The question I receive a lot is, “What do I need to do in the days before my ABOG exam?”
If you are reading this, trust me you are not alone. Everyone feels overwhelmed before the ABOG exam. In fact, as physicians we tend to overcompensate. We try to glean so much information on a specific topic that suddenly we have 14 references. In the days before the exam it can be overwhelming and frustrating. So what do you do now?
The most important thing to do is to practice speaking. You must know how to articulate and you must practice. How do you do this? I can guide you.<<<Link to mentoring packages>>>
The exam is composed of 3 sections Gynecology, Obstetrics, and Office. In each section there is a case-of-the-day format and a caselist questionnaire.
So what exactly do you need to practice?
You need to practice both types of questioning as they are very different. Let me explain.
It is important to conquer the case-of-the-day format. Why? Because it’s truly the first impression the examiners will get of you! You need to organize your thoughts and clearly state management plans clearly, calmly, and in a succinct manner.
In the case-of-the-day format you are asked questions from a computer generated case. The questions are topic or case based and will allow the examiner to gauge your understanding of that topic. For example, let me make up a case scenario. Let’s take Obstetrics; it’s my favorite section :).
The examiner will start a powerpoint and start reading.
You have a 39 year old Gravida 4 Para 3 at 39 weeks gestation that presents to labor and delivery with painful uterine contractions. She is found to be 6 cm dilated. Her past medical history is significant for gestational diabetes on insulin. Her vital signs show a BP of 150/110. The fetal heart rate monitor shows:
- What is your interpretation of this tracing?
- What is your differential diagnosis?
- What additional testing does she require?
- What is your management of this patient?
Now before you start getting sweaty palms, let’s break down the case so you can understand it better.
First what is important?
Well she’s in active labor (mind you definitions have changed see references below “Preventing the First Cesarean Delivery”), so she needs admitted. Second she’s a gestational diabetic on Insulin-Ok you have got to think here why is this important???? Gestational diabetes is a major risk factor for macrosomia or labor dystocia. In addition its a major risk for the neonate as if the patient does not have adequate glucose control sequelae of hypoglycemia can be profound in the infant. So its important that you mention to perform an acucheck if needed start an insulin drip and review weight by US of baby or leopolds, remember weight greater 4500g is a consideration for cesarean to avoid shoulder dystocia. Third, why is her BP elevated? It could be she is in pain but gestational diabetics and AMA (age over 35) can have risks for preeclampsia so getting a baseline protein, protein creatine ratio and HELLP labs is important. You’ll also have to remember that a single blood pressure does not mean she has preeclampsia so I would closely monitor her. Fourth, the tracing above shows deep variable decelerations. You must understand the pathophysiology behind this could be cord compression. In this case it is appropriate to perform intrauterine resuscitation. This would entail amniotomy, IUPC, amnioinfusion, IVF bolus and repositioning. You also have to know that this is a Category 2 tracing (New fetal monitoring was instituted in Practice Bulletin ).
After you answer this the next slide comes up and states laboratory analysis
Amniotomy performed clear fluid and Amnioinfusion started. Patient is now 8cm/100% effaced/0 station , BP 180/110. Review of history appropriate fundal height last US at 38 weeks infant 4100g. Bp in clinic at 38 weeks 6 days 140/90
Glucose 120, Protein random trace, AST 78, ALT 88, Creatine 1.5, Platelets of 50,000. Tracing is as follows
- What is your diagnosis
- What additional interventions if any does this patient need
Lets re-analyze the data. First, she’s definitely in labor, so if you have not admitted her do that. But wait can she get an epidural—no, why not? The platelets are 50,000. What would happen if she had one a spinal/ epidural hematoma? Also, it looks like she has severe preeclampsia. And wait, theres no protein!!! Right, there was a new consensus statement in November 2013 that redefined hypertension in pregnancy. Lets go over this in detail.
First, we have 2 blood pressures that are elevated one at 38 weeks 6 days and again x 2 on L&D. The consensus statement in November 2013 shows that severe preeclampsia does not necessarily need elevated protein if HELLP features are present. So immediately we need to place her on magnesium sulfate load her with a 4 gram bolus then titrate to 2g/hr. You might need to be careful though as she has HELLP syndrome and renal insufficiency so careful dosing and magnesium levels would be needed. Second we need to control her BP. What are two drugs used labetalol and hydralazine.
We also need to know how to dose them and their mechanism of action. I usually start with labetalol but I base my decision on the MAP (mean arterial pressures). The tracing shows a Category 1 tracing so you can proceed with a vaginal delivery Her Diagnosis is Severe Preeclampsia and Gestational DM. Interventions Delivery vaginal is preferred. Additional interventions I would get blood products on hand type and cross and platelets. I also would repeat HELLP labs.
Next slide: The patient is started on Magnesium sulfate and given 20 mg IV labetalol. Her BP still are 170/100.
What is your management of this patient?
You should understand that labetalol dosing is 20mg if unsuccessful then 40 mg then 80mg for maximum of 240mg. Hydralazine can then be started.
Next slide: Labetalol 40mg IV is given and BP 150/100 Patient has an uncomplicated vaginal delivery of term infant. Postpartum she notes difficulty breathing.
- What is your differential diagnosis?
- What would you perform on a physical exam?
- What is your management?
At this point you may be thinking, “Wow, thats a lot of information in this case.” Yes, but stay focused.
What is important? She has severe preeclampsia with renal insufficiency. First, she may have magnesium toxicity. I would check her 02 saturation, then place her on additional O2, check DTRs, HELLP labs and magnesium levels and consider a CXR AP and lateral. If she has a low O2 sat get an ABG. Why my differential (note you should include at least 5 possible diagnosis when they ask for a differential). Mine would be
- Magnesium toxicity ( why Cr 1.5 and you gave a Magnesium sulfate bolus)
- Pulmonary edema (why severe preeclampsia can cause this especially if IVF bolus was given during intrauterine resuscitation)
- Pulmonary embolus
- Severe anemia
The next slide shows laboratory data
The patient’s laboratory analysis shows Magnesium level 16. CXR normal. HELLP labs are unchanged. Glucose 45.
What is your diagnosis?
How would you manage the patient?
Diagnosis: Magnesium toxicity and hypoglycemia. But wait, with low glucose she could have acute fatty liver of pregnancy but usually in this scenario the transamninases would be very high. To treat her stop magnesium, give 1 amp calcium gluconate. Place patient on D5LR. Observe closely. If eclampsia develops, patient would need Ativan and possible Dilantin dosing.
As you can see there was a lot of material needed to be answered in this case. A candidate can lose valuable points if they do not have a broad differential and also treat and manage appropriately.
As far as caselist questions…. I’ll reserve this for a later post, but what is most important is to know how ACOG defines the standard of care.
- How did you consent a patient for bilateral salpingoophorectomy. There are some instances where this is appropriate those done childbearing with, endometriosis, BRCA1/2 gene mutation >35 years of age, uterine/ ovarian malignancy, adnexal mass, postmenopausal >65 years.
- How would you educate on hormone replacement therapy
- What are risks of bilateral salpingoophorectomy.
Thank you for reading my blog… As you can see from the examples above it is paramount to be updated on current standards. It is also important to practice speaking and articulate thoughts in a clear concise manner. Lastly, do not to get nervous. You are intelligent and have come far— after all you passed 4 years medical school 4 years residency and have been seeing hundreds of patients in the last few years!
Want more examples like these to try on your own? Try a virtual mock.
Think you need a live mock or a mentor?
Stay tuned as the next blogpost will focus on possible reason for candidates not passing the exam.