So I had obgyn final on the 18th and psych final on the 19th.
Obstetrics and gynaecology final
We got an e-mail the day before that the exam would start at 9. The examiner was Péter Gőcze. We drew four topics, two from ob and two from gyn, and sat down to prepare. I drew good topics, in my opinion. These are the questions I was asked.
10. Placenta praevia
I began by telling him everything I’d written down. He then begins asking questions.
- Examiner: When a patient arrives outpatient clinic with a bleeding in the second half of pregnancy, not a heavy bleeding, and you perform ultrasound and diagnose placenta praevia centralis. The patient is around 30 weeks of gestation. What can you do?
- Me: 🤷♂️ (What can you do? There isn’t really anything we can do to treat placenta praevia, right?)
- M: I think we would just call the patient back later to see if it resolves spontaneously, but if it doesn’t, we should plan an elective C-section.
- E: But the bleeding is not severe (I feel like I didn’t really understand what I said here). What can we do?
- M: I stop and think for a moment because I have no idea. I go with a far-fetched idea.
- M: Maybe we could give tranexamic acid to decrease the bleeding?
- E: No, no. Something else. Sometimes contractions can cause bleeding. (What?)
- M: Then maybe we can give something to decrease contractions, like atosiban?
- E: That’s right. Let’s say the woman is 29 weeks of gestation, what can you give to prevent the very common problem of premature newborns?
- M: Steroids to induce lung maturation.
- E: That’s right. And also, you have to store blood in the institute which is compatible with the mother, because if the patient has heavy bleeding you have to perform an urgent operation, and may need transfusion. It’s very important to have blood available.
- (It makes sense, I just thought that that was something which was always available, not that you’d have to proactively find and store it)
- E: What do you think, what is the relatively common problem if the patient has a heavy bleeding?
- M: So if the bleeding is severe enough it can compromise the circulation of the foetus as well, causing perinatal asphyxia.
- E: Yeah, and?
- M: It can also cause DIC in the mother.
- E: That’s right. What can you do in case of the DIC?
- M: It’s important to replace the clotting factors which are lost.
- E: How can you do that?
- M: It’s also a transfusion (I forgot exactly which blood product we use)
- E: Yeah but which?
- M: (I say the first that comes to mind) Prothrombin complex?
- E: No.
- M: Fresh frozen plasma?
- E: Yes. Previously a lot of women died because of this. The problem is that we don’t know which phase DIC is in, and this is why the best way is to use fresh frozen plasma because it contains all types of factors. And blood. Fresh frozen plasma and blood, this is the best method to treat DIC.
- E: Okay. What is your next topic?
20. Cervical incompetence; Etiology, diagnosis, therapy
Once again I begin by telling him what I’d written down.
- E: What is very important to do before performing cerclage? What must we always do?
- M: Once again I have no idea
- M: We should supplement progesterone? Said in a tone of absolute doubt
- E: No.
- M: Thinking
- E: If we don’t do it, we can get premature rupture of the membranes
- M: So we have to rule out infection?
- E: That’s right. It’s obligatory to make a culture. Only if the culture is sterile can we do a cervical cerclage.
- E: What kind of other procedure can you do to treat cervical incompetence before pregnancy?
- M: I’m pretty sure I’ve never heard of any such procedure. The only other thing I’ve read about which can treat cervical incompetence is progesterone supplement, so..
- M: You can give progesterone supplement?
- E: No, not that. There’s a surgical procedure which you can do.
- He turns toward the other students in the room and asks them whether they’ve heard about it. No one responds. Eventually he gets up, walks toward a whiteboard in the room, and starts drawing and explaining.
- E: So you cut out a piece of the anterior wall of the cervix, then you suture it. This forms a scar. It’s usually the anterior part of the cervix which is weak, and this strengthens it. It’s very effective but you can only do it before the pregnancy. During the pregnancy, the only option is cerclage, like you mentioned.
- E: Okay. What is your next question?
3. Indications and methods of hysterectomy
Once again I begin by telling him what I’d written down (except the part about trachelectomy).
- E: Do we always have to remove the cervix, or not?
- M: Uhm…
- E: Consider a young woman. You should know that after a total hysterectomy the vaginal prolapse can happen because of damage to the ligaments holding the vagina. And this is why we in young women often use the Chrobak operation. Have you heard about it?
- M: No I have not.
- Once again he asks the other students. No one responds.
- E: Yeah, it’s when the cervix remains in place and we just remove the body of the uterus. It can be useful because the sexual function of the woman remains normal and prolapse of the vagina can be prevented.
- Okay, so it’s just subtotal hysterectomy. Thanks for not just saying that.
- E: Okay. Next question.
13. The criteria and potential complications of IUD
I kept this for last because I didn’t actually know that many criteria and complications. I told him what I’d written down.
- E: Do you know the name of the IUD which contains progestins?
- M: Well I know the name of those used in Norway, but I don’t know if they have the same name in Hungary. Mirena and Kyleena?
- E: That’s right. What’s the indication of the Mirena? Why is it so popular? We can use not just for contraception, after all.
- M: For endometriosis as well.
- E: Yes, very good. And?
- Here I kind of blank out. I knew of other indications for hormonal IUD but I just couldn’t recall any
- E: Endometrial hyperplasia, for example. During menopause, as the progestin component. And dysmenorrhoea.
- M: Yeah, of course.
- E: Okay. I think it was good, but not excellent.
So that was it. I got a 4 in the end. The exam took like 20 minutes.
I don’t think he mentioned the name of the pre-pregnancy operation for cervical incompetence, and I’ve searched for it but found nothing. We never had a lecture or seminar on cervical incompetence, so how would I know about this?
Regarding the “Chrobak operation”, from what I can find it looks like this term is almost never used (subtotal hysterectomy instead). Also, we never had a lecture or seminar on this topic either.
Regarding screening patients for infection before cerclage, this appears to be controversial, and UpToDate states that there is insufficient evidence to support that preprocedure culture improves outcomes.
So I’ve spent a lot of time and resources writing notes for this. I’ve used many sources, including lectures, UpToDate, and the Norwegian guidelines for obstetrics and gynaecology. When I spend so much time and effort studying something, and end up not being able to answer questions on the exam because certain things were never taught to us, is basically unfindable in other sources, or not evidence-based, it makes me disappointed and annoyed. But anyway, I’m glad I’m done.
We got the email from Tényi the day before the exam that we would start at 7:00. We show up, both 6th year students and 5th year students from all three programmes. Luckily, he deliberately allowed the 6th year students to have the exam first.
There’s not to much to say about the exam. During the practice you write two patient case reports. In the exam he asked me what the two diagnoses were (schizophrenia and anorexia nervosa), and he asked me to explain a bit about the anorexia case, which I did. I realise in hindsight that I spoke mostly about my impressions around the case rather than stuff directly related to psychiatry, but it was fine. He then started asking the usual rapid-fire questions, beginning with questions related to anorexia and eating disorders, before turning to other questions.
I answered all questions correctly, except that I forgot narcissistic personality disorder when listing the cluster B ones, but it was fine. I got a 5 in the end, and the exam took like maybe 5 – 10 minutes? It was a nice experience.
I begin my paediatrics practice in Pécs on Monday, which will be my only practice in Pécs (except for 1 week of internal medicince, as I could only do 7 weeks in Norway). Paeds is my next exam, but luckily that’s some weeks away still, so I can take it easier for a while.