Free SMLE Obstetrics & Gynecology questions

A 45-year-old woman presents with continuous vaginal bleeding for 15 days, soaking six pads daily. She feels lightheaded on standing and has fainted twice. Pulse is 108 beats/min and supine blood pressure is 100/62 mm Hg. She is sexually active and uses no contraception. Which of the following is the most appropriate initial investigation?

A 42-year-old woman, para 4, reports 2 years of progressively severe cramping pain starting before and lasting through her periods, with heavy bleeding. The uterus is globally enlarged to 12 weeks size, soft, and tender on bimanual examination. Endometrial biopsy shows normal secretory endometrium and ultrasound shows no discrete mass. Which of the following is the most likely diagnosis?

A 45-year-old woman, para 6, reports chronic pelvic pain and heavy menstrual bleeding for 2 years. Her uterus is diffusely enlarged, boggy and tender, and the pregnancy test is negative. Pelvic MRI shows a diffusely thickened myometrium with a junctional zone of 16 mm. She has completed childbearing and hormonal therapy has failed. Which of the following is the most definitive treatment?

A 23-year-old primigravida at 30 weeks is admitted with regular contractions and a cervix 2 cm dilated. Membranes are intact and the cardiotocograph is normal. She is given two doses of intramuscular betamethasone 12 mg, 12 hours apart, and asks what the injections are for. Which of the following neonatal complications is most reduced by this treatment?

A 30-year-old G2P1 at 36 weeks of gestation has had painless bright red vaginal bleeding for 1 day, soaking two pads. The uterus is soft and non-tender, the lie is transverse, and the presenting part is high. Blood pressure is 118/70 mm Hg and pulse is 92 beats/min. Cardiotocography is normal. Which of the following is the most appropriate next action?

A 30-year-old woman at 33 weeks' gestation arrives in the emergency department with severe lower abdominal pain and vaginal bleeding that has soaked her clothing. Blood pressure is 92/58 mm Hg and pulse is 122 beats/min. The uterus is tense and tender. Fetal heart rate is 140 beats/min. Which of the following is the most appropriate immediate next step?

A 31-year-old woman at 7 weeks of gestation has had three consecutive unexplained first-trimester miscarriages and one unprovoked deep vein thrombosis 2 years ago, after which warfarin was started. Lupus anticoagulant and anticardiolipin IgG were positive on two occasions 12 weeks apart, confirming antiphospholipid syndrome. She stopped warfarin 10 days ago when her pregnancy test became positive. What is the most appropriate antithrombotic regimen for this pregnancy?

A 33-year-old woman at 38 weeks gestation attends a routine antenatal visit. She has no fever, dysuria, frequency, or flank pain, and her temperature is 36.8 °C. Screening urine culture grows 10⁵ colony-forming units/mL of Escherichia coli reported as susceptible to amoxicillin, cephalexin, nitrofurantoin, and gentamicin. Which of the following is the most appropriate treatment?

A 50-year-old woman with two children and no wish for further pregnancy reports 8 months of prolonged heavy menstrual bleeding. Her body mass index is 36 kg/m² and she has no cardiorespiratory disease. Pelvic ultrasound shows an endometrial thickness of 20 mm, and endometrial biopsy reports endometrial hyperplasia with atypia. Which of the following is the most appropriate management?

A 26-year-old woman presents with 2 weeks of thin, greyish-white vaginal discharge with a fishy odour that is worse after intercourse. She has no itching, dysuria, or dyspareunia. Speculum examination shows discharge coating the vaginal walls with no vulval or vaginal erythema and no cervical motion tenderness. Vaginal pH is 5.0, and potassium hydroxide releases a pungent amine odour. Which of the following is the most likely diagnosis?

A 30-year-old woman, gravida 2 para 1, was admitted 3 days ago at 30 weeks gestation with preterm premature rupture of membranes and managed expectantly. Today her temperature is 38.6 °C, pulse 120 beats/min, with marked uterine tenderness and foul-smelling vaginal discharge. Fetal heart rate baseline is 175 beats/min. Which of the following is the most likely diagnosis?

A 36-year-old woman with chronic hypertension taking hydrochlorothiazide and losartan reports two months of amenorrhea. She feels well. Blood pressure is 132/84 mm Hg, urine dipstick shows no protein, and a urine pregnancy test is positive. Ultrasound confirms an 8-week intrauterine pregnancy. Which of the following is the most appropriate treatment adjustment?

A 24-year-old woman at 10 weeks gestation reports heavy bleeding with cramping that stopped after she passed a fleshy mass at home. Blood pressure is 118/72 mm Hg, pulse 82 beats/min, and temperature 36.8 °C. The cervical os is closed with minimal blood. Transvaginal ultrasound shows an empty uterus with a thin endometrium. Which of the following is the most appropriate management?

A 26-year-old woman has had 14 weeks of amenorrhea, 3 days of light vaginal bleeding and persistent vomiting. The uterus measures 18 weeks and feels doughy, and no fetal heart is audible. Serum beta human chorionic gonadotropin is 320 000 IU/L, and ultrasound shows an enlarged uterus with a snowstorm appearance and no fetus. Which of the following is the most appropriate next step in management?

A 29-year-old woman delivers vaginally at 41 weeks. The placenta fails to separate, and manual removal fails because it is densely adherent. She declines hysterectomy and wishes to preserve fertility. The cord is ligated high, the placenta is left in situ, and methotrexate is started. Which of the following is the most likely complication of this management?

A 29-year-old woman with a mechanical mitral valve replacement is on lifelong warfarin with an INR of 2.8. She attends the family planning clinic for contraceptive advice. She has no children yet, wants a reversible method, and has regular cycles with moderate menstrual flow. She is a nonsmoker. Which of the following is the most appropriate contraceptive method?

A 20-year-old primigravida at 7 weeks gestation has a 4 cm right tubal ectopic pregnancy on transvaginal ultrasound, with no free fluid and no embryonic cardiac activity. She has no pain or bleeding, blood pressure 118/72 mm Hg, pulse 80 beats/min, and beta-hCG is 6200 mIU/mL. Which of the following is the most appropriate management?

A 30-year-old woman received single-dose methotrexate 50 mg/m² for a 3 cm unruptured tubal ectopic pregnancy one week ago. She now has worsening right iliac fossa pain, blood pressure 104/66 mm Hg, pulse 104 beats/min. Beta-hCG was 1000 mIU/mL on day 1, 1200 mIU/mL on day 4, and 2100 mIU/mL on day 7, with increasing pelvic free fluid. Which of the following is the most appropriate next step?

A 30-year-old woman has been unable to conceive for six years despite regular unprotected intercourse. She has severe cramping pelvic pain beginning two days before each period, no longer relieved by naproxen, with deep dyspareunia and pain on defecation during menstruation. Cycles are regular at 29 days. Bimanual examination reveals a fixed retroverted uterus and tender nodularity along the uterosacral ligaments. Which of the following is the most likely diagnosis?

A 33-year-old nulliparous woman reports cyclic pelvic pain, painful defecation during menses and deep dyspareunia for 3 years. Examination shows a fixed retroverted uterus with tender nodules in the posterior fornix. Diagnostic laparoscopy reveals bluish-black powder-burn lesions over the pelvic peritoneum with dense adhesions. Which of the following is the most likely diagnosis?

A 58-year-old woman reports 6 months of pelvic heaviness and increasing abdominal distension. Examination shows a distended, diffusely tender abdomen with a large abdominopelvic mass. CT and ultrasound show a 12 cm solid left ovarian mass, moderate ascites, and diffuse peritoneal thickening. CA-125 is 640 U/mL. Which of the following is the mainstay of treatment for the most likely diagnosis?

A 23-year-old primigravida at 36 weeks of gestation reports mild lower abdominal tightening every 20 to 30 minutes for 6 hours. Cardiotocography shows a baseline of 140 beats/min with accelerations, moderate variability and no decelerations. Contractions are irregular and mild. The cervix is closed, long and uneffaced, and the membranes are intact. Which of the following is the most appropriate management?

A 26-year-old woman at 9 weeks gestation presents with cramping and vaginal bleeding and completes a spontaneous miscarriage the same day. This is her first pregnancy loss. She takes no medications, has regular cycles, and has no history of diabetes, thrombophilia, or uterine surgery. Which of the following is the most likely underlying cause of this pregnancy loss?

A 22-year-old primigravida at 33 weeks of gestation is diagnosed with gestational diabetes after a 75 g oral glucose tolerance test showing a fasting glucose of 5.4 mmol/L and a 2-hour value of 9.1 mmol/L. She has no symptoms and fetal growth is on the 60th centile. Which of the following is the most appropriate first-line therapy?

A 44-year-old woman underwent suction evacuation of a partial hydatidiform mole, confirmed on histopathology. Two weeks later she has no vaginal bleeding, blood pressure is 120/76 mm Hg, hemoglobin is 118 g/L, and serum beta-hCG has fallen from 90,000 to 4,000 IU/L. She asks about surveillance. Which of the following is the most appropriate follow-up plan?

A 26-year-old woman underwent suction evacuation of a complete hydatidiform mole 6 weeks ago. Weekly serum beta-hCG values over the past month are 3,100, 3,050, 3,200, and 3,100 IU/L. She has light vaginal bleeding, and ultrasound shows no retained tissue. Chest radiograph is clear. Which of the following is the most appropriate management?

A 40-year-old woman, gravida 4 para 3, at 32 weeks presents with constant right upper quadrant pain and nausea. Blood pressure is 168/106 mm Hg, urine protein is 3+, platelets 78 × 10⁹/L, ALT 240 U/L, and lactate dehydrogenase is elevated. The gallbladder is normal on ultrasound. Which of the following is the most likely cause of her pain?

A 34-year-old woman at 38 weeks gestation reports severe headache. Blood pressure is 168/108 mm Hg with 2+ lower limb edema; no petechiae are seen and neurologic examination is normal. Platelets are 68 × 10⁹/L, AST 210 U/L, LDH 820 U/L, creatinine 88 µmol/L, urine protein 2+. Smear shows fragmented erythrocytes. Which of the following is the most appropriate management?

A 35-year-old woman underwent uncomplicated suction evacuation of a suspected molar pregnancy after a pre-procedure beta-hCG of 180000 mIU/mL. Histopathology confirms a complete hydatidiform mole. She is now well, with no bleeding, blood pressure 118/70 mm Hg and pulse 80 beats/min. Which of the following is the surveillance protocol advised after evacuation of a hydatidiform mole?

A 23-year-old woman with known immune thrombocytopenic purpura delivered vaginally at 39 weeks and is now bleeding heavily from the genital tract. The uterus is well contracted and no lacerations are seen. Platelet count is 18 × 10⁹/L, haemoglobin 105 g/L, with normal prothrombin time and fibrinogen. Which of the following is the most appropriate management?

A 30-year-old sexually active woman with regular 30-day cycles reports 5 days of bleeding between her periods. She uses no contraception. Blood pressure is 118/72 mm Hg and pulse 80 beats/min. Speculum examination shows a normal-looking cervix with blood coming from the external os. Which of the following is the most appropriate initial investigation?

A 37-year-old woman, gravida 3 para 1, at 28 weeks' gestation reports vaginal spotting 2 weeks ago and no fetal movement since. She has had no cramping and has passed no tissue. Fundal height measures 18 cm. Ultrasound shows no fetal cardiac activity and no fetal movement. Which of the following is the most likely diagnosis?

A 25-year-old woman at 9 weeks presents with vaginal spotting and passing vesicles. Uterine size is larger than dates, serum beta-hCG is 410 000 IU/L, and ultrasound shows a snowstorm appearance with no fetus. Blood pressure is 150/96 mm Hg and her blood group is O negative. Which of the following is the most appropriate management?

A 30-year-old woman with laparoscopically confirmed endometriosis has persistent dysmenorrhea and deep dyspareunia despite 3 months of regular naproxen. Pelvic examination shows tender uterosacral nodularity without an adnexal mass. She is not seeking pregnancy in the near term and has no contraindication to hormonal therapy. Which of the following is the most appropriate next step in management?

A 35-year-old woman at 8 weeks by dates has light brown vaginal spotting and mild cramps. She is afebrile, blood pressure 118/70 mm Hg, abdomen non-tender, and the cervical os is closed. Transvaginal ultrasound shows an intrauterine gestational sac measuring 5 weeks with a fetal pole and no cardiac activity. Which of the following is the most appropriate next step?

A 17-year-old primigravida attends for her first visit with a positive pregnancy test and a last menstrual period 9 weeks ago. She has no pain or bleeding, blood pressure 112/70 mm Hg, pulse 76 beats/min, and the cervical os is closed. Transvaginal ultrasound shows an intrauterine embryo with a crown-rump length of 24 mm and no cardiac activity. Which of the following is the most likely diagnosis?

A 35-year-old G3P2 with diet-controlled gestational diabetes attends at 38 weeks of gestation for planned induction of labor. She has no pain, bleeding or fluid loss. The uterus is soft, non-tender and corresponds to dates, and the cervix is closed and uneffaced. Cardiotocography shows a baseline of 135 beats/min, variability of 12 beats/min, present accelerations and no decelerations. Which of the following best describes this tracing?

A 30-year-old nulligravid woman underwent laparoscopic myomectomy for multiple symptomatic intramural fibroids. The operative note documents inadvertent entry into the endometrial cavity, which was closed in layers. She has no prior cesarean delivery or uterine curettage and now asks about future pregnancy. Which of the following best describes her risk of placenta accreta spectrum?

A 35-year-old woman with three previous cesarean sections is admitted at 37 weeks for elective repeat cesarean section. Antenatal ultrasound showed an anterior low-lying placenta with multiple lacunae and loss of the clear zone. At surgery the placenta is densely adherent to the uterine wall without invading the myometrium or bladder. Which of the following is the most likely diagnosis?

A 39-year-old woman at 37 weeks of gestation with known placenta previa totalis reports a small fresh vaginal bleed this morning that has stopped. She had two similar episodes at 30 and 34 weeks. Blood pressure is 118/70 mm Hg, pulse 88 beats/min, hemoglobin 108 g/L, and cardiotocography is reactive. Which of the following is the most appropriate timing of hospital admission?

A 27-year-old woman, gravida 4 para 2, at 37 weeks presents with painless vaginal bleeding soaking two pads in an hour. Blood pressure is 106/66 mm Hg, pulse 104 beats/min, the uterus is soft and non-tender, and the fetal tracing is reactive. Ultrasound shows the placenta covering the internal os. Which of the following is the most appropriate management?

A 36-year-old woman at 28 weeks of gestation attends for a routine scan. A single viable fetus is seen with an amniotic fluid index of 32 cm and a deepest vertical pocket of 11 cm. Fundal height measures 36 cm and she reports increasing abdominal tightness and breathlessness. Which of the following is the most likely cause of the amniotic fluid finding?

A 41-year-old woman has three months of bleeding after intercourse. Her cycles have become irregular over the past year and she has never attended cervical screening. Speculum examination shows a friable area on the anterior cervical lip that bleeds on contact. The uterus is normal-sized and mobile with no adnexal masses, and a urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A 28-year-old woman is 2 weeks postpartum after an uncomplicated vaginal delivery and is exclusively breastfeeding her infant. She wants to start contraception today. She has no vaginal bleeding, no fever, and no history of venous thromboembolism. Blood pressure is 118/74 mm Hg. Which of the following is the most appropriate contraceptive method for her now?

A 31-year-old woman with preeclampsia delivered vaginally 20 minutes ago and has ongoing bleeding of about 900 mL. The uterus is soft and boggy above the umbilicus. No lacerations or retained placental tissue are found, and blood pressure is 162/106 mm Hg. Which of the following is the most appropriate medical therapy?

A 37-year-old woman, gravida 4 para 3, delivers vaginally at 40 weeks. During placental delivery the uterus inverts, and she bleeds 1200 mL. Blood pressure is 84/50 mm Hg and pulse 128 beats/min. The genital tract shows no lacerations and coagulation studies are normal. Which of the following best explains her postpartum hemorrhage?

A 28-year-old woman with type 1 diabetes for 12 years, on insulin, has an HbA1c of 7.2% and no family history of inherited disease. She and her husband are unrelated. She asks how her diabetes will affect the pregnancy she is planning. Which of the following risks is the same for her as for the general population?

A 26-year-old woman had menarche at 15 years and now presents with no menstrual period for 9 months. She has never been pregnant and her urine pregnancy test is negative. She reports hot flushes and vaginal dryness, and has had no uterine surgery. Serum follicle-stimulating hormone is 58 IU/L, estradiol 40 pmol/L, prolactin normal, and thyroid-stimulating hormone normal. Which of the following is the most likely diagnosis?

A 15-year-old girl has crampy lower abdominal pain beginning a few hours before each period and lasting two days for the past year. Menarche was at 13 years and cycles are regular. She is not sexually active. Abdominal and pelvic examinations are normal. Which of the following is the most appropriate initial treatment?

A 23-year-old nulliparous woman has crampy pelvic pain starting the day before menses and lasting 2 days, severe enough to miss work each cycle. Symptoms began at menarche. Pelvic examination and transvaginal ultrasound are normal. She is sexually active and wants both reliable ongoing pain control and contraception. Which of the following is the most appropriate long-term treatment?

A 30-year-old woman delivered twins vaginally at term 2 hours ago. She now has heavy vaginal bleeding of about 900 mL. Blood pressure is 95/55 mm Hg and pulse 112 beats/min. The uterine fundus is soft and palpable above the umbilicus. The placenta was delivered intact and no lacerations are seen. Which of the following is the most likely cause of her bleeding?

A 26-year-old woman, gravida 1 para 0, at 40 weeks of gestation is admitted in spontaneous labour with painful contractions. The cervix is 3 cm dilated and 60% effaced with intact membranes. Fourteen hours later she is 5 cm dilated, the fetal heart tracing is category I, and she is afebrile. Beyond how many hours is her latent phase considered prolonged?

A 32-year-old primigravida at 36 weeks of gestation reports that fetal movements have been noticeably reduced for the past 24 hours. Blood pressure is 118/72 mm Hg, symphysis-fundal height is 34 cm, and the fetus is cephalic. She has no bleeding, contractions, or leaking fluid. Which of the following is the most appropriate initial investigation?

A 28-year-old woman at 20 weeks gestation reports painless vaginal spotting for one day with no trauma or intercourse. Her blood group is O negative and the antibody screen is negative. Ultrasound shows an appropriately grown fetus, a fundal placenta, and a 38 mm closed cervix. Which of the following is the most appropriate next step?

A 26-year-old woman presents with eight months of absent periods after previously regular cycles. She reports bilateral milky nipple discharge and reduced libido but no headache or visual disturbance. She takes no medication. A urine pregnancy test is negative, and pelvic examination and body mass index are normal. Which of the following is the most appropriate initial investigation?

A 19-year-old primigravida at 32 weeks is referred from the antenatal clinic with a blood pressure of 164/112 mm Hg on two readings 20 minutes apart. She has no headache or visual symptoms, urine dipstick shows 2+ protein, and the fetal heart rate is 145 beats/min. Which of the following is the most appropriate immediate next step in management?

A 27-year-old primigravida with homozygous sickle cell disease attends antenatal clinic at 16 weeks gestation. She takes folic acid, penicillin prophylaxis, and low-dose aspirin begun at 12 weeks, and had two vaso-occlusive crises last year. Hemoglobin is 82 g/L, blood pressure is 108/64 mm Hg, and urinalysis shows no protein. Apart from acute painful crisis, which complication is she most likely to develop?

A 54-year-old woman, para 4 with all vaginal deliveries, reports involuntary urine loss whenever she coughs, laughs or lifts her grandchild. She has no urgency, nocturia or dysuria. She has completed 6 months of supervised pelvic floor muscle training without improvement. The cough stress test is positive with urethral hypermobility and no prolapse beyond the hymen. Post-void residual volume is 25 mL. What is the most effective definitive treatment?

A 50-year-old woman, para 5, reports 2 years of urine leakage occurring only when she coughs, sneezes, or lifts her grandchildren. She denies urgency, frequency, nocturia, or dysuria. Urinalysis is negative and post-void residual volume is 20 mL. Which of the following is the most likely finding on her pelvic examination?

A 50-year-old woman, para 4, reports involuntary loss of urine while running and when she sneezes. She denies urgency, nocturia or dysuria. Urinalysis shows no leukocytes or nitrites, and post-void residual volume is 25 mL. Which of the following is the most appropriate next clinical evaluation to confirm the diagnosis?

A 27-year-old primigravida has 900 mL of postpartum bleeding after vaginal delivery. The uterus stays atonic despite oxytocin, misoprostol, carboprost and bimanual compression, and she is taken to theatre. She strongly wishes to preserve fertility. Blood pressure is 92/56 mm Hg with pulse 118 beats/min. Which structure is most appropriate to ligate to control the bleeding?

A 19-year-old primigravida presents with lower abdominal cramping and light vaginal bleeding. Her last menstrual period was 6 weeks ago and the pregnancy test is positive. Blood pressure is 112/70 mm Hg, pulse 92 beats/min, temperature 36.9 °C. Pelvic examination shows a closed cervical os with marked pain on moving the cervix and right adnexal tenderness. Which of the following is the most appropriate next step?

A 23-year-old woman at 38 weeks of gestation is in active labor when spontaneous rupture of membranes occurs. On examination the cervix is 6 cm dilated, the presenting part is high, and a pulsating umbilical cord is felt in the vagina below the presenting part. Which of the following cardiotocographic findings is most expected in this situation?

A 40-year-old woman, gravida 4 para 2, at 41 weeks is 6 hours into induction with vaginal prostaglandin. She develops sudden severe abdominal pain, contractions cease, and heavy vaginal bleeding occurs. Blood pressure is 78/40 mm Hg, pulse 132 beats/min, the presenting part has receded, and fetal heart tones are absent. Which of the following is the most likely diagnosis?