UPSC-CMS 2023 - Obstetrics and Gynecology Practice Questions

Q: A 40-year-old woman presents with excessive menstrual bleeding. The most appropriate first surgical treatment will be

Hysteroscopy. ***Hysteroscopy*** - This procedure allows for **direct visualization of the uterine cavity**, enabling the identification and potential treatment of intracavitary causes of excessive menstrual bleeding, such as polyps or fibroids. - It is considered the **first-line surgical diagnostic and therapeutic approach** for abnormal uterine bleeding when medical management fails or a structural cause is suspected. *Hysterectomy* - While it definitively treats excessive menstrual bleeding by **removing the uterus**, it is generally considered a **definitive and more invasive treatment** reserved for cases where conservative methods have failed or when the patient desires no future pregnancies. - As a first surgical option, it is **overly aggressive** without first attempting less invasive diagnostic and therapeutic procedures. *Myomectomy* - This procedure involves the **surgical removal of uterine fibroids**, which can cause excessive menstrual bleeding. - However, performing a myomectomy without first **diagnosing the presence and location of fibroids** (which hysteroscopy can help identify) is not the appropriate first surgical step. *Dilatation and curettage* - This procedure involves the **scraping of the uterine lining** and can provide a sample for pathology, offering temporary relief from bleeding. - It is primarily a **diagnostic procedure** to obtain endometrial tissue and may offer temporary symptomatic relief, but it is less effective for treating structural causes and is not the most appropriate first-line surgical treatment in terms of diagnostic precision and targeted therapy for all causes of excessive bleeding compared to hysteroscopy.

Q: A 15-year-old unmarried girl presents with complaints of dysmenorrhoea for about one year. She achieved menarche at 12 years of age. On abdominal and rectal examination, she has no abnormality. What will be the most appropriate management?

Reassure her and prescribe analgesics. ***Reassure her and prescribe analgesics*** - This presentation is typical for **primary dysmenorrhea**, which is common in adolescent girls and not associated with underlying pathology. - Initial management involves **reassurance** about the benign nature of the condition and symptomatic relief with **analgesics**, particularly **NSAIDs**. *Prescribe clotrimazole vaginal ovules* - **Clotrimazole** is an antifungal medication indicated for candidal vaginitis, which is not suggested by the presented symptoms or examination findings. - Dysmenorrhea is pain associated with menstruation, not typically a symptom of **vaginal infection**. *Perform dilatation and curettage* - **Dilatation and curettage (D&C)** is an invasive surgical procedure used for various uterine conditions, such as abnormal uterine bleeding or miscarriage. - It is completely inappropriate for the initial management of **primary dysmenorrhea** in an adolescent with a normal examination. *Prescribe antibiotics* - **Antibiotics** are indicated for bacterial infections, which are not suggested by the patient's complaints of dysmenorrhea and normal abdominal/rectal examination. - There is no clinical evidence of **pelvic inflammatory disease** or other infectious causes.

Q: Asherman's syndrome typically results from

Excessive curettage during abortion. ***Excessive curettage during abortion*** - **Asherman's syndrome** is characterized by the formation of **intrauterine adhesions** or **synechiae** - This results from trauma to the **basal layer of the endometrium** during procedures like excessive or repeated curettage following abortion, miscarriage, or childbirth - The curettage causes scarring that leads to partial or complete obliteration of the uterine cavity - **Most common cause** of intrauterine adhesions and presents with amenorrhea, hypomenorrhea, or infertility *Post-partum haemorrhage* - While post-partum hemorrhage can lead to uterine procedures, it is not a direct cause of Asherman's syndrome itself - The syndrome is caused by the **curettage performed** to manage the hemorrhage or retained products, not the hemorrhage directly - PPH is an indication for intervention, but the procedural trauma causes the adhesions *Prolonged usage of oral contraceptives* - Oral contraceptives work by suppressing ovulation and altering the endometrial lining - They cause endometrial thinning but do not cause physical trauma to the endometrium - They do not lead to the formation of intrauterine adhesions characteristic of Asherman's syndrome *Use of intrauterine contraceptive device* - An **intrauterine contraceptive device (IUD)** prevents pregnancy by causing a sterile inflammatory reaction - While IUDs can cause endometritis or perforation in rare cases, they do not typically lead to the severe endometrial trauma and subsequent adhesion formation seen in Asherman's syndrome - Asherman's syndrome requires basal endometrial damage, which IUDs do not typically cause

Q: A 30-year-old woman with three children has dysfunctional uterine bleeding. What will be the most appropriate management?

Levonorgestrel-releasing intrauterine device. ***Levonorgestrel-releasing intrauterine device*** - The **levonorgestrel-releasing intrauterine device (Mirena IUD)** is highly effective for reducing **menstrual blood loss** in women with **dysfunctional uterine bleeding (DUB)** due to its local endometrial suppression. - It is an excellent choice for a 30-year-old woman with three children as it offers both **contraception** and **menstrual bleeding control** without permanent sterilization. *Medical management with danazol* - **Danazol** is an **androgen derivative** that can cause significant **androgenic side effects** such as hirsutism and voice changes, making it less desirable for long-term use. - While effective in reducing menstrual blood loss, it is typically reserved for severe cases or when other treatments fail due to its side effect profile. *Transcervical endometrial resection* - **Transcervical endometrial resection**, or **endometrial ablation**, is an effective procedure for reducing heavy menstrual bleeding but is generally considered for women who have completed childbearing and do not desire future pregnancies. - While this patient has three children, the IUD offers a less invasive, reversible, and effective alternative before resorting to surgical intervention. *Abdominal hysterectomy* - **Abdominal hysterectomy** is a major surgical procedure and is considered a definitive treatment for dysfunctional uterine bleeding, but it is the most invasive option. - Given the patient's age and the availability of less invasive and effective treatments, hysterectomy would typically be reserved for cases where conservative treatments have failed or other gynecological pathologies are present.

Q: The following hormonal changes mark the Polycystic Ovarian Disease except

Raised LH, Raised FSH. ***Raised LH, Raised FSH*** - In **Polycystic Ovarian Syndrome (PCOS)**, the characteristic LH/FSH ratio is typically **high LH and low-to-normal FSH**, not elevated levels of both. - A simultaneous elevation of both **LH and FSH** is more indicative of **primary ovarian failure** rather than PCOS, as the ovaries would no longer be producing sufficient hormones, leading to increased pituitary stimulation. *Raised LH, Low-to-normal FSH* - This hormonal pattern is a hallmark of **PCOS**, where the **increased LH** stimulates the ovarian theca cells to produce excess androgens. - The **low or normal FSH** prevents proper follicular development, contributing to anovulation and cyst formation. *Hyperinsulinaemia* - **Insulin resistance** and compensatory **hyperinsulinaemia** are very common findings in PCOS, driving increased ovarian androgen production. - High insulin levels potentiate the effect of LH on ovarian androgen synthesis and suppress hepatic production of sex hormone-binding globulin (SHBG). *Hyperandrogenism* - **Hyperandrogenism**, characterized by elevated levels of androgens (e.g., testosterone), is a central feature of PCOS and responsible for symptoms like hirsutism, acne, and alopecia. - This excess androgen production originates primarily from the ovaries and, to some extent, the adrenal glands, often exacerbated by hyperinsulinaemia.

Q: A 13-year-old, obese, unmarried girl presents with the history of amenorrhea and cyclical abdominal pain. On examination, the secondary sex characters are found to be well developed. What should be the next step?

Carry out a per-rectal examination. ***Carry out a per-rectal examination*** - This presentation of **amenorrhea with cyclical abdominal pain** in a girl with developed secondary sexual characteristics strongly suggests a **cryptomenorrhea** caused by an outflow tract obstruction, like an **imperforate hymen**. - A **per-rectal examination** can help identify a bulging hymen or a pelvic mass due to retained menstrual blood (hematocolpos or hematometra), which would guide further management. *Carry out the progesterone challenge test* - A progesterone challenge test assesses the presence of **estrogenization of the endometrium** and a patent outflow tract, but it is typically used for secondary amenorrhea or primary amenorrhea without cyclical pain. - In this case, **cyclical pain** points towards an obstructed outflow tract, making the challenge test less immediate than ruling out the obstruction. *Keep her under observation for the next three months* - Observing for three months would delay the diagnosis and definitive treatment of a potentially painful and concerning condition like **hematocolpos**. - Delaying intervention could lead to worsening pain, complications like **endometriosis**, or impact fertility. *Assess the TSH and Prolactin levels* - While hormonal imbalances can cause amenorrhea, the presence of **cyclical abdominal pain** and **developed secondary sexual characteristics** makes a primary outflow tract obstruction a more likely immediate concern. - **Hypothyroidism** (high TSH) or **hyperprolactinemia** would typically cause amenorrhea without cyclical pain but could be considered later if obstruction is ruled out.

Q: A woman who has secondary amenorrhea experiences withdrawal bleeding following progesterone administration. What is the likely diagnosis?

Anovulation. ***Anovulation*** - Withdrawal bleeding after progesterone indicates that the **endometrium was adequately primed with estrogen** but there was no ovulation to produce progesterone. - This scenario points to **anovulation** as the underlying cause of secondary amenorrhea, where estrogen is present, but a corpus luteum does not form to secrete progesterone. *Asherman's syndrome* - This condition involves **intrauterine adhesions** that prevent endometrial shedding, even in the presence of hormones. - A woman with Asherman's syndrome would typically **not experience withdrawal bleeding** after progesterone, as the endometrium is damaged or absent. *Premature ovarian failure* - In **premature ovarian failure**, the ovaries stop functioning, leading to **low estrogen levels**. - Without sufficient estrogen to prime the endometrium, administering progesterone would **not result in withdrawal bleeding**. *Hypothalamic amenorrhea* - This type of amenorrhea is characterized by **low estrogen levels** due to dysfunction in the hypothalamus. - Similar to premature ovarian failure, a lack of estrogen would mean the endometrium is not prepared, and **progesterone withdrawal bleeding would not occur**.

Q: A woman of child-bearing age develops a second-degree uterine prolapse with supravaginal elongation of the cervix. What will be the most appropriate management?

Fothergill's operation. ***Fothergill's operation*** - This procedure, also known as **mancuni operation**, is ideal for women of childbearing age with **second-degree uterine prolapse** and **supravaginal elongation of the cervix**. - It involves **cervical amputation**, anterior colporrhaphy, and posterior colpoperineorrhaphy, effectively correcting the prolapse while preserving the uterus for future pregnancies. *Sling operation* - A sling operation (e.g., sacrocolpopexy) is primarily used for **vaginal vault prolapse** after hysterectomy, or for severe uterine prolapse when preservation of the uterus is not a priority. - It involves suspending the uterus or vagina using synthetic mesh or biological material, which is not the first-line for this specific presentation in a woman desiring future fertility. *Vaginal hysterectomy and pelvic floor repair* - This approach is typically chosen for women who have **completed childbearing** or do not desire future pregnancies, as it involves removal of the uterus. - While it effectively corrects prolapse, it is not the most appropriate management for a woman of childbearing age who may wish to conceive. *Amputation of the cervix* - While cervical amputation is a component of Fothergill's operation, performing only **cervical amputation in isolation** would not adequately address the entire prolapse or offer sufficient pelvic floor support. - This option is incomplete as a definitive management strategy for uterine prolapse with supravaginal elongation.

Q: The diagnostic criteria for bacterial vaginosis include the following except

Vaginal pH 4.5**, due to the decrease in lactic acid-producing bacteria. *Presence of clue cells* - **Clue cells** are a hallmark of bacterial vaginosis, characterized by vaginal epithelial cells studded with bacteria, obscuring their borders. - Their presence is one of the **Amsel criteria** for diagnosing bacterial vaginosis. *Positive whiff test* - A **positive whiff test** involves adding a drop of 10% potassium hydroxide (KOH) to vaginal discharge, producing a strong, fishy odor. - This odor is due to the release of **amines** produced by anaerobic bacteria, and it is a key diagnostic criterion for bacterial vaginosis. *Homogenous vaginal discharge* - The discharge in bacterial vaginosis is typically described as **thin, milky white, or grayish, and homogenous**. - This characteristic appearance is one of the **Amsel criteria** and helps distinguish it from other forms of vaginitis.

Q: A woman, who is in the reproductively active age group, presents with a history of greenish and frothy vaginal discharge. On examination, she has multiple punctuate strawberry-like spots. What is the likely diagnosis?

Trichomoniasis. ***Trichomoniasis*** - The classic presentation of **greenish, frothy vaginal discharge** coupled with **strawberry cervix (multiple punctate spots)** is highly characteristic of trichomoniasis, caused by the parasite *Trichomonas vaginalis*. - This infection often causes **vaginal itching, irritation**, and dyspareunia. *Chlamydia infection* - Chlamydia often presents with **mucopurulent cervical discharge** and can be **asymptomatic**, but typically does not cause frothy, green discharge or strawberry cervix. - It is more commonly associated with symptoms like **dysuria** or **post-coital bleeding** when symptomatic. *Gonococcal vaginitis* - Gonorrhea typically causes **purulent discharge** that may be yellowish or greenish, but it is not typically frothy. - It is also associated with **dysuria** and pelvic pain, but the strawberry cervix is not a common finding. *Candidiasis* - Candidiasis (yeast infection) typically presents with a **thick, white, curd-like vaginal discharge**, often described as cottage cheese-like. - It is associated with **intense vulvovaginal itching and burning**, but not a frothy discharge or strawberry cervix.

Question 1

A 40-year-old woman presents with excessive menstrual bleeding. The most appropriate first surgical treatment will be

Accepted Answer

Hysteroscopy

Answer

Hysterectomy

Answer

Myomectomy

Answer

Dilatation and curettage

Question 2

A 15-year-old unmarried girl presents with complaints of dysmenorrhoea for about one year. She achieved menarche at 12 years of age. On abdominal and rectal examination, she has no abnormality. What will be the most appropriate management?

Accepted Answer

Reassure her and prescribe analgesics

Answer

Prescribe clotrimazole vaginal ovules

Answer

Perform dilatation and curettage

Answer

Prescribe antibiotics

Question 3

Asherman's syndrome typically results from

Accepted Answer

Excessive curettage during abortion

Answer

Post-partum haemorrhage

Answer

Prolonged usage of oral contraceptives

Answer

Use of intrauterine contraceptive device

Question 4

A 30-year-old woman with three children has dysfunctional uterine bleeding. What will be the most appropriate management?

Accepted Answer

Levonorgestrel-releasing intrauterine device

Answer

Medical management with danazol

Answer

Transcervical endometrial resection

Answer

Abdominal hysterectomy

Question 5

The following hormonal changes mark the Polycystic Ovarian Disease except

Accepted Answer

Raised LH, Raised FSH

Answer

Raised LH, Low-to-normal FSH

Answer

Hyperinsulinaemia

Answer

Hyperandrogenism

Question 6

A 13-year-old, obese, unmarried girl presents with the history of amenorrhea and cyclical abdominal pain. On examination, the secondary sex characters are found to be well developed. What should be the next step?

Accepted Answer

Carry out a per-rectal examination

Answer

Carry out the progesterone challenge test

Answer

Keep her under observation for the next three months

Answer

Assess the TSH and Prolactin levels

Question 7

A woman who has secondary amenorrhea experiences withdrawal bleeding following progesterone administration. What is the likely diagnosis?

Accepted Answer

Anovulation

Answer

Asherman's syndrome

Answer

Premature ovarian failure

Answer

Hypothalamic amenorrhea

Question 8

A woman of child-bearing age develops a second-degree uterine prolapse with supravaginal elongation of the cervix. What will be the most appropriate management?

Accepted Answer

Fothergill's operation

Answer

Sling operation

Answer

Vaginal hysterectomy and pelvic floor repair

Answer

Amputation of the cervix

Question 9

The diagnostic criteria for bacterial vaginosis include the following except

Accepted Answer

Vaginal pH < 4.5

Answer

Presence of clue cells

Answer

Positive whiff test

Answer

Homogenous vaginal discharge

Question 10

A woman, who is in the reproductively active age group, presents with a history of greenish and frothy vaginal discharge. On examination, she has multiple punctuate strawberry-like spots. What is the likely diagnosis?

Accepted Answer

Trichomoniasis

Answer

Chlamydia infection

Answer

Gonococcal vaginitis

Answer

Candidiasis

UPSC-CMS 2023 — Obstetrics and Gynecology