FMGE 2019 - Obstetrics and Gynecology Practice Questions

Q: Which of the following can be a cause of Oligohydramnios?

Renal agenesis. ***Renal agenesis*** - **Fetal urine production** is the primary source of **amniotic fluid** in the latter half of pregnancy, so **bilateral renal agenesis** prevents this production. - Oligohydramnios due to renal agenesis is often associated with **Potter sequence**, characterized by facial anomalies, limb deformities, and pulmonary hypoplasia due to prolonged severe oligohydramnios. *Macrosomia* - **Macrosomia** (large baby) is not a cause of oligohydramnios; a larger fetus does not directly reduce amniotic fluid volume. - In fact, conditions like **gestational diabetes** which can cause macrosomia, are often associated with **polyhydramnios** (excess amniotic fluid) due to increased fetal urination. *Multiparity* - **Multiparity** (having had multiple previous pregnancies) is not directly associated with oligohydramnios. - While it can be a risk factor for certain pregnancy complications, it does not physiologically lead to reduced amniotic fluid. *Twins* - A multifetal pregnancy, such as **twins**, can sometimes be associated with complications like **twin-to-twin transfusion syndrome**, where one twin might develop oligohydramnios and the other polyhydramnios. - However, the presence of twins itself does not intrinsically cause oligohydramnios; it is a potential complication of specific twin types or their pathologies rather than a direct cause.

Q: Absolute contraindication of IUCD is?

Acute PID. ***Acute PID*** - **Acute pelvic inflammatory disease (PID)** is an absolute contraindication for IUCD insertion because the device can potentially worsen the existing infection or spread it further into the uterus and fallopian tubes. - Inserting an IUCD in the presence of acute PID significantly increases the risk of serious complications, including **sepsis** and **infertility**. *Previous history of abortion* - A **previous history of abortion** is generally not an absolute contraindication for IUCD insertion; rather, it may be a relative contraindication depending on factors such as the recency of the abortion or presence of infection risks. - IUCDs can be safely inserted after an abortion if there are no signs of infection and the uterus has involuted sufficiently. *Breast cancer* - **Breast cancer** is primarily a contraindication for **hormonal contraceptives** (like hormonal IUCDs) due to the potential estrogen or progestin sensitivity of certain cancers. - However, **copper IUCDs** (which are non-hormonal) are generally safe to use in patients with a history of breast cancer. *PCOD* - **Polycystic ovary syndrome (PCOS)** is not a contraindication for IUCD insertion; in fact, hormonal IUCDs can sometimes be beneficial in managing symptoms like heavy menstrual bleeding associated with PCOS. - IUCDs do not interfere with the underlying pathophysiology of PCOS.

Q: Late rupture of tubal pregnancy is seen in?

Interstitial. ***Interstitial*** - The interstitial portion of the fallopian tube is the segment that passes through the **myometrium** of the uterus. This muscular wall provides greater distensibility and support, allowing the pregnancy to grow for a longer period before rupture. - Rupture in the interstitial part typically occurs later (around **8-12 weeks**) and is often more catastrophic due to its proximity to the **uterine blood vessels**, leading to severe hemorrhage. *Fimbriae* - Pregnancies rarely implant in the fimbriae, and if they do, they are more likely to undergo **tubal abortion** rather than rupture. - The fimbriae are finger-like projections at the end of the fallopian tube which is why they cannot hold pregnancy for a longer duration. *Ampulla* - The ampulla is the **widest part** of the fallopian tube and is the most common site of ectopic pregnancy (about 70%). - Rupture in the ampulla typically occurs earlier, around **6-8 weeks**, as its wall is thinner and less distensible compared to the interstitial segment. *Isthmus* - The isthmus is a **narrower, more muscular** segment of the fallopian tube. - Pregnancy in the isthmus tends to rupture early (around **4-6 weeks**) because the lumen is very narrow and the wall is rigid, accommodating very little expansion.

Q: Lady presents with infertility and diagnosed with bilateral cornual block on hysterosalpingography. What is the next step?

Laparoscopy and hysteroscopy. ***Laparoscopy and hysteroscopy*** - A **laparoscopy** allows for direct visualization of the fallopian tubes to confirm the tubal obstruction and assess for other pelvic pathology like **endometriosis** or **adhesions**. - A **hysteroscopy** can be performed concurrently to inspect the uterine cavity and the tubal ostia for any intracavitary abnormalities or to attempt **canalization of the cornual block**. *Tuboplasty* - **Tuboplasty** is a corrective surgical procedure for tubal obstruction, but it is typically considered *after* a definitive diagnosis and assessment of the block's extent have been made via diagnostic procedures. - Its success rate varies depending on the location and nature of the block, and it is not the immediate next step for diagnosis. *USG* - **Transvaginal ultrasonography (USG)** is a useful tool for evaluating uterine and ovarian morphology but is generally *not definitive* for diagnosing tubal patency or specific locations of tubal blockage. - While it can identify some pathologies, it cannot visualize the fallopian tubes with sufficient clarity to determine cornual obstruction. *IVF* - **In vitro fertilization (IVF)** is an *assisted reproductive technology* used to bypass tubal factor infertility, but it is a treatment option, not a diagnostic step. - It would be considered *after* a full diagnostic workup has confirmed the tubal blockage and other fertility factors, and after counseling regarding prognosis and success rates.

Q: What is the dose of mifepristone in emergency contraception?

10 mg. ***10 mg*** - **10 mg is the WHO-recommended dose** of mifepristone for emergency contraception. - This single dose is **equally effective** as higher doses (25-50 mg) and works primarily by **delaying or inhibiting ovulation**. - It has been validated through **multiple international clinical trials** and is the standard regimen used globally. - When taken within **72-120 hours** of unprotected intercourse, it significantly reduces pregnancy risk. *25 mg* - While 25 mg of mifepristone has been studied for emergency contraception and shows efficacy, it is **not the standard recommended dose**. - The **10 mg dose is preferred** as it achieves similar efficacy with potentially fewer side effects and lower cost. - Some countries may use 25 mg, but **WHO guidelines recommend 10 mg** as the optimal dose. *200 mg* - A 200 mg dose of mifepristone is typically utilized for **medical abortion regimens**, often in combination with a prostaglandin analog (misoprostol). - This dosage achieves a different pharmacological effect, leading to **detachment of the embryo** and uterine contractions. - This is **far higher than needed** for emergency contraception purposes. *200 mcg* - **Mifepristone is not dosed in micrograms** (mcg) for emergency contraception or medical abortion; it is measured in milligrams (mg). - This unit and dosage are more commonly associated with other medications, such as **misoprostol** when used for obstetric indications. - 200 mcg would be 0.2 mg, which is **subtherapeutic** for any mifepristone indication.

Q: 32 years old lady with twin dichorionic diamniotic pregnancy, first baby breech presentation and second baby cephalic presentation. What is the management?

C - Section. ***C-Section*** - When **twin A is in breech presentation** in a dichorionic diamniotic twin pregnancy, **elective Cesarean section** is the recommended mode of delivery according to ACOG and most international guidelines. - The primary concern is the **increased risk of complications with breech delivery** of the first twin, including **head entrapment**, **cord prolapse**, and **birth trauma**. - While twin B is cephalic (which would be favorable for vaginal delivery if it were the presenting twin), the non-cephalic presentation of twin A dictates the mode of delivery for both twins. *Assisted breech* - While breech extraction may be considered in select cases where **twin A is cephalic and twin B is breech**, attempting vaginal breech delivery when twin A presents as breech is generally not recommended. - The risks of breech delivery for the first twin include **difficulty delivering the aftercoming head**, **cord prolapse**, and **birth asphyxia**, which are unacceptable in an elective situation where cesarean section is readily available. *Instrumental delivery* - Instrumental delivery (forceps or vacuum) is used to assist delivery of a **cephalic presentation** in the second stage of labor. - It cannot be used for **breech presentation** of twin A, making it inappropriate as a primary management strategy in this scenario. *Normal vaginal delivery* - Vaginal delivery with **twin A in non-cephalic (breech) presentation** is contraindicated in most modern obstetric guidelines due to significantly increased perinatal morbidity and mortality. - Even though twin B is cephalic, the presentation of twin A determines the overall delivery approach in twin pregnancies.

Q: Risk of endometrial cancer is least in:

Multipara. ***Multipara*** - **Multiparity** (having multiple successful pregnancies) is associated with a reduced risk of **endometrial cancer**. Each pregnancy provides a period of reduced estrogen exposure and increased progesterone, which is protective against endometrial hyperplasia. - The protective effect is thought to be cumulative, with **higher parity** correlating with a lower risk. *Late menopause* - **Late menopause** prolongs the duration of lifetime exposure to endogenous unopposed estrogen, which significantly increases the risk of **endometrial cancer**. - Estrogen stimulates **endometrial proliferation**, and continued exposure without the counter-regulatory effects of progesterone (as seen in later menopause) can lead to atypical hyperplasia and malignancy. *A positive family history* - A **positive family history** of endometrial cancer suggests a genetic predisposition, which is a significant **risk factor**. - Conditions like **Lynch syndrome** (hereditary non-polyposis colorectal cancer or HNPCC) are strongly associated with an increased risk of endometrial cancer. *Obesity* - **Obesity** is a major risk factor for **endometrial cancer** due to increased peripheral conversion of androgens to estrogens in adipose tissue. - This leads to higher levels of **unopposed estrogen**, promoting endometrial proliferation and increasing cancer risk.

Q: A 35-year-old woman at 36 weeks of gestation presents with a history of 5 convulsions at home. Her BP is 170/100 mmHg. The diagnosis made by the doctor is eclampsia. What is the next management?

MgSO4 + Labetalol. ***MgSO4 + Labetalol*** - The patient presents with **eclampsia**, characterized by convulsions and severe hypertension (BP 170/100 mmHg) during pregnancy. Magnesium sulfate (**MgSO4**) is the **first-line treatment for preventing and managing eclamptic seizures**. - **Labetalol** is an appropriate antihypertensive for **severe hypertension in pregnancy** (BP ≥160/110 mmHg) and must be used concurrently with MgSO4 to control the high blood pressure and prevent maternal complications like stroke or placental abruption. - Both medications are required for comprehensive management of eclampsia with severe hypertension. *Clonidine* - **Clonidine** is an alpha-2 adrenergic agonist used to treat hypertension but is **not the first-line antihypertensive choice in acute eclampsia** due to potential sedative effects and slower onset compared to other agents like Labetalol, Hydralazine, or Nifedipine. - While it can lower blood pressure, it **does not address the seizure risk** in eclampsia. *Only Labetalol* - While **Labetalol** is crucial for managing severe hypertension, treating eclampsia requires both seizure control and blood pressure management. Administering only Labetalol would **fail to prevent recurrent seizures**, which is the primary life-threatening concern. - It would adequately lower blood pressure but **does not address the underlying seizure pathology** of eclampsia. *Only MgSO4* - **MgSO4** is essential for seizure prophylaxis and treatment in eclampsia. However, in this patient with a blood pressure of **170/100 mmHg (severe hypertension)**, **MgSO4 alone would not adequately control the severe hypertension**, which poses risks of maternal complications like stroke, intracerebral hemorrhage, or placental abruption. - While it prevents seizures effectively, it **does not sufficiently manage severe maternal hypertension**, requiring an additional antihypertensive agent like Labetalol.

Q: hCG is secreted by?

Syncytiotrophoblast. ***Syncytiotrophoblast*** - The **syncytiotrophoblast** is the outer layer of the trophoblast that invades the uterine wall and is responsible for producing human chorionic gonadotropin (**hCG**). - Production of **hCG** by the **syncytiotrophoblast** begins shortly after implantation and is crucial for maintaining the **corpus luteum** and thus **progesterone** secretion during early pregnancy. *Cytotrophoblast* - The **cytotrophoblast** is the inner layer of the trophoblast that proliferates and differentiates into the **syncytiotrophoblast**. - While essential for placental development, the **cytotrophoblast** itself does not directly secrete **hCG**. *Yolk sac* - The **yolk sac** is involved in early nourishment of the embryo and plays a role in the formation of **primitive blood cells** and **germ cells**. - It does not produce **hCG**; its main functions are related to nutrition and hematopoiesis before the placenta is fully functional. *Decidua* - The **decidua** is the modified endometrial lining of the uterus during pregnancy, derived from **maternal tissue**. - It does not produce **hCG** as it is maternal in origin, whereas **hCG** is produced by fetal-derived **trophoblastic cells**.

Q: The contraceptive which is contraindicated in DVT is?

OCP. ***OCP*** - **Oral contraceptive pills (OCPs)**, especially those containing estrogen, increase the risk of **venous thromboembolism (VTE)**, including deep vein thrombosis (DVT). - Estrogen promotes a **hypercoagulable state** by increasing clotting factors and decreasing natural anticoagulants. *Barrier method* - **Barrier methods** like condoms or diaphragms are non-hormonal and act physically to prevent sperm from reaching the egg. - They have **no systemic effects** on coagulation and are safe for individuals with DVT. *Non hormonal IUCD* - **Non-hormonal intrauterine contraceptive devices (IUCDs)**, such as copper IUCDs, prevent conception primarily by causing a local inflammatory reaction in the uterus. - They do not release hormones and therefore **do not affect coagulation** or increase DVT risk. *Billing's method* - The **Billing's ovulation method** (cervical mucus method) is a natural family planning technique based on observing changes in cervical mucus. - It involves no medications or devices and thus has **no impact on DVT risk**.

Question 1

Which of the following can be a cause of Oligohydramnios?

Accepted Answer

Renal agenesis

Answer

Macrosomia

Answer

Multiparity

Answer

Twins

Question 2

Absolute contraindication of IUCD is?

Accepted Answer

Acute PID

Answer

Previous history of abortion

Answer

Breast cancer

Answer

PCOD

Question 3

Late rupture of tubal pregnancy is seen in?

Accepted Answer

Interstitial

Answer

Fimbriae

Answer

Ampulla

Answer

Isthmus

Question 4

Lady presents with infertility and diagnosed with bilateral cornual block on hysterosalpingography. What is the next step?

Accepted Answer

Laparoscopy and hysteroscopy

Answer

Tuboplasty

Answer

USG

Answer

IVF

Question 5

What is the dose of mifepristone in emergency contraception?

Accepted Answer

10 mg

Answer

25 mg

Answer

200 mcg

Answer

200 mg

Question 6

32 years old lady with twin dichorionic diamniotic pregnancy, first baby breech presentation and second baby cephalic presentation. What is the management?

Accepted Answer

C - Section

Answer

Assisted breech

Answer

Instrumental delivery

Answer

Normal vaginal delivery

Question 7

Risk of endometrial cancer is least in:

Accepted Answer

Multipara

Answer

Late menopause

Answer

A positive family history

Answer

Obesity

Question 8

A 35-year-old woman at 36 weeks of gestation presents with a history of 5 convulsions at home. Her BP is 170/100 mmHg. The diagnosis made by the doctor is eclampsia. What is the next management?

Accepted Answer

MgSO4 + Labetalol

Answer

Clonidine

Answer

Only Labetalol

Answer

Only MgSO4

Question 9

hCG is secreted by?

Accepted Answer

Syncytiotrophoblast

Answer

Cytotrophoblast

Answer

Yolk sac

Answer

Decidua

Question 10

The contraceptive which is contraindicated in DVT is?

Accepted Answer

OCP

Answer

Barrier method

Answer

Non hormonal IUCD

Answer

Billing's method

FMGE 2019 — Obstetrics and Gynecology