Question: According to NYHA grading, Patients with marked limitation to physical activity belongs to

New York Hea Association Functional Classification of Cardiac diseaseGrade I: Patients have no limitation of physical activityGrade II: Patients have slight limitation of physical activityGrade III: Patients have marked limitation of physical activityGrade IV: Patients have an inability to carry on the physical activity without symptomsReference: Practical Guide to High-Risk Pregnancy and Delivery; Chapter 20; Cardiac Disease and Pregnancy

Medical, surgical and gynaecological illness complicating pregnancy


Question: Coaptation is

Submucosal vascular network aids in Urethral mucosal approximation called as coaptation, which improves continence.

Adaptation of bladder to large volumes of filtrate.

Constriction of ureters in response to low volumes of urine.


Question: Contraindication of induction of labour among the following is

Methods to induce or augment labor are contraindicated by most conditions that preclude spontaneous labor or delivery. The few maternal contraindications are related toPrior uterine incisionType contracted or distoed pelvic anatomy,Abnormally implanted placentas, and Uncommon conditions such as active genital herpes infection or cervical cancer. Fetal factors include Appreciable macrosomiaSevere hydrocephalusMalpresentationNonreassuring fetal statusRef: Willaim&;s Obstetrics; 25th edition


Question: Germ cells appear in yolk sac at

By 11th to 12th-day cells appear between the inner surface of the cytotrophoblast and the outer surface of the yolk sac.
These cells lie loosely and are called extraembryonic mesoderm. A cavity formed within it called the extraembryonic coelom or chorionic cavity.
This covers both the yolk sac and amniotic cavity except where the embryoblast is connected to trophoblast through the connecting stalk


Question: Oral hypoglycemic safely given in pregnancy is

Oral hypoglycemic drugs have found to be effective and safe. Commonly used drugs are Glibenclamide and metformin. Both the drugs cross the placenta However, No teratogenic effect has been observed yet. Glibenclamide appears to be superior when compared to metformine. Reference: DC.Duttas textbook of OBG,9th edition,page 267

Medical, surgical and gynaecological illness complicating pregnancy


Question: Best investigation endometriosis is

Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera.
The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen


Question: Most common abnormality in first trimester abortion

A. i.e. (Defective genes) (161 - Dutta)* Genetic factor (50%) of early miscarriage are due to chromosomal abnormality in the conceptus. Autosomal trisomy is the commonest (50%) cytogenic abnormality in FIRST TRIMESTER*** Cervical incompetence (congenital or acquired) is the most common abnormality in SECOND TRIMESTER*** The cause of fetal death in ectopic pregnancy is postulated as vascular accident*** Most valuable diagnostic test in a case of suspected ectopic pregnancy is - Transvaginal USG**


Question: Test used to differentiate maternal from fetal blood

The Apt test is most commonly used in cases of vaginal bleeding late during pregnancy (antepaum haemorrhage) to determine if the bleeding is from the mother or the fetus.


Question: Daily Iodine requirement during pregnancy is

Recommendation of the daily requirement of iodine during pregnancy is 220mcg and during lactation is 290mcg.(Ref: William's Obstetrics; 25th edition)


Question: Leiomyomatosis is

Extra-uterine smooth - muscle tumors, Which are benign yet infiltrative, may develop in women with concurrent or prior uterine leiomyoma ⇒ Leiomyomatosis.


Question: Ambiguous genitalia in males is due to

5 - α Reductase deficiency causes ambiguous genitalia in males. Rest all options cause ambigous genitalia in females.


Question: Condition not responsive to medical therapy

Ans. is'c' i.e., Hydatidiform moleIt is an abnormal condition o[ the placenta where there are paly degenerative and paly proliferative changes in the young chorionic villi.It is best regarded benign neoplasia of the chorion with rnalignant potential.Management: Suction evacuation

Persistent gestational trophoblastic disease


Question: Caudal regression syndrome is seen in babies of the mother having

The caudal regression sequence is a rare malformation frequently associated with maternal diabetes.Ref: William&;s Obstetrics; 24th edition; Chapter 57; Diabetes Mellitus

Medical, surgical and gynaecological illness complicating pregnancy


Question: The most sensitive method for detecting cervical chlamydia trachomatis infection is


Question: Emergency presentation of imperforate hymen is

Imperforate hymen present with Amenorrhea with secondary sexual characters Cyclical abdominal discomfo Retention of urine Palpation of midline hypogastric lump Ref: Shaw Gynecology 17 e pg 67.


Question: After delivery of Hea disease patient the following should be given

Inj. furosemide is given to decrease preload in hea disease patient post delivery. Labour Management of Cardiac Patient Limit I.V. fluids Position - semi recumbent Pain relief - opioids and epidural analgesia avoid straining in 2nd stage of labour- Cut sho it by forceps/vaccum Inj. furosemide and I.V./ I.M. Oxytocin given to decrease preload methyl ergometrine is C/I Observation in high risk ward for 24 hrs.


Question: Ideal contraceptive for lactating mothers is aEUR'

Lactational amenorrhoea An almost similar question was asked previously in 'All India' examination. Note that previously 'Most effective' contraceptive was asked. Now the question is different -Ideal' contraceptive is asked. Practically, there are no ideal contraceptives (neither for lactating women, nor for non-lactating women). An Ideal contraceptive is one which is - 100% effective, 100% safe, reversible with no side effects, and minimal effect on lactation. The Barrier methods and Combined OCPs can be easily ruled out; as barrier methods have high failure rates if used alone, while combined OCPs have a negative effect on breast milk production. Lactational amenorrhoea is the most ideal contraceptive for a lactating women, as it has viually no side effects, rather it has plethora of benefits for both mother and child. About effectiveness, it is almost equally effective to Progesterone only pills (POPs) when used perfectly. (see the below table) Failure rates: Contraceptive method Typical use Perfect use LAM (6 months only) 2.0 0.5 IUD 0.8 0.6 POP 'mini pill' 8.0 0.5 Combined oral contraceptive 6-8 0.1 Barrier method 14 3.0 Lactational amenorrhoea (LAM) is a natural, safe and effective contraceptive method which can be used upto 6 months post paum if the following conditions are met. (Note that LAM is not pure simple exclusive breast feeding; following conditions need to be fulfilled) I. The mother should not experience vaginal bleeding after the 8 weeks postpaum. The baby is less than 6 months old. The baby is exclusively breastfed. Breast feeding is done at least every 4 hrs. during the day and every 6 hrs during night. If the above conditions are fulfilled then LAM can give more than 98% protection from pregnancy. It has the added benefit of promoting exclusive breast feeding which is the ideal nutrition for infants. Lactational Amenorrhoea Advantages Disadvantages * Very effective if used perfectly * Can be used only for a sho period * Has no side effects (6 months post paum) * Promotes exclusive breast feeding, and therefore enhances maternal and infant health. * Does not require inseion of any device at the time of sexual intercourse * Can be initiated immediately postpaum * Is economical and requires no commodities or supplies * Reduces mother's lifetime risk of breast cancer. Physiology of LAM: Infant's suckling is the stimulus that initiates the state of lactational amenorrhea for breastfeeding women. The act of suckling elevates prolactin levels, and reduces GnRH from the hypothalamus. This reduces LH release thus inhibiting .follicular maturation. This prevents ovulation. But, even with continued nursing, ovulation eventually returns after 6 months, so another method of contraception should be used 6 months postpaum, or sooner if the menses resume. Ovalation has been seen to resume even earlier in some patients, so some books advice 'Rule of 3' i.e. - another contraceptive method should be use along with LAM beginning from the 3rd postpaum month. - and if the women is paially breastfeeding or not breastfeeding, the contraceptive should begin by the 3rd postpaum week. Progesterone only pills are the most effective contraceptive during lactation amongst the options provided. They have drawbacks like: - Have to be taken regularly at the same time - Cause spotting or irregular bleeding, ectopic pregnancy, headache, nausea, acne, hirsuitism and weight gain


Question: 37 weeks primi with uterine contraction for 10 hours, cervix is 1 cms dilated and poorly effaced. Management is

The patient is presenting at 37 weeks with mild labor pains for 10 hours. Cervix is 1 cms dilated and is not effaced. Now this can either be a case of false labor pains or it can be prolonged latent phase of labor.
Lack of progress during the latent phase is defined as lack of change or minimal change in cervical effacement and dilatation during a 2 hour period in a woman having regular uterine contractions.
The patient in the question has been having mild labor pains for 10 hours with no change in cervical dilatation and effacement. But again the question does not specify whether she is having regular uterine contractions or not.

False labor can be differentiated from latent phase of labor by therapetuic rest i.e., patient is sedated with morphine.


Question: The following complication is seen in

Couvelaire Uterus: Seen in cases of placental abruption. At the time of cesarean delivery, it is not uncommon to find widespread extravasation of blood into the uterine musculature and beneath the serosa. It is named after Couvelaire, who in the early 1900s termed it uteroplacental apoplexy. Effusions of blood are also seen beneath the tubal serosa, between the leaves of the broad ligaments, in the substance of the ovaries, and free in the peritoneal cavity. These myometrial hemorrhages seldom cause uterine atony, and alone they are not an indication for hysterectomy(Ref: William's Obstetrics; 25th edition)


Question: Gas most commonly used in laparoscopy is

Ans. is a i.e. CO2 CO2 is the gas used to create pneumoperitoneum during laparoscopy. Other option is N20. But it is expensive, less soluble in blood and suppos combustion. Also know : Instrument used for creating pneumoperitoneum is veress needle. Flow Rate of CO2 for creating pneumoperitoneum 200 -- 2000 ml/min and pressure between 15 -- 25 mm of Hg.


Question: Infertility in women with endometriosis is most likely due to

Adhesions causing tubal obstruction and thereby impairing oocyte - pickup is responsible to cause infertility in women with endometriosis.


Question: The risk of endometrial cancer is highest with the following histological pattern of endometrial hyperplasia

Ans. is d i.e. Complex hyperplasia with atypia Friends, let's first try to figure out this question on the basis of our basic knowledge of neoplasia. We all have read time and again that in 'Neoplasia' atypical cells are present, therefore obviously out of the given options, either option "b"or -d"is correct and since neoplasia is most likely to occur in complex situations therefore out of the given options even if I don't know anything about Endometrial hyperplasia I would have gone for option "d". Let's now have a look at Endometrial hyperplasia. Endometrial Hyperplasia It represents a spectrum of morphological and biological alteration of endometrium (both glandsdeg +Stromadeg), ranging from an exaggerated physiological state to carcinoma in situ. They are clinically impoant because : They cause abnormal bleeding.deg Either preceede or occur simultaneously with Endometrial carcinoma. Endometrial Hyperplasia can be : If atypical cells are present in either of the two types - chances of malignancy increase. Simple atypical hyperplasia is a relatively uncommon diagnosis. In general, most atypical hyperplasias have a complex architecture. Characteristics of Atypical cells :deg You must have already learnt in pathology, but I will brief it up here for convenience : Large in sizedeg Loss of polaritydeg Irregular shapedeg Hyperchromatic nucleusdeg and prominent nucleolideg Altered nucleus/cytoplasmic ratio.deg Chances of Progression to Carcinoma : Type of hyperplasia Simple without atypia Complex without atypia Simple with atypia Complex with atypia Thus, minimum chances of progression to carcinoma are with simple-hyperplasia without atypia and maximum chances of carcinoma are with complex hyperplasia with atypia.deg


Question: Fecundability is

Fecundability is probability to achive pregnancy within one menstrual cycle.

Probability to achieve a live birth within one menstrual cycle

Probability to achive pregnancy within one menstrual cycle

Probability to achive a twin pregnancy within one menstrual cycle

Probability to achive a live birth within one year of treatment for infertility


Question: Serum testosterone levels exceeding 200ng /dL is suggestive of

Very high testosterone levels are suggestive of ovarian or adrenal androgen-producing tumor.


Question: CPD is best assessed by

Methods of assesment of Pelvis

Clinically
Imaging studies

Clinical Pelvimetry :

Done manually
Can be done beyond 37th week, better done after onset of labour
Following are to be observed

Sacrum
Sacrosciatic notch
Iscial spines
Side walls
Pubic arch
Pubic angle
Transverse diameter of outlet

Imaging :

X-ray pelvimetry
USG
CT
MRI

X-ray pelvimetry :

Limited value in diagnosis
Can only assess size and shape of pelvis
Useful in cases with pelvic fractures
Disadvantage : Radiation exposure to both mother and foetus (885 milirad)
Erect lateral view

CT

Easier to perform
Radiation exposure(45-425milirad)
More accurate

MRI

More accurate to assess bony pelvis
Assess pelvic capacity in different planes
Assess foetal size and head volume, pelvic soft tissues
No radiation risk
Expensive,limited availability, more time taking

USG :

Accurately measures the biparietal diameter


Question: Most specific marker for neural tube defects is

Both alpha-fetoprotein and acetylcholinesterase in amniotic fluid are markers for neural tube defects. But acetylcholinesterase is the most specific marker. Ref : Dutta book of obstetrics 8th Ed


Question: Gonads do not acquire male or female characteristics until

Gonads acquire male or female characteristics only after 6 weeks of development (that is in the 7th week)


Question: EMACO regimen of chemotherapy is used in the treatment of

EMA-CO a cyclic non, cross-resistant combination of etoposide, methotrexate, and actinomycin D alternating with cyclophosphamide and vincristine.Etoposide induces complete remission in 95% of patients with nonmetastatic and low-risk metastatic GTN. The use of EMA-CO induced an 83% remission rate in patients with metastasis and a high-risk score.Ref: Berek and Novak&;s Gynecology; 15th edition; Chapter 39 Gestational Trophoblastic Disease


Question: Formula used for estimation of the total iron requirement is

(4.4 x body weight (kg) x Hb deficit (g/dl) (269-Dutta 6th) (549-KDT)Estimation of the total requirement* 0.3 x W (100-Hb%) mg of elemental iron, where W= patients weight in pounds, Hb% = observed haemoglobin concentration in percentage. Additional 50% as to be added for partial replenishment of the body store iron.Examples - The total requirement of iron in anaemic patients weighing 100 lb with haemoglobin 50% is calculated as follows 0.3 x 100 (100-50) = 3/10 x 100 x 50 = 1500. Add 50% = 750 mg. Total iron requirement = 2250 mg.Iron requirement (mg) = 4.4 x body weight (kg) X Hb deficit (g/dl)

3.3 x body weight (kg) x Hb deficit (g/dl)


Question: 46, XY chromosomal pattern with uterus and cervix but poorly developed breasts are seen in

Complete Gonadal Dysgenesis (Swyer Syndrome)Swyer syndrome is an uncommon form of gonadal dysgenesis, characterized by a 46, XY karyotype.Despite the presence of a Y chromosome, the phenotype is female because the dysgenetic (streak) gonads produce neither AMH nor androgens. Consequently, the vagina, cervix, uterus, and fallopian tubes develop normally and the internal and external genitalia do not masculinize but due to hypoestrogenism breasts are poorly developed.Reference: Clinical gynecologic endocrinology; 10th edition; Chapter 9; Normal and Abnormal Sexual Development; Page no: 365


Question: Intrauterine Infections most commonly associated with Neural tube defects is

Toxoplasmosis and rubella are most commonly associated with Neural tube defects Toxoplasmosis in fetus occurs mostly if the infection is in the later pa of the pregnancy and is associated with Neurologic abnormalities, hydrocephalous, cerebral calcification, chorioretinal scars with or with out severe visual impairment. Rubella is one of the most complete teratogens, and sequelae of fetal infection are worst during organogenesis


Question: A 52 years postmenopausal female presents unilocular with a ovarian cyst of 6 cms with normal CA 125 levels management is;

A simple unilocular ovarian cyst less than 5 cm can be observed with repeat ultrasound and CA-125 every 3 months.Many resolve in 6 months.A persistant cyst calls for its removal laparoscopically or by laparotomy.Aspiration of the cyst is contraindicated because of low yield of malignant cells and possibility of spread of malignancy if the cyst proves malignant histologically.Many perform bilateral oophorectomy and hysterectomy SHAW&;S TEXTBOOK OF GYNECOLOGY,Pg no:388,15th edition


Question: Cervix to uterine body ratio in a prepubeal girl

The pubeal uterus has the adult pear configuration (fundus larger than cervix) (fundus-to-cervix ratio  2/1 to 3/1) (4-8) (Fig 3) and is 5-8cm long, 3 cm wide, and 1.5 cm thick. The endometrial lining is seen and varies with the phases of the menstrual cycle. Overfilling of the bladder can modify the uterine shape


Question: Fetal sex can be detected by USG at

Male development is completed by 12 weeks and female development by 15 weeks
By 28 weeks,the testis descends to the internal inguinal ring.By 36 weeks, one testis and by 38-40 weeks both testes descend into scrotum
In female, the genital tubercle becones clitoris, the genital folds become the labia minora and the genital swellings became the labia majora


Question: During pregnancy, GFR

GFR increases by 50% as filtering capacity of kidney increases due to - a) Decrease oncotic pressure due to hemodilution b) Increased renal blood flow by 80% in 2nd trimester and 50% in 3rd trimester.


Question: Pelvic outlet is said to be contracted if

8cm is threshold to define pelvic outlet contraction.

Interischial tuberous diameter is < 7 cm

Interischial tuberous diameter is < 8 cm

Interischial tuberous diameter is < 9 cm

Interischial tuberous diameter is < 10 cm


Question: Termination of pregnancy in placenta previa is indicated in a) Active bleedingb) Active labourc) Gestational age > 34 weeks with live fetusd) Fetal malformatione) Unstable lie


Question: Ligamentum teres is formed after

Umbilical vein closure occurs shortly after closure of umbilical arteries and forms the ligamentum teres.


Question: Endometrial cancer involving 50% of endometrium, extending to vagina, lymph nodes negative with positive peritoneal cytology is staged as

3b FIGO STAGING OF ENDOMETRIAL CANCER STAGE I Cancer confined to corpus uteri IA --> Limited to endometrium IB --> < 1/2 myometrial thickness IC > 1/2 myometrial thickness STAGE II Tumour involves cervix but does not extend beyond uterus (la --> Cervical glandular involvement llb --> Cervical stromal involvement STAGE III Local and/or regional spread Ilia --> Uterine serosa, positive peritoneal washings Adnexal involvement Ilib -4 Vaginal involvement (lymph node absent) 111c --> Positive lymph node no pelvis and paraaoic lymph node STAGE IV Tumour widespread IVa - Bladder or bowel mucosa IVb --> Distant metastasis


Question: Periconceptional use of the following agent leads to reduced incidence of neural tube defects

Women should begin taking folic acid supplements before becoming pregnant and continue taking the supplements of at least 0.4 mg/day throughout the first trimester to reduce the risk of neural tube defects. It has been shown to reduce the occurrence and recurrence of neural tube defects . For low-risk women, folic acid supplementation of 400 micrograms per day currently is recommended For women at high risk of NTDs or who have had a previous pregnancy with an NTD, folic acid supplementation of 4 mg per day is recommended.

Intra Uterine Growth Restriction, Intrapaum and Antepaum Fetal Surviellance


Question: Hidradenoma of vulva occurs arises from

Ans. is 'a' i.e., Apocrine glandsHidradenoma - arises from the apocrine glands ofvulva.It rarely exceeds 1 cm sizeHistologically it shows cystic spaces enclosing a papillary adenomatous massIt may undergo malignant change and thus requires excision.


Question: Karyotype of Paial mole

Paial moles have a triploid karyotype (69 chromosomes); the extra haploid set of chromosomes usually is derived from the father.When a fetus is present in conjunction with a paial mole, it generally exhibitsthe stigmata of triploidy, including growth retardation and multiple congenital malformations such as syndactyly and hydrocephaly.Ref: Berek and Novak&;s Gynecology; 15th edition; Chapter 39


Question: The major contribution of the amniotic fluid after 20 weeks of gestation

Amniotic fluid: - * pH = 7.1 -7.3 * Specific gravity= 1.008-1.010 * Osmolality = 250 mOsm/L * Rate of amniotic fluid turnover is 500cc/hr * Completely changed and replaced in every 3 hours * Main source- fetal urine (overall) * Main source after 20 weeks- fetal urine Ref:- Mudaliar and Menon's 12th Edition; Pg num:- 28.


Question: The relation of fetal axis with uterine axis is known as

Ans. b (Lie). (Ref. Dutta, Obstetrics 4th ed.78, William's Obst 21st ed.- 291)TermDefinitionLieRelationship of the long axis of the fetus to the long axis of centralized uterus or maternal spine. The commonest being longitudinal.PresentationPart of fetus which occupies lower pole of uterus.Presenting partPart of presentation which overlies internal os.AttitudeRelationship of different parts of fetus to one another.DenominatorArbitrary bony fixed point on the presenting part which comes in relation with various quadrants of maternal pelvis.PositionRelation of denominator to different quadrants of pelvis.


Question: Most common endocrine disorder of reproductive aged women is

PCOD is most common endocrine disorder in reproductive age woman.


Question: The commonest cause of primary Amenorrhoea is

Ans. is b i.e. Ovarian dysgenesis Primary amenorrhea is a condition when a female has not attained menarche by the age of 14deg in the absence of growth or development of secondary sexual characteristics. OR No menarche by the age of 16 yearsdeg regardless of the presence of normal growth and development of secondary sexual characteristics. "Mullerian agenesis - is a relatively common cause of primary amenorrhea. more frequent than congenital androgen insensitivity and second only to gonadal dysgenesis." Remember-Most common cause of Primary Amenorrhea = Gonadal dysgenesisdeg Ilnd most common cause of Primary Amenorrhea = Mullerian Agenesis (Mayer Rokitansky Kuster Hauser Syndrome). deg Also know : Causes of Primary Amenorrhea Friends most of the textbooks have given an exhaustive list of the causes of Primary amenorrhea which is quite difficult to mug, but if you try to understand and then learn. I think you will be able to recall them better during exams. Let's first see what are the basic requirements for a female to menstruate normally. An intact out flow tract which connects the uterine cavity with outside and a normally developed uterus with its endometrium lining. Proper quantity and sequence of steroid hormones i.e. Estrogen and Progesterone which inturn originate from ovary. The maturation of follicular apparatus is guided by Gonadotropins - FSH and LH (released by pituitary). The secretion of these hormones is inturn dependant on Gonadotropin Releasing Hormone (released by hypothalamus). So, broadly we can classify the causes of amenorrhea into the following compaments.


Question: Absence of corkscrew glands is seen in

Ans. D. Metropathia hemorrhagicaEndometrial histology - secretory phasea. The characteristic feature of endometrium in Metropathia hemorrhagica is cystic glandular hyperplasia.b. Another important feature is absence of secretory endometrium with absence of corkscrew glands.c. Endometrium is usually thick and polypoidal.d. Thin polypi project into the uterine cavity.


Question: Best treatment for severe stress incontinence without prolapse is

Students, Please read this: From Novaks Gynecology 15th edition Comparing various surgeries for the treatment of stress incontinence, Numerous panels and studies conducted in the late 90's concluded that colposuspension (e.g., Burch, Marshall- Marchetti-Krantz ) and slings were more effective than transvaginal needle suspensions or anterior repairs for long-term success (48-month cure/dry rates).... Now, there were many journals which came out with the information that the TVT/TOT are now better, but since it never came in a book, it was actually never asked of you for the last 5-6 years Now, the 2020 Novaks gynecology 16th writes this: Over the past two decades, there has been an accumulation of a large body of evidence on mid-urethral slings from randomized controlled trials, including several meta-analyses and Cochrane reviews . The overarching summary is that mid-urethral slings have become the procedure of choice in treating women with stress urinary incontinence. They have a good safety profile with a significant improvement of QOL measures, and irrespective of route of placement, they are highly effective in the sho, medium, and long term. There is evidence to suggest that the mid-urethral slings are more effective than the Burch colposuspension procedure, and as effective as the autologous pubovaginal sling ... SO yes, now we change our answer to: that the mid urethral TVT/TOT slings are the best procedures..


Question: Carcinoma cervix is commonly associated with following sub type of HPV

(A) HPV - 16, 18# HUMAN PAPILLOMAVIRUS (HPV):> HPV plays an important role in the development of CIN. HPV infected cells (koilocytes) are characterized by enlarged cells with perinuclear halos. The nucleus is large, irregular and hyperchromatic. Depending on their oncogenic potential, HPV types are broadly grouped into two. More than 130 HPV types have been identified.> High oncogenic risk - Types 16, 18, 31, 58> Low oncogenic risk - Types 6, 11,42, 43> Over 90% of patients with CIN and invasive cancer are found to be positive with HPV DNA. HPV DNA detection in cervical tissues may be a screening procedure as that of pap smear. Polymerase chain reaction or southern blot or hybrid capture (HC) technique is used for HPV DNA detection.


Question: Commonest cause of the Postpartum haemorrhage is

(Atonic uterus): Ref: 411-DPost partum haemorrhage the amount of blood loss in excess of 500 ml following birth of the babyCAUSES1. Atonic uterus: (80%) commonest cause of PPHGrand multipara, overdistension of the uterus, Malnutrition and anaemia, APH, prolong labour, Anaesthesia,Initiation or augmentation of delivery by oxytocin, Persistent uterine distensionMalformation of the uterus, uterine fibroids, Mismanaged third stage labour, constriction ring, Precipitate labour,2. Traumatic (20%), similarly blood loss in C.S. amounting to 800 - 1000 ml is most often ignored, episiotomy and lacerations3. Combination of atonic and traumatic causes4. Blood coagulation disorders, acquired or congenital: may be due to diminished procagulants (washout phenomenon) or increased fibrinolytic activity.The conditions where such disorders may occur are abruptioplacentae, jaundice in pregnancy, thrombocytopenia purpura, HELLP syndrome or in IVD


Question: Most vulnerable period for teratogenicity during fetal development is

The preimplantation period is the 2 weeks from feilisation to implantation and is known as the "all or none" period. As the zygote undergoes cleavage, an insult damaging a large number of cells typically causes embryonic death.However if few cells are injured compensation may be possible, with normal development. The embryonic period is from the 2nd -8th week post feilisation, encompasses organogenesis and is thus the most critical period with regard to structural malformations. The fetal period, which is beyound 8 weeks, is characterised by continued maturition and functional development and during this time, ceain organs remain vulnerable. Reference: William's Textbook of Gynaecology 4th edition page 242


Question: Type of seizures in Eclampsia

Eclampsia is an extremely severe form of preeclampsia characterized by the sudden onset of generalized tonic-clonic seizures.Reference: Reference: Practical guide to High-risk pregnancy and delivery; Chapter 16; Hypeensive DIsorders of Pregnancy

Medical, surgical and gynaecological illness complicating pregnancy


Question: Marker for ovarian cancer is


Question: Biggest fetal skull diameter is


Question: After a full term normal delivery patient went into shock. Most probable cause is aEUR'

Inversion of uterus ?? 'c' i.e., Amniotic fluid embolism The patient went into unexplained shock after postpaum. Both uterine inversion and amniotic fluid embolism can cause unexplained shock. Uterine inversion is more common and impoant cause of unexplained shock than amniotic fluid embolism. Munrokerr's operative obstetrics says "In all cases of unexplained shock after delivery make a careful vaginal examination to exclude the possibility of occult rupture of the uterus, paial uterine inversion or pelvic hematonza". Munrokerr fuher adds Uterine inversion is the most impoant cause of unexplained shock Three degrees of inversion are generally described. i) Where the inveed .fundus reaches the internal os ii) Where the whole body of the uterus is inveed upto the internal os. iii) Where uterus, cervix and vagina are completely inveed Symptoms of uterine inversion Symptoms of uterine inversion are not always well defined. If however the inversion occurs quickly or is of severe degree there is .feelling of something coming down and pain followed by collapse and hemorrhage of variable severity. When the inversion is of lesser degree and is contained within the vagina or when the .fundus does not come beyond the os externum, only pain and hemorrhage may be present. Inversion is also the most impoant cause of unexplained shock - In these cases the shock is not primarily due to loss of blood or trauma but is really of neurogenic origin. - In this connection it has been suggested by several authors that as one or both ovaries may be pulled into the invagination, pressure on them may be responsible for shock. - The traction on the infundibulopelvic ligaments, peritoneum and broad ligaments stimulate the "parasympathetic system" producing shock. Amniotic fluid embolism may also cause unexplained shock -Amniotic fluid embolism is brought about by the uterine contractions forcing the liquor amni with its contained paicles of meconium, lanugo, and vernix caseosa into a patent uterine sinus from where it is carried into the lungs. - We have opted for uterine inversion as it is the more common cause for unexplained shock. Postpaum collapse from Ian Donald 6/e edited by Renu Mishra Postpaum maternal collapse is serious obstetric complication Majority of these cases occur as hemorrhage that is revealed. But a small minority of cases of collapse after deliver occur without obvious vaginal bleeding but these are the ones that pose a greater challenge .for diagnosis and management. The conzmon causes of postpaum collapse without bleeding are -Eclampsia - Uterine rupture - Vasovagal .syncope - Pulmonary embolism (Amniotic fluid embolism) - Septic shock - Uterine inversion Renu Mishra fuher adds - "Acute inversion of the uterus should be one of the first possibilities to cross the obstetricians mind in case of unexplained shock" Amniotic fluid embolism It is a life threatening complication of pregnancy with an extremely high moality rate. 300 The pathogenesis of the condition is not clear. Amniotic fluid probably enter the maternal venous circulation through a breach in the barrier b/w the maternal vasculature and the amniotic fluid most likely from the placental site or at the site of a uterine trauma after the membranes have ruptured. Classically amniotic fluid embolism presents during labour or immediately after the delivery with sudden onset maternal collapse associated with tachyapnea, cyanosis, hypotension, altered mental DIC. So, there is nothing to differentiate between uterine inversion and amniotic fluid embolism in terms of clinical presentation. We have opted for uterine inversion as it seems to be the more impoant and more common cause of unexplained shock. But we are still not sure - A patient with amniotic fluid embolism will always present in this manner i.e., unexplained death following normal de livery . - On the other hand uterine inversion commonly present as life threatening post paum hemorrhage. - It may present as unexplained shock but this is not its usual presentation. - If there is a case of postpaum collapse and no other significant findings are present the first diagnosis that comes to the mind is embolism. - All other causes of postpaum collapse will have some clinical .feature which would point towards to cause. Clinically most of the obstetricianl would suspect amniotic fluid embolism if any other abnormality is absent in case post paum collapse.


Question: Herniation of meninges through cranial defect is known as

Anencephaly is characterized by the absence of the cranium and telencephalic structures, with the skull base and orbits covered only by angiomatous stroma. Acrania is the absence of the cranium, with protrusion of disorganized brain tissue.Cephalocele is the herniation of meninges through a cranial defect, typically located in the midline occipital region. When brain tissue herniates through the skull defect, the anomaly is termed an encephalocele(Ref: William's Obstetrics; 25th edition)


Question: Treatment of choice for extragenital endometriosis is

Treatment of extragenital endometriosis will depend on the site. If complete excision is possible, this is the treatment of choice. When this is not possible, long-term medical treatment is necessary using the same principles of medical treatment for pelvic endometriosis. Surgical treatment of Bladder endometriosis -excision of the lesion and primary closure of the bladder wall. Ureteral lesions may be excised after stenting the ureter, Abdominal wall and perineal endometriosis -complete excision of the nodule. Appendicular endometriosis-Appendectomy.


Question: GnRH agonist therapy for leiomyoma is given for

GnRH agonist treatment is continued for 3 → 6 months.


Question: Fetal anomaly characterized by the absence of the cranium is

Anencephaly is characterized by the absence of the cranium and telencephalic structures, with the skull base and orbits covered only by angiomatous stroma. Acrania is the absence of the cranium, with protrusion of disorganized brain tissue. Both are generally grouped together, and anencephaly is considered to be the final stage of acrania.Ref: William&;s Obstetrics; 24th edition; Chapter: 10


Question: Battledore placenta is associated with highest risk of

Battle dore placenta - marginal insertion of umbilical cord, occasionally results in cord avulsion during delivery of placenta.


Question: Following ectopic pregnancy, recurrence is seen approximately in

Following an ectopic pregnancy, approximately 15% of women will have a subsequent ectopic pregnancy.Ref: Berek and Novak&;s Gynecology; 15th edition; Chapter 20


Question: Normal sperm concentration in semen analysis should be

Normal Semen Analysis: World Health Organization Volume>=1.5 mLSperm concentration>=15 million/mL Sperm motility>=32% progressive>25% rapidly progressiveMorphology (strict criteria)>=4% normal formWhite blood cells<1 million/mLReference: Novak's Gynecology; 14th edition; Chapter 32; Infeility and Assisted Reproductive Technology


Question: Recurrent miscarriage is defined as

Recurrent miscarriage is classically defined as three or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams. (Ref: William's Obstetrics; 25th edition)

One or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams

Two or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams

Three or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams

Four or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams


Question: Beneficial effects of hormone replacement therapy in early menopause


Question: Treatment of deep transverse arrest is

Ans. a (LSCS). (Ref. Williams, Obstetrics, 21st ed., 301)Deep transverse arrest (DTA)# Occipitotransverse (OT) head position frequently results in a deep transverse arrest and resultant cephalopelvic disproportion.# DTA occurs in the second stage of labor where the fetus maintains an OT position at a low pelvic station.# In most cases, this requires rotation of the fetal head to OA or OP to allow vaginal delivery, but occasionally, patients with a platypelloid pelvis will spontaneously deliver a baby with a transverse head.# The options open to the modem obstetrician faced with a deep transverse arrest in an OT position include:- Digital or manual rotation- Rotation with traction using a vacuum extractor- Rotation with forceps- Cesarean section# Unless the operator has had sufficient training and experience with rotational delivery using forceps, cesarean section is frequently the most prudent choice.


Question: Primary Amenorrhea with Absent uterus, Normal breasts and Scanty pubic hair is seen in

Testicular Feminising Syndrome Complete AIS (testicular feminization) is a form of male pseudohermaphroditism Gonadal sex (male) and the Contrasting phenotype (female) Normal male karyotype (46,XY) and testes that produce both testosterone and AMH An inactivating mutation in the gene encoding the intracellular androgen receptor (located on the long arm of the X chromosome, Xq) results in an end organ insensitivity to androgen actions that prevents normal masculinization of the internal and external genitalia during embryonic development Consequently, the external genitalia are those of a female (absent androgen action), the cervix and uterus are absent (due to normal AMH action), and the vagina is sho and ends blindly (derived only from the urogenital sinus) Reference: Clinical Endocrinologic Gynecology and Infeility; Eigth Edition; Chapter 11


Question: In a young female of reproductive age an absolute contraindication for prescribing oral contraceptive pills is

Ans. is d i.e. Impaired liver function Contraindications of OCP, Absolute contraindications include : I have a mnemonic which might prove helpful in learning the absolute contraindlactions : Relative contraindications of OCP's Migraine with Aura Diabetes mellitus/Gestational diabetes Hypeension (mild) Smoking Uterine leiomyoma Elective surgery (OCP should be stopped four weeks before any scheduled surgery) Seizure disorders Obstructive Jaundice in pregnancy Sickle cell disease Gall bladder disease SLE Mitrel valve prolapse Hyperlipidemia Hepatic disease


Question: Diethylstilbesterol causes the following defects expect

Diethylstilbesterol defects Neural tube defects Vaginal and cervical adenosis Clearcell adenocarcinoma Uterine anomalies Cryptorchidism Testicular hypoplasia TEXTBOOK OF OBSTETRICS,SHEILA BALAKRISHNAN,PG NO:565,2nd edition


Question: Aspiration of sperms from testes is done in

TESA (Testicular sperm aspiration)- It is a method of obtaining sperm for ICSI (Intracytoplasmic sperm injection).
MESA (Microsurgical epididymal sperm aspiration) it is another method of sperm collection from the epididymis.


Question: A patient is diagnosed to have CIN II. She approaches you for advice. You can definitely tell her the risk of malignancy as

CIN I and CIN II, the lesions have a 5-10% chance to progress to a high grade lesion CIN III progressing to cervical cancer is almost 10-30% Transformation Rates Form low grade CIN to High grade CIN takes around 5-6 years From High Grade CIN to invasive cancer takes around 10 years time. HPV related cervical lesions occur more on the cervical anterior lip than the lower lip (2:1 incidence).


Question: Contraction of uterine pain is carried by

In the early stages of labour pains are mainly uterine in origin because of painful uterine contractions It is distributed along the cutaneous nerve distribution of T10 - L 1. In the later stages pain is due to cervical dilatation This pain is referred to back through sacral plexus. Ref: Dutta Obs 9e pg 112.


Question: Virus responsible for non immune hydrops fetalis is

Hydrops is defined as the accumulation of extracellular fluid in tissues and serous cavities. Hydrops fetalis is more common because of non-immune reasons rather than Rh isoimmunization. Most common cause of non-immune hydrops is due to congenital hea block (cardiac causes) Most common infection causing non immune hydrops- Parvovirus B19 infections


Question: Polycystic ovarian disease not related to

(A) (Hypertension) (459,469, Dutta Gynae 6th)POLYCYSTIC OVARIAN SYNDROME (PCOS)Multifactorial and polygenic conditionsMost obese woman with oligomenorrhea have the polycystic ovarian syndrome (PCOS), with its associated anovulation and ovarian hypcrandrogenism 40% of women with PCOS are absess (Not always). Most non obese with PCOS are also insulin resistance, hyperinsulinemia or the combination of the two are causative or contribute to the ovarian pathophysiology in PCOS in both obese and lean individuals (476-H17th)PCOS (Novak's Gynaecology)Clinical characteristicDiagnostic Criteria* Hirsutism* Obesity* Oligomenorrhea or AmenorrheaMajor criteria Minor criteria* Chronic anovulation* Pre menarchial onset of* Infertility* Hyper androgcncmia (in absence of any notable cause)- Hirsutism- Obesity* Insulin resistance (Abnormal glucose tolerance)* Elevated LH (LH/FSH ratio>2)* Intermittent anovulation associated with hyperandrogenemia (| ed free estosterone, |ed DHEAS)* Multiple cysts are located peripherally along the surface of the ovary giving a ''Necklace" appearance in UCG is diagnostic* The increased conversion of androstenedione to estrogen which occurs to a greater degree in women with lower body obesity may contribute to the increased incidence of uterine cancer in post menopausal women with obesity (467-HI 7th)* PCOS is most strongly associated with a risk of endometrial carcinoma and may also be associateed with an increased risk of ovarian and breast cancer**** Long term sequelae of PCOS- Diabetes mellitus- CVS disorders- MI- Lipidaemia- Hypertension- Endometrial cancer- Breast cancer- Premature ovarian failure following surgery* Autosomal dominant inherited factor** were added as aetiological factor in the development of PCOS CYP21 gene mutation has been discovered in this connectionSerum level in PCOSAndrogens (|)Estrogens (|)LH/FSHInsulinAndroeen excessEstroeen excessLH levels are |edInsulin |ed* Excess production of androgens is seen from both the ovaries and adrenals, (postulated to be due to abnormal regulation of androgen forming enzyme)* Estrogen levels are increased due to peripheral aromatization of androgens* EstrogenQ levels are raised(Estrone>Estradiol)* Enhanced estrogen levels exert a- Positive feedback on LH levels (|ed)- Negative feedback on FSH levels (|ed)* | ed insulin resistance LH/FSH Ratio is characteristically >2


Question: Normal pregnancy can be continued in

Hea disease in which Termination of pregnancy is advised Pulmonary hypeension- primary or secondary Marfans syndrome with aoa involvement Eisenmenger syndrome Any hea disease which belongs to NYHA Class 3 or 4 Ejection fraction < 40% Severe aoic stenosis or Severe mitral stenosis Previous peripaum cardiomyopathy with any residual impairment of LV function ABSOLUTE INDICATIONS FOR TERMINATION OF PREGNANCY Pulmonary HTN Eisenmenger's Syndrome Pulmonary veno-occlusive disease. Reference: William's Obstetrics; 24th edition; Chapter 49 Reference: DC.Duttas textbook of OBG,9th edition,page 259

Medical, surgical and gynaecological illness complicating pregnancy


Question: The best way to diagnose the degree of placenta pre is


Question: Commonest cause of pyometra

Ans. is b i.e. Carcinoma endometrium Pyometra is collection of pus or mixture of pus and blood within the uterus. Causes : * Most common cause is Carcinoma endometriumdeg 2'ld most common cause is Senile endometritts. Other causes : * Congenital atresia of the vagina/cervix Stenosis of cervix/vagina following : - Operations - Burns - Radiotherapy Endometritis : - Senile - Tuberculous - Puerperal Carcinoma : Ca endometrium (most common) Ca cervix Ca corporis


Question: Most common cause of breech presentation is

Causes of breech presentation : Prematurity - Most common cause Undue mobility of the fetus Fetal abnormality Favorable adaptation Ref: Dutta Obs 9e pg 352.


Question: In terms of birth defect potential, the safest of the following drugs is

Alcohol is an enormous contributor to otherwise preventable birth defects. Sequelae include retardation of intrauterine growth, craniofacial abnormalities, and mental retardation. The occasional drink in pregnancy has not been proved to be deleterious. Isotretinoin (Accutane) is a powerful drug for acne that has enormous potential for producing congenital anomalies when ingested in early pregnancy; it should never be used in pregnancy. Tetracyclines interfere with development of bone and can lead to stained teeth in children. Progesterone have been implicated in multiple birth defects, but controlled studies have failed to demonstrate a significant association with increased risk. Patients who have inadvertently become pregnant while on birth control pills should be reassured that the incidence of birth defects is no higher for them than for the general population. Phenytoin (Dilantin) is used for epilepsy and can be associated with a spectrum of abnormalities, including digital hypoplasia and facial abnormalities.


Question: Steroids used in treatment of HELLP syndrome

In patients with HELLP syndrome with dangerously low platelet count, steroids might serve to increase platelets.

Increase platelet count in severe thrombocytopenia.

Increase rate of recovery of liver enzymes.


Question: Most common cause of infertility in females is due to the disorder of

(B) Ovarian# Common causes of infertility of females include:> Ovulation problems (E.g. Polycystic ovarian syndrome, PCOS, the leading reason why women present to fertility clinics due to anovulatory infertility, tubal blockage, pelvic inflammatory disease caused by infections like tuberculosis> Age-related factors, Uterine problems, Previous tubal ligation, Endometriosis, Advanced maternal age


Question: Bilateral ovarian cancer with; capsule breached; ascites positive for malignant cells. Stage is;

Stage 1: tumor confined to ovaries or fallopian tubes. 1c: tumor limited to one or both ovaries. : Surgical spill : Capsule rupture before surgery or tumor on ovarian surface : Malignant cells present in ascites or peritoneal washings Reference : textbook of gynaecology Sheila balakrishnan, 2nd edition, pg no:277 <\p>


Question: Vaginal artery arising from anterior division of hypogastric artery corresponds to

Vaginal artery usually arises from uterine artery. In some cases, it arises from anterior division of hypogastric artery where it corresponds to inferior vesical artery in male.


Question: Maximum chances of ureteric injury are seen with

Wertheim's hysterectomy : Its a radical procedure, hence more chances of injuries while dissecting ureter in parametrial tissue


Question: With increasing gestational age, the S/D (Systolic / Diastolic ratio) of umbilical aery ...

The systolic/diastolic (S/D) ratio of flow velocities was measured as an index of peripheral resistance. The S/D ratio normally declines from appx. 4 at 20 weeks gestation, to generally <3 after 30 weeks and finally to 2 at bih Doppler indices show a continuous reduction throughout the second half of pregnancy without any plateau or increase near term.

Intra Uterine Growth Restriction, Intrapaum and Antepaum Fetal Surviellance


Question: Clue cell is seen in aEUR'

Bacterial vaginosis Clue cells are seen in bacterial vaginosis -Clue cells are vaginal epithelial cells coated with coccobacillary organisms which have granular appearance and indistinct borders, on a wet mount prepared by mixing vaginal secretions with normal saline in a ratio of -1:1. Amsel criteria for the diagnosis of bacterial vaginosis Includes any three of the following four clinical abnormalities i) Objective signs of increased white homogenous vaginal discharge. ii) Vaginal discharge pH of >4.5 iii) Liberation of distinct .fishy odour (attributable to volatile amines such as trimethylamine) immediately after vaginal secretions are mixed with a 10% solution of KOH. iv) Microscopic demonstration of clue cells.


Question: Levels of sex hormone binding globulin in PCOD


Question: Most common etiology of abnormal uterine bleeding in childhood age group

Vulvovaginitis is commonest etiology of AUB in childhood age group.


Question: Kidney size increases in pregnancy by

Kidney size increases approximately 1.5 cm, returns to normal size in postpaum.(Ref: William's Obstetrics; 25th edition)


Question: A woman presents with a fluctuant non tender swelling at the introitus. The best treatment is

Ans. is a i.e. Marsupilisation Fluctuant non tender swelling at the introitus suggests a diagnosis of baholins cyst. Baholins cyst 7 It is the commonest cyst of vulva. Baholins cyst are produced from accumulation of secretions of Baholins gland. The cyst may develop either in the duct (more common) or in the gland Aetiology : cyst formation occurs due to the obstruction of the main duct or opening of an acinus. The cause of obstruction is usually fibrosis which follows either infection or trauma. It was formerly believed that the infection was invarialy gonococcal but almost any orgnaism can be responsible. Left Baholins gland is more often affected than the right. Presentation : Usually presents as a unilateral swelling that bulges across the vaginal introitus. Size of the cyst rarely exceeds hens egg. Swelling is present characteristically on the inner side of the junction of the anterior 2/3rd with posterior 1/3rd of the labium majus. The swelling is fluctuant and usually non tender. May present with discomfo, dyspareunia or infection. Treatment of choice is Marsupialization : Marsupialization is the gratifying surgery for Baholins cyst. It is preferred over traditional exicision operations.


Question: Treatment recommended for secondary syphilis is

Benzathine penicillin G 2.4 mIU i.m weekly, 3 doses

Benzathine penicillin G 2.4 mIU i.m single dose

Benzathine penicillin G 2.4 mIU i.m twice weekly, 4 doses

Benzathine penicillin G 2.4 mIU i.m twice daily for 2 weeks.


Question: Most common uterine malignancy

75 to 80 % of endometrial tumors are type1, which are endometroid adenocarcinomas.


Question: Least likely physiological change in pregnancy

Normal pregnancy is characterized by increased plasma volume (preload), increased Cardiac Output and decreased PVR. These changes result in a physiologic decrease in mean blood pressure during the second trimester.

Increase in peripheral vascular resistance


Question: A9 month old pregnant lady presents with Jaundice and distension, pedal edema after delivering normal baby. Her clinical condition deteriorates with increasing abdominal distension and severe ascites. Her bilirubin is 5 mg/dl, S. alkaline phosphatase was 450 u/L and ALT (345 Iu). There is tender hepatomegaly 6 cm below costal margin and ascitic fluid shw protein less than 2 mg%. Diagnosis is

Budd chiari syndrome The most common cause of an acute severe livery injury in a young pregnant women are - Viral hepatitis (HAV, HBV) - Eclampsia, preeclampsia (HELLP syndrome) - Acute fatty liver of pregnancy - Budd chiary syndrome Let us discuss the options Preeclampsia and Eclampsia - It is the most common cause of abnormal liver chemistry test in women. Liver enzyme tests are only mildly abnormal in patients with liver diseases. Aminotransferases are modestly elevated. Alkaline phosphatase is subtantially increased But in these cases delivery of the fetus is followed by rapid normalization of the hepatic abnormalities. Moreover there is no mention of history of P.I.H, hemolysis and thrombocytopenia (HELLP syndrome) Acute Fatty liver of pregnancy Acute fatty liver develops after 34th week of pregnancy Jaundice develops a few days after the onset, the serum bilirubin is rarely above 10 mg/dl. Alkaline phosphate is markedly elevated. Aminotransferases are moderately elevated. A markedly raised serum ammonia is the most diagnostic finding in establishing the diagnosis of acute fatty liver-of pregnancy Fulminant hepatic failure The patient presents with features of severe acute hepatitis leading to the development of hepatic encephalopathy within 8 weeks of onset. The bilirubin increases to 20-30 mg/d1. The aminotransferase levels are very high (> 1000) alkaline phosphatase moderately elevated. Delivery is usually the best treatment. Paurition usually results in resolution. Budd chiary syndrome It is a disorder characterized by thrombotic occlusion of the hepatis veins. It is a rare complication of pregnancy. Most of the cases presents within few weeks of delivery but in several cases onset occurs during pregnancy. Clinical triad of B.C. syndrome includes sudden onset of abdominal pain, hepatontegaly and ascites near tee_ rn or sholy after delivery. Tender hepatomegaly is one of the hallmark of Budd chiari syndrome. Ascites with a high protein content is always present. Aminotransferases are mildly elevated. Jaundice is seen in only half of the cases.


Question: Decidualization of endometrium is due to

Progesterone is responsible for decidualization of endometrium.


Question: Most common cause of maternal anaemia in pregnancy

According to WHO anemia in pregnancy is defined as haemoglobin level below 11g/dl Iron deficiency anemia is the most common cause of anaemia both in the non pregnant and pregnant state Reference: Text Book of Obstetrics; Sheila Balakrishnan; 2nd edition; Page no: 285

Medical, surgical and gynaecological illness complicating pregnancy


Question: Congenital anamolies are most severe in

Ans. is 'a' Rubella infectionRubella causes numerous serious defects in the fetus, but nowhere is it specifically written that it causes most severe congenital deformities. Just have a look at the various defects caused by Rubella and you won't need any further confirmation for the answer.Various fetal defects caused d/t RubellaCardiac malformations* PDA (most common)* VSD, PS, (Coarctation of Aorta is not present)*Deafness*Cataract*Glaucoma*Retinopathy*Microcephaly*Cerebral palsy*1UGRHepatosplenomegalyMental & Motor retardationThese defects occuring singly or in combination are known as "Congenital Rubella Syndrome"


Question: The below abnormality is seen in

Ans. A. Monochorionic diamniotic twins"All monochorionic placentas likely share some anastomotic connections. And, with rare exceptions, anastomoses between twins are unique to monochorionic twin placentas.""Artery-to-artery anastomoses are most frequent and are identified on the chorionic surface of the placenta in up to 75 percent of monochorionic twin placentas. Vein-to-vein and artery-to-vein communications are each found in approximately half. One vessel may have several connections, sometimes to both arteries and veins. In contrast to these superficial vascular connections on the surface of the chorion, deep artery-to-vein communications can extend through the capillary bed of a given villus. These deep arteriovenous anastomoses create a common villous compartment or "third circulation" that has been identified in approximately half of monochorionic twin placentas." "Whether these anastomoses are dangerous to either twin depends on the degree to which they are hemodynamically balanced. In those with significant pressure or flow gradients, a shunt will develop between fetuses. This chronic fetofetal transfusion may result in several clinical syndromes that include twin-twin transfusion syndrome (TTTS), twin anemia polycythemia sequence (TAPS), and acardiac twinning."


Question: Women with PCOD and Hirsutism, Management is

Treatment of Hirsutism

Estrogen-Progestin Contraceptives
Antiandrogens

Mechanism of action

Androgen production in hirsuite women usually is an LH-dependent process

Estrogen-progestin contraceptives suppress pituitary LH secretion and thus suppress ovarian androgen production

The high level of estrogen in oral contraceptives stimulates hepatic SHBG production, which decreases the amount of free/active androgen
Directly or indirectly, estrogen-progestin contraceptives decrease adrenal DHEA-S secretion
Contraceptive progestins inhibit 5 alfa-reductase activity in the skin, which decreases the production of dihydrotestosterone (DHT), the major nuclear androgen in hair follicles and sebaceous glands. Treatment with estrogen-progestin contraceptives induces regular, predictable menses and attenuates endometrial growth, thereby eliminating the risk for developing endometrial hyperplasia and neoplasia Current oral contraceptives contain ethinyl estradiol, in doses ranging from 20 mcg to 50 mcg daily, and one of a variety of progestins All low-dose oral contraceptives (containing 20–35 µg ethinyl estradiol) have similar effectiveness in the treatment of acne and hirsutism Cyproterone is a derivative of 17a-hydroxyprogesterone (17OHP), has potent progestational activity that inhibits gonadotropin secretion and also acts as competitive androgen receptor antagonist which inhibits enzymes involved in androgen synthesis
“Dianette” or “Diane 35” contains 2 mg cyproterone acetate and 35 mg ethinyl estradiol
Antiandrogens are an effective treatment for hirsutism but are best used in combination with oral contraceptives or another means of highly effective contraception, because they adversely affect sexual development in a male fetus if the patient conceives during treatment


Question: Normal blood loss in menstruation is

Normal blood loss during menstruation is 30-40ml Ref: Internet sources

Reproductive physiology and hormones in females


Question: Cervical carcinoma arises from

Carcinoma of cervix arise from the Squamocolumnar juction Vagina and Ectocervix are covered by stratified squamous epithelium and the endocervix is covered by columnar epithelium. The two meet at squamocolumnar junction which is dynamic. Reference : Textbook of Gynaecology; Sheila balakrishnan; 2nd edition; Pg no:257


Question: The most important indication for surgical repair of a double uterus, such as a septate or bicornuate uterus, is

Habitual abortion is the most important indication for surgical treatment of women who have a double uterus. The abortion rate in women who have a double uterus is two to three times greater than that of the general population. Therefore, women who present with habitual abortion should be evaluated to detect a possible double uterus. Hysterosalpingography, hysteroscopy, ultrasound, CT, and magnetic resonance imaging (MRI) are all potentially useful imaging modalities in this investigation. Dysmenorrhea, premature delivery, dyspareunia, and menometrorrhagia are other, less important indicators for surgical intervention.


Question: Conjugate of the diagonal is taken as 'a' cm, then obstetric conjugate will be

Obstetrical conjugate

It is the shortest distance between the sacral promontory and the symphysis pubis
Normally, this measures 10 cm or more, but it cannot be measured directly with examining fingers
Thus, for clinical purposes, the obstetrical conjugate is estimated indirectly by subtracting 1.5 to 2 cm from the diagonal conjugate, which is determined by measuring the distance from the lowest  margin of the symphysis to the sacral promontory


Question: 'Twin peak" sign is seen in

(A) Dichorionic diamniotic twins # Twin peak sign indicates the presence of a dichorionic-diamniotic twin gestation. It represents the extension of placental villi into the potential space that is formed from the reflection of apposed amniotic and chorionic layers from each fetus.> By performing an obstetric ultrasound at a gestational age of 10-14 weeks, mono- chorionic-diamniotic twins are discerned from dichorionic twins.> Presence of a "T-sign" at the inter-twin membrane-placental junction is indicative of monochorionic-diamniotic twins (that is, the junction between the inter-twin membraneand the external rim forms a right angle), whereas dichorionic twins present with a "lambda (I) sign" (that is, the chorion forms a wedge-shaped protrusion into the inter-twin space, creating a rather curved junction).> The "Lambda sign" is also called the "twin peak sign".> At ultrasound at a gestational age of 16-20 weeks, the "lambda sign" is indicative of dichorionicity but its absence does not exclude it.


Question: Polymenorrhoea Means

Polymenorrhoea means regular and shoened cycles Reference: Shaw&;s textbook of gynaecology; 16th edition; Page no 293


Question: ln multiparous women, external os is i


Question: Remnants of WolFion ducts in a female are in

Ganer&;s duct remnants of mesonephric duct in female Located in Broad ligament ref : BD CHAURASIA


Question: Marker for granulosa cell tumor;

<p> - inhibin B is a peptide growth factor secreted by granulosa cells. - it is a measure of diminished ovarian reserve. - inhibin B is elevated in granulosa cell tumors. Reference : textbook of gynaecology Sheila balakrishnan, 2nd edition, pg no: 135 <\p>


Question: End product of progesterone metabolism found in urine

Fate of progesterone

Within a few minutes after secretion, almost all the progesterone is degraded to other steroids that have no progesterone effect
The major end product of progesterone degradation is pregnanediol. Approximately 10%  is excreted in urine in this form


Question: The sensitivity of uterine musculature is

Progesterone reduces muscle excitability by increasing calcium binding, thereby reducing free intracellular calcium. Oestrogen has the opposite effect and increases myometrial excitability.Refer page no 106 of Textbook of obstetrics, Sheila Balakrishnan, 2 nd edition.

Enhanced by estrogen and Inhibited by progesterone


Question: Most common cause of postpartum haemorrhage (PPH) is

Ans. a (Atonic uterus). (Ref. Textbook of Obstetrics by Dutta, 3rd ed., 424)*Most Common Cause Of Primary PPH is atonicity of the uterus (80%)*Most Common Cause Of secondary PPH is retained bits of cotyledon or membrane.RISK FACTORS FOR POSTPARTUM HEMORRHAGE# Multiple Gestations# Large baby# Polyhydramnios# Multiparity (particularly grand multiparity, more than 5 term pregnancies)# Prolonged labor (uterine inertia)# Labor augmented with Pitocin# General Anesthesia# Placenta Previa# Abruptio Placentae# Magnesium Sulfate infusion


Question: Shoest diameter of foetal skull is


Question: Fate of Inner cell mass in embryo development...

Cells of blastocyst differentiate into an outer trophoectoderm and inner cell mass. Just before implantation trophoectoderm fuher divided into: Cytotrophoblast & Syncytiotrophoblast Placenta and fetal membrances are derived from trophoectoderm. Inner cell mass helps in the development of embryo proper.

Expelled out of developing embryo by 7 weeks


Question: Lymph Nodes not involved in Cervical cancer

Lymphatic spread of Cervical Cancer includes: Pelvic nodes Parametrial Obturator Internal iliac External iliac Common iliac Sacral Para aoic nodes Reference : Textbook of Gynaecology; Sheila balakrishnan; 2nd edition; Pg no: 258


Question: Cervical myoma is

Cervical stroma being poor in smooth muscle fibers, majority of myoma arise from isthumus of uterus.
In contrast to uterine myomas, cervical myoma is usually solitary.


Question: The expectant line of management in placenta prae is contraindicated in

Active InterferenceThe indication of active treatment in placenta pre are: Bleeding is continuingBaby is dead or known to be congenitally deformed Bleeding occurs at or beyond 38 weeks of pregnancy Patients is in emarginated state on admissionPatient is labour.


Question: Conservative surgical treatment of PPH includes

Ans. a (Internal iliac artery ligation). (Ref. Dutta, Obstetrics 4th/ 447, Williams, Obstertrics, 21st/620, 635)Traditionally, postpartum hemorrhage (PPH) has been defined as the loss of 500 mL of blood or more after completion of the third stage of labor. This is unreasonable, because nearly half of all women who are delivered vaginally shed that amount of blood or more when measured quantitatively. After the first 24 hours it is designated late postpartum hemorrhage.Scheme for the management of true PPH:# If uterus is flabby:- Massage uterus- IV methergin (Drug of choice) - MH 2006- Oxytocin- Bladder catheterization- Examine expelled placenta# Bleeding Unresponsive to Oxytocics: Following management should be initiated immediately:- Use bimanual uterine compression- Begin blood transfusions- Explore the uterine cavity manually for retained placental fragments or lacerations.- If still flabby, hot uterine douche and intrauterine packing and- If this fails, either hysterectomy or bilateral ligation of anterior division of internal iliac arteries (in exceptional cases as an alternative to hysterectomy).


Question: Most important criteria in semen analysis is

Most important criteria in semen analysis is sperm morphology > Sperm motility > Sperm concentration.


Question: Polyhydramnios not associated with

Ans. is 'a' i.e. B/L renal agenesis Polyhydramnios is defined as a state where liquour amni exceeds 2000 ml.Amniotic fluid measures about 50 ml at 12 weeks, 400 ml at 20 weeks and reaches its peak of 1 litre at 36-38 weeks.There after the amount diminishes till at term it measures about 600-800 ml Amniotic fluid formation:- Early pregnancy - Ultrafiltrate of plasma Beginning of 2nd trimester - Composed largely of extracellular fluid that diffuses through the fetal skin. After 20 weeks - Cornification of fetal skin prevents this diffusion and the amniotic fluid is composed largely of fetal urine.The fluid in the amniotic fluid is completely changed and replaced in every 3 hours.Causes of increase in amniotic fluid (Polyhydramnios)Because the fetus normally swallows the amniotic fluid and excretes it through urine it has been assumed that this mechanism is one of the ways by which the volume is controlled.Thus renal agenesis will lead to oligohydramnios not polyhydramnios.Anencephaly causes polyhydramnios because of transudation from exposed meninges and absence of fetal swallowing reflex.Open spina bifida leads to polyhydramnios because of transudation of meninges.Causes of polyhydramnios MaternalPh isoimmunisationDiabetes PlacentalPlacental chrioangiomaCircumvallate placenta syndrome FetalMultiple pregnancyFetal anomaliesCNS abnormalities (Anencephaly)G.L abnormalities (Oesophageal or duodenal atresia)G. U. abnormalitiesSkeletal malformationsFetal tumoursCardiac anomaliesChromosomal abnormalitiesGenetic syndromesHematological disordersIntrauterine infectionsMiscellaneous IdiopathicComplications of Polyhydramnios:Most of the maternal complications of polyhydramnios arise purely from pressure exerted within the overdistended uterus and upon adjacent organs. Which areRespiratory discomfortPremature rupture of membranePremature labourPregnancy induced hypertensionAbruptio placentaCord prolapsePlacental insufficiencyPost partum hemorrhageFetal complications:Fetal morbidity and mortality is significant in cases of polyhydramnios.The major causes of mortality are congenital abnormalities incompatible with life.


Question: Lichen sclerosus lesions are limited by

Lesions of lichen sclerosus are always limited by labia majora.


Question: Cervical pregnancy is confirmed by the presence of

Ans is 'd' i.e., Histology showing presence of villi inside the cervical stromaCervical PregnancyIn cervical pregnancy, the bleeding is painless and the uterine body lies above the distended cervix. Intractable bleeding following evacuation or expulsion of the products brings about suspicion.The morbidity and moality is high because of profuse hemorrhage.Clinical diagnostic criteria (Rubin-1983) for cervical pregnancy are?Soft, enlarged cervix equal to or larger than the fundus.Uterine bleeding following amenorrhea, without cramping pain.Products of conception entirely confined within and firmly attached to endocervix.A closed internal cervical os and a paially opened external os.Sonography reveals the pregnancy in the cervical canal and an empty uterine cavity.Confirmation is done by histological evidence of the presence of villi inside the cervical stroma.

Intractable bleeding following evacuation or ex pulsion of products


Question: Most frequent chromosomal abnormality found in those with heart defect

Trisomy 21 >> Trisomy 18 >> 22q Microdeletion >> Trisomy 13 >> monosomy X.
This is order of occurrence of heart defect most commonly and frequently.


Question: At 8 weeks postpaum, uterus should weigh about

During pregnancy, uterus weighs about 1000g At the end of 6weeks ,it's measurement is almost similar to the prepregnant state which is about 60g . Decrease in size of uterus is seen with serial MRI Ref: Dutta Obs 9e pg 137.


Question: Lactational amenorrhoea is due to

Ans. is 'a' i.e. Prolactin induced inhibition of GnRH Suppression of the female ovarian cycles in nursing mothers for many months after delivery.In most nursing mothers, the ovarian cycle and ovulation does not resume until a few weeks after cessation of nursing the babyThe cause of this seems to be that the same nervous signals from the breasts to the hypothalamus that cause prolactin secretion during suckling either because of the nervous signals themselves or because of the subsequent effect of the increased prolactin, inhibit secretion of gonadotropin releasing hormone by the hypothalamus.This in turn, suppresses the formation of the pituitary gonadotrophic hormones, leutinizing hormones and follicle stimulating hormone.Yet, after several months of lactation in some mothers, especially in those who nurse their babies only part of the time, the pituitary does begin again to secrete sufficient gonadotropic hormones to reinstate the monthly sexual cycle even though nursing continues.

Endocrine Control of the Menstrual Cycle


Question: Most common cause of hirsutism is

Ans. is 'a' Polycystic Ovary disease We have already discussed that hirsutism occurs d/t androgen excess in a female and the most common cause of androgen excess is polycystic ovary disease.


Question: Genetic component of Superfemale is

Superfemale (Triple X Chromosome)The possession of an extra X is not excessively rare since it is quite compatible with complete feminine normality. There is, however, a well-recognized triple X syndrome in which the patient, who is often mentally subnormal, suffers from scanty or irregular menstruation and infeility. Clinical examination may reveal hypoplasia of the genital tract.Reference: Shaw's textbook of gynecology; 16th edition; Page no 146


Question: During Dilatation and curettage, if uterine fundus is perforated, most appropriate management is

Laparotomy or laparoscopy to examine abdominal contents is safest to rule out intraabdominal damage, perionitis due to bowel injury.


Question: Endosalpingitis is best diagnosed by

Clinical Triad for Diagnosis of PID Pelvic organ tenderness, Adnexal tenderness, Cervical motion tenderness (Suggests the presence of peritoneal inflammation, which causes pain when the peritoneum is stretched by moving the cervix and causing traction of the adnexa on the pelvic peritoneum) Direct or rebound abdominal tenderness may be present. Evaluation of both vaginal and endocervical secretions is a crucial pa of the workup of a patient with PID. Increased number of polymorphonuclear leukocytes may be detected in a wet mount of the vaginal secretions or in the mucopurulent discharge. More elaborate tests include Endometrial biopsy to confirm the presence of endometritis, Ultrasound or radiologic tests to characterize a tubo-ovarian abscess laparoscopy to confirm salpingitis visually A laparoscopy, if asked in the Questions, is indeed the best test to diagnose PID. Its not a practical option always since this is a common presentation in the OPD and will be impossible to do on every one . Regular OPD diagnosis is made by the clinical triad If a Laparoscopy is being done for some indication & the surgeon notices inflamed tubes, then it is diagnostic of a PID Also: Please note that for diagnosis of PID , any uterine procedure like hysteroscopy, HSG, sonosalpingography ,will all push in fluids through the Uterus and this can in fact increase the PID.

Genital Tract Infections (Too hot to handle!)


Question: Causative organism of strawberry cervix is

Trichomonas Vaginitis Vulvar erythema and edema Copious frothy yellow green foul smelling discharge Punctate lesions of cervix-Strawberry cervix Vaginal pH >4.5 Ref: Shaw Gynecology 17 e pg 330.


Question: According to Naegele's rule, calculate EDD of a patient with LMP 9/01/2017

Naegel's rule = 9 months + 7 days (add to the first day of last menstrual period) - LMP = 9/01/2017- Apply naegel's rule and add 9 months + 7 days =16/10/2017 (add 7 to date and 9 to month)


Question: The weight of placenta at term is

(500 gm): Ref: 29-D, 23-H & BPlacenta at term. The mature placenta is a Fleshy, discoid organ weighing about 500 gm usually weighing about 1/6 of the fetal weight. It is about 20 - 25 cm in diameter and 2.5 cm thickness at term, about four-fifths ofplacenta is of fetal origin.


Question: Absolute contraindication for Transvaginal sonography

Imperforate hymen and patient refusal are the only absolute contraindications for Transvaginal sonography.


Question: Alpha fetoprotein synthesized from

(Yolk sac) (107-D)* AFP - is a oncofetal protein it is produced by yolksac and fetal liver* Highest level of AFT in fetal serum and amniotic fluid reached around 13 weeks and thereafter it decreases* Maternal serum level reaches a peak around 32 weeks* * Test is done between 15-18 weeksMSAFP level is elevated in(a) Wrong gestational age(b) Open neural tube defects(c) Multiple pregnancy(d) IUCD(e) Anterior abdominal wall defects(f) Renal anomaliesMSAFP level is lowin Trisomies (Down's syndrome) gestational trophoblastic disease* Triple test - includes MSAFP, hCG and UE3 (Unconjugated oestriol)


Question: M/C uterine malformation associated with infeility

Septate uterus The two mullerian ducts are fused together but there is a persistance of septum in between the either two paially or completely Infeility and dyspareunia are often associated with vaginal septum D.C.DUTTA&;S TEXTBOOK OF GYNAECOLOGY,Pg no:44,6th edition


Question: M/C site of ureteric injury during hysterectomy

The injury to ureter occurs at the infundibulopelvic junction on the lateral pelvic wall, in the ureteric canal when the uterine vessels are ligated, near the internal cervical os and near the uterosacral ligamentIt is impoant to identify the ureter during Weheim hysterectomy, broad ligament tumour dissection and ligating internal iliac aeryRef: Shaw&;s Textbook of Gynaecology, 15th edition, page no: 14


Question: Vitamin K injection given to newborn within 1 hour of birth

Vitamin K dependent hemorrhagic disease of newborn is prevented by vitamin - K injection.


Question: Uterine blood flow at term is aEUR'

500-750 ml "Uterine blood flow is increased from 50 ml/min in non pregnant states to about 750 ml near term". "Uterine blood increase from 50m/min in early gestation to 500-750 m/min by term".


Question: The most common pure germ cell tumour of the ovary

Ans. is b i.e. Dysgerminoma "Dysgerminoma is the most common malignant germ cell tumour accounting for about 40% of all ovarian cancers of germ cell origin." "Dysgerminomas are the most common malignant germ cell tumours of the ovary and have been considered the female - equivalent of seminoma." Most common germ cell tumour of ovary is dermoid cyst (mature teratoma). It is benign in nature. Dysgerminoma Commonest malignant germ cell tumourdeg of ovary. Primarily affect young women (average age of incidence is 20 yearsdeg). Usually unilateraldeg but they are the only germ cell malignancy with a significant rate of bilateral ovarian involvement - 15 to 20%. Can be found at gonadal as well as extra gonadal sites.deg Pathologically it is a solid neoplasm with areas of softeningdeg due to degeneration. They are the most common ovarian malignancy detected during pregnancy. Histologically as in seminoma, it mimics the pattern of primitive gonad, lymphocytic infiltration may be seen (good prognostic sign).deg Clinically as with all germ cell tumours most dysgerminoma are diagnosed at an early stage. Unlike other germ cell tumours it does not secrete AFP and HCG is only rarely secreted, however it secretes LDH and placental alkaline phosphate, which are used as tumour marker of dysgerminoma. Although dysgerminoma is most radio sensitive tumouty2treatment of choice is surgery (unilateral salpingo oophorectomy) followed by Bleomycin, Etoposide and Cisplatin (BEP) based chemotherapy as feility can be preserved. They have the best prognosis of all malignant ovarian germ cell variants. Tumours associated with it : - Immature teratoma - Choriocarcinoma - Endodermal sinus tumour. Dysgerminomas are also seen in phenotypic females with abnormal gonads like : Pure gonadal dysgenesis (46XY with bilateral streak gonads, swyer syndrome) Mixed gonadal dysgenesis Testicular feminization syndrome (46XY) Klinfelter syndrome For patients in whom karyotype reveals Y chromosome, both ovaries should be removed although uterus may be left in situ for possible future embryo transfer.


Question: Halban's sign is seen in

Halban's sign refers to tender, softened uterus on premenstrual bimanual examination in adenomyosis.


Question: Not a barrier contraceptive among the following is

Centchroman

Non-hormonal contraceptive pill
It is a selective estrogen receptor modulator


Question: In accidental hemorrhage, TOC

Ans. is c i.e. Simultaneous emptying of uterus and blood transfusion

Rx of hypofibrinogenemia then blood transfusion


Question: Ovarian tumor involving retroperitoneal lymph nodes is seen in stage

-Ovarian cancer staging: Stage III Tumor involves 1 or both ovaries or fallopian tubes or primary peritoneal cancer with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes. -Stage IIIa: Involvement of retroperitoneal lymph nodes and/or microscopic metastasis beyond the pelvis. -Stage IIIa1: positive retroperitoneal lymph nodes only Stage IIIa1(i): metastasis < 10mm Stage IIIa1(ii): metastasis > or = 10mm -Stage IIIa2: Microscopic, extrapelvic peritoneal extension with or without positive retroperitoneal lymph nodes. Reference : textbook of gynaecology Sheila balakrishnan, 2nd edition, pg no: 277 <\p>


Question: A 29yrs old nulliparous woman complains of severe menorrhagia and lower abdominal pain since 3months .On examination there was a 14 weeks size uterus with fundal fibroid .The treatment of choice is

Routes of myomectomy : Abdominal myomectomy Vaginal myomectomy: Done in case of submucosal pedunculated fibroid Hysteroscopic myomectomy: Submucosal fibroid which cannot be removed by simple vaginal route can be removed with the help of hysteroscope use when myoma <5 cms in size Laproscopic myomectomy: Indicated for pedunculated subserosal fibroids <10 cms in size Intramural fibroids can also be removed by laproscopy but it is very time consuming Myolysis or myoma coagulation using lazer: In this procedure lasers are used to drill holes into substance of intramural myoma As the patient is having severe menorrhagia and chronic abdominal pain These indications are strong enough for surgical intervention .earlier size of fibroid >12 weeks was also an indication of surgery Indications of myomectomy Myomectomy is specifically indicated in an infeile woman or woman desirous of bearing child ,uterus should be retained Ref Shaw 16/e pg 395


Question: Side effects of magnesium sulfate includes

Side effects flushing perspiration headache muscle weakness rarely pulmonary edema neonatal side effects lethargy hypotonia respiratory depression D.C.DUTTA&;S TEXTBOOK OF OBSTETRICS,Pg no:508,7th edition

Medical, surgical and gynaecological illness complicating pregnancy


Question: Fibroids cause infertility and pregnancy wastage because

Fibroids are associated with endometrial inflammation and vascular changes that may disrupt implantation.


Question: Not an indication for blood  transfusion

Indications for Blood Transfusion

To correct anemia due to blood loss and to combat postpartum hemorrhage
Patient with severe anemia seen in later months of pregnancy (beyond 36 weeks)
Refractory anemia: Anemia not responding to either oral or parenteral therapy in spite of correct treatment
Associated infection


Question: Transobturator tape approach in treatment of urinary incontinence is known to

TOT approach was introduced with the intention to reduce vascular and lower urinary tract injury risks that can be associated with traversing retropubic space.

Reduce vascular and lower urinary tract injury risks.

Overlie over proximal tendon of adductor magnus.

Traverse retropubic space, causing neurovascular injury.


Question: Gestational sac can be seen earliest on transvaginal scan at

Gestational sac Cardiac activity Transvaginal sonography 4 + weeks 5 + weeks Transabdominal sonography 5 +weeks 6 + weeks Please note: in exams the same information may be asked as 'Which week gestational sac is seen" ? the answer choice maybe given as 5th week. so please realize that '4 wks + some days' is actually the 5th week.

Ectopic Pregnancy (Hello ! Where are you ?)


Question: Precocious menstruation denotes the occurence of menstruation before the age of

Precocious menstruation denotes the occurence of menstruation before the age of 10 years. Precocious menstruation is one of the menstrual cycle irregularities. Precocious pubey in a girl is the appearance of any of the secondary sexual characteristics before the age of 8 years or the occurence of menarche before the age of 10 years. Precocious pubey in boys is the onset of secondary sexual characterstics before the age of nine years. Ref: Shaw&;s textbook of Gynaecology 17th edition Pgno: 122


Question: Spontaneous movements of fetus begins at

12th Gestational Week The uterus usually is just palpable above the symphysis pubis, and the fetal crown-rump length is 6 to 7 cm. Centers of ossification have appeared in most fetal bones, and the fingers and toes have become differentiated. Skin and nails have developed, and scattered rudiments of hair appear. The external genitalia are beginning to show definitive signs of male or female gender. The fetus begins to make spontaneous movements.Reference: WIlliam's Obstetrics; 24th edition; Chapter 7; Embryogenesis and Fetal Morphological Development


Question: Treatment of transverse lies at labour is

(Caesarean section): Ref: 393, 397-DTRANSVERSE LIE: - When the long axis of the fetus lies perpendicularly to the maternal spine or centralized uterine axis it is called transverse lies* In dorso-posterior, chance of fetal extension is common with increased risk of arm prolopse, left one being common than right* Dorso-anterior is the commonest (60%) positionManagement of Transverse lie at labourEarly labourLate labour* External cephalic version* Caesarian section is the preferred method of delivery, if version fails or contraindicated* Baby alive - caesarean section prefer* Internal version - Not only it might inflect injury to the uterus (rupture uterus) but the fetal mortality is increased to the extent of about 50%In modem obstetric practice internal version is not recommended except in the case of second twin* Baby dead - caesarean section is prefer.* There is no mechanism of labour in transverse lie


Question: In terms of bih defect potential, the safest of the following drugs is

Alcohol sequelae include retardation of intrauterine growth, craniofacial abnormalities, and mental retardation. Isotretinoin, a drug for acne, is asoociated with congenital anomalies like Microtia, Micrognathia, cleft palate, thymic aplasia, CVS anomalies, NTDs Tetracyclines interfere with development of bone and can lead to stained teeth in children. Regarding progesterones use in pregnancy, controlled studies have failed to demonstrate a significant association with increased risk.


Question: Patients with organic hea disease in pregnancy most commonly die during

Maternal moality in Hea disease complicatin Pregnancy Maternal moality is lowest with rheumatic hea lesions and acyanotic group of hea diseases ie <1% With the elevation of pulmonary vascular resistance especially with cyanotic hea diseases the moality may be raised to 50%( Eisenmengers syndrome) Most of the deaths occur due to cardiac failure and maximum deaths occurs following bih. Management Of Cardiac Failure: The principle if management is same as in the non-pregnant women. A cardiologist should be involved Propped up position O2 Adminstration Monitoring with ECG and pulse oximetry Diuretic: Frusemide (40-80mg) IV - Anticipatory aggresive diuresis is needed to avoid pulmonary congestion. Mechanical Ventilation Injection morphine 15mg IM Digoxin 0.5mg IM followed by Tab.Digoxin 0.25mg P/O Dysrhythmias -Quinidine or electrica cardiaversion Tachyarhymias -Adenosine(3-12mg) IV or DC conversion. Reference: D.C.Dutta's Textbook of Obstetrics; 9th edition; Page no: 258 & 260

Medical, surgical and gynaecological illness complicating pregnancy


Question: Ovarian follicles produce increased amounts of Oestrogen and inhibin during

During mid follicular phase, follicles produce increased amounts of oestrogen and inhibin, resulting in decline in FSH levels through negative feed back.


Question: Risk of HIV transmission is highest during


Question: A female of 35yrs old that has completed her family is having asymptomatic 10 weeks size fibroid . The most appropriate management is

Indications of hysterectomy : It&;s called removal of uterus .is indicated in a woman over 40years of age.multiparous woman or when associated with malignancy uncontrolled haemorrhage and unforeseen surgical difficulties during myomectomy for the above case given observation and myomectomy may be appropriate for management However in these conditions hysterectomy should be performed at any cost Abdominal benign: Menorrhagia Uterine fibromyoma Adenomyosis Tubo ovarian mass Carcinoma insitu Atypical endometrial hyperplasia Endometriosis malignancy: Ca.of cervix Ca.of endometrium Ca.ovary Uterine sarcoma mixed mesodermal tumor Choriocarcinoma Obstetric: Rupture of uterus pPH ,molar pregnancy Ca.cervix vaginal: Prolapse Ca.insitu Ca.cervix+ lymphadenectomy Menorrhagia uterine fibroid Genital prolapse In case of asymptomatic condition, wait and watch is the correct option... Following every year with scans to check the size of fibroid Ref Shaw 16/e pg 405,406

Hysterectomy with bilateral salpingoophorectomy


Question: HIV Positive Primi Near Term, Advice Given isa) Treatment should be started before labourb) Avoid mixing of blood intrapartamc) Vaginal delivery preferredd) Ceaserian section would be decrease transmission of HIV to baby


Question: Ureter pierces the following structure in pelvis

Ureter pierces Mackenrodt's ligament where a canal, the ureteric canal is developed.


Question: To avoid conception, DMPA is given


Question: In carcinoma cervix, the causative etiological factor is


Question: Puerperium is the period

Purperium begins as soon as the placenta is expelled and lasts for approximately 6wks when the uterus becomes regressed almost to the nonpregnant size.


Question: Vaginal delivary is contraindicated in

A. i.e. (Central placenta previa) (252 - Dutta 6th)Indication of caesarean section in APH are1. Severe degree of placenta praevia ( Type IIposterior,Type III (Incomplete or partil central) Type IV (central or total). This is indicated for maternal interest even where the baby is dead2. Lesser degree of placenta praevia where amniotomy fails to stop bleeding or fetal distress appears3. Complicating factors associated with lesser degrees of placenta praevia where vaginal delivery is unsafe* Type II posterior is dangerous placenta**


Question: Capillary invasion of corpus luteum begins

Capillary invasion begins 2 days after ovulaton and reaches center of corpus luteum by 4th day.


Question: Most common site of metastasis in choriocarcinoma

(Lung) (233 - Shaw's 14th)CHORIOCARCINOMA - Malignant growths arising in the body of uterus* Most common, metastases are seen in the lungs (80%), brain and liver* Less common sites are GIT, kidney, spleen, genital tract and lymphnodes (10%)* "Cannon ball" metastasis in lung is typical of a malignant lesion* beta - hCG is very specific marker*** Purple haemorrhagic projections either into the lower third of the vagina or around the vaginal orifice is characteristic and pathognomic of chorio carcinoma* The development of chorio carcinoma following H. mole ranges between 2 - 10%* A post molar GTN may be benign or malignant. But a GTN after non-molar pregnancy is always a choriocarcinoma (201 - Dutta 6lh)


Question: A female with recurrent aboion and isolated prolonged APTT is most likely associated with

Lupus anticoagulant They have asked about antiphospholipid antibody syndrome. Antiphospholipid antibodies account for 3% to 5% of patients with repetitive pregnancy losses. The frequency of fetal death and recurrent aboion in untreated patients with antiphospholipid antibodies is greater than 90%. There are several antiphospholipid antibodies. The most relevant to obstetricians are: - The lupus anticoagulant (LAC), - The anticardiolipin antibody and - The antibody that cause false positive syphilis test (BFP-ST). The name lupus anticoagulant was derived from the fact that this antibody was found first in patients with systemic lupus erythematosus and acted as an anticoagulant by prolonging the paial thromboplastin time (PTT). This name was a poor choice because soon it was found that lupus anticoagulant was present in many patients who did not have lupus and that in majority of patients the antibody was responsible for episodes of thrombosis, rather than anticoagulation. In the laboratory, LAC is not measured directly. - It is assessed by its effect on PTT and the kaolin clotting time. - Typically patients with lupus anticoagulant have a prolonged PTT and a normal PT. - Unfounately, a normal PTT does not exclude the possibility of LAC, and if the clinical suspicion is strong and the PIT is normal a kaolin clotting time or a dilute Russel viper venom time should be performed. - It has also been found that some patients with LAC and recurrent aboions have elevated values of serum 1gM. Other antiphospholipid antibodies The anticardiolipin antibody is the antiphospholipid antibody, most commonly found in patients with repetitive early pregnancy losses. Anlicardiolipin antibody is found in 90% of patients with L.A.C. but the majority of patients with positive anticardiolipin antibody do not have L.A.C. - Anticardiolipin antibody is measured in the laboratory by the ELISA test. BFP-ST - It is the less common antiphospholipid antibody. - Both BFP-ST and Anticardiolipin antibody, measure the antibody against cardiolipin but they are not the same. Clinical features of antiphospholipid antibodies. The presence of any or several of the three antiphospholipid antibodies is associated with - Recurrent early pregnancy losses. - Episodes of venous and aerial thrombosis - Severe preeclampsia - Chorea gravidarum - Pilo ischemic strokes, transient ischemic episodes, migraine headaches. - Postpaum complications such as pulmonary infiltrates, fever, and cardiac symptoms. Aboions in antiphospholipid antibody syndrome - Typically these patients give a history of a live fetus documented by ultrasound or by Doppler before demise or aboion occurs. The majority of the pregnancy losses occur between 14 and 18 weeks. Fetal death is these patients is caused by extensive thrombosis of the placental vessels and the placenta is usually smaller than expected for the gestational age.


Question: Most common cause of intrauterine infection

Ans. is 'd' Cytomegalovirus Most common cause of intrauterine infection is cytomegalovirus.


Question: Nile blue sulphatase test in amniotic fluid is for

Nile blue sulphate test - Place on a slide, one drop of amniotic fluid and add one drop of 0.1% Nile blue sulphate. Place on slide with a cover slip and observe under high power microscope. More than 50% foetal squamous cells becoming orange in colour is considered as an indicator of foetal lung maturity. ( Please note: NBS test is NOT for Skin maturity)


Question: Normal menstrual cycle duration in an adolescent is

Parameters for Normal Menstrual Cycles in AdolescentsParameterNormalMenstrual cycle frequency21 - 45 daysCycle variation from cycle to cycleLess than adultsDuration of flow4 - 8 daysVolume of flow4 - 80mlParameters for Normal Menstrual Cycles in Reproductive age womenParameterNormalMenstrual cycle frequency24 - 38 daysCycle variation from cycle to cycle2 - 20 daysDuration of flow4 - 8 daysVolume of flow4 - 80ml


Question: Aspermia is the term used to describe

Aspermia- means no semen Azoospermia- no sperm in semen Asthenospermia-no motile sperms or diminished motility
Teratospermia- abnormal morphology of sperms.


Question: To diagnose prolonged latent phase in a nulliparous women, latent phase should be prolonged for

ParityProlonged latent phaseNulliparous> 20 hoursMultiparous> 14 hoursReference: William's Obstetrics; 25th edition; Chapter 23; Abnormal Labor


Question: Hormone therapy is not indicated in

Ans. (b) CVDRef: Shaw's Textbook of Gynecology 16th Ed; Page No-74Hormone Replacement TherapyBenefits and risks* Estrogen therapy is the most effective FDA-approved method for relief of menopausal vasomotor symptoms (hot flashes), it is also used in genitourinary atrophy and dyspareunia.* Hot flashes:# Excess amount of sweating and sensation of heat is felt by 75% of menopausal women.# It is mediated through the hypothalamic thermoregulatory center.# Due to peripheral conversion of androgens to estrone in their peripheral adipose tissues; obese women are less commonly to undergo hot flashes.* The Womens Health Initiative (WHI) study of the National Institutes of Health (NIH) studied 27,000 postmenopausal women with a mean age of 63 years. These included women with a uterus on hormone therapy (HT), both estrogen and progestin, and hysterectomized women on estrogen therapy (ET) only.Critique of Women's Health Initiative StudyExcludes patients with vasomotor symptoms* Primary indication for hormone replacementMean patient age was 63 years* Missed the 10-year "window of opportunity"Same dose of hormone for all ages* Older women don't need as a high dose as do younger womenPatients were not all healthy* Hypertension (40%), | cholesterol (15%), diabetes mellitus (7%), myocardial infarction (3%)* Benefits: Both HT and ET groups in WHI had decreased osteoporotic fractures and lower rates of colorectal cancer.* Risks: Both HT and ET groups in WHI were found to have small increases in deep vein thrombosis (DVT). The HT group also had increased heart attacks and breast cancer, but these were not increased in the ET group.WHI-Benefit and Risk (Mean Age of 63 Years) Estrogen and progestinEstrogen onlyVaginal drynessBenefitBenefitHot flashesBenefitBenefitVasomotor symptomsBenefitBenefitOsteoporosisBenefitBenefitBreast cancerRiskNo changeHeart diseaseRiskNo changeStrokeRiskRiskContraindications* Personal history of an estrogen-sensitive cancer (breast or endometrium), active liver disease, active thrombosis, or unexplained vaginal bleedingModalities* The route of Estrogen can be administered by oral, transdermal, vaginal, or parenteral routes.* All routes will yield the benefits described. Estrogen is contraindicated in Women with uterus cancer.* All women with uterus cancer should be treated with progestin therapy to prevent endometrial hyperplasia.* The most common current regimen is oral estrogen and progestin given continuously.


Question: Treatment of choice for adenomyosis is

Treatment of adenomyosis: Diagnostic hysteroscopy combined with curretage is the initial management Total hysterectomy is the treatment in elderly Ref: Shaw Gynecology 17 e pg 186.


Question: A 28 yrs old lady, is suspected to have polycystic ovarian disease ,sample for testing LH and FSH are best taken on the following days of menstrual cycle

In PCOD Determination of FSH and LH may help to confirm the diagnosis of poly cystic ovaries . These are assayed on the second or third day of cycle Lutenizing Hormone (LH) and Follicle Stimulating Hormone (FSH) LH and FSH are the hormones that encourage ovulation. Both LH and FSH are secreted by the pituitary gland in the brain. At the beginning of the cycle, LH and FSH levels usually range between about 5-20 mlU/ml. Most women have about equal amounts of LH and FSH during the early pa of their cycle. However, there is a LH surge in which the amount of LH increases to about 25-40 mlU/ml 24 hours before ovulation occurs. Once the egg is released by the ovary, the LH levels goes back down. While many women with PCOS still have LH and FSH still within the 5-20 mlU/ml range, their LH level is often two or three times that of the FSH level. For example, it is typical for women with PCOS to have an LH level of about 18 mlU/ml and a FSH level of about 6 mlU/ml (notice that both levels fall within the normal range of 5-20 mlU/ml). This situation is called an elevated LH to FSH ratio or a ratio of 3:1. This change in the LH to FSH ratio is enough to disrupt ovulation. While this used to be considered an impoant aspect in diagnosing PCOS, it is now considered less useful in diagnosing PCOS, but is still helpful when looking at the overall picture. Ref jeffcoate 6/e ,pg 205