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USMLE Step 2 CK High-Yield Obstetrics/Gynecology Topics

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Obstetrics/Gynecology

High Yield USMLE Step 2 CK Notes

Welcome to the Obstetrics/Gynecology High-Yield Notes for Step 2 CK.

These are the most commonly tested topics on the exam—ideal for quick review in your last 2 weeks before the exam, when you’re short on time, or when you’re just starting out and want to focus on what is high yield. Created and peer-reviewed by physicians who scored 260+ on Step 2 CK in a Q&A style to reinforce active learning.

How to use this file

Read the question ➔ cover the answer ➔ self-quiz before revealing.
Review the NOTES ➔ they include high-yield details you don’t want to miss.
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Don’t forget to watch the video lessons that go with this file. Learn more here.

Prenatal Testing & Supplementation

1. A 35F 10 weeks gestation presents to you in her first trimester with elevated beta HCG, decreased PAPP-A, and increased nuchal translucency. What’s the diagnosis?
➔ Down syndrome (1st trimester infant + Elevated beta HCG + low PAPPA → think Down Syndrome)

Note: a) Other markers for Down syndrome (trisomy 21) include increased inhibin levels, decreased estriol, and decreased AFP levels.

Trisomy	B-HCG	PAPPA	AFP	Inhibin	Estriol
21	↑	↓	↓	↑	↓
18	↓	↓	↓	↓ or –	↓
13	–	–	–	–	–

b) First-trimester screen is often part of non-invasive prenatal testing (NIPT) for early aneuploidy risk assessment. If positive, next step → do diagnostic testing → CVS at 10–13 weeks or amniocentesis at ≥15
Advanced maternal age (≥35 years) increases the risk of chromosomal anomalies → these screens are especially important
c) Cell-free fetal DNA → A highly useful test that can be used to detect fetal abnormalities in <10 weeks of gestation. It is a non-invasive test with a very high sensitivity to detect chromosomal abnormalities
d) Remember that high AFP is indicative of abdominal wall defects, multiple gestations, incorrect dating, and neural tube defects

2. A 22F presents to your clinic in her first trimester to establish care. She has an incomplete history of childhood vaccinations. Which vaccine-preventable illness does she need to get tested for?
➔ Rubella (Part of the MMR vaccine → Live attenuated → Contraindicated in pregnancy (if Rubella IgG is negative, wait and vaccinate postpartum before you discharge the patient)

Note: a) If she gets infected → It can lead to Congenital Rubella Syndrome → Triad of Sensorineural hearing loss, Congenital cataracts, and Patent Ductus Arteriosus)
b) Several tests are recommended on the first prenatal visit. Here is a table you would want to remember.

Initial Prenatal Visit	RhD Antigen/Antibody	For infections, you can use the following mnemonic: “Hi (HIV), We (Varicella), aRe (Rubella), Happy Babies (Hep B), and we will Happily See (Hep C), the rainbow Colored (Chlamydia) Sky (Syphilis).”
	Urine Culture
	Urine dipstick for protein
	HIV
	Chlamydia
	Syphilis (VDRL/RPR)
	Hep B (HbsAg)
	Hep C (Anti-HCV ab)
	Rubella
	Varicella
24-28 weeks	Hemoglobin/Hematocrit
	Antibody Screen (if RhD negative)
	1-hour 50g Glucose tolerance test
36-38 weeks	Group B Streptococcus Rectovaginal Culture

c) Asymptomatic bacteruria on urine culture → Needs to be treated with a first-generation cephalosporin or nitrofurantoin.

3. A 33F woman comes to you with severe right adnexal pain. On ultrasound, you find ectopic pregnancy. Should this patient receive RhoGAM?
➔ Yes (Rho(D) immune globulin is given to Rh-negative mothers to prevent alloimmunization from exposure to Rh-positive fetal red blood cells.)
Ectopic pregnancy, like any pregnancy loss or complication with potential fetomaternal hemorrhage, can lead to maternal sensitization → Administer RhoGAM prophylactically.)

Note: a) When NOT to Give RhoGAM:
○ The patient is Rh-positive
○ Father is confirmed Rh-negative (no Rh+ fetus possible)
○ The mother is already sensitized (Rh antibody screen positive) → RhoGAM is not effective at that point.
b) When to give RhoGAM:
○ If the mother is RhD-negative and has no RhD antibodies (i.e., antibody screen negative).

Indications for RhoGAM
28–32 weeks of gestation
< 72 hours after delivery
Ectopic pregnancy
Threatened abortion
Hydatidiform mole
Amniocentesis
Chorionic villous sampling
2nd or 3rd trimester bleeding
Abdominal trauma

Step 2 CK will often give scenarios like ectopic pregnancy, miscarriage, or trauma, and test if you remember to give RhoGAM within 72 hours.

4. A Rh-negative woman presents to you with a ruptured ectopic pregnancy. How do you determine the dose of RhoGAM in this patient?
➔ Kleihauer-Betke test → Used to determine the dose of RhoGAM by measuring the fetal RBCs in maternal serum

Note: a) Rosette test→ Generally used to determine if the feto-maternal mixing of the blood occurred (usually done before the Kleihauer-Betke test)

5. A 29F at 28 weeks’ gestation comes to your clinic to establish care in January. Which vaccination should she be provided at this visit?
➔ Tdap and Inactivated Influenza (Tdap → 24-28 weeks of gestation, whereas an inactivated influenza shot → Can be given any time but generally given from October to April every year.)

Note: a) Remember that live vaccines are contraindicated in:
○ Pregnant women
○ Children less than 1 year old (except rotavirus vaccine)
○ Immunosuppressed population (HIV and Organ transplant).
○ Live vaccines include MMR, Varicella, HPV, and live-attenuated influenza
b) Key USMLE Scenarios:
○ Tdap: Every pregnancy, ideally at 28 weeks
○ Influenza vaccine (inactivated): Every pregnancy during flu season
○ MMR/Varicella: Only postpartum if non-immune
○ Hep B vaccine: Safe during pregnancy if not previously vaccinated or high-risk

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6. A 22F has a history of hyperthyroidism. She is in her first trimester and consistently takes antithyroid medications. If her medication is not stopped, what abnormality is the infant likely to develop?
➔ Cutis Aplasia (caused by Methimazole)

First trimester of pregnancy → Manage hyperthyroidism with Propylthiouracil

Second and third trimesters of pregnancy → Manage hyperthyroidism with methimazole (propylthiouracil leads to hepatotoxicity in that period)

Note: a) Here are some known teratogens and their potential effects:

Teratogen	Effects
Lithium	Can lead to Ebstein’s anomaly (atrialization of the right ventricle). Generally avoided during pregnancy, but if the bipolar symptoms are well-controlled, you could sometimes continue it during pregnancy
Vitamin A (isotretinoin)	Highly teratogenic. Before you start a patient on isotretinoin, → Perform a urine beta-hCG test.
Warfarin	Leads to nasal hypoplasia, stippling of bone epiphyses, and intrauterine growth restriction.
ACE inhibitors or Angiotensin Receptor Blockers	Lead to renal agenesis (could lead to Potter sequence)
Phenytoin	Leads to fetal hydantoin syndrome- heart defects like VSD or ASD, along with cleft palate and neurological deficits
Tetracyclines	Disrupts the bone growth and causes teeth discoloration

7. A pregnant woman presents to you with HIV. What is the next best step in management?
➔ Finding out the viral load

Note: a) If the viral load is <50 → Treatment is with antiretroviral therapy (ART) + Vaginal delivery.
b) If the viral load is >50 and <1000 → Treatment is with ART + Vaginal delivery + Zidovudine.
c) If the viral load is >1000 → Treatment is with ART + Cesarean Delivery + Zidovudine.
d) Avoid amniotomy and fetal scalp electrodes to reduce vertical transmission risk

Pregnancy Complications

8. A 30F pregnant woman presents to you with the onset of labor and rupture of membranes that leads to chorioamnionitis. Fetal tocography findings reveal tachycardia (HR > 160 bpm). What is the likely cause of it?
➔ Maternal fever (due to chorioamnionitis)

Note: a) Chorioamnionitis— Key Clues:
○ Fever, uterine tenderness, maternal tachycardia, fetal tachycardia
○ ↑ Risk with prolonged ROM (>18 hours)
b) Management:
○ Broad-spectrum antibiotics (e.g., ampicillin + gentamicin)
○ Delivery (regardless of gestational age) — do not delay
c) Other causes of fetal tachycardia include hypoxia, fetal anemia, and intra-amniotic infections
d) Causes of fetal bradycardia (HR <110 bpm) :
○ Maternal hypotension
○ Uteroplacental insufficiency
○ Fetal sleep state
○ Fetal atrioventricular block in a pregnant woman with Sjögren syndrome or SLE

9. A 24F presents at 6 weeks of gestation with a complaint of increased morning sickness episodes. You find the beta-HCG levels to be 10,000. What is the next best step?
➔ Pelvic ultrasound (hydatidiform mole)

Note: a) Hydatidiform mole usually presents with → Hyperemesis gravidarum, abnormal vaginal bleeding, uterine enlargement, and hyperthyroidism (due to Beta-HCG mimicking TSH and acting on thyroid gland to release T4)
b) Risk factors → Extremes of maternal age + History of hydatidiform mole
c) Management:
○ Confirm diagnosis → Pelvic ultrasound
○ Suction curettage (preferred over medical evacuation)
○ Monitor β-hCG weekly until undetectable, then monthly for 6 months
○ Reliable contraception is needed during follow-up (avoid pregnancy to distinguish rising β-hCG from malignancy)

A Twin Pregnancy of Partial Mole Coexisting with a Normal Fetus: A Case Report – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Ultrasound-image-showing-the-snow-storm-appearance-of-the-molar-tissue_fig2_361208886 [accessed 2 Aug 2025]

10. A 24F pregnant woman with hypertension, proteinuria, and uterus raised up to the umbilicus at 14 weeks of gestation. What is the diagnosis?
➔ Hydatidiform mole (VS pre-eclampsia, which would occur after 20 weeks of gestation + uterus normally presents to be at the level of the umbilicus after 20 weeks; however, the uterus ends up being larger in size than normal)

Note: a) Remember that a complete mole → Increases the risk of choriocarcinoma (risk is much higher with a complete mole than a partial mole)

11. A pregnant woman presents with recurrent nausea and vomiting in the morning for the past 3 weeks. She is discovered to have a twin pregnancy. What effect will HG have on this woman’s fetuses?
➔ HG has no significant adverse effects on the fetuses

Note: a) Hyperemesis gravidarum → Intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia (contrast from normal pregnancy vomiting, which is not as severe and doesn’t lead to weight loss or ketonemia)
b) Recurrent vomiting due to HG can lead to → Wernicke’s encephalopathy (other causes are chronic alcohol use, malabsorption due to gastric bypass, and anorexia nervosa)
c) Treatment of Wernicke’s encephalopathy is with thiamine (Vitamin B1)

12. A pregnant woman presents with decreased fetal movements. What is the next best step in management?
➔ A Non-stress test: Includes monitoring fetal heart rate- can be reactive (normal/healthy response) or non-reactive (indicates decreased fetal activity). If inconclusive → Biophysical profile (Non-stress + ultrasound)

Note: a) If BPP is inconclusive → Do a contraction stress test. If CST is inconclusive → Doppler ultrasound of the umbilical artery.
b) Common causes of decreased fetal movements include IUD, fetal sleep state, gestational age <24 weeks, placental insufficiency, and fetal growth restriction.

13. A 26F, 32 weeks gestation presents with oligohydramnios. She has a history of chronic, uncontrolled hypertension. What is the likely cause of her oligohydramnios?
➔ Uteroplacental insufficiency (occurs due to chronic hypertension → leading to decreased perfusion of the fetal kidneys → decreased production of fetal urine)

Note: a) Pre-eclampsia, gestational hypertension, and chronic hypertension → All lead to oligohydramnios (due to underperfusion of the kidneys)
b) Complications include umbilical cord compression and meconium aspiration syndrome. Here is a table of other causes of oligohydramnios:

Other Causes of Oligohydramnios
1) Renal agenesis → Kidneys are not able to produce urine appropriately → Leads to Potter sequence (flat face, pulmonary hypoplasia, and deformed limbs)
2) NSAID use (indomethacin) → ↓ prostaglandins → renal vasoconstriction → ↓ urine
3) Post-term pregnancy → Placental aging → ↓ perfusion → Placental infarcts

14. A pregnant woman at 43 weeks’ gestation presents to you due to decreased fetal movements. She has oligohydramnios. What is the next best step in management?
➔ Induce labor (Symptoms suggest post-term pregnancy → don’t try to correct the oligohydramnios)

Note: a) At >42 weeks gestation, the placenta starts aging → placental infarcts and calcifications → ↓ placental function → leading to Oligohydramnios
b) In post-term pregnancy with oligohydramnios, induce labor immediately. Do not try to treat the low amniotic fluid — the problem is with the aging placenta, and the solution is delivery before 43 weeks.
c) Labor can be induced by giving misoprostol (prostaglandin E1 analog)

15. A 27F recently underwent a cesarean delivery. Now presents with fever, chills, and uterine tenderness. What is the likely diagnosis?
➔ Endometritis (fever + uterine tenderness after a c-section are the only criteria you need to make the diagnosis)

Note: a) The most common cause of endometritis → coli
b) Always think of endometritis in a postpartum woman with uterine tenderness and fever, especially after cesarean delivery. Don’t get distracted by other causes of postpartum fever unless other features are present (e.g., wound erythema → surgical site infection, breast pain → mastitis).
c) Plasma cells in the uterus are a characteristic finding of chronic endometritis
d) Treatment → Gentamycin + Clindamycin (remember that we treat without taking uterine cultures and can be prevented by pre-operative antibiotic prophylaxis)

16. A 26F at 32 weeks of gestation presents to you with a sudden onset of rupture of membranes and onset of labor. She does not have any signs of infection. What is the next best step in management?
➔ Administration of corticosteroids (betamethasone or dexamethasone for surfactant production and lung maturation)

Note: a) Women with unknown GBS status and preterm delivery should be given GBS prophylaxis → Intrapartum penicillin
b) Biggest risk factor for preterm labor → History of preterm labor (other risk factors include cervical insufficiency, bicornuate uterus, premature rupture of membranes, etc.)
c) Preterm labor:
○ If there are signs of maternal instability or intrauterine fetal demise → Immediate delivery
○ If there are no signs of maternal instability or intrauterine fetal demise → Evaluate based on gestational age
d) If the gestational age is:
○ <32 weeks gestation → Indomethacin + Magnesium sulfate + antenatal corticosteroids
○ 32-34 weeks gestation → Antenatal corticosteroids + penicillin if positive for GBS + Nifedipine for tocolysis
○ 34-37 weeks gestation → Antenatal corticosteroids + penicillin if positive for GBS

17. A 30F presents for her follow-up scan at the 24th week of gestation. Which screening test is recommended at this visit?
➔ Oral glucose tolerance test (to test for gestational diabetes mellitus)

Note: a) At 24-28 weeks of gestation, all pregnant women should undergo a 1-hour and a 3-hour OGTT. → Generally, it is diagnosed if the blood sugar comes out to be >140 mg/dl on OGTT
b) Pregnant women who are at a HIGHER RISK of having GDM- Screen early (first trimester) if the woman has:
○ Prior history of GDM
○ Obesity (BMI >30)
○ PCOS
○ Prior macrosomic baby (>4,000–4,500 g)
○ Strong family history of diabetes
c) Women who have delivered the baby → Need postpartum screening → If the blood sugar doesn’t normalize → Type 2 diabetes mellitus is diagnosed
d) Postpartum Follow-Up:
○ 6–12 weeks postpartum: Screen with fasting glucose or 75g OGTT
○ If blood glucose remains elevated → consider diagnosis of Type 2 Diabetes Mellitus

Maternal and fetal complications of gestational diabetes

Category	Complications
Maternal	• Polyhydramnios • Increased risk of Type 2 diabetes mellitus postpartum • Shoulder dystocia due to macrosomia • Recurrent GDM in future pregnancies
Fetal	• Macrosomia (>4,000 g) • Shoulder dystocia/birth trauma • Neonatal hypoglycemia (due to islet cell hyperplasia) • Neonatal hyperbilirubinemia • Neonatal respiratory distress syndrome (delayed surfactant) • Hypocalcemia

18. A 25F primigravida patient has not dilated any further from 7cm for the past 5 hours. Her contractions are adequate. What is the diagnosis and the next best step in management?
➔ Active labor arrest → Cesarean delivery

Note: a) Arrest of active labor is diagnosed when all the following are present:
○ Cervical dilation ≥6 cm
○ Ruptured membranes
○ No cervical change for ≥4 hours despite adequate uterine contractions (defined as ≥200 Montevideo units in 10 minutes)
○ Or no change for ≥6 hours if contractions are inadequate
b) Labor is divided into 3 phases: 1,2,3
○ The first phase:
○ Latent phase: cervical dilatation from 0 to 6cm
○ Active phase: 6-10 cm
○ Second phase of labor → Delivery of the infant after cervical dilation of 10cm
○ Third phase of labor → Delivery of the placenta
c) Here is a table about the arrest of labor in different phases and their management:

Phase & Arrest Type	Definition	Management
Latent Phase (0–5 cm) – Prolonged latent phase	Failure to progress beyond 5 cm after many hours (traditionally >20 hrs in nulliparas or >14 hrs in multiparas).	• Supportive care (hydration, rest) • Reassess periodically unless fetal/maternal compromise
Active Phase (≥6 cm) – Arrest of dilation	Cervical dilation ≥6 cm with ruptured membranes and: • No cervical change for ≥4 hrs with adequate contractions (≥200 Montevideo units) OR • No change for ≥6 hrs with inadequate contractions	• Confirm rupture of membranes • Start or adjust oxytocin if contractions are inadequate • Wait 4–6 hrs based on contraction strength • If no progress → Cesarean delivery
Second Stage (10 cm) – Arrest of descent (Risk factors: cephalopelvic disproportion, nulliparity, fetal macrosomia, etc.)	Full cervical dilation with: • No fetal descent after ≥3 hrs in nulliparas with epidural (2 hrs without) OR • ≥2 hrs in multiparas with epidural (1 hr without)	• Evaluate fetal position & station • If low station (+2 or more)-indicates that head is engaged in the pelvis and favorable → Operative vaginal delivery (can lead to facial nerve palsy or cephalohematoma) • If high station or not suitable → Cesarean delivery • Ensure proper pushing and allow sufficient time

19. A 32F presents with the onset of labor. Her cervical dilation is 6 cm. She has one contraction in 5 minutes. What is the next best step in management?
➔ Administration of oxytocin → Indicated if inadequate contractions → less than 3-5/10 minutes or less than 200 Montevideo units →

Note: a) The third phase of labor includes → Delivery of placenta → It is recommended to use oxytocin to help with the delivery of the placenta
b) Oxytocin toxicity leads to → SIADH (euvolemic hyponatremia) since oxytocin has a similar structure to ADH

20. A 28F primigravida has just given birth. She is bleeding profusely from the vagina. What is the likely diagnosis and management?
➔ Postpartum hemorrhage → The first step to manage is uterine massage, followed by IV oxytocin administration

Note: a) Here is a breakdown of various causes of postpartum hemorrhage and how they present clinically:

Causes	Description	Clinical Presentation
Tone (uterine atony)	Failure of the uterus to contract effectively after delivery (most common cause)	• Soft, boggy uterus above the umbilical level on palpation • Usually, immediate heavy bleeding after delivery
Tissue (retained placental tissue)	Retention of placental tissue within the uterus	• Presents as secondary PPH (≥24 hours postpartum) • May show ultrasound evidence of retained products
Trauma (genital tract injury)	Lacerations of the cervix, vagina, or perineum due to delivery	• Firm uterus with ongoing bleeding • History of difficult delivery, instrumental delivery, macrosomia • Visible laceration or hematoma
Thrombin (coagulopathy)	Clotting disorder impairs hemostasis	• History of bleeding disorder (e.g., hemophilia, vWD) or DIC • Persistent bleeding despite good uterine tone • Abnormal coagulation profile
Inversion (uterine inversion)	The uterus turns inside out, often during the delivery of the placenta	• Uterus not palpable in normal pelvic position • May feel mass at vaginal introitus • Sudden shock and pain with heavy bleeding

21. A 33F with postpartum hemorrhage refractory to uterine massage and oxytocin. What is the next best step in management?
➔ Administration of tranexamic acid (antithrombolytic- can also be given in intracranial hemorrhage)

22. A 30F + 30 weeks gestation presents with fluid leakage since the past two days. She does not have any contractions. What is the next best step in management?
➔ Sterile speculum examination of vagina (likely diagnosis is preterm premature rupture of membranes- the biggest risk factors are history of premature ROM as well as ascending infection)

Note: a) If there is premature rupture of membranes (ROM at term without the onset of labor) → Induce labor by giving prostaglandins or misoprostol (only if >34 weeks gestation age, or <34 weeks gestation age + signs of infection like fever or hemodynamic instability)
b) Signs of amniotic fluid leakage include → Ferning or nitrazine test (nitrazine paper turns blue)
c) PPROM patients generally require GBS prophylaxis (intrapartum penicillin) to prevent GBS infection
d) If the patient with PROM or PPROM develops intrapartum fever → Suspect chorioamnionitis (can lead to fetal tachycardia) → Treat with broad-spectrum antibiotics

23. 32F + 36 weeks gestation presents with the onset of labor. On cardiotocography, you find variable decelerations. What is the likely diagnosis?
➔ Umbilical cord compression → Manage it with amnioinfusion

Note: a) Here is a breakdown of types and causes of decelerations observed on cardiotocography:

Type	Timing and Shape	Cause	Management
Early Decelerations	Gradual deceleration that mirrors uterine contractions; nadir occurs with the peak of contraction	Fetal head compression	No intervention needed; normal finding during labor
Variable Decelerations	Abrupt onset (onset to nadir <30 sec); variable shape (V, W, or U-shaped); not consistent with contractions	Umbilical cord compression (most commonly due to oligohydramnios)	• Reposition mother (left lateral) • Amnioinfusion if recurrent/severe (contraindicated if history of uterine surgery) • O₂ & IVF if needed; cesarean delivery if decelerations don’t resolve
Late Decelerations	Gradual deceleration starting after the onset of contraction and returning to baseline after contraction ends	Uteroplacental insufficiency (fetal hypoxia)	• Reposition mother • O₂ by mask, IV fluids • Stop oxytocin if running • Consider delivery if persistent/recurrent
Prolonged Decelerations	>2 minutes but <10 minutes decrease in FHR from baseline	Prolonged hypoxia, cord prolapse, uterine rupture, or maternal hypotension	• Treat the underlying cause immediately • Reposition, O₂, IVF, stop oxytocin • Emergency delivery if unresolved

24. A 28F with a chronic history of hypertension presents with late decelerations on cardiotocography. What is the likely diagnosis?
➔ Uteroplacental insufficiency (chronic hypertension is a big clue for it; another common cause could be pre-eclampsia) → Leads to late decelerations

Note: a) Management of late decelerations → Reposition the mother towards the left side
b) If repositioning doesn’t improve the late decelerations, → then proceed with emergency cesarean delivery.
c) Uteroplacental insufficiency leads to → Ischemia in the fetal tissues → Increased lactic acid production → Fetal metabolic acidosis

Myths at the core of Intrapartum Cardiotocography Interpretation -Risks of false Ideology, Prospect theory and way forward. Clinical Obstetrics, Gynecology and Reproductive Medicine – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Diagrammatic-representation-of-early-late-and-variable-decelerations-as-practiced-in_fig5_334448517 [accessed 5 Aug 2025]

d) There can also be a sinusoidal wave pattern on cardiotocography → It indicates severe fetal anemia, hypoxia, or hemorrhage

25. A 23-year-old female at 18 weeks of gestation presents with per vaginal bleeding. On pelvic ultrasound, you find an empty uterus without any fetal content. The cervical os is closed. What s the most likely diagnosis?
➔ Complete abortion (per-vaginal bleeding + closed cervical os, + no gestational sac on pelvic ultrasound are all features of complete abortion)

Note: a) Here are different types of abortions and a detailed breakdown:

Feature	Missed Abortion	Threatened Abortion	Inevitable Abortion	Septic Abortion
Per-Vaginal Bleeding	Absent or minimal	Present	Present, often heavy	Present, may be foul-smelling
Cervical Os	Closed	Closed	Open	Open or closed
Pelvic Ultrasound	No gestational sac or nonviable fetus	Gestational sac visible, fetus viable	Gestational sac present, often at or near os	Retained products may be seen
Uterine Contents	Retained	Retained	In the process of expulsion	Often retained with infected debris
Systemic Symptoms	None	None	None	Fever, chills, uterine tenderness, sepsis
Key Differentiation	No bleeding, closed os, nonviable pregnancy	Bleeding with a viable pregnancy and a closed os	Active miscarriage with open os	Infection signs with retained products. Most commonly occurs due to Clostridium species

b) The biggest risk factor for spontaneous abortion → Previous history of spontaneous abortion
c) Management of threatened abortion or any other abortion <12 weeks gestation → Expectant management → RhoGAM administration in case of a Rh-negative woman and a Rh-positive fetus

26. A couple who had a baby boy 2 weeks ago presents to your clinic with the complaint that the mother does not feed the child because she believes her breast milk contains all sorts of bacteria that can harm the baby. What is the likely diagnosis?
➔ Postpartum psychosis (woman who recently had a child + eccentric behavior/believes regarding the baby → Postpartum psychosis)

Note: a) Management of postpartum psychosis → Involuntary hospitalization of the mother (because the mother might hurt the child due to psychosis)
b) CBT and antipsychotics are also commonly used

27. A woman delivered a baby 5 days ago and now presents with complaints of tiredness, loss of appetite, and difficulty sleeping. What is the next best step in management?
➔ Reassurance (diagnosis is postpartum blues)

Note: a) Postpartum blues → symptoms of crying, tiredness, loss of appetite, difficulty sleeping within 2 weeks of delivery → Reassurance
b) If symptoms persist for >2 weeks → Postpartum depression → Cognitive behavioral therapy + SSRIs

28. A 30F at 18 weeks of gestation presents with an abnormal blood pressure reading of 145/95. What is the likely diagnosis?
➔ Chronic hypertension (Elevated BP (>140/90) before 20 weeks of gestation confirms the diagnosis of chronic hypertension)

Note: a) Here is a detailed breakdown of hypertensive disorders of pregnancy:

Condition	Blood Pressure Criteria	Additional Features	Key Diagnostic Clues
Chronic Hypertension	BP ≥140/90 mmHg on two occasions, ≥4 hours apart <20 weeks gestation	No proteinuria or end-organ damage	High blood pressure is less than 20 weeks of gestation
Gestational Hypertension	BP ≥140/90 mmHg on two occasions, ≥4 hours apart >20 weeks gestation	No proteinuria or end-organ damage	Onset after 20 weeks of gestation in a previously normotensive woman
Pre-eclampsia	BP ≥140/90 mmHg after 20 weeks + Proteinuria	+ Proteinuria (≥300 mg/24h or protein/creatinine ratio ≥0.3) OR signs of end-organ dysfunction (elevated LFTs, thrombocytopenia, etc.)	New-onset hypertension plus proteinuria or organ dysfunction
Eclampsia	Pre-eclampsia criteria	+ Seizures (generalized tonic-clonic) not attributable to other causes	Seizures in a pre-eclamptic patient

29. A 30F at 25 weeks of gestation presents with an abnormal blood pressure reading of 150/95 along with mild proteinuria. She is diagnosed with preeclampsia. What is the next best step in management?
➔ Expectant management (<37 weeks gestation and no severe features → Manage with lowering the BP + close monitoring + seizure prophylaxis with magnesium sulfate)

Note: a) >37 weeks gestation or <37 weeks + severe features → Delivery
b) Biggest risk factor for pre-eclampsia → Previous history of pre-eclampsia (other risk factors include family history of pre-eclampsia, obesity, multiple pregnancies, chronic history of hypertension)
c) Here is a breakdown of severe features of pre-eclampsia and their management:

Severe Feature	Description	Management
Severe hypertension	Systolic ≥160 mmHg or Diastolic ≥110 mmHg (on 2 readings ≥4 hrs apart)	• Lower BP with IV labetalol, IV hydralazine, or oral nifedipine • Proceed to delivery if ≥37 weeks or unstable
Thrombocytopenia	Platelet count <100,000/mm³	• Monitor platelets • Prepare for delivery if deteriorating
Elevated liver enzymes and RUQ pain	AST/ALT ≥2× ULN + RUQ or epigastric pain (hepatic involvement)	• Symptomatic control • Delivery if pain persists or labs worsen
Renal Insufficiency	Creatinine >1.1 mg/dL or doubling from baseline	• Monitor renal function • Avoid nephrotoxic drugs • Delivery if worsening
Pulmonary edema	Fluid overload with respiratory compromise	• Oxygen, diuretics if needed • ICU support • Immediate delivery if maternal instability
CNS symptoms	Headache, visual disturbances, altered mental status	• Start IV magnesium sulfate for seizure prophylaxis • Delivery indicated
Eclampsia	Pre-eclampsia with generalized tonic-clonic seizures	• IV magnesium sulfate (bolus + maintenance) – contraindicated in Myasthenia Gravis • Stabilize airway & vitals • Urgent delivery after stabilization

30. A 28F multigravida woman with a history of c-section presents at 30 weeks of gestation with painless vaginal bleeding. What is the likely diagnosis?
➔ Placenta previa (Painless bleeding after 20 weeks of gestation + History of c-section → Think placenta previa- Placenta attaches to the opening of the cervical os)

Expression of NF-κB and VEGF in normal placenta and placenta previa patients – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Schematic-diagram-of-the-normal-location-of-the-placenta-and-of-placenta-previa_fig1_365391903 [accessed 2 Aug 2025]

Note: a) The biggest risk factor for placenta previa → History of previa or a history of c-section (more commonly tested)
b) If actively bleeding → stabilize the patient with IV fluids → Pelvic ultrasound to confirm the diagnosis → Reassure the patient and plan for an elective C-section.
Never perform a digital vaginal exam in a case of placenta previa- ultrasonography is however completely safe
c) Management:
○ Stable: Admit, give betamethasone, plan C-section at 36–37 weeks
○ Unstable or fetal distress → Emergency C-section

31. A 35 weeks gestation multigravida presents with vaginal bleeding along with painful cramps. Her BP is 90/60. What is the next best step in management?
➔ Emergency cesarean delivery (Vaginal bleeding + rigid or tender uterus or tachysystole + abdominal cramps/pain → Think placental abruption)

Note: a) Placental abruption management → Always an emergency c-section (no need to confirm on pelvic ultrasound because it is a clinical diagnosis).
If ultrasound is performed → Retroplacental hematoma is the buzzword
b) The most significant risk factor for placental abruption → Previous history of placental abruption or hypertension (Cocaine use and trauma are also highly significant risk factors)
c) Most likely complication of pre-eclampsia → Placental abruption.
d) The most common cause of DIC in pregnancy → Placental abruption

32 A 28F pregnant woman at 32 weeks gestation presents with painless vaginal bleeding with rupture of membranes. What is the likely diagnosis?
➔ Vasa previa (vessels from the placenta pass over the cervical os opening)

Australia, Healthdirect. “Vasa Praevia.” Text/html. December 11, 2024. https://www.pregnancybirthbaby.org.au/vasa-praevia.

Note: a) Management → Emergency C-section (fetal distress signs include lowering of heart rate or sinusoidal wave pattern on tocograph)
b) Differentiate from placental abruption → It can present with bleeding with rupture of membranes, but the bleeding will be painful in case of abruption
c) Differentiate from placenta previa → It can present with painless bleeding, but bleeding does not occur along with rupture of membranes

33. A 30F multigravida with a history of multiple c-sections presents with difficult labor and then eventually has a loss of fetal station and severe intra-abdominal pain. What is the likely diagnosis and the next best step in management?
➔ Uterine rupture → Loss of fetal station is the most important criterion for the diagnosis of uterine rupture → Management is to perform emergent laparotomy

Note: a) The biggest risk factor for uterine rupture → history of cesarean delivery
b) History of classic cesarean delivery or abdominal myomectomy → are contraindications to normal labor and delivery due to increased risk of → uterine rupture

34. A 26F, 32 weeks gestation presents with polyhydramnios. She currently has gestational diabetes mellitus. What is the likely cause of her polyhydramnios?
➔ Fetal polyuria caused by hyperglycemia in the mother ➞ Leads to polyhydramnios (the most common cause of polyhydramnios is GDM)

Note: a) Other causes of polyhydramnios include ➞ anencephaly (the head isn’t formed, so unable to swallow the amniotic fluid), esophageal atresia, duodenal atresia, jejunal atresia (atretic segments due to which swallowing is impaired), fetal infection with parvovirus, or twin-to-twin transfusion syndrome
b) If the mother has polyhydramnios, the next best step ➞ Antenatal testing (e.g., NST, BPP) (you do not try to correct the polyhydramnios itself)
c) Complications of polyhydramnios ➞ Fetal malposition, umbilical cord prolapse, preterm labor, and PPROM.

Aspect	Oligohydramnios	Polyhydramnios
Definition	Amniotic fluid index (AFI) <5 cm or deepest pocket <2 cm	AFI >24 cm or deepest pocket >8 cm
Causes	Renal agenesis, maternal hypertension, pre-eclampsia, eclampsia	Gestational diabetes (most common risk factor), anencephaly, esophageal atresia, duodenal atresia, jejunoileal atresia
Fetal complications	• Pulmonary hypoplasia (especially if early) • Limb contractures (Potter sequence) • Cord compression → variable decelerations • Intrauterine growth restriction (IUGR)	• Fetal malposition (e.g., breech) • Umbilical cord prolapse • Preterm labor • Fetal anomalies (e.g., anencephaly, GI obstruction)
Maternal complications	• Prolonged labor due to malposition • Increased risk of operative delivery	• Uterine overdistension → respiratory discomfort • Preterm premature rupture of membranes (PPROM) • Postpartum hemorrhage due to uterine atony

35. A 23-year-old female became unconscious after delivering a baby. Before becoming unconscious, she complained of difficulty breathing. Now she has severe vaginal bleeding as well as bleeding from IV sites. What is the most likely diagnosis?
➔ Amniotic fluid embolism (presents as disseminated intravascular coagulation)

Note: a) Triggered by amniotic fluid entering maternal circulation.
○ Triad: Hypoxia (dyspnea → ARDS → collapse), Hypotension/shock, DIC (uncontrolled bleeding from vagina + IV sites)
○ Occurs during labor or shortly postpartum
○ Differentiation: AFE, Pulmonary embolism, Uterine atony
b) Pulmonary embolism also occurs during pregnancy or shortly after it, due to estrogen, → induces a hypercoagulable state
c) Manage amniotic fluid embolism with → Respiratory support (intubation) and hemodynamic support (fluids and vasopressors)

36. A 24F presents at 6 weeks of gestation with a complaint of hyperemesis gravidarum. A pelvic ultrasound reveals a complete molar pregnancy. What should be the levels of pH, chloride, potassium, and bicarbonate in this patient?
➔ pH ⬆️, Chloride ⬇️, Potassium ⬇️, Bicarbonate ⬆️ (hypokalemic, hypochloremic metabolic alkalosis)

Note: a) Electrolyte abnormalities:
○ Loss of HCl → leads to low chloride levels and low hydrogen ion levels → Hypochloremic metabolic alkalosis
○ Loss of fluid volume → leads to activation of RAAS → Aldosterone leads to hypokalemia and contributes further to metabolic alkalosis
b) Hyperemesis gravidarum:
○ Present in molar pregnancy and twin pregnancy
○ Leads to weight loss, ketonuria, dehydration, and hemoconcentration
○ Treat with hospital admission + IV fluids and antiemetics

37. A 25F multigravida gets pregnant with monochorionic diamniotic twins. Which complication is this patient at risk for?
➔ Twin to twin transfusion syndrome (monochorionic diamniotic twins are characterized by the T sign, on pelvic ultrasound)

Note: a) Monochorionic monoamniotic twins are at risk for → Cord entanglement or Conjoined twins
b) Dichorionic diamniotic twins are at risk for → Preterm birth (characterized by lambda sign on pelvic ultrasound → Lambda sign represents the intertwin membrane.)
c) Maternal complications in twin pregnancy include pre-eclampsia, gestational diabetes mellitus, hyperemesis gravidarum, iron deficiency anemia, and polyhydramnios.

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Miscellaneous Topics

38. A 34F has a history of multiple c-sections, and recently had the operation 1 month ago. Since then she has been having persistent leakage of malodorous fluid from the vagina. Most likely diagnosis?
➔ Vesicovaginal fistula (painless continuous urine leakage from vagina + History positive for pelvic surgery, radiation, genitourinary trauma → Think VVF)

Note: a) Rectovaginal fistula → Can also be a complication of multiple C-sections→ Presents with foul smelling brown colored discharge from the vagina
b) Diagnosis is made by → Bladder dye testing or cystourethrogram

39. A 39-year-old female presents with difficulty breathing, hemoptysis, bloody vaginal discharge, dizziness, and confusion after 4 weeks of delivering a child. She has bilateral cystic ovarian masses. What is the likely diagnosis?
➔ Choriocarcinoma- Bloody cough + bloody vaginal discharge after recent delivery are big clues for diagnosis → Choriocarcinoma commonly metastasizes to the lungs and brain

Note: a) Choriocarcinoma → High malignant potential → Metastasizes to lungs (cannonball metastasis), brain, vagina, and liver
b) Treatment of choriocarcinoma → Methotrexate → Dihydrofolate reducatase inhibitor
c) Follow β-hCG levels serially until undetectable → Avoid pregnancy until β-hCG remains normal for 6 months

40. 32F presents with a history of recurrent miscarriages. What is the likely diagnosis?
➔ Antiphospholipid antibody syndrome (measure lupus anticoagulant, Anti-cardiolipin antibodies, Anti-β2 glycoprotein I antibody)

Note: a) Occurs secondary to systemic lupus erythematosus → leads to recurrent placental thromboses and fetal death
b) Prevent by giving aspirin (an irreversible COX inhibitor) or heparin (binds to antithrombin 3 and increases its efficacy)

41. A 28F at 35 weeks gestation presents with seizures, elevated BP. She receives IV magnesium and now has new-onset hyporeflexia and respiratory depression. What is the likely diagnosis?
➔ Magnesium toxicity → New onset hyporeflexia + respiratory depression while being treated for pre-eclampsia/eclampsia

Note: a) Women with a history of pre-eclampsia or eclampsia → need to start aspirin prophylaxis at 12 weeks of gestation
b) Magnesium toxicity needs to be treated with → Calcium gluconate
c) Calcium gluconate or calcium carbonate is also used to treat → Hyperkalemia or hypocalcemia

42. A 31-year-old woman presents to you with right lower quadrant pain. She also has fever, leukocytosis, and abdominal tenderness. What is the likely diagnosis?
➔ Appendicitis

Note: a) Differentials for abdominopelvic pain in young women:

Condition	Key Diagnostic Clues
Ectopic pregnancy	• Right or left lower quadrant pain • Missed period + positive β-hCG • Vaginal bleeding • ± Hypotension if ruptured
Ovarian torsion	• Sudden, severe unilateral pelvic pain • Often follows exertion or intercourse • ± Nausea and vomiting
Ruptured ovarian cyst	• Acute onset of pelvic pain • No fever or systemic symptoms • USG shows fluid in pelvis, and may show the cyst. • Often occurs mid-cycle
Pelvic inflammatory disease	• Bilateral pelvic pain • Cervical motion tenderness • Vaginal discharge ± fever

43. A 32F at 24 weeks’ gestation with numbness in the thumb and index finger. What is the likely diagnosis?
➔ Carpal tunnel syndrome (median nerve gets entrapped in the flexor retinaculum)

Note: a) Carpal tunnel syndrome in pregnancy → Occurs due to edema in peripheral tissues → Self-resolves after pregnancy
b) Here are some other causes of carpal tunnel syndrome:

Category	Cause	Notes
Storage disorders	Amyloidosis	Amyloid deposits in the carpal tunnel are an early sign of systemic disease
Endocrine	Hypothyroidism	Myxedema causes nerve compression
Rheumatologic	Rheumatoid arthritis	Synovial inflammation compresses the median nerve
Obesity	Increased adipose tissue	Causes increased pressure within the tunnel
Repetitive use	Typing, assembly line work	Prolonged wrist flexion or extension → median nerve entrapment

44. A 33F primigravida presents with a sudden onset of SOB, tachycardia, and dyspnea. Her O2 sats are 80%. What is the next best step in management?
➔ IV heparin (sudden onset SOB + Dyspnea + Low O2 sats → Think pulmonary embolism)

Note: a) First step is to give IV heparin → Anticoagulate the patient due to a suspected high clinical diagnosis
b) Then perform a V/Q scan → Spiral CT scan is the gold standard, but it is contraindicated during pregnancy

45. A 30-year-old female presents with a double footling breach in labor. What is this patient most likely at risk of?
➔ Prolapse of the fetal umbilical cord

Boston, Marcus. “Surviving Umbilical Cord Prolapse And HIE.” Boston Law Group, LLC, April 6, 2024. https://bostonlawllc.com/2024/04/06/surviving-umbilical-cord-prolapse-and-hie/.

Note: a) Management → Immediate cesarean delivery
b) If the fetus is in breech position in less than 37 weeks of gestation → Wait for spontaneous version
c) If the fetus is in breech position after 37 weeks of gestation → Do external cephalic version → If refractory → Cesarean delivery

46. A 28-year-old female presents to you at 33 weeks of gestation with the complaint of mild dyspnea and shortness of breath. On examination, all the findings are normal. What is the next best step in management?
➔ Reassurance and observation (simple physiological changes in pregnancy increase respiratory rate and often lead to dyspnea)

Note: a) Here is a table summarizing all the physiological changes occurring during pregnancy

System	Physiological Changes
Cardiovascular system	↑ Blood volume & CO, ↓ SVR & BP (mid-pregnancy), ↑ HR
Respiratory system	↑ Tidal volume & minute ventilation, ↓ FRC, mild alkalosis
Renal system	↑ GFR, ↓ Cr/BUN, mild glucosuria/proteinuria
Gastrointestinal system	↓ Motility → constipation, ↑ GERD, ↑ gallstone risk (effects of high progesterone)
Hematologic system	Dilutional anemia, hypercoagulable state (due to hyperestrogenemia)
Endocrine system	↑ Estrogen, progesterone, hCG, and insulin resistance
Skin	Linea nigra, melasma, striae
MSK	↑ Lordosis, ligament laxity
Immune	Shift to humoral immunity (tolerates fetus)

47. A neonate develops severe jaundice within the first 24 hours of life. What is the diagnosis?
➔ Rh incompatibility

Note: a) Occurs when an Rh-negative mother forms anti-D antibodies against an Rh-positive fetus, leading to hemolytic anemia and jaundice on the first day. It can cause hydrops fetalis.
b) Prevented with Rho(D) immune globulin during pregnancy and postpartum.
c) It affects the second pregnancy VS ABO incompatibility affects the first.

48. A type O mother delivers a baby with jaundice in the first 24 hours. What is the diagnosis?
➔ ABO incompatibility

Note: a) The most common cause of hemolytic disease in newborns. Affects the first pregnancy. Less severe than Rh incompatibility. Coombs test is positive.
b) Treat with phototherapy.

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Gynecology

Puberty & Menstrual Disorders

1. A 17-year-old female is brought to the OPD because of weight loss. She has become obsessed with losing weight, and her BMI is 17 kg/m2. Her menstrual cycles have stopped for the past 6 months. What is she most likely at risk for?
➔ Anorexia leads to –> decreased GnRH –> leads to decreased estrogen –> osteoporosis

Note: a) Management → Psychotherapy and Nutritional rehab → Olanzapine may be considered if refractory
b) Indications for hospitalization:

Indications For Hospitalization In Anorexia Nervosa
1) Severe bradycardia (<40 bpm)
2) Hypotension (<80/60 mmHg)
3) Hypothermia (<35 °C)
4) Severe dehydration
5) BMI <15 kg/m²

c) Contrast with → Bulimia nervosa → Episodes of binge-eating followed by compensatory behavior, but normal BMI (>17.5 kg/m2 → Treat with SSRIs

2. A 28-year-old female presents to you with complaints of the absence of menses for the past 6 months. Her beta-HCG, TSH, FSH, and prolactin levels are within the normal parameters. On the progesterone withdrawal test, she experiences bleeding. What is the likely cause of her complaints?
➔ Anovulation (bleeding on progesterone withdrawal means that the patient has adequate normal estrogen → leading to endometrial proliferation, but no ovulation → no progesterone → amenorrhea)

Note: a) If bleeding does not occur on progesterone withdrawal, it can indicate three things:
○ Inadequate estrogen production by the ovaries (premature ovarian failure)
○ Inadequate endometrial lining (Asherman syndrome) or obstruction as imperforate hymen
○ Dysfunctional HPA axis (low GnRH or FSH levels would lead to low estrogen)

3. A 32-year-old woman presents with a history of irregular menses. She also complains of increased facial hair growth. Her BMI is 38 kg/m2, and she also has type 2 diabetes mellitus. What is the likely diagnosis?
➔ Polycystic ovarian syndrome (triad of androgenization + irregular menses + polycystic ovaries on ultrasound) → Need 2 out of 3 to make a diagnosis

Note: a) First line management for PCOS → Weight loss
b) Management for irregular menses → OCPs (supplies progestin, which inhibits unregulated estrogen effects)
c) Management for infertility & Hirsutism
○ Clomiphene: Partial estrogen agonist at GnRH receptors.
○ Letrozole: Aromatase inhibitor used for induction of ovulation
○ Spironolactone: Androgen receptor antagonist → Treatment for hirsutism
d) Type 2 DM → Extremely common comorbidity → All patients with suspected PCOS should undergo HbA1C test for DM
e) In PCOS, the LH/FSH ratio is elevated due to increased pulsatile GnRH secretion favoring LH release → High LH stimulates the theca cells in the ovary to produce excess androgens, while relatively low FSH is insufficient to support normal follicular maturation → Dominant follicles fail to develop, leading to chronic anovulation and the formation of multiple small cystic follicles seen on ultrasound.

4. A 30-year-old woman presents with complaints of heavy menstrual bleeding. On pelvic examination, she has an irregularly enlarged uterus. She is otherwise asymptomatic. What is the most likely diagnosis?
➔ Leiomyoma uteri (uterine fibroids)

Note: a) Diagnosis → Pelvic ultrasound
b) Classic case of pre-menopausal woman + dysmenorrhea + irregularly shaped uterus
b) Management:
○ If asymptomatic: Observation and Reassurance
○ If symptomatic: OCPs or GnRH agonists, or perform resection

5. A 44-year-old woman presents with complaints of painful and heavy menses. On pelvic examination, the uterus appears symmetrically enlarged, globular, and tender. What is the likely diagnosis?
➔ Adenomyosis (abnormal endometrial tissue within the myometrium)

Note: a) Diagnosis → Made on clinical examination and pelvic ultrasound (thickened myometrium)
b) Management:
○ First line: OCPs
○ Definitive management: Hysterectomy
c) Contrast adenomyosis with → Uterine fibroids (PV heavy bleeding + irregularly enlarged uterus)

6. A 14-year-old patient is brought to the OPD by her mother with complaints of amenorrhea. Her breast development is Tanner stage 4. What is the next step in management?
➔ Reassurance and observation (Primary amenorrhea with appropriate secondary sexual characteristics → Normal until age 15)

Note: a) Primary amenorrhea is primarily defined as no menarche by age 15, along with normal growth and secondary sexual characteristics development, or no menarche by age 13 without secondary sexual characteristics development

7. A 17-year-old woman presented to you with complaints of amenorrhea, and on pelvic ultrasound, you find the uterus to be absent. What is the next step in management?
➔ Karyotype analysis

Note: a) Evaluate for Androgen insensitivity (testicular feminization syndrome- 46 XY) or Mullerian agenesis (Mayer‐Rokitansky‐Küster‐Hauser syndrome- 46 XX)
b) Here is a table that would help differentiate between the two conditions:

Feature	Androgen Insensitivity Syndrome	Müllerian Agenesis
Karyotype	46 XY	46 XX
Gonads	Testes (undescended)	Ovaries
Pubic/Axillary hair	Sparse or absent	Normal
Breast development	Normal	Normal
Hormone levels	High testosterone (androgen resistance)	Normal female hormones
Cause of absent uterus	Anti-Müllerian hormone secreted from the testes causes regression of the uterus	Congenital absence of Müllerian ducts

8. A 16-year-old woman presented to you with complaints of amenorrhea, and on pelvic ultrasound, you find the uterus to be present and FSH levels to be normal. What is the likely diagnosis?
➔ Imperforate hymen (Amenorrhea + Normal hormones + Bluish bulging membrane → Think imperforate hymen)

Note: a) Management → Incision and Drainage

9. A 16-year-old woman presented to you with complaints of amenorrhea, and on pelvic ultrasound, you find the uterus to be present and FSH levels to be high. She has a short height and underdeveloped breasts. What is the next best in management?
➔ Karyotype analysis → Evaluate for Turner syndrome (XO)

Note: a) Main features of Turner syndrome include:
○ Short height
○ Streak ovaries
○ Hypoplastic uterus
○ Webbed neck
b) Comorbidities in Turner Syndrome:
○ Cystic hygroma
○ Bicuspid aortic valve
○ Aortic dissection
○ Horseshoe kidney
c) Turner syndrome → Low estrogen + High GnRH + High FSH + High LH
d) Contrast with → Klinefelter’s syndrome → Tall height + small firm testes + gynecomastia + infertility → (47XXY) or (mosaic pattern of 46,XY+47,XXY)

10. A 17-year-old girl presents with complaints of amenorrhea. Her BMI is 17kg/m2, and her FSH levels are low. What is the likely cause of her amenorrhea?
➔ Functional hypothalamic amenorrhea → Immaturity of Hypothalamic-Pituitary-Axis (HPA) → Due to caloric restriction and strenuous exercise

Note: a) FHA → Hormonal abnormality of low GnRH, low FSH, and low LH
b) FHA commonly occurs in → Anorexics (BMI <18.5 kg/m2)

11. A 30-year-old female presents with complaints of amenorrhea for the past two months. What is the next best step in management?
➔ Urine Beta HCG (to rule out pregnancy)

Note: a) Here is an algorithm for secondary amenorrhea that you should remember:

12. A 23-year-old with previously normal menses now complains of amenorrhea, headaches, and vision loss. What is the likely diagnosis?
➔ Prolactinoma (high prolactin and normal TSH)

Note: a) A prolactin-producing pituitary tumor compresses the optic chiasm → leading to bitemporal hemianopia.
b) Treatment → Dopamine agonist like bromocriptine or cabergoline → If refractory or vision threatening → Go for transsphenoidal resection
c) If High prolactin + High TSH → Think hypothyroidism (depression, bradycardia, cold intolerance, etc)

13. A 32-year-old woman presents with complaints of amenorrhea for the past 5 months. She has a history of undergoing a dilation and curettage for a previous IUD of the fetus. Her FSH, LH, Prolactin, and TSH levels are normal. What is the diagnosis?
➔ Asherman syndrome- Also called uterine synechiae (Endometrial scarring after uterine instrumentation leads to impaired shedding despite normal hormone levels.)

Note: a) If Amenorrhea + Obesity + Elevated testosterone → Thick PCOS
b) If Amenorrhea + high TSH → Think hypothyroidism

14. A 7-year-old girl presents to you with complaints of increased hair in her axillae and facial acne. His parents also report that she has had some breast development throughout the past 6 months. What is the diagnosis?
➔ Precocious puberty → Puberty signs in <8 year old girls or <9 year old boys

Note: a) For precocious puberty → Next best step is to assess the bone age
b) If bone age is:
○ Increased → Next best step is to assess the basal LH levels
○ Decreased → Diagnose it as isolated pubarche or isolated thelarche
c) If basal LH levels:
○ Increased → Confirms central precocious puberty
○ Decreased → Do GnRH stimulation test → If LH levels are still low → Confirms peripheral precocious puberty

15. A 6-year-old girl presents to you with complaints of onset of menstruation and acne. On bone analysis, you find the bone age to be advanced and underlying LH levels to be low. What is the diagnosis?
➔ Peripheral precocious puberty

Note: a) Likely source for precocious puberty →Peripheral tumor or congenital adrenal hyperplasia
b) Estrogen-producing tumor → Granulosa cell tumor → Call-Exner bodies observed histologically
c) Pituitary GnRH producing tumor → Can lead to central precocious puberty → Treat with leuprolide

16. A 13-year-old girl is brought to you by her mother for right breast tenderness for the past two months. The right breast is slightly tender and raised, while the left breast is unremarkable. What is the next best step in management?
➔ Reassurance (this is normal puberty, for which we would just simply reassure)

Note: a) Similarly, for mild vaginal spotting in young adolescent girls, → Likely also indicates the start of menstruation and puberty → The best next step is to reassure
b) Boys can also develop unilateral or bilateral breast mass or tenderness during puberty → The best next step is to reassure
c) Imaging is needed when:
○ Rapid progression
○ Associated mass, skin changes, or prominent discharge
○ Symptoms outside the pubertal age

17. A 28-year-old female presents to you with complaints of infertility and abdominopelvic pain during the menses. What is the likely diagnosis?
➔ Endometriosis → Endometrial tissue outside the uterus, particularly in other pelvic organs like the ovaries, bladder, rectouterine pouch, etc.

Note: a) Triad of endometriosis:
○ Dysmenorrhea (pain with menses)
○ Dyspareunia (pain with sexual intercourse)
○ Dyschezia (pain with defecation)
b) Endometriosis → Leads to cyclical pelvic pain during menses only → Also leads to infertility or hematuria (due to bladder implants) or hematochezia (due to implants in rectum)
c) Diagnosis → Usually a clinical diagnosis → However, the gold standard is laparoscopic surgical biopsy
d) Treatment:
○ First line → Treat with oral contraceptives (OCPs) or NSAIDs
○ Second-line → GnRH agonists (e.g., leuprolide)
○ If refractory → Surgery (laparoscopic ablation or excision) for persistent or severe disease

Condition	Key Features	Diagnostic Clue
Endometriosis	Cyclic pain, infertility, triad present	Laparoscopy confirms “chocolate cysts”
Adenomyosis	Diffusely enlarged, tender uterus	Menorrhagia + dysmenorrhea in multiparas
Pelvic inflammatory disease	Acute pelvic pain + cervical motion tenderness	Fever, vaginal discharge, WBCs
Fibroids	Heavy bleeding + firm, irregular uterus	Ultrasound confirms a mass

18. A 28-year-old female presents to you with right adnexal pain and tenderness. Her last menstrual period was 5 weeks ago. Her urine beta-HCG is positive. What is the diagnosis and management?
➔ Ectopic pregnancy → The implantation of pregnancy outside the uterus → Most commonly in the ampulla of the fallopian tube, but can also be present at the cornua of the uterus

Note: a) Risk factors → Previous history of ectopic pregnancy, history of pelvic inflammatory disease, and previous pelvic/tubal surgery
b) Management of suspected ectopic pregnancy:
○ Hemodynamically unstable → Laparoscopy
○ Hemodynamically stable → Transvaginal ultrasound to confirm it
c) If transvaginal ultrasound shows:
○ Adnexal mass → Confirms your diagnosis
○ Intrauterine mass → Normal pregnancy confirmed
○ Nondiagnostic → Assess serum beta-HCG levels
d) Here is a table that helps you differentiate between similar conditions:

Condition	Clue Differences
Ectopic pregnancy	Unilateral pain, no intrauterine pregnancy on U/S
Threatened abortion	Intrauterine pregnancy + vaginal bleeding
Ovarian torsion	Sudden onset of pain, no β-hCG elevation
Ruptured corpus luteum cyst	Acute pain, normal β-hCG

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Infectious Disorders

19. A 25-year-old female presents to you with complaints of purulent vaginal discharge, painful vesicles on an erythematous base on the vagina, along with painful lymphadenopathy. What is the likely diagnosis?
➔ Herpes simplex virus (HSV-2 most commonly affects the genitals.)

Note: a) Manage HSV infections with → IV acyclovir (if active lesions at delivery → C-section)
b) If you have a history of HSV infection before or during the pregnancy, → HSV prophylaxis begins at 36 weeks of gestation

20. A 32-year-old female patient presents with complaints of a painless vaginal ulcer with a nonerythematous base and painless lymphadenopathy. She has recently had a new sexual partner. What is the likely diagnosis?
➔ Genital primary syphilis infection (spirochete)

Note: a) Treat syphilis with penicillin G
b) Secondary syphilis → Recent history of sexual contact + pigmented maculopapular rash along the palms and soles + fever + headache

21. A 30-year-old female presents with a painful ulcer with a gray exudative base and severe purulent lymphadenopathy. What is the most likely diagnosis?
➔ Hemophilus ducreyi infection

Note: a) Hemophilus ducreyi (chancroid) → Tender nonindurated ulcer that bleeds easily when touched
b) Diagnosis → Bacterial culture is the preferred diagnostic method
c) Management → Treat with ceftriaxone, azithromycin, or fluoroquinolone
d) Differential diagnosis for genital lesions:

Condition	Ulcer characteristics	Painful/Painless	Lymphadenopathy	Treatment
Chancroid	Soft, ragged ulcer with yellow-gray exudate and irregular borders (can bleed sometimes)	Painful	Painful, unilateral, may suppurate	Azithromycin
HSV	Multiple, shallow vesicles/ulcers with erythematous base	Painful	Tender, bilateral, or unilateral	Acyclovir
Syphilis	Single, firm (indurated), round, clean-based chancre	Painless	Painless, bilateral	Benzathine penicillin G
LGV (Chlamydia)	Small, transient, painless ulcer, often unnoticed → painful buboes later	Painless	Painful, tender, unilateral, may suppurate	Doxycycline
Granuloma Inguinale	Beefy red, painless, raised ulcer that bleeds easily	Painless	No lymphadenopathy, but pseudobuboes may form	Doxycycline

22. A 32-year-old female presents with a fever, purulent vaginal discharge, and pain. What is the most likely diagnosis?
➔ Pelvic inflammatory disease → Caused by Neisseria gonorrhea or Chlamydia trachomatis

Note: a) All sexually active women <25 years need to → Undergo annual screening for chlamydia and gonorrhea → Nucleic acid amplification test (NAAT)
b) Clinical criteria for PID (≥1 required):
○ Cervical motion tenderness
○ Uterine tenderness
○ Adnexal tenderness
c) Treatment:
○ Empirically → Ceftriaxone + Doxycycline (azithromycin in pregnancy).
○ If confirmed, gonorrhea → Ceftriaxone
○ If confirmed chlamydia → Doxycycline (azithromycin in pregnancy)

23. A 24-year-old female presents to you with a widespread rash, hypotension, fever, and severe fatigue. She reports that she has been using tampons for her menses recently. What is the likely diagnosis?
➔ Toxic shock syndrome (rash + fever+ shock + tampon use in a woman = Toxic Shock Syndrome)

Note: a) Causative organism for toxic shock syndrome → Staphylococcus aureus → Caused by TSST-1 (toxic shock staphylococcal toxin-1)
b) Complication of Toxic Shock Syndrome → Acute Respiratory Distress Syndrome

24. A 22-year-old female presents with white watery vaginal discharge with a fishy odor. The pH of the discharge is >4.5. What is the most likely diagnosis?
➔ Bacterial vaginosis → Clue cells on microscopy + Positive whiff test (amine odor with KOH) is diagnostic

Wikipedia. “Gardnerella vaginalis.” July 16, 2025. https://en.wikipedia.org/w/index.php?title=Gardnerella_vaginalis&oldid=1300837394.

Note: a) Here is a table comparing three causative organisms for vaginal discharge:

Feature	Bacterial Vaginosis	Vaginal Candidiasis	Trichomoniasis
Causative organism	Gardnerella vaginalis (anaerobic imbalance)	Candida albicans (fungus)	Trichomonas vaginalis (protozoa)
Discharge	Thin, gray-white, fishy odor	Thick, white, “cottage cheese” like	Frothy, yellow-green, malodorous
Vaginal pH	>4.5	<4.5 (normal)	>4.5
Microscopy findings	Clue cells, few WBCs	Pseudohyphae or budding yeast, many WBCs	Motile trichomonads, many WBCs
Whiff Test (KOH Test)	Positive (fishy odor)	Negative	Often positive
Vaginal inflammation	Minimal or none	Present (erythema, itching, burning)	Present (strawberry cervix – punctate hemorrhages on cervix)
Treatment	Metronidazole or clindamycin	Fluconazole (oral) or topical azoles	Metronidazole (treat partner too)

Wikipedia. “Trichomoniasis.” July 24, 2025. https://en.wikipedia.org/w/index.php?title=Trichomoniasis&oldid=1302356810.

https://www.sciencephoto.com/media/1297469/view/candidiasis-albicans-fungus-light-micrograph

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Breast

25. A 23-year-old female presents with a 2cm breast mass. The mass is nontender and immobile on palpation. What is the next best step in management?
➔ Breast ultrasound (all breast masses always need to be evaluated; you would never just reassure without evaluating it appropriately)

Note: a) Here is an algorithm you need to remember for the evaluation of a breast mass:

26. A 28-year-old female presents to you with a breast mass that is non-tender, mobile, and compressible. What is the diagnosis and management?
➔ Breast cyst → Evaluate with ultrasound

Note: a) If it’s a simple tender cyst → Next best step is to do FNA
b) If FNA reveals:
○ Bloody aspirate → Next best step is to do a core needle biopsy
○ Nonbloody aspirate and cyst resolves → Next best step is to do observation
○ Nonbloody aspirate and cyst recurs → Next best step is to do a core needle biopsy
c) If it is a complex breast cyst → Next best step is to do a core needle biopsy

27. A 17-year-old female presents with a 2 cm, well-circumscribed, mobile, non-tender breast mass. Breast ultrasound shows no features suggestive of malignancy. What is the next step?
➔ Observation and follow-up in 6 months

Note: a) Findings are classic for a fibroadenoma — a benign, mobile, painless mass in a young woman. With reassuring ultrasound and small size, the next step is monitoring, not biopsy or excision.)
b) Fibroadenoma may also present with → Cyclic premenstrual tenderness
c) Fibroadenoma In adolescents (<20 years) :
○ No imaging required initially
○ Reassure the patient and re-evaluate in 6 weeks, as many regress spontaneously →This is because, unlike adults, adolescents don’t have a higher baseline risk for malignancy
d) Contrast fibroadenoma with → Fat necrosis (usually follows a trauma or surgery and appears as a calcified mass on imaging)

28. A 32-year-old female presents with a unilateral bloody nipple discharge. She does not have any breast mass or lymphadenopathy. What is the likely diagnosis?
➔ Intraductal papilloma (bloody discharge from breast + negative mass on exam- benign papillary tumor arising from the ductal lining)

Note: a) If there was unilateral bloody nipple discharge along with a breast mass → It would most likely indicate an underlying malignancy → Mammography or Ultrasound based on the age
b) Brown or Green painful nipple discharge along with tender breasts in a 45-year-old woman → Ductal ectasia
c) Bilateral nonbloody nipple discharge along with normal breast examination → Physiologic breast discharge (for example, during pregnancy) → Next step would be to do a pregnancy test

29. A 62-year-old woman presents with a mass and bloody nipple discharge. What is the likely diagnosis?
➔ Breast cancer → The next best step would be to do a mammography, followed by a core needle biopsy

Note: a) The biggest risk factor for breast cancer and prostate cancer → Age
b) Other risk factors for breast cancer include → Exogenous estrogen use, family history of breast cancer, genetic mutation (eg, BRCA 1 or 2), early menarche, late menopause, nulliparity, obesity, and African American ethnicity
c) Breast cancer & prostate cancer are most likely to metastasize to → Vertebral bones

30. A 30-year-old female who recently gave birth presents to you with unilateral breast pain, fever, and tenderness. What is the likely diagnosis?
➔ Lactational mastitis

Note: a) Treatment → Oral dicloxacillin
b) Complications → Breast abscess (fluctuant mass + tenderness + fever) → Diagnose with breast ultrasound
c) Contrast with → Breast engorgement (bilateral symptoms + erythematous swollen tender breasts)

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Acute Gynecologic Emergencies

31. A 25-year-old female presented in the emergency department with a sudden onset of severe left adnexal pain while she was exercising. A pelvic ultrasound revealed no mass and decreased blood flow to the left ovary. What is the next step in management?
➔ Laparoscopic detorsion (to preserve fertility in a young woman) → If the ovary is necrotic or nonviable → Perform an oophorectomy

Note: a) Unlike testicular torsion (which is a clinical diagnosis), ovarian torsion must be confirmed with Doppler ultrasound (shows ↓ or absent blood flow)
b) Ovarian vessels can get compromised secondary to → Either a tumor, a cyst, or ovulation induction treatment
c) If torsion is secondary to a cyst or a tumor → Resect that cyst or tumor instead of performing an oophorectomy to preserve fertility

32. A 25-year-old woman presents with recurrent monthly mild unilateral abdominal pain, and the pain lasts from hours to days. What is the next best step in management?
➔ Observation and Reassurance

Note: a) Mittelschmerz → Occurs due to rupture of the follicular cyst to release the ovum and causes subsequent mild peritoneal irritation and mild abdominal pain
b) Contrast with other unilateral causes of pelvic/abdominal pain in young women:

Condition	Pain Characteristics	Associated findings	Pregnancy test	Fever/WBC	Imaging Tests
Ectopic Pregnancy	Sudden, unilateral pelvic pain	Missed period, vaginal bleeding	Positive	Usually no	TVUS: Empty uterus, adnexal mass ± free fluid
Appendicitis	Starts periumbilical → RLQ pain	Fever, nausea, anorexia, rebound tenderness	Negative	Yes	US or CT: Inflamed appendix
Ovarian Torsion	Sudden, severe unilateral pain	Nausea, vomiting, no bleeding, not cyclic	Negative	Sometimes	Doppler US: Enlarged ovary, ↓/absent flow
Ruptured Ovarian Cyst	Sudden, sharp unilateral pain	May occur mid-cycle or post-exertion, light bleeding	Negative	No	TVUS: Free fluid, collapsed cyst

Screening & Contraception

33. A 28-year-old female presented with acne vulgaris on her face and was prescribed isotretinoin therapy for it. What test will you do before initiating her on this therapy?
➔ Urine beta-HCG (you need to confirm that she is not pregnant because isotretinoin is highly teratogenic)

Note: a) Remember that retinoids (along with growth hormone and oral contraceptives) put you at an increased risk for → Pseudotumor cerebri (idiopathic intracranial hypertension)
b) When you start on retinoids → Two forms of contraception are required

34. A 28-year-old female presents to you with a history of unprotected sexual intercourse last night. She requests an emergency contraception. What will be the best prescription for her?
➔ IUD (copper, progestin releasing, or ullipristal)

Note: a) Copper and Progestin IUDs are 99% effective emergency contraception methods
b) Contraindications for IUD:
○ History of heavy bleeding during menses
○ Unexplained vaginal bleeding
○ Active pelvic infection
○ Known or suspected uterine or cervical cancer
○ Uterine anomalies like fibroids
c) Here are some options for emergency contraception and their contraindications:

Emergency Contraception Option	Contraindications
Levonorgestrel	Known pregnancy, active breast cancer
Ullipristal	No known contraindications
Copper IUD	Current PID, active STI, uterine abnormalities, copper allergy, Wilson’s disease, pregnancy

35. A 27-year-old woman with a history of rape one day ago presented to you for medical checkup. Which contraception would you prescribe?
➔ Emergency contraception

Note: a) Antibiotic prophylaxis for STIs → Ceftriaxone + Doxycycline (or azithromycin)

36. A 25-year-old woman presents for a routine check-up and asks when she should begin cervical cancer screening. Her last pap smear was 4 years ago. What is the next best step in management?
➔ Perform a pap smear

Note: a) Begin Pap smear at age 21, regardless of sexual activity, and continue for every 3 years until age 29
b) From ages 30–65:
○ Pap smear every 3 years (cytology only) OR
○ Every 5 years if co-testing with HPV.
c) Do not screen:
○ Before age 21
○ After age 65, if adequate prior screening and no high-risk factors
○ Post-hysterectomy with cervix removal for benign reasons

37. A 13-year-old girl presents for a routine health checkup at your clinic. She is not sexually active. Her mother asks for HPV vaccine advice. What is the next best step in management?
➔ Start her on a 2-dose vaccine regimen (HPV vaccine is recommended for all patients aged 9–26, regardless of sexual activity. At age <15, a 2-dose schedule is sufficient.)

Note: a) If age <15 → Start on a two-dose regimen → schedule at 0 and 6–12 months
b) If age >15 or immunocompromised → Start on a three-dose regimen → schedule at 0, 1–2, and 6 months
c) No Pap smear before age 21 but screen for chlamydia and gonorrhea with NAAT, even if sexually active (Important differentiation — Step 2 CK may test this as a trap)

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Gynecological Cancers

38. A 38F cervical pap smear reveals atypical glandular cells. What is the next best step in management?
➔ Endometrial biopsy (atypical glandular cells can indicate underlying endometrial cancer)

Note: a) Here is a related algorithm for finding atypical glandular cells on a pap smear:

Scenario	Next Step
AGC + Age ≥35 or RFs for endometrial cancer	Endometrial biopsy + colposcopy ± Endocervical Curettage
AGC + Age <35, no RFs	Colposcopy ± Endocervical Curettage
AGC suspicious for AIS (adenocarcinoma in situ) or finding endometrial cells on regular Pap smear in a woman >45 years	Colposcopy + Endocervical Curettage + Endometrial biopsy

b) Here is a table for Cervical intraepithelial neoplasia

CIN Grade	Treatment Options	Notes
CIN 1	– Observation (most regress spontaneously) – Repeat Pap/HPV in 12 months	Especially if associated with low-risk HPV and the patient is <25 years old
CIN 2	– Excisional procedure (LEEP, cold knife conization) – Observation of young and reliable follow-up	Observation may be an option for adolescents or pregnant patients
CIN 3	– LEEP or cold knife conization – Hysterectomy if childbearing is complete	Higher risk of progression to invasive cancer if untreated

39. A 62-year-old female presented with post-menopausal bleeding. What is your next best step in management?
➔ Pelvic ultrasound (to confirm whether there is endometrial thickening equal to or greater than >4mm)

Note: a) If pelvic ultrasound:
○ Shows endometrial thickening to be equal or >4mm → Perform an endometrial biopsy
○ Shows endometrial thickening to be <4mm → Evaluate for other causes like vaginal trauma, atrophic vaginitis, or sexual abuse
b) Risk factors for the development of endometrial cancer:
○ Obesity
○ Unopposed or prolonged estrogen exposure
○ Tamoxifen use
○ Early menarche
○ Late menopause
○ Nulliparity
c) The most common indications for endometrial biopsy are:
○ Abnormal uterine bleeding
○ Postmenopausal bleeding
○ Evaluation for endometrial cancer or hyperplasia
○ Infertility evaluation
○ Monitoring response to hormone therapy (e.g., tamoxifen)

40. A 58-year-old woman presents with complaints of a pelvic mass. On pelvic ultrasound, you find a large ovarian mass. What is the next step in management?
➔ Oophorectomy (do not biopsy ovarian masses before resection due to seeding risk)

Note: a) Next best step → CT/MRI for more details + locating metastasis
b) Remember that for testicular and ovarian cancers, we usually directly resect without taking any biopsy → Due to these tumors being highly vascularized, we could risk metastasis
c) Ovarian mass → Can lead to ovarian torsion

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Miscellaneous

41. A 35-year-old with a history of multiple macrosomic babies presents with urine leaking on sneezing and coughing. What is the diagnosis?
➔ Urinary stress incontinence → Also called urethral hypermobility → Also called downward mobility of urethrovesical junction

Note: a) Other signs for stress incontinence → Urine leaking with lifting weights or laughing hard, or performing any exertional task that increases intra-abdominal pressure
b) Here is a table summarizing different types of incontinence:

Condition	Description	Notes
Stress Incontinence	Urine leakage during activities that increase intra-abdominal pressure, such as sneezing, coughing, laughing, or lifting.	– Also called urethral hypermobility – Due to the downward mobility of the urethrovesical junction – Management: Pelvic floor exercises (Kegels); if refractory, use intravaginal pessary
Urge Incontinence	Sudden onset of the urge to urinate with inability to hold urine.	– Common in conditions like multiple sclerosis (bladder-sphincter dyssynergia) – Overactive bladder is a cause – Treated with anticholinergics like oxybutynin
Overflow Incontinence	Involuntary leakage due to an overfilled bladder, usually with high post-void residual volume.	– Associated with an underactive bladder – Often due to diabetic neuropathy or bladder outlet obstruction (like BPH) – Management: Cholinergic agents (e.g., bethanechol), intermittent self-catheterization, Foley’s catheter in BPH cases

42. A 75-year-old woman presented to the OPD with complaints of inability to hold urine. On examination, she has vaginal atrophy. Her urinalysis is normal. What is the likely diagnosis?
➔ Atrophic vaginitis → Also called genitourinary syndrome of menopause (urge incontinence occurs secondary to loss of estrogen in older women)

Note: a) Other symptoms → Dyspareunia, pruritus, vaginal bleeding, and recurrent UTIs
b) Management → First line management is vaginal moisturizer or lubricant → If refractory, go for topical vaginal estrogen

43. A 28-year-old woman presents for a routine examination. Her LMP was 3 weeks ago, and she has mild adnexal tenderness. On pelvic ultrasound, there is a cyst present. What is the diagnosis?
➔ Corpus luteal cyst (in some instances, the normal physiological corpus luteum can form a cyst and persist)

Note: a) Corpus luteal cysts:
○ Usually asymptomatic
○ Sometimes they can rupture following physical activity or sexual intercourse
○ Ruptured cysts present with unilateral,sudden-onset, severe abdominal pain and hemoperitoneum
b) Management of corpus luteal cyst→ Repeat transvaginal ultrasound after 6 weeks to confirm the diagnosis and persistence of the cyst.

44. An 80-year-old woman presents to you with vaginal bleeding. On examination, there is a verrucous mass partially covering the anal verge in the perineum. What is the diagnosis?
➔ Vulvar carcinoma (do not confuse it with rectal carcinoma, which would not present with vaginal bleeding)

Note: a) Lichen sclerosus → Acts as a precursor for vulvar carcinoma (most common cause of vulvar cancer is HPV)
b) Other risk factors include → Tobacco use, immunodeficiency, and vulvar intraepithelial neoplasia

45. A 28-year-old woman presents with complaints of difficulty and pain during sexual intercourse. Abdominal examination and menstrual cycles are normal. What is the likely diagnosis?
➔ Vaginismus (also called vulvodynia)

Note: a) Vaginismus → Happens due to vaginal muscles spasming, often arising due to stress or anxiety related to sexual intercourse
b) Contrast with → Genitourinary syndrome of menopause → Post-menopausal woman + Vaginal atrophy + Urge incontinence

46. A 55-year-old woman presented with hot flashes, night sweats, mood swings, and vaginal dryness. What is the likely diagnosis?
➔ Menopause

Note: a) Loss of estrogen in menopause → Leads to osteoporosis → Treat with bisphosphonates

47. A 17-year-old female presents with painful menses during the first 2 days of menstruation and the pain resolves after menstruation ends. She does not have any other accompanying symptoms. What is the likely treatment?
➔ NSAIDs (OCPs, if refractory to NSAIDs)

Note: a) Diagnosis → Primary dysmenorrhea → Occurs due to excessive prostaglandin production in the endometrium during menstruation

48. A 28-year-old woman presents with sudden onset of voice changes and facial hair growth. Her serum FSH, LH, and testosterone levels are normal. What is the likely diagnosis?
➔ Idiopathic hirsutism

Note: a) Here are some differential diagnoses for hirsutism:

Cause	Key clinical issues
Polycystic Ovary Syndrome	Irregular periods, signs of excess androgens (acne, hirsutism), often with obesity and features of metabolic syndrome (e.g., insulin resistance, hypertension)
Idiopathic Hirsutism	Normal menstrual cycles and hormone levels; slow onset of mild hair growth
Late-Onset CAH (21-OH Deficiency)	Resembles PCOS but with raised 17-hydroxyprogesterone levels
Androgen-Producing Tumors / Ovarian Hyperthecosis	Seen more often in older women; rapid hair growth with male-like features and very high androgen levels
Cushing Syndrome	Central obesity, moon face, menstrual disturbances, and signs of androgen excess

49. A 22-year-old male presents with sudden onset of testicular pain during sports. On examination, he has absent cremasteric reflex. What is the likely diagnosis?
➔ Testicular torsion (blood supply to testes gets compromised)

Note: a) Diagnosis → Usually a clinic diagnosis, but can do the Doppler flow ultrasound
b) Treatment → Surgical detorsion of the affected testis + bilateral orchiopexy (fixing the testes to the scrotal wall) → If necrosis had occurred in the affected testis → Orchiectomy (removal of the testis)

50. A 25-year-old male presented with a testicular swelling which has a bag-of-worms appearance. The swelling becomes more apparent on Valsalva and resolves when supine. What is the likely diagnosis?
➔ Varicocele (dilation of the pampiniform plexus)

Note: a) Here is a differential diagnosis table for testicular swelling

Condition	Key Features	Transillumination	Pain	Physical exam findings	Other notes
Hydrocele	Painless scrotal swelling due to fluid accumulation in tunica vaginalis	Positive	Painless	Soft, non-tender, fluctuant mass in scrotum	Often idiopathic or post-infectious/traumatic
Varicocele	Dilated pampiniform plexus veins; feels like a “bag of worms.”	Negative	Dull ache, worse standing	Mass increases with Valsalva, decreases when supine	More common on left side due to venous drainage angle
Testicular cancer	Firm, painless testicular nodule or mass	Negative	Painless	Hard, fixed mass that may present with lymphadenopathy	Common in 15–35 years; risk ↑ with cryptorchidism
Inguinal hernia	Protrusion of abdominal contents through inguinal canal	Negative	May be painful or painless	Mass may reduce when supine; may have bowel sounds	Increased with straining/coughing; indirect hernia can extend into scrotum
Epididymitis	Infection/inflammation of epididymis, usually from STI or UTI	Negative	Painful	Tender, swollen epididymis; relief with scrotal elevation (Prehn’s sign)	May have fever, dysuria, or urethral discharge

51. A newborn male was found to have one testis in the scrotum. Which future complication is he at risk for developing?
➔ Testicular cancer (diagnosis → cryptorchidism)

Note: a) Undescended testis (Cryptorchidism) → Leads to malignancy development + infertility (increased body temperature predisposes to these complications)
b) Management:
○ If age <6 months → Monitor for spontaneous descent
○ If age >6 months → Surgical correction (orchiopexy)

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🏁 Final Thoughts

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Disclaimer

Version 1.0 August 2025. No part of this document may be reproduced or distributed without written permission. For personal study only. Medical information herein is for educational purposes and does not constitute clinical advice. Always confirm with current guidelines and your institution’s policies.

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USMLE Step 2 CK High-Yield Obstetrics/Gynecology Topics

Obstetrics/Gynecology

High Yield USMLE Step 2 CK Notes

Table of Contents

Prenatal Testing & Supplementation

Pregnancy Complications

Miscellaneous Topics

Gynecology

Puberty & Menstrual Disorders

Infectious Disorders

Breast

Acute Gynecologic Emergencies

Screening & Contraception

Gynecological Cancers

Miscellaneous

🏁 Final Thoughts

Disclaimer

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