PRE – Licensure EXAM ORIENTATION COURSE

1. PRE – Licensure EXAM ORIENTATION COURSE DR LOULA MOHAMED A SALIH

2. IMPORTANT SUBJECTS TO REVIEW NORMAL LABOR

3. ABNORMAL LABOR 1-Abnormal presentation breech presentation & ECV 2-Abnormal lie 3-Prolonged labour (dystocia) 4-Cephalo-pelvic disproportion (CPD)

4. 5-Shoulder dystocia • 6-Cord prolapse • 7-Instrumental deliveries • 8-Ceserian section, indications ,pre & post oprative management • 9-Fetal distress & abnormal fetal monitoring • PPROM & 10-Preterm labor

5. ANTE-PARTUM HEAMORRHAGE • 1-Placenta preveia • 2-Abruptio placenta • 3-Trauma in obstetrics

6. POT-PARTUM HEAMORRHAGE OBSTETRIC EMERGENCY

7. PET & ECLAMPSIA • OBSTETRIC EMERGENCY

8. MEDICAL PROPLEMS WITH PREGNANCY • 1-DM • 2-HTN • 3-UTI • 4-CARDIOVASCULAR DISEASES 5-ANEMIA IN PREGNANCY 6-GESTITIONAL THROMBOCTOPENIA 7-THROMBOSIS WITH PREGNANCY

9. GYNAECOLOGYbleeding early in pregnancy • 1-ECTOPIC PREGNANCY; • obstetric emergency • 2-ABORTION/MISSCARRIAGE

10. GYNAECOLOGY • *DUB • *POST MENPAUSAL BLEEDING • *MENSTRUAL ABNORMALITIS; • e.g.; -Amenorrhea • -Menorrhagia

11. Other Important Subjects • 1-ANC & Prepregnancy counseling • 2-Fetal growth (IUGR & SGA) • 3-Contraception 4-purpurium & puerperal sepsis

12. 5-Vaginitis & vaginal discharges • 6-Drugs & Anesthesia in pregnancy • 7-General knowledge of maternal physiology & changes in pregnancy • 8-Oncoloogy screening

13. MCQS

14. MCQ INSTRUCTIONS

15. MCQs – Study Guide Test strategies:` •Read the directions carefully •Know if each question has one or more correct option •Know if you are penalized for guessing •Know how much time is allowed (this governs your strategy) •Preview the test •Read through the test quickly and answer the easiest questions first •Mark those you think you know in some way that is appropriate •Read through the test a second time and answer more difficult questions •You may pick up cues for answers from the first reading, or become more comfortable in the testing situation •If time allows, review both questions and answers •It is possible you mis-read questions the first time

16. Answering options • Improve your odds, think critically: • *Cover the options, read the stem, and try to • answer • *Select the option that most closely matches your answer • *Read the stem with each option • *Treat each option as a true-false question, and choose the "most true“

17. Strategies to answer difficult questions: • •Eliminate options you know to be incorrect • •If allowed, mark words or alternatives in questions that eliminate the option • •Give each option of a question the "true-false test:" • •This may reduce your selection to the best answer • •Question options that grammatically don't fit with the stem • •Question options that are totally unfamiliar to you • •Question options that contain negative or absolute words. • •Try substituting a qualified term for the absolute one, like frequently for always; or typical for every to see if you can eliminate it

18. •"All of the above:" • •If you know two of three options seem correct, "all of the above" is a strong possibility • •Number answers: • •toss out the high and low and consider the middle range numbers • •"Look alike options" • •probably one is correct; choose the best but eliminate choices that mean basically the same thing, and thus cancel each other out

19. •Echo options: • •If two options are opposite each other, chances are one of them is correct • •The result is longer, more inclusive items that better fill the role of the answer • •If two alternatives seem correct, compare them for differences , then refer to the stem to find your best answer

20. Guessing: •Always guess when there is no penalty • for guessing or you can eliminate option • •Don't guess if you are penalized for guessing • and if you have no basis for your choice • •Use hints from questions you know to answer questions you do not. • Change your first answers when you are sure of the correction, or other cues in the test cue you to change.

21. Remember that you are looking for the best answer,not only a correct one, and not one which must be true all of the time, in all cases, and without exception

22. MCQ EXAM

23. 1-A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy? • a)Ampicillin • b)Ampicillin-gentamicin • c)Clindamycin-gentamicin • d)Clindamycin-metronidazole • e)Metronidazole

24. 2-. A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery? • a) 0% • b) 25% • c)50% • d)70% • e) 100

25. 3-.A 32-year-old woman, gravida 3, Para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response? • a)There is no evidence that breast-feeding increases HCV transmission • b)There is strong evidencethat breast-feeding increases HCV transmission • c)Complete isolation is not needed but breast-feeding is prohibited • d)The patient should be completely isolated from the baby • e)Casual contact with the baby is prohibited

26. 4-.A 25-year-old woman, gravida 2, Para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management? • a) No further treatment or diagnostic study is necessary • b)Prophylactic antibiotics for the remainder of the pregnancy • c)Intravenous antibiotics for the remainder of the pregnancy • d)Intravenous pyelogram • e)Abdominal CT Scan

27. 5-A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nulliparity, and early age at menarche. She takes no other medications. Examination is within normal limits. Which of the following is this patient most likely to develop while taking tamoxifen? • a) Breast cancer • b)Elevated LDL cholesterol • c)Endometrial changes • d)Myocardial infarction • e)Osteoporosis

28. 6-.A 39-year-old woman, gravida 3, Para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate • management of this patient? • a)Administer antibiotics to the mother after vaginal delivery • b)Administer antibiotics to the mother now and allow vaginal delivery • c)Perform cesarean delivery • d) Perform cesarean delivery and then administer antibiotics to the mother • e)Perform intra-amniotic injection of antibiotics

29. 7-. A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response? • a) Gestational diabetes is associated with fetal anomalies • b)Gestational diabetes is associated with intrauterine growth restriction • c)Gestational diabetes is associated with macrosomia • d)Gestational diabetes is not associated with future diabetes • e)Gestational diabetes with normal fasting glucose is associated with stillbirth

30. 8-.A 36-year-old primigravid woman at 36 weeks' gestation comes to the physician for a prenatal visit. She is experiencing good fetal movement and has had no loss of fluid, bleeding from the vagina, or contractions. She has no complaints. Her past medical history is significant for mitral stenosis, which she developed after an episode of rheumatic fever as a child. She also has asthma for which she uses an albuterol inhaler daily. She has herpes outbreaks approximately once a year. At her last visit she was found to be positive for Group B Streptococcus colonization. For which of the following disease processes would this patient benefit by having a forceps-assisted vaginal delivery at the time of delivery? • a)Asthma • b)Group B Streptococcus (GBS) colonization • c)Herpes • d)Mitral stenosis • e)This patient would not benefit from a forceps-assisted vaginal delivery

31. 9-A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management? • a)Offer elective cesarean section after amniocentesis to determine lung maturity • b)Offer elective cesarean section at 38 weeks • c)Offer elective cesarean section at 34 weeks • d)Recommend forceps-assisted vaginal delivery • e) Recommend vaginal delivery

32. 10. A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis? • a) Constitutional delay • b) Dysfunctional uterine bleeding • c)Dysmenorrhea • d)Primary amenorrhea • e)Secondary amenorrhea

33. 11.A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5 centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5 centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management? • a)Expectant management • b)Intravenous oxytocin • c)Cesarean delivery • d)Forceps-assisted vaginal delivery • e)Vacuum-assisted vaginal delivery

34. 12-.A 24-year-old woman comes to the physician because of right lower quadrant abdominal pain. She has had the pain off and on for the past month, but it is now increasing. She has no other symptoms and no medical problems. Examination reveals a mildly tender, right adnexal mass. Pelvic ultrasound shows a 7 cm right adnexal complex cyst. Urine hCG is negative. The patient is taken to the operating room for laparotomy and right ovarian cystectomy. Microscopically the cyst has cartilage, adipose tissue, intestinal glands, hair, and a calcification that appears to be a tooth. There is also a large amount of thyroid tissue. Which of the following is the most likely diagnosis? • a)Corpus luteum • b)Ectopic pregnancy • c)Gastric carcinoma • d)Struma ovarii • e) Thyroid carcinoma

35. 13. A 62-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman in no apparent distress. Pelvic examination is unremarkable. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. Which of the following is the most appropriate next step in management? • a) Chemotherapy • b)Cone biopsy • c)Dilation and curettage • d)Hysteroscopy • e)Hysterectomy

36. 14-.A 35-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward after a gush of clear fluid from the vagina. After the gush, she has had increasing contractions. Sterile speculum examination shows a pool of clear fluid in the vagina that is nitrazine positive. Cervical examination shows that the patient is 5 cm dilated, with the fetal face presenting in a mentum anterior position. External uterine monitoring shows that the patient is contracting every 2 minutes, and external fetal monitoring shows that the fetal heart rate is in the 140s and reactive. Which of the following is the most appropriate next step in management? • a)Expectant management • b)Oxytocin augmentation • c)Forceps delivery • d)Vacuum delivery • e)Cesarean section

37. 15-.A 36-year-old woman, gravida 3, para 2, at 33 weeks' gestation comes to the physician for a prenatal visit. She has some fatigue but no other complaints. Her current pregnancy has been complicated by a Group B Streptococcus urine infection at 16 weeks. Her past obstetric history is significant for a primary, classic cesarean delivery 5 years ago for a non-reassuring fetal tracing. Two years ago, she had a repeat cesarean delivery. Past surgical history is significant for an appendectomy 10 years ago. Which of the following is the major contraindication to a vaginal birth after cesarean (VBAC) in this patient? • a) Classic uterine scar • b)Group B Streptococcus urine infection • c)Previous appendectomy • d)Prior cesarean delivery for non-reassuring fetal tracing • e)Two prior cesarean deliveries

38. 16-.A patient who has been taking tamoxifen to prevent breast cancer for the past 6 months presents complaining of irregular vaginal bleeding. An endometrial biopsy is performed that demonstrates atypical hyperplasia. Which of the following is the most appropriate next step in management? • a)Discontinue the tamoxifen • b)Increase the tamoxifen dose • c)Repeat the endometrial biopsy • d)Schedule a pelvic ultrasound • e)Switch the patient to estrogen

39. 17-.A 18-year-old woman comes to the physician for an annual examination. She has no complaints. She has been sexually active for the past 2 years. She uses the oral contraceptive pill for contraception. She has depression for which she takes fluoxetine. She takes no other medications and has no allergies to medications. Her family history is negative for cancer and cardiac disease. Examination is unremarkable. Which of the following screening • tests should this patient most likely have? • a) Colonoscopy • b)Mammogram • c)Pap smear • d)Pelvic ultrasound • e)Sigmoidoscopy

40. 18- A 35 year old woman gravida 7, para 5 ,abortus 1, is in the active phase of labor with the vertex at -1 station .She complains of abdominal pain with the contractions . At the height of one contraction the pain becomes very intense. Following this intense pain, utrine contractions ceased. The maternal systolic blood pressure drops 15 mm Hg .You should: A)Immediately perform a pelvic examination B)Place the patient on her side & reassure her C)Manage expectantly D)Begin oxytocin E)Perform an U/S

41. 19-An inter-stitial ectopic pregnancy: • A)Rarely exceeds 4 weeks of gestation. • B)Is generally more dangerous than an ampullary ectopic pregnancy • C) Requires hysterectomy • D) Is extra uterine

42. 20-Relative contra-indications to the use of vacuum extraction for delivery include A)Fetal coagulopathy • B) Following fetal scalp sampling • C)Fetal prematurity • D)non-vertex presentation • E) All of the above

43. MCQ DISCUSSION

44. 1-A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy? • a)Ampicillin • b)Ampicillin-gentamicin • c)Clindamycin-gentamicin • d)Clindamycin-metronidazole • e)Metronidazole

45. 1) Explanation: • The correct answer is • C). This patient has signs and symptoms that are most consistent with endometritis. Postpartum endometritis is believed to result from organisms ascending from the vagina and causing a polymicrobial infection of the endometrium. Infection may also involve the myometrium and parametrial tissues. Patients with endometritis typically present with fever and chills, lower abdominal pain, a foul-smelling vaginal discharge, and malaise. Examination is significant for fever, abdominal tenderness, and uterine tenderness. Cesarean section is the major risk factor for postpartum endometritis. Patients undergoing cesarean section have a several-fold higher risk of developing endometritis compared with those having a vaginal delivery. The treatment of choice for endometritis following a cesarean section must include anaerobic coverage, along with gram-positive and gram-negative coverage. Therefore, the treatment of choice is clindamycin and gentamicin. Ampicillin (choice A) and ampicillin-gentamicin (choice B) fail to cover the anaerobic organisms that play an important role in the pathophysiology of post-cesarean section endometritis. Clindamycin-metronidazole (choice D) and metronidazole (choice E) have good activity against anaerobic organisms, but fail to cover gram-negative organisms.

46. 2-. A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery? • a) 0% • b) 25% • c)50% • d)70% • e) 100

47. 2) Explanation: • The correct answer is • D. The cesarean delivery rate in the U.S. is roughly 25%. Much effort has been put into trying to lower this rate. One third of all cesarean births are a result of elective repeat cesarean delivery. Therefore, much attention has been focused on vaginal birth after cesarean (VBAC). A few decades ago, there was an obstetric dictum that "once a cesarean, always a cesarean." This is no longer the case. Some women are allowed to attempt vaginal birth after a prior cesarean delivery. And, in fact, the attempt is often successful. Estimates are that approximately 70% of all women that attempt VBAC will be successful. This patient has had one prior cesarean delivery, and it was through a low transverse uterine hysterotomy. Right now, she has no contraindications to VBA Therefore, a VBAC attempt may be tried. If the success rate of VBAC were 0% (choice A) or even 25% (choice B), the topic would be a non-issue. The fact that the success rate of VBAC is so high is what makes the choice between repeat cesarean and VBAC more complicated. 50% (choice C) is approximately the success rate in women who attempt VBAC who had a prior cesarean for dystocia. Women with a prior cesarean delivery for dystocia have a VBAC success rate of approximately 50% to 70%. Although this rate is still good, it is consistently lower than the rate for women with non-recurring indications, such as a non-reassuring fetal tracing. Attempts at vaginal delivery are not 100% (choice E) successful even in women who have never had a cesarean delivery. In fact, the success rate for vaginal delivery in women who have not undergone previous cesarean delivery is about 70%--the same success rate as women attempting VBAC with a non-recurring indication.

48. 3-.A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response? • a)There is no evidence that breast-feeding increases HCV transmission • b)There is strong evidence that breast-feeding increases HCV transmission • c)Complete isolation is not needed but breast-feeding is prohibited • d)The patient should be completely isolated from the baby • e)Casual contact with the baby is prohibited

49. 3) Explanation: • The correct answer is • A. In the U.S., hepatitis C virus (HCV) is the most common blood-borne infection. HCV is a single-stranded RNA virus that is transmitted by blood-borne transmission or through sexual contact. With the disease being so prevalent-it affects 3.9 million Americans-it is not rare to find a pregnant patient with hepatitis • C. In fact, it appears to infect as much as 0.6% of the pregnant population. Studies that have been performed so far show that the rate of infection of infants born to hepatitis C-positive, HIV-negative mothers is about 5%. Hepatitis C transmission through breast milk has not been clearly proven. Breast-fed and bottle-fed infants have a rate of infection that is approximately 4%. Therefore, the patient should be told that casual contact is permitted and that currently there is no evidence that breast-feeding increases HCV transmission to the baby. To state that there is strong evidence that breast-feeding increases HCV transmission to the baby (choice B) is incorrect. As explained above, the available studies do not demonstrate that breast-feeding increases HCV transmission. To state that complete isolation is not needed but breast-feeding is prohibited (choice C) is incorrect for the reasons detailed above. To state that the patient should be completely isolated from the baby (choice D), or that casual contact with the baby is prohibited (choice E) are both incorrect for the reasons detailed above. If patients with hepatitis C were not allowed contact with their infants, they would have to give them up, because hepatitis C is a chronic disease. Fifty percent of patients with HCV develop biochemical evidence of chronic liver disease. Hepatitis C is not like varicella-zoster (chickenpox), where a neonate can be isolated from the mother until she is no longer infectious.

50. 4-.A 25-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management? • a) No further treatment or diagnostic study is necessary • b)Prophylactic antibiotics for the remainder of the pregnancy • c)Intravenous antibiotics for the remainder of the pregnancy • d)Intravenous pyelogram • e)Abdominal CT Scan