NOVEMBER 2019

1. the following statement is true regarding the physiological adaptation to pregnancy?

a. the increase in maternal hearth rate contributes to an increase in cardiac output during
pregnancy
b. mean arterial blood pressure falls because of a rising in systematic vascular resistance
c. anatomical and physiological changes in the lungs allow a pregnant woman to witstand hypoxia
better than a non-pregnant woman
d. the lower bicarbonate levels in pregnant women reflect a state of metabolic acidosis
e. TSH (thyrotropin) leves fall in the first trimester but returns fastly to normal by term

2. a 29 year old woman with a positive pregnancy test presents with a good history of tissue expulsion
vaginally passing tissue per vagina. A transvaginal ultrasound scan shows an empty uterus with an
endometrial thickness of 11 mm. regarding her diagnosis, you consider that
a. she has had a complete miscarriage and needs no further treatment
b. she has had a pregnancy of unknown location and needs further invastigations
c. she should be offered a hysteroscopy
d. she should be offered medical management of miscarriage
e. a laparoscopy should be performed to exclude an ectopic pregnancy

3. which of the following is true about the screening and diagnosis of spina bifida?
a. A maternal serum alpha-fetal protein (MSAFP) of 2.5 multiples of median (MoM) is diagnostic of
NTD
b. first trimester ultrasound of NTDs primarily involves identification of a normal posterior fossa
during aneuploidy screening to rule out the presence of a Arnold-chiari II malformation
c. magnetic resonance imaging (MRI) has proven to be a better diagnostic tool for NTDs than
ultrasound
d. the banana sign is indicative of ventriculomegaly, which is present in most cases of open NTDs
e. Diagnosis of lesion level requires three-dimensional ultrasound of MRI modalities

4. On prenatal ultrasound, which of the following feature characterize gastroschisis?

a. the abdominal wall defect is superior to cord insertion
b. ectopia cordis is present
c. the abdominal wall defect is lateral to cord insertion
d. the abdominal wall defect is lower than cord insertion
e. the bladder cannot be visualized

5. A 39 yo female G2P1 15 wga presents to your clinic for having routine anc. On physical exam, you
found her fundal height equals umbilical point. You performed ultrasound and saw a multilocular
hyperechoic mass size 10 cm (in diameters) in her left adnexa. No free fluid in her abdomen and
pelvis. Whats is your consideration in this case?
a. the incidence of adnexal masses in pregnancy is 1%
b. the incidence of ovarian cancers in pregnancy is between 1:1000
c. the most common type of benign ovarian cyst in pregnancy is a mature teratoma
 d. the most common histopatological subtype for malignant ovarian tumor in pregnancy is
epithelial ovarian tumor
e. the resolution rate of adnexal masses in the second trimester of pregnancy is 60-70%

6. the patient does not believe that she has ovarian cyst during pregnancy. She is really concern about
the possibility of malignancy. Regarding this situation, what would you inform her?
a. the most common mode of presentation of an adnexal mass is pain
b. the sensitivity of detection of ovarian cysts on clinical examination alone is less than 5%
c. the size of ovarian cyst that should prompt investigation for malignancy is 10 cm
d. the validated sensitivity and specificity of rules on ultrasound evaluation of an ovarian cyst is :
sens :78% ; spec : 87%
e. the sensitivity and specificity of MRI in the diagnosis of malignancy is 100 and 94% respectively

7. you checked her ca 125 serum level and the result was 350 μ/ml. you performed conservative
surgical staging by laparotomy because her frozen section revealed malignancy cyst. After 1 week,
pathology result serous papillary carcinoma of left ovary. She is planned for chemotherapy. What
will you inform to her regarding chemotherapy for ovarian cancer during pregnancy?
a. in a patient with ovarian cancer in pregnancy receiving chemotherapy the delivery should be
planned at completion of chemotherapy
b. use of chemotherapy in pregnancy generally considered safe after 20 wga
c. CNS and neural tube complications occur during the week 8-12 wga
d. this percentage of patient receiving chemotherapy in pregnancy who develop major congenital
malformation is 30-40%
e. cardiovascular defects are common congenital malformations in platin based chemotherapy

A 28 y.o woman, G1 36 wga, went to your clinic to do routine anc. During ultrasound, the doctor told
her that she will be expecting baby boy with estimated fetal weigth 2500g, however, amniotic fluid
considered to be less than normal. Then you asked the patient to drink minimal of 2L of water a day and
get herself another ultrasound within 3 days to evaluate the amniotic fluid.

8. oligyhidramnios is defined as which of the following “

a. AFI < 5 cm
b. SDP < 2 cm
c. AFI <90th percentile
d. all of the above
e. none of the above

William obs study guide p69

9. amniotic fluid volume is balanced between production and resorption, what is the primary
mechanism of fluid resorption ?
a. fetal breathing
b. fetal swallowing
c. absorption across fetal skin
d. absorption by fetal kidneys
e. filtration by fetal kidneys
William obs study guide p68
10. in a normal fetus at term, what is the daily volume of fetal urine that contributes to the amount of
amniotic fluid present?
a. 200 ml
b. 250 ml
c. 500 ml
d. 750 ml
e. 1000 ml
William obs study guide p68

Mrs A, 26 y.o, G1P0A0, according to her LMP is 34 wga, came for her first anc. She said she had 20 kg of
weight gain during her pregnancy with swelling ankles for the past 4 weeks. She never took any iron of
vitamin supplementation. From the physical findings, BP 145/95 mmHg, HR 86x/min, RR 20x/min, BMI
35 kg/m2. US exam confirmed twins in breech presentation. Results from urinalysis were as follows :
color cloudy yellow, specific gravity 1/013, albumin +2, RBC 0 -1, WBC 2-5, negative bacterial count.

11. what is the most likely diagnosis ?

a. acute fatty necrosis of the liver
b. chronis hypertension
c. preeclampsia
d. renal disease
e. pyelonephritis

Mrs B, 37 y.o came to your office at 32 wga according to her LMP. She has no US exam before and didn’t
do her routine anc. The vital sign is within normal limit. She has body mass index 19 kg/m2. During
physical examination, the uterine fundal height is 22 cm. from US exam, the fetus has biometric values
that correlate with 30 week fetus.

12. which of the following is the next best step in managing this patient?
a. anc routinely for next 2 weeks
b. evaluate maternal status and comorbidities
c. consider deliver the baby
d. repeat sonography for fetal growth in 2 weeks
e. Doppler velocimetry evaluation every 3 days
William obs study guide 24 p297

13. according to algoritm for management od fetal-growth restriction, you evaluate the Doppler
velocimetry then find reversed end diastolic flow and oligohydramnios. What is the appropriate
management at this time ?
a. regular fetal testing
b. weekly evaluation of amniotic fluid
c. consider corticosteroids for lung maturation
d. deliver the baby
e. reevaluate middle cerebral arteries and ductus venosus
William obs study guide 24 p297

14. fetal growth restriction is associated with all of the following, except
 a. antiphospolipid antibody syndrome
b. inherited thrombophilias
c. infertility
d. immunosuppressive drugs
e. social deprivation
William obs study guide 24 p296

Mrs E 32 yo referred from midwife with antepartum hemorrhage. She is G3P2 term pregnancy. On
Examination her BP is 160/100mmHg. HR 100x/m. she looks anemic, not icteric. Obstetrical exam reveal
contraction 4-5x/10m, FHR 170 bpm, head presentation 3/5. After through examination it is concluded
that there is a placental abruption with retroplacental hematoma size 6x5 cm. this patient is planned to
do CS.
15. if during operation the uterus is couvelaire but with good contraction, how would you manage that
condition?
a. perform prophylactic b-lynch suture
b. ascending uterine artery ligation
c. hypogastric artery ligation
d. sub total hysterectomy
e. uterotonic and observation

16. postoperative period is very crucial in this patient. Which of the following isn’t included as a
parameter needed to be evaluated in early warning system
a. blood pressure
b. hearth rate
c. urine production
d. central venous pressure
e. all of the above

a 26 yo woman, G1P0A0 was admitted to ER because she lost her consciousness around 1 hour ago.
According to her husband, she is 36 wga. She performed anc at scheduled time, and never missed one.
Her husband said, she never had any hypertension or any other disease before. Three days prior
hospitalization, she had severe nausea and vomiting. Physical exam reveals, BP 120/80 mmHg, pulse
rate 87x/m, RR 18 x/m, temp 36,5. You notice there is an icteric sclera. Other physical exam was
remarkable. Obstetrical exam reveals no fetal hearthbeat was detected. Lab exam reveals CBC
10.2/29.9/8900/263000, Ur/Cr 18/0.6, AST 458/878; RGB 32, UL within normal limit

17. what is the bestnext management in this case?

a. abdominal US
b. induction of labour
c. emergency CS
d. whole blood transfusion
e. injections of 40% dextrose

18. ALL EXCEPT which of the following are clinical characteristics that increase the risk for acute fatty
liver of pregnancy ?
a. nulliparity
b. female fetus
 c. male fetus
d. twin gestation
e. third trimester

19. what is the underlying pathophysiology of intrahepatic cholestasis of pregnancy?

a. acute hepatocellular destruction
b. incomplete clearance of bile acids
c. microvascular thrombus accumulation
d. eosinophil infiltration of the liver
e. hepatocellular injury

William obs study guide 24 p361 -362

A 17 yo G1 woman presents at 25 wga complaining of headache for the past 36 hours. She has had
regular prenatal visits going back to her first prenatal visit at 8 wga. A 20 week US redated her
pregnancy by 2 weeks as it was 15 days earlier than her LMP dating. She has a BP 155/104 mmHg.

20. you review her medical record and determine that she doesn’t have chronic hypertension. The
patient denies having RUQ pain because of your high suspicion of severe preeclampsia you order a
CBC, liver enzyms, renal function test, and 24-hour urine protein. Her lab test result reveal a normal
platelet count and liver enzymes but slightly elevated creatinine and proteinuria of 550 mg in 24
hours. Her headache has resolve after dose of acetaminophen. What is the next best step in her
management?
a. give her prescription for labetalol and have her follow up in clinic in 2 week
b. (a) plus bed rest
c. hospitalization for further evaluation and treatment
d. immediate delivery
e. begin induction of labor

A 17-year-old woman presents at 25 weeks gestation complaning of headache for the past 36 hours. She
has had regular prenatal visits going back to her first prenatal visit at 8 weeks gestation. A 20-week
ultrasound redated her pregnancy by 2 weeks as it was 15 days earlier than her LMP dating. Shea has a
BP of 155/104 mm Hg.
21. Over the next 12 hours, her BP’s rise above 160 mmHg on several occasions, most natably to
174/102 mmHg 2 hours after admission and to 168/96 mmHg 9 hours after admission. Her headache
doesnt return and she has no RUQ pain or visual symptoms. A setof repeat laboratory test results are
unchanged and by increasing her labetalol dose to 400 mg TID, her BP’s decrease to 140s-150s/ 70-90
mmHg. She is also started on magnesium sulfate. What change in physical or laboratory examination
do you observe that would indicate delivery?
a. Another BP of 174/ 102 mmHg
b. Headache returning
c. Double vision
d. Platelets of 108
e. AST of 265
A 35-year-old woman, G4P3, at 37 weeks gestation presented in hospital with a ten-day history of low
extremities edema, with idiophatic hypertension for 1 year. At presentation, she had a blood pressure of
170/100 mmHg. Laboratory findings were normal except urinanalysis (protein +2). She was diagnosed
with superimposed severe preeclampsia. It was decided to deliver the fetus by means of a C-section by
indication transverse lie. Blood pressure measurement was 150/100 mmHg. She lost consciusness for 30
seconds, five hours after operation. The laboratory studies gave the following results, serum aspartate
aminotransaminase (AST), 225 IU/L; serum alanine aminotransaminase (ALT), 140 IU/L; serum lactate
dehydrogenase (LDH), 1017 IU/L; serum urea and creatine were normal; hemoglobin, 10,6 mg/dl.
Platelet count, 50 x 103 µ/ ml. A brain computed tomography (CT) scan was performed on patient which
revealed the left frontal lobe lacunar infarction. The patient was transferred to intensive care unit.
22. What is the most appropriate diagnosis
A. DIC
B. Acute fatty liver in pregnancy
C. HELLP Syndrome
D. Severe puerpural infection
E. Trombotic thrombositopenci purpura

23. What is the best management after, for this case

A. Fresh-frozen plasma and trombocytes concentrates
B. Anti platelets
C. Anti-oxidant
D. Corticosteroid
E. Magnesium sulfate

24. Twelve hours observation showed urine production was 100 ml

A. Immediately giving diuretics bolus IV
B. Immediately giving diuretics maintained by syringe-pump
C. Check albumin level, giving diuretic justified after hipoalbuminemia condition had been distinguished
D. Renal failure due to micro thrombopathy suspected, heparin provision could be considered
E. Immediately step on fluid rescucitation

A 33-year-old woman, G1P0A0, came to hospital with major complaint watery leakage. She was on her
33 weeks of gestational age. Data from medical record showed that she came previously a week ago,
complaining vaginal dischargel. Vaginal swab was done.
25. In case above, what kind of examination should you performed for establishing diagnosis.
A. Vaginal examination
B. Inspeculo
C. Blood test.
D. Ultrasound
E. Simple urine test
Sudah jelas ya, untuk diagnosis PPROM --> inspekulo (pooling, tes valsava, lakmus)

26. You found on Leopold 1, hard, round with ballotement (+). Contraction was infrequent and weak. A
what was your next plan?
A. went for labour induction
B. Immediate C-Section
C. Tocolyctic and corticosteroid provision
 D. Performed ultrasound
E. Performed external version
Preterm 33 minggu, kepala, kontraksi (+) irreguler --> tokolitik dan pematangan paru

27. Lack of baby movement had been felt for two days, fetal heart rate was 146 bpm. What was your
next step?
A. termination of pregnancy
B. Giving oxygenation and left lateral position
C. Ensuring fetal well-being by Manning criteria
D. Fetal lung maturation
E. Giving intravenous fluid rehidration

Fetal movement berkurang dapat merupakan tanda fetal stress, DJJ masih dalam range normal. Jawaban
B dan E adalah managemen resusitasi janin intrauterine. Untuk evaluasi fetal well being bisa dengan
non-stress test (CTG), biophysical profile (manning).

William 25e page 338

28. Cardiotocography, showed low variability with chechmark pattern and no desceleration. What as
your interpretation and the best management throught?
a. Category one, continued for fetal lung maturation
B. Category two, intrauterine rescucitation for 24 hours and reevaluation after
C. Category two, went for doppler velocymetry
D. Category three, went for doppler velocymetry ultrasound exam
E. Category three, delivered the baby

29. A primigravida at 36 weeks gestation is measuring large for dates. Ultrasound shows AC > 97 th
centile. GTT performed shows poorly controlled gestational diabetes. What is the immediate
management plan?
A. Give steroids
B. Start induction
C. Start hypoglicaemics
D. Wait and watch
E. Start sliding scale and deliver

Usia kehamilan 36 minggu (preterm), tidak ada data menunjukkan fetal distress dan dengan DMG risiko
delayed lung maturation --> dari soal ini tidak ada indikasi terminasi segera. Managemen saat ini kontrol
gula
Blueprints page 349.

30. A 38 year old G2P1 presents to the antenatal clinic. She had an emergency caesarean section for
sudden onset hypertension and placental abruption at 30 weeks in her previous pregnancy. She is
currently 20 weeks of gestation and enquires about further plan of fetal monitoring in this
pregnancy. What is the most appropriate advice?
A. No extra moitoring is required
B. Uterine artery doppler at 22 weeks
 C. Serial scans starting from 24 weeks
D. Serial cardiotocograph monitoring from 28 weeks
E. Serial scans from 28 weeks
Jawaban bisa C atau B. Notching berhubungan dengan risiko preeklampsia tapi memiliki predictive value
rendah (williams) serial scaning mungkin lebih bermanfaat buat observasi ketat imho

31. A 34 year old pregnant lady, G2P1 has been diagnosed with ductal carcinoma of the right breast
(stage 1). She is currently 22 weeks pregnant. What is the initial treatment of choice for her?
A. Termination of pregnancy
B. Local mastectomy with reconstruction
C. Local mastectomy without reconstruction
D. Local radiotheraphy
E. Single dose chemotheraphy with trastuzuma

32. A triple test is performed for Down’s screening at 16 weeks in a 40-year old woman. The result
suggests a high risk of trisomy 21. What would the results typically show?
A. Reduced AFP, reduced estriol, increased B-hCG
B. Increased AFP, reduced estriol, increased B-hCG
C. Reduced AFP, increased estriol, increased B-hCG
D. Reduced AFP, increased estriol, reduced B-hCG
E. Increased AFP, increased estriol, increased B-hCG

The maternal serum alpha feto-protein and unconjugated estriol both show a reduction by about 25% of
the normal and the β-hCG may increase by double in a Down’s fetus.
(MRCOG Part II)

33. Woman with one or more previous caesarean section scars and an anterior placenta are at of
placenta accreta. Which test has been shown in recent research to provide the highest sensitivity and
specificity for antenatal diagnosis of placenta accreta?
A. Colour doppler
B. 3D Power doppler
C. Contrast CT
D. Gadolinium contrast MRI
E. Grey Scale Ultrasound

A study comparing the different ultrasound signs concluded that the presence of abnormal vasculature
on colour Doppler ultrasound had the best combination of sensitivity and specificity. The best specificity
was the presence of an abnormal uterus–bladder interface.

34. A 22 year old unbooked primigravida presents to the Emergency Department at 26 week of
gestation with a history of spontaneous painless bleeding at about 500 ml. What is the best
investigation to secure a diagnosis?
A. MRI scan
B. Transabdominal scan
C. CTG
D. Transvaginal scan
E. CT scan
Best diagnosisn exam for PPT --> USG TV

35. A primigravida at 35 weeks gestation presents with pain in the right hypochondrium and right side of
her back. There is no history of nausea or vomiting, hypertension, urinary symptoms and bowel
problems. Vital signs; pulse 106, temperature 38,1, BP 128/75. Abdominal examination is
unremarkable. Chest is clear. Fetal monitoring is normal. Urine shows 2+ leucocytes and 1+ blood.
White cell count 16x109/L. What is the most likely diagnosis?
A. Appendicitis
B. Cholecystitis
C. Pyelonephritis
D. Abruption
E. Right basal pneumonitis
Pyelonephritis signs and symptoms often include fever (> 38°C), shaking chills, anorexia, nausea,
vomiting, and costovertebral angle tenderness. Right-side flank pain is more common than left-side or
bilateral flank pain. Pyuria is a common finding. Patients may also present with hypothermia (as low as
34°C). Symptoms of simple cystitis are not always present.

36. A 35-year old P2 is 36 weeks pregnant. Clinically there is a suspicion of left calf DVT. CTG is normal.
What is the next step in the immediate management?
A. Plan delivery
B. Therapeutic dose of tinzaparin
C. Prophylactic dose of tinzaparin
D. FBC, coagulation screen, LFTs
E. Thormophilia screen
Baseline bloods should be done before starting heparin low molecular weight therapy. (MRCOG part II)

37. A 24-year-old G2P1 woman at 39 weeks and 3 days is seen in clinic. She has been experiencing more
frequent contractions and thinks she might be in labor. Her last pregnancy ended with caesarean
delivery after a stage 1 arrest. There was no evidence of cephalic disproportion. Earlier in the course
of her current pregnancy she had desired a scheduled repeat caesarean, but now that she might be in
labor she would like to try and delivery vaginally.
What would be a contra indication to a trial a labor after cesarean (TOLAC)?
A. Prior classical hysterectomy
B. Prior Kerr hysterotomy
C. Small for gestational age fetus
D. Oligohydramnios
E. GBS + mother

■ Vaginal Birth after Cesarean Vaginal birth after cesarean (VBAC) can be attempted if the proper
setting exists. This includes an in-house obstetrician, anesthesiologist, surgical team, and informed
patient consent. The prior hysterotomy needs to be either a Kerr (low transverse incision) or Kronig
(low vertical incision) without any extensions into the cervix or upper uterine segment. The greatest
risk during a trial of labor after cesarean (TOLAC) is that of rupture of the prior uterine scar, which
occurs approximately 0.5% to 1.0% of the time. Prior classical hysterotomies, or vertical incisions
through the thick upper segment of the uterine corpus, are at a higher risk for uterine rupture in
labor, and women who have had this type of cesarean are not usually allowed to attempt a trial of
labor.
38. A 25-year-old G1P0 presents to the emergency room with vaginal bleeding. Her last normal
menstrual period was 6 weeks earlier. She reports that she is sexually active with male partners and
does not use any hormonal or barrier methods for contraception. On arrival, her temperature is 37C,
blood pressure is 115/80, pulse is 75 beats per minute, respiratory rate is 16 breaths per minute,
and she has 100% oxygen saturation on room air. A pelvic examination reveals a small amount of
dark blood in the vagina. The external cervical os appears 1 to 2 cm dilated. Her uterus is mildly
enlarged, anteverted, and nontender. A urine pregnancy test is positive. A pelvic ultrasound is
obtained and shows an intreuterin gestational sac with yolk sac. No fetal pole or cardiac motion si
seen. Billateral adnexa are normal. What is her diagnosis?
A. Incomplete abortion
B. Threatened abortion
C. Ectopic pregnancy
D. Missed abortion
E. Inevitable abortion

(Blueprints 6E hal 447)

e. An inevitable abortion is a pregnancy complicated by vaginal bleeding with a dilated cervix such
that the pregnancy is likely to pass soon.
a. An incomplete abortion is partial expulsion of POC prior to 20 weeks. This patient has not had any
tissue expelled.
b. A threatened abortion does present with vaginal bleeding, but in this type of abortion the patient
does not have cervical dilation.
c. This patient has an intrauterine pregnancy, as confirmed by an intrauterine gestational sac and
yolk sac.
d. Missed abortion is the death of an embryo with complete retention of all POCs. If the patient does
not pass any tissue spontaneously, a missed abortion may develop. However, this is not the best
initial diagnosis.

39. During a routine return OB visit, an 18-year-old G1P0 patient at 23 weeks gestational age undergoes
a urinalysis. The dipstick done by the nurse indicates the presence of trace glucosuria. All other
parameters of the urine test are normal. Which of the following is the most lilely etiology of the
increased sugar detected in the urine?
A. The patient has diabetes
B. The patient has a urine infection
C. The patient’s urinalysis is consistent with normal pregnancy
D. The patient’s urine sample is contaminated
E. The patient has kidney disease
40. A maternal fetal medicine specialist is consulted and performs an indepth sonogram. The sonogram
indicates that the fetuses are both male, and the placenta apears to be diamniotic and
monochorionic. Twin B is noted to have oligohydramnios and to be much smaller than twin A. In this
clinical picture, all of the follwoing are concerns for twin A except
A. Congestive heart failure
B. Anemia
C. Hypervolemia
D. Polycitemia
E. Hydramion
 41. You are called in to evaluate the heart of a 19-year-old primigravida at term. Listening
carefully to the heart, you determine that there is a split Sl, normal S2, S3 easily audible
With a 2/6 systolic ejection murmur greater during inspiration, and a soft diastolic murmur.
You immediately recognize that
a. The presence of the S3 is abnormal
b. The systolic ejection murmur is unusual in a pregnant woman at term
c. Diastolic murmurs are rare In pregnant women
d. The combination of a prominent S3 and soft diastolic murmur is a significant abnormality
e. All findings recorded are normal changes in pregnancy
Sumber : William 24 E

A 25-year-old woman in her first pregnancy is noted to have prolonged first and second stages
of labour. She was induced at 38 weeks' pregnancy. The baby was delivered by forceps. After
delivery the placenta she is noted to have heavy vaginal bleeding. Abdominal examination
demonstrates a relaxed uterus.

42. What is the most likely cause of bleeding.

A Uterine atony
B. Uterine rupture
C. Retained placenta
D. Genital tract laceration
E. DIC

The fundus should always be palpated following placental delivery to confrm that the uterus is well
contracted. If it is not frm, then vigorous fundal massage usually prevents postpartum hemorrhage from
atony (Hofmeyr, 2008). Primiparity has been cited to be a risk factor. Labor abnormalities predispose to
atony

43. What should we do if the fundus not firm after placental delivery.
A. Methylergonovine (Methergine)
B. Carboprost (Hemabate, PGF2-alpha)
C. Fundal Massage
D. Misoprostol (PGEI)
E. Dinoprostone-prostaglandin E2

The fundus should always be palpated following placental delivery to confrm that the uterus is well
contracted. If it is not frm, then vigorous fundal massage usually prevents postpartum hemorrhage from
atony (Hofmeyr, 2008). Sumber : william 24 E

A 30-year-old multiparous woman has rapid delivery soon after arriving in emergency room. After
delivery the placenta she is noted to have heavy vaginal bleeding. Help has been summoned.
Abdominal examination demonstrates the fundus was soft.
44. What is the most appropriate next step?
A. Intravenous access for fluid resuscitation
B. Uterine packing
C. Balloon tamponade
 D. Suture the laceration
E. Misoprostol administration

Simultaneously, 20 units of oxytocin in 1000 mL of cyrstaloid solutions will be effective given

intravenously at 10ml/min for a dose of 200 mU/min. Sumber : William 24 E

45. After use of a 20 units of oxytocin in 1000 mL of crystalloid solution to increase the tone of her
uterus stop the bleeding; however, you continue to notice a massive bleeding from the vagina.
What is the most appropriate next step in the evaluation of this patient's bleeding?
A. Perform a bedside ultrasound for retained products of conception
B. Perform a ultrasound to look for blood in the abdomen significant for uterine rupture
C. Perform a manual exploration of the uterine fundus and exploration for retained clots or
products
D. Examine the perineum and vaginal for laceration during delivery
E. Consult interventional radiology for uterine artery embolization

Persistent bleeding despite a firm, well contracted uterus suggest that hemorrhage most likely is from
lacerations. To confirm that lacerations are a source of bleeding, careful inspection of the vagina,
cervix and uterus is essential
Sumber william 24 E

46. Labor induction and augmentation are NOT associated with which Of the following risk?
A. postpartum hemorrhage from uterine atony is more common in women undergoing induction
or augmentation
B. Amniotic fluid embolism in a laboring patient receiving oxytocin can be occurred
C. The increased risk for cesarean delivery undergoing induction is related with cervical
favorability (Bishop Score)
D. The uterine rupture risk is increased threefold for women in spontaneous labor with uterine
Scar
E. Women Whose labor is managed with amniotomy have lower incidence of chorioamnionitis
compared with those in spontaneous labor
Amniotomy is often selected to augment labor. Women whose labor is managed with amniotomy
have an increased incidence of chorioamnionitis compared with those in spontaneous labor
( American College of Obstetricians and Gynecologists). Sumber : William 24 E

A 32-years-old woman comes to your clinics due to shortness of breath, that worsen since 2
days ago. On history taking, she told you that she had ever diagnosed of having significant mitral
stenosis. She is 33 weeks pregnant. The fetus is size-date appropriate. She has had a recent
echocardiography showing ejection fraction of 54% with moderate-severe pulmonary
hypertension.

47. What is the best management for this patient currently?

A. Perform emergency C section
B. Lung maturation and C section
C. Conservative management until term pregnancy
D. Second stage acceleration
E. Induction of labor
 48. What is the most common cause Of heart failure during pregnancy and the puerperium?
A. Chronic hypertension with severe preeclampsia
B. Viral myocarditis
C. Obesity
D. Valvular heart disease
E. Pulmonary Artery Hypertension

49. For patients with congenital heart disease, what is the most common adverse cardiovascular
event encountered in pregnancy?
A. Heart failure
B. Arrhythmia
C. Thromboembolic event
D. Cerebrovascular hemorrhage
E. Heart axis changes

50. A 24-year-old women at 32 weeks' gestation complains of shortness of breath during her
pregnancy, especially with physical exertion. She has no prior medical history. Her respiratory rate
is 16x/m,• her lungs are clear to auscultation; and your offce oxygen saturation monitor reveals
her oxygen saturation to be 98% on room air. You reassure her that this sensation is normal and
explain which of the following?
A. Pulmonary resistance increases during pregnancy.
B. Airway conductance is decreased during pregnancy.
C. Small amniotic fluid emboli are shed throughout pregnancy.
D. Maximal breathing capacity is not altered by pregnancy.
E. Because Of enlarging uterus pushing up on the diaphragm, her vital capacity is decreased by 20%.

A 32-year-old woman G2PIAO presented to delivery ward at 30 weeks gestation with worsening
abdominal pain for few hours. She had also had some vaginal bleeding within the past hour. Her
uterus was tender and firm to palpation. She was found to have low-amplitude, high-frequency
uterine contractions, and the fetal heart rate tracing showed recurrent late decelerations and
reduced variability. Her blood pressure was 160/100 mmHg and she has had a +2 proteinuria. She
did her antenatal care in your hospital and ultrasound examination was performed 3 times with no
remarkable abnormalities.

51. The most likely diagnosis is :

A. Vasa Previa
B. Preterm labor
C. Placenta previa
D. Placental abruption
E. Preterm Premature Rupture of Membrane (PPROM)
52. From obstetrical examination you found her cervix was unfavorable. Your next plan is to deliver
the baby by
A. Vaginal delivery
B. Elective C-section
C. Emergency C-section
D. Operative vaginal delivery
E. Observation until the cervix was favorable
 53. you are counseling a couple in your clinic who desire VBAC. Her baby is in a vertex
presentation, appropriate size for 37 weeks, and her previous low transverse procedure was
for breech presentation. You have to give inform consern about VBAC. In providing informed
mnsent, in which of the following ways do you explain the risk of uterine rupture?
A. Less than 1%
B. Between 2% and 5 %
C. Between 15-20%
D. Depend on the length of her labor
E. Depend on the location and proximity of the scar site to the placental implantation

54. Corticosteroids administered to women at risk for preterm birth have been demonstrated to
decrease rates Of neonatal respiratory distress if the birth is delayed for at least what amount
of time after the initiation of therapy?
A. 12 hours
B. 24 hours
C. 36 hours
D. 48 hours
E. 72 hours

55. A 24-year-old patient, P2, has just delivered vaginally an infant weighing 3000 g after a
spontaneous uncomplicated VBAC. Her prior obstetric history was a low uterine segment
transverse cesarean section for breech. She has had no problems during the pregnancy and
labor. The placenta delivers spontaneously. There is immediate vaginal bleeding of greater
than 500 cc. Although all of the following can be the cause for postpartum hemorrhage, which
is the most frequent cause of immediate hemorrhage as seen in this patient?
A. Uterine atony
B. Coagulopathies
C. Uterine rupture
D. Retained placental fragments
E. Vaginal and/or cervical lacerations

Currently, there are few indications for a primary verical incision. In those instances for example ,
preterm breech fetus with an undeveloped lower segment- the” low vertical” incision almost
invariably extends into the active segments. It is not known , however , how far upward the incision
has to extend before risks become those of a true classical incision. It is helpful in the operative
report to document in its exact extent. William 24 E p 613

56. A 89-year-old female patient with multiple, serious medical comorbidities presents to discuss
options for treatment of her high-grade prolapse. The prolapse is externalized and becoming
ulcerated from friction against her undergarments. She cannot tolerate a pessary. Her main
priority is to "fix or get rid of this thing: but her primary care provider has cautioned against a
lengthy or open abdominal procedure. She is not interested in future intercourse. what can
you offer this patient?
A. Nothing can be done
B. Open abdominal sacral colpopexy
C. Robot-assisted laparoscopic sacral colpopexy
 D. Hysterectomy with anterior and posterior colpomhaphy, vault suspension.
E. Colpocieisis

82 years old woman P6 came to outpatient clinic with chief complaint of bulging mass rotrudes
from vagina since 3 months ago. The mass usually occurs during activity and also 'hen she
defecate , and disappear when lying down. There were no difficulty in voiding and efecation. No
urinary leakage during coughing and sneezing. She is not sexually active.

57. If on the Pelvic Organ Prolapse Quantification examination result showing below, what is the
diagnosis of this patient?

Aa Ba C

+3 +4 +5

GH Pb TVL

5 2 8
Ap Bp D
o o
+3

a. Uterine prolapse grade 2, cystoce!e grade 2, rectocele grade 1

b. Uterine prolapse grade 4, cystocele grade 3, rectocele grade 2
c. Uterine prolapse grade 3, cystocele grade 3, rectocele grade 2
d. Uterine prolapse grade 3, cystocele grade 2, rectocele grade 2
e. Uterine prolapse grade 4, cystocete grade 4, rectocele grade 3
58. If the patient choose to use pessary instead of surgery, how to choose the right size of the
pessary?
A. The smallest size that do not fall off and doesn't cause pain and obstruction of urination and
defecation
B. The biggest size that do not fall off. but doesn't cause pain and obstruction of urination and
defecation
C. The intermediate size that do not fall off, but doesn't cause pain and obstruction of urination
and defecation
D. By measuring the genital hiatus of the patient
E. By measuring the total vaginal length

The type of device selected may be affected by patient factors such as hormonal status, sexual activity,
prior hysterectomy, and stage and site of POP. After a pessary is selected, a woman should be fitted with
the largest size that can be comfortably worn. If a pessary is ideally fitted, a patient is not aware of its
presence. As a woman ages and gains or loses weight, alternate sizes may be required.

Patient 65 years Old, P4 came to outpatient clinic with chief complaint of frequent urination. Since
6 months ago she feels the urge to void every hour and also she has to wake up 3-4 times in the
night to void. She never leaks urine. She doesn't feel any pain during urination and no blood in the
urine: She already came to general practitioner and got antibiotics for 7 days but the symptoms
remained.
59. What is the most useful supporting examination in this patient?
A. Urine culture
B. Pelvic floor ultrasaound
C. Gynecology ultrasound
D. Bladder diary
E. Urodynamic evaluation

60. What is the most likely diagnosis of this patient?

A. pyelonephritis
B. Overactive bladder
C. Urge incontinence
D. Stress urinary incontinence
E. Painfull bladder syndrome

A 30 years old patient came with complaint of infertility. Her husband is a 33 year old who has had a
semen analysis, which was reported as normal. On further history, the patient reports that her periods
have been quiet irregular over the last year and that she has not had period in the last 6 months. She
also reports insomnia, vaginal dryness, and decreased libido
61. What is the most likely diagnosis for this patient based on her story?
a. Polycystic ovarian syndrome
b. Primary ovarian insufficiency
c. Endometriosis
d. Kallman syndrome
e. Spontaneous pregnancy

62. Which of the following condition that corresponds to the above possible diagnosis?
 a. Day 3 FSH level 10 IU
b. Serum AMH level 1,2 pmol/ml
c. Positive Clomiphene citrate challenge test
d. Midluteal progesterone level 15 ng/ml
e. Follicel antral basal count of 10

63. If the diagnosis was confirmed, what is her best option to achieve pregnancy?
a. Clomiphene citrate – IUI
b. Gonadotropin – IUI
c. Minimal stimulation
d. IVF with oocyte donation
e. High dose gonadotropin IVF

Blue print
A 34-year old women with primary infertility 3 years, oligomenorrhea and a body mass index (BMI) of 26. Day 23
progesterone level result was 5 ng/ml. Transvaginal ultrasound shows multiple small follicle size 5-8 mm
in both ovaries. HSG shows bilateral patent tubes. Her partner’s semen analysis shows a volume of 3 ml,
pH of 7 and sperm count of 20 million/ml.

64. What is the most appropriate step of management?

a. Examine TSH and prolactin
b. Measure FSH, LH, and estradiol
c. Measure serum testosterone level
d. Give aromatase inhibitor
e. Start ovulation induction using gonadotropin

65. According to the current International Guidelines, which of the following medication considered to
be the first line of therapy for ovulation induction?
a. Letrozole 1x2,5 mg
b. Clomiphene citrate starting at dose 50 mg/day for 5 days
c. Clomiphene citrate 50 mg/day combined with Metformin 2x500 mg
d. Metformin 2x500 mg
e. Gonadotropin injection 75 IU/day

Mrs. N, 37 years old with chief complain of infertility for 6 years with history of severe dysmenorrhea. From
hysterosalpingography, both tubes were non-patent. Pelvic ultrasound found bilateral cystic mass with
internal echo sized 50 and 60 mm in diameter. Her husband sperm examination was within normal limit.

66. What is the next appropriate management?

a. Offer IUI
b. Perform laparoscopy cystectomy and adhesiolysis
c. Give GnRH analog for 3 months continue with IUI
d. Give Dinogest 1x2 mg for 6 months
e. Offer her IVF
 67. Her AMH level was 0,9 ng/ml. What is the reason for performing surgery in subfertile patient with
bilateral endometrioma and diminished ovarian reserve?
a. Removal endometrioma
b. Ablation of all endometriosis lesion
c. To prevent infection in endometrioma
d. To improve access for follicle aspiraton
e. Removal of deep infiltrating endometriosis

68. Which of the following is true regarding low ovarian reserve in endometriosis?
a. Ovulation rate in ovary with endometrioma is higher compared to ovary without endometrioma
b. There is higher density of follicle in ovary with endometrioma
c. Ovary with endometrioma has higher response rate to gonadotropin
d. Loss of ovarian stromal appearance and fibrosis are present in ovarian cortex with
endometrioma
e. Low ovarian reserve in endometriosis only happen after surgery

A 18-year old adolescent female complains of not having started her menses. Her breast development is Tanner
stage IV, pubic hair development was stage I. from vaginal examination found a blind vaginal pouch and
no uterus and cervix.

69. Which of the following describes the most likely diagnosis?

a. Partial androgen insensitivity syndrome
b. Complete androgen insensitivity syndrome
c. Kallman syndrome
d. Turner syndrome
e. Polycystic ovarian syndrome

70. From ultrasound examination found no uterus and there was difficulty in identifying in the gonads.
What is the next plan?
a. Prolactin measurement
b. Kariotyping
c. FSH and LH examination
d. FSH, LH, dan E2 examination
e. TSH, fT4 examination

71. Which of the following management will be appropriate for this condition?
a. Give progestin 14 days on off
b. Give estrogen-progestin sequential
c. Give combined oral contraception
d. Vaginal reconstructive surgery
e. Laparoscopy gonad removal

An-18 year-old young woman presents to you with complaint of amenorrhea. She notes that she has never had
a menstrual period, but that she had mild cyclic abdominal bloating. She is sexually active, but she
complains of painful sexual intercourse. Her past medical and surgical history is unremarkable. On
physical examination, you note normal appearing axillary and pubic hair. Her breast development is
normal. Pelvic examination reveals normal appearing external genitalia, and a shortened vaginal ending
in a blind pouch.
 72. Which of the following test would be your first step in determining the diagnosis?
a. Karyotype
b. Pelvic ultrasound
c. Serum FSH
d. Serum FSH, E2
e. Diagnostic laparoscopy

Blue print

73. From further examination it was found that uterus cannot be visualized both both ovaries were
normal. What is the most likely diagnosis?
a. Imperforate hymen
b. Transverse vaginal septum
c. Mullerian agenesis
d. Androgen insensitivity dynrome
e. Gonadal dysgenesis

74. Which additional organ system should you be evaluating in patient with this disorder?
a. Pancreas and duodenum
b. Cerebral circulation
c. Olfactory system
d. Renal and urinary collecting system
e. Distal gastrointestinal tract
A 34 year old female, para 1, presented to our clinic with secondary amenorrhea and severe, progressive
hirsutism. On clinical examination she was noted to have severe hirsutism and male-pattern scalp
balding. Her BMI was 30 kg/m2. Laboratory results showed an elevated total testosterone (T) level of
140 ng/dl (reference value in our laboratory is 0-80 ng/dl) and androstenendione of 272 ng/dl (reference
value of 30-250 ng/dl). CT of the abdomen and pelvis showed normal adrenal glands. Pelvic ultrasound
of the pelvis demonstrated mildly prominent ovaries, containing numerous small follicle around
periphery.

75. What is your most probable diagnosis?

a. Multicystic ovary
b. Congenital adrenal hyperplasia
c. Polycystic ovary syndrome
d. Hyperprolactinemia
e. Microadenoma pituitary

76. Your diagnosis according to ASRM/ESHRE definition, based on two of the following criteria:
a. Polycystic ovaries on ultrasound, oligo or amenorrhea, or evidence of hyperandrogenism
b. Polycystic ovaries on ultrasound, amenorrhea, obesity
c. Polycystic ovaries on ultrasound, amenorrhea, hirsutism
d. Presence of hyperandrogenism, ovarian dysfunction and exclusion of related disorders
e. Polycystic ovaries on ultrasound, hirsutism, obesity
Pada konsensus ASRM/ESHRE tahun 2003 disepakati diagnosis SOPK ditegakkan dengan adanya 2 dari 3 gejala
yaitu (i) tanda klinis atau biokimia hiperandrogenisme; (ii) gangguan ovulasi kronik; dan (iii) ditemukan
adanya gambaran morfologi ovarium polikistik pada pemeriksaan Ultrasonografi (USG).

A 27 year-old woman presents to your office with a positive home pregnancy test and a 3-day history of vaginal
bleeding. She is concerned that she may be having a miscarriage. On examination, the uterine fundus is
the at the level of umbilicus. By her last period, she should be around 8 weeks gestation. On pelvic
examination, there is a moderate amount of blood and vesicle-like tissue in the vaginal vault, and the
cervix is closed. The lab then calls you to say that her serum b-HCG results is greater than 1,000,000
mIU/mL

77. Which of the following is the best next step in this patients’s evaluatin?
a. Complete pelvic ultrasound
b. Determination of Rh status
c. Surgical intervention (suction curettage)
d. Methrotrexate administration
e. Schedule a follow-up visit in 2 to 4 weeks to recheck a b-HCG level

78. The patient undergoes an uncomplicated suction D & C. The pathology report is available the next
day and is consistent with a complete molar gestation. What is the best next step in the care of this
patient’s condition?
a. Repeat pelvic imaging
b. Radiation therapy
c. Chemoterapy
d. Surveillance of serum b-HCG
e. No further follow-up is required

79. During further visit, you meet with your office about 3 months after the index visit. Which of the
following interventions is most important to emphasize during the follow-up period?
a. No further pregnancies are recommended
b. Await pregnancy attempt for 2 years
c. Reliable contraception during surveillance
d. Prophylactic antibiotic use during surveillance
e. Prophylactic chemotherapy to decrease the risk of persistent and recurrent disease

A 46 years old woman experiences irregular vaginal bleeding of 3 months duration. You perform an endometrial
biopsy, which obtains copious tissue with a velvety, lobulated textrure. The pathologist report shows
proliferation of glandular and stroma elements with dilated endometrial glands, consistent with simple
hyperplasia. Cytologic atypia is absent.

80. Which of the following is the best way to advise the patient?
a. She should be treated to estrogen and progestin hormone therapy
b. The tissue will progress to cancer in approximately 10% of cases
c. The tissue may be weakly premalignant and progresses to cancer in approximately 1% of cases
d. She requires a hysterectomy
e. No further therapy is needed
81. She agreed for a medical treatment, which of the following is the most appropriate?
A. Norethisterone acetate 1x5 mg for 14 days on-off
B. MPA 1x2,5 mg for 14 days on-off
C. Nomegestrek 1x2,5 mg for 14 days on-off
D. LNG IUS
E. Combined oral contraception
82. A 7-year-old girl presents to her pediatrician with her parents who are concerned about her early
sexual development. She is developing breasts, axillary hair, and pubic hair, and they are noticing
body odor. A thorough clinical workup reveals the child has an irregular, echogenic, thickly septated
ovarian mass on her left ovary. What type of tumor is responsible for this childs clinical
presentastion?
A. Dysgerminoma
B. Embryonal carcinoma
C. Sertoli-Leydig cell tumor
D. Endodermal sinus tumor
E. Granulosa-theca cell tumor

A 36 years old patient, P0, presents to your clinic for fertility workup. She had been married for 2 years
with regular intercourse. Her menstrual cycle is normal. Her general status was normal. Vaginal
examination revealed normal findings.

83. Which of the following examination that is NOT included in basic workup in the patient above?
A. Hysterosalpingography
B. Ultrasonography
C. Semen analysis
D. Mid luteal progesterone examination
E. Serum AMH

84. The following month she came back with the result of hysterosalpingography (see the picture below)

What will be your next plan?

A. Repeat HSG next month
B. Schedule diagnostic laparoscopy
C. Gives clomiphene citrate and plan for natural conception
D. Gives clomiphene citrate and plan for intrauterine insemination
E. Plan for IVF

A 52-year-old woman presents to your office. She complained about her sexual problems of low self
esteem, and difficulties of initiating sexual intercourse, vaginal dryness and pain during intercourse. She
has the history of 3 full term normal vaginal delivery and she had already menopause and she has no
history of hereditary disease. She underwent the lab investigation such RBG – 129 mg/dl; Hb 10,6 mg/dl,
urea 21; creatinine 0,5. Chest x-ray and pelvic ultrasound studies showed no abnormalities

85. What is your diagnosis

A. Sexual desire disorder
B. Genital arousal disorder
C. Vaginismus
D. Orgasmic disorder
E. All of above

86. The most possible cause of sexual disorder of this patients is

A. Menopause
B. Multiparity
C. Alcohol uses
D. Sexual abuse
E. Pain

Mrs. 32-year old, P0, comes to your outpatient clinic due to her prolonged menstrual duration. She
reports her menstrual duration until 14 days and using 10 pads per day. She feels fatigue easily. On
physical examination, you palpate an irregularly enlarged uterus, non tender with firm contour. Cervix
appears to be hyperemic without mass appearance or other abnormalities.

87. By which mechanism does fibroid creates a hyperestrogenic environment requisites for their growth
A. Fibroid contains higher level of cytochrome P450 aromatase, which allows for conversion of
androgens to estrogens
B. Fibroid converts more estradiol to estrone
C. Fibroid cells contain less density of estrogen receptors compared with normal
myometrium
D. Increased adipose conversion of androgens to estrogen
E. All of above

88. What is the cause of necrotic and degenerative process in fibroids?

A. Mitotic activity
B. Limited blood supply with tumors
C. Chromosomal defects
D. Hyperperfusion
E. Cytogenetic mutations
Sesuai dengan teori di Williams gynecology. Mioma disuplai oleh satu pembuluh darah utama. Proses
degenerative bisa terjadi karena iskemik yang berkepanjangan.

89. Childhood neoplastic ovarian masses most commonly originate from:

A. Gonadal epithelium
B. Gonadal stroma
C. Sex cords
D. Germ cells
E. Metastatic disease
Lebih dari 80% neoplasma pada anak-anak berasal dari germ cells.
90. An 18-year-old nulligrevid women presents to the student health clinic with a 4-week history of
yellow vaginal discharge. She also reports vulvar itching and imitation. She is sexually active and
monogamous with her boyfriend. They use condoms inconsistently. On physical examination, she is
found to be nontoxic and afebrile. On genitourinary examination, vulvar and vaginal erythema is
noted along with a yellow, frothy, malodorous discharge with a pH of 6.5. The cervix appears to
have erythematous punctuations. There is no cervical, uterine, or adnexal tendemess. The addition
of 10% KOH to the vaginal discharge does not produce an amine odor. Wet prep microscopic
examination of the vaginal swabs is perfomed. What would you expect to see under microscopy?
A. Branching hyphae
B. Multinucleated giant cells
C. Scant WBC
D. Flagellated, motile organisms
E. Epthelial cells covered with bacteria

91. A 25 year old lady come with abnormal pap smear result. She underwent colposcopy examination
and the result is a acetowhite lesion with punctuation and atypical vessels. Biopsy result confirms
CIN I with HPV DNA test positive. What do you suggest for patient?
A. LEEP procedure
B. Reevaluation of HPV DNA
C. Cold knife conization
D. Repeat cytology in 12 months
E. Repeat cytology in 6 months
A 45 years old woman presents to your office for consultation regarding her symptoms of menopause.
She stopped having periods 13 months ago after TAH-BSO operation and is having severe hot flushes.
The hot flushes are causing her considerable stress.

92. What should you tell her regarding the psychological symptoms of the climacteric?
A. They are not related to her changing levels of estrogen and progesterone
B. They commonly include insomnia, irritability, frustration, and malaise
C. They are related to a drop in gonadotropin levels
D. They are not affected by environmental factors
E. They are primarily a reaction to the cessation of menstrual flow
A salah karena berhubungan dengan perubahan esterogen dan progesterone saat menopause. C salah
karena seharusnya level gonadotropin meningkat. Untuk pilihan D, menopause juga dipengaruhi faktor
lingkungan seperti merokok, pubertas dini.

93. Which of the following is an absolute contraindication for hormonal therapy?

A. Diabetes mellitus
B. Coronary heart disease
C. Endometriosis
D. Impairment of liver function
E. Migraine

94. Which of the following medication that you will give for hormonal therapy?
A. Estrogen only therapy
 B. Biphasic combined oral contraception
C. Monophasic combined oral contraception
D. Triphasic combined oral contraception
E. Sequential estrogen-progestrin therapy
Pada pasien ini, telah dilakukan operasi histerektomi. Sehingga aman untuk pemberian terapi esterogen
saja. Terapi kombinasi hanya dilakukan pada pasien yang tidak ada riwayat histerektomi.

A women P2 came to outpatient clinic due to inability to control defecation since 3 months ago after
delivering her 3rd child with vacuum extraction. On examination you identify perineal wound break with
external anal sphincter totally torn, but internal sphincter and anal mucosa were still intact

95. What is the most likely diagnosis of this patient?

A. Chronic perineal rupture grade II
B. Chronic perineal rupture grade IIIA
C. Chronic perineal rupture grade IIIB
D. Chronic perineal rupture grade IIIC
E. Chronic total perineal rupture
Karena sfingter ani eksterna robek >50% namun sfingter ani interna intak.

96. What is the best method to repair external anal sphincter?

A. End to end using chromic cat gut 2-0
B. End to end using polyglycolic acid 2-0
C. Overlapping using chromic cat gut 2-0
D. Overlapping using polyglycolic acid 2-0
E. Overlapping using polydioxanone 3-0
Teknik yang terbaik adalah teknik overlapping dan menggunakan benang PGA 2-0. A dan B salah karena
tidak menggunakan teknik overlapping. Pilihan lain salah karena benangnya tidak sesuai.

97. What is the proper management given to this patient post sphincter and perineal repair?
A. Analgesic suppository, IV antibiotic, laxative agent
B. Oral analgesic, oral antibiotic, stool softener
C. Analgesic suppository, oral antibiotic, stool softener
D. Oral analgesic, oral antibiotic, liquid diet
E. Analgesic suppository, IV antibiotic, high fiber diet

Tidak boleh diberikan analgesik suppositoria dan tidak ada indikasi antibiotik IV. Pasien dapat diet biasa,
dengan catatan diberikan pelunak feses, tidak perlu diet liquid.

A woman 28 years old came to outpatient clinic referred by obgyn specialist due to continuous leakage
of urine since 2 weeks ago, she underwent cesarean section due to dystocia on second stage of labor.
The baby’s weight was 4200 g. on examination the cervix was torn at 11 o’clock position until anterior
fornix, but the hole was not seen clearly

98. what is the next step to confirm diagnosis in this case?

A. Intravenous pyelography
B. Ultrasound
C. Indigo carmine test
D. Consult to urologist
 E. Blue dye test
Soalnya mirip dengan blue print. Indigo carmine test adalah untuk memvisualisasikan fistulanya.

99. What is the best management of this case this time

A. Put indwelling transurethral catheter, evaluate 3 months post cesarean section
B. Transvaginal fistula repair with Latzcko procedure as soon as possible
C. Transabdominal fistula repair as soon as possible
D. Trans-vesical fistula repair 3 months from now
E. Antibiotics for 7 days continue with transvaginal fistula repair
100. What is the criteria of simple vesicovaginal fistula?
A. Size < 1,5 cm
B. Size < 2 cm
C. Size < 2,5 cm
D. Size < 3 cm
E. Size < 4 cm
Sumber: dari google (Research Gate). Fistula simpel jika kurang dari 4 cm, kompleks dari 4 cm.