal: cephalopelvic disproportion, failed induction.

Maternal: eclampsia, cervical cancer, fibroids/tumor, herpes.

Fetal: non-reassuring fetal HR/bradycardia, cord prolapse, malpresentation, multiple gestation, fetal abnormalities such as hydrocephalus.

Placental: previa, abruptio.

Question: Classification of C/S indications

Elective: maternal previous CS/underlying disease; fetal threatened asphyxia; maternofetal dystocia/prolonged labor/twin pregnancy.

Vital: maternal DIC/severe hemorrhage; fetal asphyxia/transverse lie/umbilical cord prolapse; maternofetal eclampsia/uteroplacental insufficiency/placenta previa/abruption/uterine rupture.

Question: Technique of C-section

Abdominal wall: transverse Pfannenstiel or vertical midline.

Uterus: lower segment transverse incision or classical vertical incision.

O53. Placenta and umbilical cord

Question: Difference between umbilical cord prolapse and cord presentation

Cord prolapse is when the membranes rupture; cord presentation has intact membranes.

Question: Cord prolapse as C-section indication

Fetal/vital indication for rapid delivery, usually emergency C-section.

O54. Obstetric statistics

Question: Statistics

Neonatal mortality rate: neonatal deaths during first month per 1,000 live births.

Early NMR: 1st week. Late NMR: 2nd-4th weeks.

Perinatal mortality rate: stillbirths + neonatal deaths per 1,000 total births; examiner note gives from 22nd/24th week to 7th day postpartum.

Question: Neonatal death from what week?

24th week in examiner note.

O56. Female pelvis and fetal skull

Question: Fetal parameters for potential CPD

Biparietal diameter about 10 cm and head circumference.

Question: Maternal parameters for potential CPD

Pelvic size/shape and maternal height; short height increases dystocia risk.

O57. Mechanism of normal labor

Question: Fetal head movements

Flexion, internal rotation, extension and external rotation.

O60. Advice during pregnancy

Question: Advice during pregnancy

No alcohol, no drugs, proper diet, seatbelt, stop smoking and avoid toxoplasmosis risks.

Gynecology

G1. Anatomy of female genitalia

Question: Location of Bartholin's cyst

Lower 1/3 of labia majora.

Question: Marsupialization of Bartholin's cyst

Cyst opened at the edges and sutured, forming an open pocket.

Question: Differentiate Bartholin cyst vs abscess

Abscess is painful.

Question: Female equivalent of prostate

Skene's/paraurethral glands are the usual female prostate equivalent; examiner note confusingly mentions glands equivalent to upper 1/3 vagina.

Question: External female genitalia parts

Vulva: labia minora/majora, clitoris, Bartholin glands, perineum.

G2. Development of female genitalia

Question: Female sex development

External genitalia develop from genital and urogenital folds.

Mullerian/paramesonephric ducts give rise to uterus, cervix, upper vagina and fallopian tubes.

Absence of Y chromosome leads to regression of Wolffian/mesonephric ducts.

Ovaries develop from germinal epithelium.

G3. Female reproductive endocrinology

Question: Changes during puberty

Pulsatile GnRH release increases in frequency and amplitude from hypothalamus, stimulating anterior pituitary LH and FSH release.

G4. Primary amenorrhea

Question: Primary amenorrhea - when begin evaluation?

Ages in notes: age 16 or 2 years after onset of puberty, or age 14 if no puberty; examiner also said nowadays people may wait until 18.

Question: Causes of primary amenorrhea

Mullerian agenesis/MRKH, androgen insensitivity syndrome, pregnancy, imperforate hymen.

Primary hypogonadism: Turner syndrome. Secondary hypogonadism: Kallmann syndrome or pituitary tumor/craniopharyngioma.

G5. Secondary amenorrhea

Question: Normal causes of secondary amenorrhea

Pregnancy, menopause, lactation.

Question: Other causes of secondary amenorrhea

Hyperthyroidism, antidopaminergic drugs, pituitary tumors/prolactinoma.

Question: Progestin test

Give progestin then withdraw it. Withdrawal bleeding suggests estrogenized endometrium/anovulation such as PCOS; no bleeding needs further diagnostic tests.

G6. Stein-Leventhal syndrome / PCOS

Question: Stein-Leventhal syndrome

PCOS.

Question: PCOS symptoms

Hirsutism, acne, obesity, amenorrhea, insulin resistance.

Question: Diagnostic criteria/labs

Anovulation, hyperandrogenism, >10 follicles in examiner note; LH/FSH ratio 3:1.

Question: Metabolic disorder associated with PCOS

Insulin resistance/DM.

G7. Dysfunctional uterine bleeding

Question: Stopping uterine bleeding

Young: progesterone to preserve fertility. Old: D&C.

Question: Dysfunctional uterine bleeding in a 42-year-old woman

D&C.

G8. Dysmenorrhea

Question: Cause of dysmenorrhea

Endometriosis, idiopathic.

Question: 40-year-old woman with dysmenorrhea - test?

D&C.

G9. Chromosomal abnormalities

Question: Primary hypogonadism cause

Turner syndrome = hypergonadotropic hypogonadism.

Question: Secondary hypogonadism cause

Kallmann syndrome = impaired GnRH release + anosmia.

G10. Causes of infertility

Question: Most common causes of infertility

Male: sperm disorders, erectile dysfunction.

Female: anatomical causes such as PID, Asherman syndrome, endometriosis; ovulatory dysfunction; abnormal cervical mucus.

G11. Infertility investigation/treatment

Question: How check for fallopian stricture?

Hysterosalpingography.

Question: IVF: in whom do we do it immediately?

Tubal ligation/strictures.

Question: IVF: what is it and how performed?

Ovarian follicular stimulation → retrieve egg by US guidance → mix sperm and egg → incubation → transfer 2-5 embryos into uterus in cleavage/blastocyst stage.

Best timing in examiner note: day 20-24 of menstrual cycle.

G12. Hormonal contraception and IUD

Question: Long-term OCP use - benefits

Decreased ovarian/endometrial cancer, decreased bone loss, decreased dysmenorrhea, acne improvement, decreased risk of trisomies with increased maternal age, cycle regulation.

Question: Long-term OCP use - risks

Increased DVT/stroke, increased BP, weight gain, depression.

Question: Pearl index

Number of pregnancies in 100 females/year with chosen contraceptive.

Question: Pearl index examples

OCP 0.1-2.5; post-coital pill 0.5-2.5; IUD 0.5-5; condom 3-28; sterilization 0.3-6.

G13. Barrier and chemical contraceptives

Question: Barrier contraceptives

Female and male condoms, pessaries, cervical cups, sponges, diaphragm.

Question: Pearl index definition and condom

Number of unintended pregnancies in 100 women during 1 year of contraception use; condom 3-26/28 in examiner notes.

G14. Puberty

Question: Puberty

Tanner stages I-V; based on breast development and pubic hair growth.

Question: Changes in puberty

Accelerated growth/growth spurt, secondary sexual characteristics, axillary hair growth, pubic hair growth and breast development.

G15. Pediatric gynecology

Question: Pediatric gynecology - most common complaints

Infection, amenorrhea, precocious or delayed puberty.

G16. Perimenopause

Question: Symptoms of perimenopause

Hot flashes, night sweats, mood swings, vaginal dryness, loss of libido.

Question: Perimenopause diagnosis

Exclude pregnancy; FSH consistently increased; no follicles in ovaries on US; vulvovaginal atrophy on physical exam.

Question: Lab in postmenopausal diagnosis

FSH, consistently elevated.

G17. Vulvovaginal inflammatory disorders

Question: Most common vaginal infections

Bacterial vaginosis, Trichomonas, Candida/mycosis, condyloma.

Question: Inflammatory disorders of vulva and vagina

Bacterial vaginosis: Gardnerella/Mycoplasma; Trichomonas; Candida.

G18. Sexually transmitted diseases

Question: Common STDs

Chlamydia, gonorrhea, syphilis, genital herpes HSV-2, genital warts HPV.

Question: Symptoms of genital herpes

Vesicles on genitals with pain, pruritus, discharge, dysuria; sometimes fever, malaise, lymphadenopathy.

Question: Painless vs painful lymphadenopathy with genital lesions

Painless: syphilis with painless ulcer and painless lymphadenopathy. Painful: lymphogranuloma venereum.

Question: Syphilis treatment

Penicillin G 2.4 million units.

G19. Benign vulvar/vaginal lesions

Question: How treat vulvar benign lesions?

Surgical excision.

Question: Mention benign lesions of vulva

Lichen sclerosus, lichen simplex chronicus, vulvodynia.

Question: What is vulvodynia?

Vulvar discomfort, usually burning pain, without relevant visible findings or specific identifiable neurologic disorder.

G20. Vulvar and vaginal cancer

Question: Vulvar cancer treatment

Local excision in VIN; radical vulvectomy with inguinofemoral lymphadenectomy.

Question: Radical vulvectomy

Surgical removal of vulva + inguinofemoral lymph nodes.

Question: Vulvar/vaginal cancer FIGO staging

Keep full FIGO staging table in baseline note; key oral answer: local disease → local/radical surgery, nodal/distant spread changes stage and therapy.

G21. Cervical cancer etiology

Question: Etiology of cervical cancer

HPV 16 and 18.

Question: LSIL/HSIL

LSIL: condyloma, CIN I. HSIL: CIN II, CIN III → in situ → invasive cervical cancer.

G22. Cervical cancer symptoms/screening

Question: Pap smear

P0 improper sample. P1 negative/superficial cells. P2 superficial cells and WBCs. P3 unsure. P4 atypical cells/suspect malignancy. P5 true malignancy.

Question: Bethesda

Pap smear reporting: slide quality, positive/negative result, cell details such as LSIL/HSIL, physician recommendation.

Question: How diagnose cervical cancer?

Pap smear.

G23. Cervical cancer staging/therapy

Question: At which stage cervical cancer visible with naked eye?

Stage IB.

Question: Cervical cancer stages

I confined to cervix; IA microscopic; IB macroscopic.

II beyond uterus/upper vagina, not pelvic wall. III pelvic wall or lower 1/3 vagina. IV bladder/rectum or distant metastasis.

Question: Treatment of cervical cancer

Depends on stage: hysterectomy/radical hysterectomy, lymphadenectomy, chemoradiation, palliative chemo/RT/surgery.

Question: Stage III cervical cancer

IIIA lower third of vagina; IIIB parametrial/pelvic wall/obstructive uropathy; treatment: chemoradiation.

G24. Benign uterine diseases

Question: Asherman's syndrome

Adhesions/fibrosis of uterine cavity, usually from D&C; reversible infertility.

Question: Types of uterine fibroids

Intramural, subserosal, submucosal and broad-ligament fibroids.

Question: Endometrial benign lesions that are not fibroids

Adenomyosis and endometrial polyps.

G25. Endometrial hyperplasia

Question: Types of endometrial hyperplasia

Simple typical: increased glands, normal architecture.

Complex typical: crowded irregular glands.

Simple atypical: simple hyperplasia with atypical cells.

Complex atypical: complex hyperplasia with atypical cells; highest malignant potential around 30%.

G26. Endometrial cancer symptoms/screening

Question: Symptom of corporal cancer

Vaginal bleeding.

Question: Endometrial cancer - who screen and how?

High-risk women with long-term estrogen exposure such as PCOS, HRT, family history.

Transvaginal US and endometrial thickness; examiner note uses total 8 mm cutoff.

Question: Postmenopausal thickened endometrium on US - next step

D&C → histology.

Question: Screening method for corporal cancer

No population screening; TV-US can assess endometrial thickness; examiner corrected to total cutoff 8 mm.

G27. Endometrial cancer staging/therapy

Question: Endometrial/corporal cancer FIGO

0 CIS; I limited to uterus; IA <50% myometrial invasion; IB >50%; II cervical involvement; III local spread/nodes; IV bladder/rectum or distant metastasis.

Question: Stage 1 corporal cancer - diagnosis

Myometrial invasion < or >50%; diagnose with US and D&C.

G28. Functional ovarian cysts

Question: Functional ovarian cyst appearance

Unilateral, uniloculated, simple inside, no papillary protrusion.

Question: Types

Follicular cyst, corpus luteum cyst, theca-lutein cyst.

Question: Single unilocular cyst on one ovary US

Probably follicular cyst; watchful waiting usually enough, surgical removal if torsion/rupture risk.

G29. Benign ovarian tumors

Question: Types of benign ovarian tumors

Epithelial: serous cystadenoma, mucinous cystadenoma, endometrioid.

Gonadal stromal: granulosa-theca cell tumors, Sertoli-Leydig cell tumors.

Germ cell: dysgerminoma, teratoma.

G30. Ovarian tumor etiology/screening

Question: How screen for ovarian cancer?

High-risk women: serum CA-125 + ultrasound of ovaries.

Question: Differentiate malignant from benign ovarian cysts

MRI, US, CA-125, biopsy.

Question: Ovarian cancer screening/etiology

US, CA-125, HE4; RMI >200 suspicious, using US features, menopausal status and CA-125.

G31. Ovarian cancer staging/therapy

Question: Staging of ovarian cancer

I confined to ovaries/fallopian tubes. II pelvic extension/peritoneal involvement. III peritoneal spread outside pelvis and/or retroperitoneal nodes. IV distant metastasis such as liver, lung or pleural fluid.

G32. Endometriosis and adenomyosis

Question: Endometriosis

Endometrial-like tissue outside uterine cavity.

Question: Diagnosis

Gold standard: laparoscopic visualization.

Question: Treatment

Surgery or drugs: pseudopregnancy; pseudomenopause with GnRH analogue.

Question: Cause of dysmenorrhea

Endometriosis or idiopathic.

G33. Genital prolapse

Question: In uterine prolapse, what type of surgery?

Vaginal hysterectomy.

Question: What is enterocele?

Part of small intestine protrudes into vagina due to wall weakness.

Question: Treatment for complete uterine prolapse

Vaginal hysterectomy.

G34. Urinary incontinence

Question: Urinary incontinence types

Stress, urge, overflow/neurogenic, bypass/fistula.

Question: Irritative symptoms

Urinalysis → cystitis/tumor/foreign body.

Question: Stress

Loss of bladder support → leakage with cough.

Question: Urge

Hypertonic/increased detrusor; treatment: anticholinergics.

Question: Overflow/neurogenic

Hypotonic bladder with dribbling; treatment in examiner note: cholinergics.

G35. Urinary tract infections

Question: UTI types in urinary incontinence work-up

Irritative symptoms → urinalysis to exclude cystitis/tumor/foreign body.

G36. Pelvic inflammatory disease

Question: PID treatment, how long and why

Empirical antibiotics. Outpatient: single IM ceftriaxone + oral doxycycline; add metronidazole if vaginitis signs.

Inpatient: IV cephalosporin such as cefoxitin/cefotaxime + doxycycline; add metronidazole if tubo-ovarian abscess.

Treat to prevent Fitz-Hugh-Curtis syndrome, tubo-ovarian abscess, infertility, ectopic pregnancy and chronic pelvic pain.

G37. Pelvic pain

Question: Causes of pelvic pain

Endometriosis, PID, ruptured ectopic pregnancy, adnexal torsion.

G38. Ectopic pregnancy

Question: Exclude ectopic pregnancy

Measure beta-hCG: 1,000 U/L → gestational sac; 7,000 U/L → yolk sac; 10,000 U/L → embryo in examiner note.

Brown spotting and abdominal pain suggests ectopic pregnancy → check fallopian tubes.

Beta-hCG doubles every 2nd day; if high but not doubling → ectopic pregnancy.

Question: Ectopic pregnancy case

7 weeks amenorrhea + no intrauterine pregnancy → measure beta-hCG; elevated but not doubling every 2nd day suggests ectopic; next step laparoscopy in examiner note.

Question: Ectopic pregnancy treatment

Laparoscopy: salpingostomy or salpingectomy.

Question: Possible locations of ectopic pregnancy

Fallopian tube/ampulla, uterine horns, cervix, previous C-section scar, abdomen.

G39. Genital tract malformations

Question: Mayer-Rokitansky-Kuster-Hauser syndrome

Mullerian agenesis; congenital malformation due to failure of Mullerian duct development.

Missing uterus, cervix and vagina; variable upper vaginal hypoplasia/shortening.

Causes 15% of primary amenorrhea in examiner note; ovaries intact, ovulation usually occurs; puberty and secondary sex characteristics present.

Question: What are some genital malformations?

Mullerian agenesis/MRKH, bicornuate uterus, septate uterus, transverse vaginal septum, vaginal atresia, imperforate hymen.

G40. Disorders of sexual differentiation

Question: How confirm intersexuality/DSD - 4 steps

Karyotyping, secondary sex characteristics, check internal gonads, mental/psychological assessment in examiner note.

Question: 18-year-old with primary amenorrhea, 46XY, breasts developed, no pubic hair

Androgen insensitivity syndrome.

Question: Female sex development

Mullerian ducts form uterus, cervix, upper vagina and fallopian tubes; absence of Y → Wolffian regression; ovaries from germinal epithelium.

G42. Breast cancer

Question: Breast cancer TNM

Tis DCIS/LCIS. T1 ≤2 cm; T2 2-5 cm; T3 >5 cm; T4 chest wall/skin/inflammatory cancer.

N describes lymph nodes; M0 no metastasis, M1 metastasis.

Question: Radical mastectomy

Entire breast removed + axillary lymph node dissection.

Question: Types of breast cancer surgery

Lumpectomy, quadrantectomy, mastectomy, radical mastectomy.

Question: Histology of breast cancer

Ductal and lobular carcinoma.

G43. Human sexuality

Question: Classification of human sexuality

Heterosexual, homosexual, bisexual, transsexual etc. in examiner note; keep distinction: orientation vs gender identity.

G44. Gynecologic operations

Question: Gynecology operation techniques - conization

Cone-shaped excision using scalpel, laser or electrosurgical techniques; diagnostic for HSIL or therapeutic for CIN2/3.

Question: Pregnant woman needing conization - what is different?

Risk of bleeding and premature birth.

Question: D&C indications in examiner notes

Dysfunctional uterine bleeding at age 42, dysmenorrhea in a 40-year-old, postmenopausal thickened endometrium → histology.

G45. Virilism and hirsutism

Question: Virilism and hirsutism difference

Hirsutism is a clinical sign of virilization: male-pattern hair growth in a female.

Other virilization signs: clitoromegaly, deep voice, male-pattern hair loss, acne, increased muscle mass.

G46. Hydatidiform mole

Question: Hydatidiform mole - which lab?

Beta-hCG, highly increased.

Question: Diagnosis of hydatidiform mole

Very high beta-hCG, snowstorm/honeycomb pattern on US, confirm with biopsy.

Question: Hydatidiform mole

Snowstorm pattern on US, no fetus.

G47. Choriocarcinoma

Question: Choriocarcinoma follow-up

Beta-hCG.

Question: Treatment/prognosis/5-year survival

Methotrexate, good prognosis, 95% 5-year survival in examiner note.

G48. Principles of cancer therapy

Question: Basics of cancer therapy

Surgery, radiotherapy and chemotherapy; most cases use a combination.