OBGYN – Obstetrics and Gynecology – is one of the more difficult exams, with some years coming in at a 74% pass rate. It’s also a specialty with few good study resources. We offer several OBGYN Board review practice questions below. Make sure to time yourself when going through question banks so that you know how to pace yourself.
Sample OBGYN Board Questions
Question 1. OB-Ultrasound and Imaging QID 18718
A 26 year old G2P1001 at 28 weeks gestation with one prior uncomplicated spontaneous vaginal delivery at term presents for routine follow-up and is subsequently diagnosed with hydrops fetalis based on ultrasound findings including an AFI of 14, pericardial effusion, ascites and skin edema. After full work-up the fetus is found to have persistent tachycardia on ultrasound with rate in the 230’s. The most common type of fetal tachycardia is diagnosed. What is the next step in management?
A. Immediate delivery
B. Start Amiodarone
C. Start Flecainide
E. Start Digoxin
Answer: E. Start Digoxin.
Causes of nonimmune hydrops fetalis include genetics (aneuploidy, metabolic storage disorders), cardiac arrhythmias (SVT, atrial flutter), cardiac structural defects, nonimmune fetal anemia (e.g., due to alpha-thalassemia or fetal-to-maternal hemorrhage), and infection (CMV, toxoplasmosis, Parvovirus B19, Syphilis) among others.
Fetal arrhythmias are best evaluated with fetal M-mode echocardiography, two-dimensional ultrasonography, and pulsed wave Doppler velocimetry. Supraventricular tachycardia is the most common fetal tachycardia and can lead to hydrops if sustained for greater than 24 hours as is found to be the case with this fetus. Indications for medical treatment of fetal SVT include the following: 1) Sustained tachycardia greater than 220 bpm, 2) a gestational age less than 34 weeks, and 3) evidence of hydrops. Given this fetus has all three indications, the correct answer to this case is Choice E, start Digoxin.
In a nonrandomized multicenter study comparing digoxin, flecainide and sotalol, flecainide and digoxin were superior to sotalol in converting SVT to a normal rhythm and in slowing both AF and SVT to better-tolerated ventricular rates . Conclusions from this trial have led to recommending Digoxin as first line, followed by flecainide, then sotalol or amiodarone if the fetal condition is not improving or is deteriorating despite adequate maternal digoxin levels. Therefore Choices B and C would not be the appropriate next step prior to trial of Digoxin.
Choices A and D would be inappropriate as delivery at 28 weeks would carry significant risk of perinatal mortality and observation is inappropriate given the fetal status and evidence of hydrops on ultrasound likely caused by SVT which has treatment options mentioned above.
Summary: Fetal arrhythmias can cause hydrops fetalis and represent a non-immune cause of the disease. Fetal arrhythmias are best assessed using fetal m-mode echo, 2-D ultrasound, and pulsed wave doppler. SVT is the most common fetal tachyarrhythmia and should be treated if rate is greater than 220bpm, gestational age < 34 weeks, or there is evidence of hydrops fetalis.
References: 1. Lockwood CJ and Svena J. Nonimmune hydrops fetalis. Uptodate.com. Accessed: December 31, 2013. 2. Jaeggi ET, Carvalho JS, De Groot E, et al. Comparison of transplacental treatment of fetal supraventricular tachyarrythmias with digoxin, flecainide, and sotalol: results of a nonrandomized multicenter study. Circulation. 2011 Oct 18;124(16):1747-54.
Question 2. GYN-Ovarian Neoplasms QID 17468
A 52 y/o woman returns to your office 2 weeks postoperatively. She initially presented with a 12cm pelvic mass and an elevated CA-125 (300 U/mL). She underwent an uncomplicated total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy. Outside of the ovary, the only apparent disease at the time of surgery was a 4cm implant on the distal omentum. At the completion of surgery, there was no visible residual disease and the final pathology revealed a high-grade serous ovarian carcinoma with metastatic disease in the omental implant. Her postoperative course has been without complications thus far and she is otherwise healthy and without medical comorbidities. In speaking with her about adjuvant therapy, she expresses that she is willing to accept increased treatment related toxicity if it may result in a survival advantage. Based on the patient’s preferences, surgical stage and clinical characteristics, what is the MOST appropriate adjuvant treatment?
A. Whole abdominal radiation
B. Intravenous (IV) cisplatin and IV paclitaxel
C. Intraperitoneal (IP) cisplatin and IV/IP paclitaxel
D. IV carboplatin and IV docetaxel
E. Single-agent carboplatin
Answer: C. Intraperitoneal (IP) cisplatin and IV/IP paclitaxel.
Compared with IV chemotherapy, intraperitoneal chemotherapy provides a several-fold increase in drug concentration to be achieved within the intraperitoneal cavity.
In 2006, the Gynecologic Oncology Group (GOG) published the results of GOG 172, comparing adjuvant IV cisplatin and IV paclitaxel to IP cisplatin with IV/IP paclitaxel among patients who underwent optimal (<1cm residual disease) primary cytoreductive surgery. The IV/IP arm was associated with greater chemotherapy-related toxicity but had an improvement in both progression-free survival and overall survival. Coinciding with the publication of the results of GOG172, the National Cancer Institute issued a clinical announcement endorsing the IV/IP regimen used in GOG172 as the preferred method of adjuvant treatment for women with advanced ovarian cancer.
A. Primary cytoreductive surgery followed by platinum-taxane based chemotherapy is the preferred treatment for advanced stage ovarian cancer and has been shown to improve overall survival. Whole abdominal radiation would not be an appropriate adjuvant therapy.
B. As described above, the use of IP cisplatin and IV/IP paclitaxel is associated with a survival advantage when compared to IV cisplatin and IV paclitaxel. Since this patient is asking specifically for the treatment regimen associated with a survival advantage, answer C is most appropriate.
D. While this regimen is a platinum-taxane based regimen, the most appropriate regimen would include IP chemotherapy. Specifically, the regimen listed for answer C would be preferred.
E. As mentioned above, first-line adjuvant therapy after optimal, primary cytoreductive surgery should include a platinum and a taxane. Summary: In this otherwise healthy woman, desiring an adjuvant chemotherapy regimen associated with the greatest survival advantage, the use of IP cisplatin and IV/IP paclitaxel is most appropriate. This regimen is associated with an increased rate of treatment-related toxicity and the patient should be counseled with respect to this risk.
References: 1) Armstrong DK, Bundy B, Wenzel L, Huang HQ, Baergen R, Lele S, Copeland LJ, Walker JL, Burger RA; Gynecologic Oncology Group. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. 2006 Jan 5;354(1):34-43. 2) National Cancer Institute. (2006). NCI Issues Clinical Announcement for Preferred Method of Treatment for Advanced Ovarian Cancer [Press release]. Retrieved from http://www.cancer.gov/newscenter/newsfromnci/2006/ipchemotherapyrelease. 3) Prognostic factors for stage III epithelial ovarian cancer treated with intraperitoneal chemotherapy: a Gynecologic Oncology Group study. AU Landrum LM, Java J, Mathews CA, Lanneau GS Jr, Copeland LJ, Armstrong DK, Walker JL SO Gynecol Oncol. 2013 Jul;130(1):12-8. Epub 2013 Apr 8.
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