Q.1. Pregnancy with severely affected Rh Immunised fetus may be complicated by (Bihar/AYUSH/ Homoeo/MO/QP/2014):
a) Polyhydramnios
b) Fetal hydrops
c) Fetal cardiac failure
d) All of the above
Answer: (d)
Note Among the above given variables (d) All of the above – is suggested-for pregnancy with severely affected Rh immunised fetus.
Stem: Rh immunised fetus
Recall
Rh disease (also known as Rhesus iso-immunisation, Rh (D) disease, Rhesus incompatibility, Rhesus disease, RhD hemolytic disease of the newborn, Rhesus D hemolytic disease of the newborn or RhD HDN) is one of the causes of hemolytic disease of the newborn (HDN).
However, owing to preventative methods developed in the 1970s Rh disease has markedly declined. Rh disease can be prevented by administration of anti-D IgG (Rho(D) Immune Globulin) injections to RhD- negative mothers during pregnancy and/or within 72 hours of the delivery. However, a small percentage of pregnant mothers are still susceptible to Rh disease even after having been administered anti-D IgG (Rho(D) Immune Globulin)
Ref: http://en.wikipedia.org/wiki/Rh_disease
Review of variables
a) Polyhydramnios
Polyhydramnios (polyhydramnion, hydramnios, polyhydramnios) is characterized by excess of amniotic fluid in the amniotic sac. Rhesus disease causes the mother’s antibodies to cross the placenta, often resulting in fetal anemia – which is one of the principal causes of Polyhydramnios. Ref: http://en.wikipedia.org/wiki/Polyhydramnios
b) Fetal hydrops
Fetal hydrops is a condition in which a fetus accumulates fluids, usually stems from fetal anaemia. Rh disease is a cause for immune-mediated hydrops foetalis. Ref: http://en.wikipedia.org/wiki/Hydrops_fetalis
c) Fetal cardiac failure
Hydrops foetalis usually stems from fetal anemia, the heart needs to pump a much greater volume of blood to deliver the same amount of oxygen. The increased demand for cardiac output leads to heart failure, and corresponding edema. Ref: http://en.wikipedia.org/wiki/Hydrops_fetalis
Q2. Pregnancy can be first diagnosed by ultrasound at (Bihar/AYUSH/HMO/2014):
a) 2 weeks
b) 5 weeks
c) 12 weeks
d) 16 weeks
Answer: (b)
Note Among the above given variables (b) 5 weeks – is suggested for pregnancy to be diagnosed by ultrasound.
Recall
Ultrasonography; Intra decidual gestational sac (GS) is identified as early as 29 to 35 days of gestation.
Ref: Pg-68. Textbook of Obstetrics by D.C. Dutta, 7th Ed
Extended information
US can detect early pregnancy and it depends on the visualization of the gestational sac or the embryo. Advanced or past the first 6-8 weeks, a pregnancy is easier to visualize. In general, pregnancy is detectable 25 days after ovulation by transvaginal sonography (usually corresponding to an hCG level of > 1,500 mIU/ml).
Ref: http://www.babymed.com/pregnancy-tests/how-early-can-pregnancy-be-detected-with-a-test#sthash. GGINO6fh.dpuf
Q.3. All of the following are indications for termination of pregnancy in APH EXCEPT:
a) Intra-uterine death
b) 37 weeks
c) Transverse lie
d) Continuous bleeding
Answer: (c)
Note Out of the variable given above (c) Transverse lie – is not an indication for termination of pregnancy in APH
Stem: Antepartum haemorrhage
Recall
Antepartum haemorrhage (APH) is a grave obstetrical emergency and is a leading cause of maternal and perinatal mortality and morbidity. APH is defined as haemorrhage from the genital tract after 20 weeks of gestation but before the delivery of the baby. It complicates about 2-5% of all the pregnancies.
Ref: https://ispub.com/IJGO/9/2/3465
Review of variables
a) Intra-uterine death
Fetal death in-utero is indication for termination of pregnancy. Ref: Pg-249. D.C. Dutta’s Textbook of Obstetrics by Harilal Konar
b) 37 weeks
Indications of definitive management (delivery) is bleeding occurs at or after 37 weeks of pregnancy. Ref: Pg-249. D.C. Dutta’s Textbook of Obstetrics by Harilal Konar
c) Transverse lie
Transverse lie is not an indication for termination of pregnancy
d) Continuous bleeding
Continuous bleeding is an indication for termination of pregnancy. Ref: Pg-249. D.C. Dutta’s Textbook of Obstetrics by Harilal Konar
Q4. DNA analysis of chorionic villus / Amniocentesis is not likely to detect (Bihar/AYUSH/MO/ QP/2014):
a) Tay Sach’s Disease
b) Haemophilia A
c) Sickle cell disease
d) Duchenne muscular dystrophy
Answer: (d)
Note Out of above given variables (d) Duchenne muscular dystrophy – is suggested
Stem: Prenatal diagnostics-DNA analysis of chorionic villus/amniocentesis
Review of variables
(a) Tay Sach’s disease:
It is a rare autosomal recessive genetic disorder. It causes a progressive deterioration of nerve cells and of mental and physical abilities that begins around six months of age and usually results in death by the age of four.
Prenatal tests: Available currently.
Ref: http://en.wikipedia.org/wiki/Tay%E2%80%93Sachs_disease
(b) Haemophilia A:
Hemophilia A is a genetic deficiency in clotting factor VIII, which causes increased bleeding and usually affects males. About 70% of the time it is inherited as an X-linked recessive trait, but around 30% of cases arise from spontaneous mutations.
Prenatal diagnosis: Available currently
(c) Sickle cell disease:
SCD is a hereditary blood disorder, characterized by an abnormality in the oxygen-carrying haemoglobin molecule in red blood cells. The RBC assume an abnormal, rigid, sickle-like shape under certain circumstances. Sickle-cell disease is associated with a number of acute and chronic health problems, such as severe infections, attacks of severe pain (“sickle-cell crisis”), and stroke.
Prenatal diagnosis: Available currently.
(d) Duchenne Muscular dystrophy:
Duchenne muscular dystrophy (DMD) is a recessive X-linked form of muscular dystrophy, affecting around 1 in 3,600 boys, which results in muscle degeneration and eventual death.
Prenatal diagnosis: Available-but currently there are limitations to this diagnosis.
Extended information
The difference between amniocentesis and CVS is that CVS is done much earlier in pregnancy and thus the results are received earlier. CVS is avoided before 11-14 weeks because of reports of limb abnormalities occurring when carried out earlier the 11 weeks. Amniocentesis is done after 15 – 18 weeks.
Q.5. Which part of the fallopian tube is the most common site for ectopic pregnancy (Bihar AYUSH Homoeo/MO/QP/2014):
a) Isthmic
b) Fimbrial
c) Interstitial
d) Ampulla
Answer: (d)
Note Out of above given variables (d) Ampullary part of fallopian tube-is most common site for ectopic pregnancy.
Stem: Most common site for ectopic pregnancy
Recall
The fallopian tube can be divided into 4 parts:
1. Fimbriae: Finger-like, ciliated projections which capture the ovum from the surface of the ovary.
2. Infundibulum: Funnel-shaped opening near the ovary to which fimbriae are attached. Largest and longest (5cm) part.
3. Ampulla: Widest section of the uterine tubes. Fertilization usually occurs here.
4. Isthmus: Narrow section of the uterine tubes connecting the ampulla to the uterine cavity.
Q6. Blood stained discharges from nipple is typical of (Bihar/AYUSH/MO/QP/2014):
a) Intraductal papilloma
b) Fibroadenoma
c) Filarial mastitis
d) Paget’s disease of nipple
Answer: (a)
Note Out of the above-given variables (a) Intraductal papilloma –for blood-stained discharge – is suggested.
Stem: Blood stained discharges from nipple
Review of variables
(a) Intraductal papilloma:
Ductal papilloma causes blood-stained discharge. The cytology of discharge, mammography and Ultrasound locate the lesion. Ductoscopy confirms the nature of the lesion. It can turn malignant and require excision.
Ref: Pg-480, 15th Ed, Shaw’s Textbook of Gynaecology.
Intraductal papillomas of the breast are benign lesions with an incidence of approximately 2-3% most common cause of bloody nipple discharge in women age 20-40 and generally do not show up on mammography due to their small size, so the next step in treatment would be a galactogram to guide the subsequent biopsy.
The masses are often too small to be palpated or felt. A galactogram is, therefore, necessary to rule out the lesion.
Excision is sometimes performed. Microdochectomy /microdochotomy (removal of a breast duct) is the treatment of choice.
Ref: http://en.wikipedia.org/wiki/Intraductal_papilloma
(b) Fibroadenoma:
Fibroadenoma of the breast is a benign tumor. Lumps are easily moveable under the skin, firm, painless and rubbery on palpation. No discharge from nipple. Fibroadenomas are sometimes called breast mice or a breast mouse owing to their high mobility in the breast. A fibroadenoma is usually diagnosed through clinical examination, ultrasound or mammography, and often a needle biopsy sample of the lump.
Ref: http//en.wikipedia.org/wiki/Fibroadenoma
(c) Filarial mastitis:
Acute filarial mastitis is second common filariasis in female’s next to filariasis of limbs. Normally males do not suffer from filarial mastitis. Acute filarial mastitis is common in age 25 to 40 years and very rare after the age of 70 years as well as atrophic breast. It is presented with pain, fever, discomfort in breast and axilla of same side. As soon as the infection becomes localized due to the treatment or due to body’s immune response fever subsides and breast starts swelling. The upper and outer quadrant is more prone to suffer due to more amount of breast tissue. The nipple, areola and skin of breast may be edematous and congested. There may be dimpling of skin due to lymphatic edema.
Ref: Pani’s Filariasis. Pg-59-60
(d) Paget’s disease of nipple:
Paget’s disease of the breast or nipple is a malignant condition that outwardly presents as eczema, involving the nipple of the breast. The condition is an uncommon disease accounting for 1-4.3% of all breast cancers and was first described by Sir James Paget in 1874.
According to the migratory theory, ductal carcinoma in situ cells migrate into the lactiferous sinuses and the nipple skin. Cancer cells disrupt the normal epithelial barrier and extracellular fluid accumulates on the surface of the skin, resulting in the crusting of the areola skin. Diagnostic investigations induce; mammogram and biopsy, however, cytopathology may be helpful.
Paget’s disease is difficult to diagnose due to its resemblance to dermatitis and eczema. Eczema tends to affect the areola first, and then the nipple, whereas Paget’s spreads from the nipple.
Ref: http://en.wikipedia.org/wiki/Paget%27s_disease_ of_the_breast
Q.7. After hysterectomy for fibroid uterus woman has recurrent urinary retention, most possible cause is (Bihar/AYUSH/HMO/2014):
a) Atrophic and stenotic urethra
b) Lumbar disc prolapse
c) Injury to bladder neck
d) Injury to hypogastric plexi
Answer: (d)
Note Out of the above given variables (d) Injury to hypogastric plexi – is suggested for recurrent urinary retention after hysterectomy
Stem: Post hysterectomy; recurrent urinary retention.
Review of variables
(a) Atrophic and stenotic urethra:
Atrophic urethritis in perimenopausal or postmenopausal women. (Menopause can occur if the ovaries are removed.) It is characterized by frequency, urgency, urge incontinence, nocturia, dysuria and dyspareunia. On examination urethra is inelastic and hyperemic; the mucosa is atrophic and bleeds easily. Vaginal palpation reveals a tender urethra. Senile urethritis is frequently accompanied by eversion of urethral mucosa and by senile vaginitis.
Ref: http://www.karger.com/Article/PDF/306163#
(b) Lumbar disc prolapse:
Disc prolapse is by far the most popular and common cause of sciatica.
Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2200714/
(c) Injury to bladder neck:
The bladder neck is at most risk during vaginal hysterectomy or reconstructive surgeries of the anterior vaginal wall. The most common sites of ureteral injury are at the pelvic brim, near the infundibulopelvic ligament, and deeper in the pelvis, as it courses by the uterosacral ligament under the uterine artery approaching the cardinal ligaments.
Ref: http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/modernmedicine/ modern-medicine-feature-articles/preventing-urinary-tract-inj?page=full
(d) Injury to hypogastric plexi:
Urinary retention is common after surgical operations on vagina and perineum. Post-operative edema may cause obstruction to the flow of urine and pain from the pelvic region may lead to reflect spasm of the bladder sphincter.
Radical operations like Wertheim’s hysterectomy involve extensive dissection causing denervation of the bladder, leading the patient with insensitive bladder which is comparable to neurological bladder. Spinal and epidural anaesthesia accounts for the retention of urine in first 12–24 hours of post- operative period. Surgery for the stress incontinence and on the vagina also causes retention of urine. Ref: 175, 176-15th Ed, Shaw’s Textbook of Gynaecology.
Q.8. What type of abnormal bleeding is associated with endometriosis? (Bihar/AYUSH/MO/QP/2014):
a) Menorrhagia
b) Anovulatory bleeding
c) Amenorrhoea
d) Hypermenorrhoea metrorrhagia
Answer: (a)
Note Out of the above given variables (a) Menorrhagia – is suggested for type of abnormal bleeding associated with endometriosis
Stem: ‘Type of abnormal bleeding associated with endometriosis’
Recall
In case of endometriosis symptoms vary according to the site and do not co-relate to the extent of the disease.
The classic symptom complex includes:
-Dysmenorrhoea
-Dyspareunia
-Menorrhagia
-Infertility.
Ref: Pg468 – 15th Ed, Shaw’s Textbook of Gynaecology
Review of variables
(a) Menorrhagia:
Definition: Bleeding more than 7 days is abnormal (menorrhagia). Menorrhagia (hypermenorrhoea) is prolonged (more than 7 days) or excessive (greater than 80 mL) uterine bleeding occurring at regular intervals. [Note: In normal women, the average menstrual cycle is 28 ± 7 days, the mean duration of menstrual flow is 4 ± 2 days, and the average blood loss is 35 to 80 ml. Few women with normal menses bleed more than 7 days.]
Causes: Most common causes include:
Disorders of blood coagulation:
(Von Willebrand’s disease, Factor XI deficiency-in adolescents with excessive irregular bleeding, ITP, Leukemia), Iatrogenic; anticoagulation therapy.
Hypothyroidism:
Hypothyroidism is frequently associated with menorrhagia as well as inter-menstrual bleeding. TSH should be measured in women with menorrhagia of undetermined origin.
Accidents of pregnancy:
The most common causes of abnormal uterine bleeding in women of reproductive age are diseases associated with pregnancy (e.g., abortion, ectopic pregnancy, trophoblastic disease).
Malignancy of genital tract:
Endometrial and cervical cancer may present as abnormal bleeding. Less commonly, vaginal, vulvar, and fallopian tube cancer may produce abnormal bleeding. Estrogen producing ovarian tumors (e.g. Granulosa-theca cell tumors) may present with excessive uterine bleeding.
Endometriosis:
Endometriosis may also cause abnormal bleeding and frequently presents as premenstrual spotting, anatomic uterine abnormalities such as sub-mucous myomas, endometrial polyps, and adenomyosis frequently produce symptoms of prolonged and excessive regular uterine bleeding. Endometriosis may present as prolonged menses; though episodic inter-menstrual spotting is a more common symptom.
Ref: http://www.medicinemcq.com/pdf/QA_1383393465.pdf
(b) An-ovulatory bleeding:
Definition: (An-ovulatory bleeding/Irregular bleeding): Irregularly ovulating women, there is a pattern of estrogen and progesterone stimulation and withdrawal. In women with anovulation, disorganized and unpredictable patterns of hormone production lead to irregular menstrual bleeding (dysfunctional uterine bleeding). The an-ovulatory woman is always in the follicular phase of the ovarian cycle. There is no luteal phase because ovulation does not occur. The end result is constant estrogen stimulation and increasing proliferation of the endometrium. Over time, the endometrium thickens and becomes fragile. Without the support of progesterone to organize and stabilize it, the endometrium begins to break down and bleed. The tissue loss is superficial and does not reach the basal endometrial layer. Vasoconstriction of the basal and myometrial vessels does not occur, leading to continued bleeding. Alterations in endometrial prostaglandin synthesis and balance also result in less vasoconstriction and more blood loss.
Common cause of an-ovulatory bleed:
An-ovulatory bleeding [In most women, history can establish the diagnosis. Women with infrequent, unpredictable, irregular bleeding that varies in amount, duration, and character are most likely having an-ovulatory bleeding. Anovulation is most often observed in teenagers, peri-menopausal women, obese women, and women with polycystic ovarian syndrome.]
Ref: http://www.medicinemcq.com/pdf/QA_1383393465.pdf
(c) Amenorrhoea:
Definition: No menstruation for more than 6 months in women of reproductive age.
Causes:
Primary: Menstruation cycles never starting. Causes; congenital absence of uterus
Secondary: Defined as the absence of menses for three months in women with previously normal menstruation. Menstrual cycle ceasing. Often caused by hormonal disturbances from hypothalamus and pituitary gland.
Ref: http://en.wikipedia.org/wiki/Amenorrhoea
(d) Hyper-menorrhoea metrorrhagia:
Definition: Metrorrhagia is defined as irregular bleeding or bleeding between periods, the amount being variable.
Causes:
Metrorrhagia may be a sign of an underlying disorder:
-Hormone imbalance, endometriosis, uterine fibroids or, less commonly, cancer of the uterus. Metrorrhagia may cause significant anemia.
Ref: http://www.medicinenet.com/script/main/art.asp?articlekey=4367
Hyper-menorrhoea:
-Abnormally heavy or prolonged menstruation
Ref: http://www.thefreedictionary.com/hypermenorrhea
Causes:
Hormonal imbalance, Ovarian dysfunction, Uterine fibroid, Polyps, Adenomyosis, IUD, Uterine Ca, Cervical Ca, Bleeding disorders, Iatrogenic; Anticoagulants, Pelvic inflammatory disease, Thyroid problem, Endometriosis.
Ref: http://www.mayoclinic.org/diseases-conditions/menorrhagia/basics/causes/con-20021959
Q.9. Clotting factor which is not increased by pregnancy is (NHMC/MD/Ent/2014):
a) Factor 2
b) Factor 7
c) Factor 10
d) Factor 11
Answer: Use your discretion
Note The choice among above variables suggested is (a) Factor 2 and (d) Factor 11
Stem: Clotting factors during pregnancy
Recall
Normal pregnancy is associated with major changes in many aspects of haemostasis all contributing to maintain placental function during pregnancy and to prevent excessive bleeding in delivery. Most changes in blood coagulation and fibrinolysis create a state of hypercoagulability.
This phenomenon protects the woman from haemorrhage during delivery but predisposes her to thromboembolism both during pregnancy and in puerperium. The changes in the coagulation system in normal pregnancy are consistent with a continuing low-grade process of intravascular coagulation.
Review of variables
| S.No. | Variables / Review | Remark |
| a. | Factor 2 (Prothrombin): | No change |
| b. | Factor 7 (Stable factor, Pro-convertin): | Raised |
| c. | Factor 10 | Raised |
| d. | Factor 11 | No change or decreased |
Ref: www.pagepress.org/journals/index.php/hmr/article/download/340/273
Q.10. In a normal human female, the number of oocytes is greatest at (NHMC/MD/Ent/2014):
a) Intrauterine life
b) Birth
c) Puberty
d) Peak reproductive period
Answer: (a)
Note The number of oocytes is greatest at – (a) intrauterine life – is most suitable choice suggested out of above given variables.
Stem: ‘Oocytes’
Recall
Changes in the number of germ cells in the human ovary over the life span. (After Baker 1970.)
In the human embryo, the thousand or so oogonia divide rapidly from the second to the seventh month of gestation to form roughly 7 million germ cells (Figure 19.19). After the seventh month of embryonic development, however, the number of germ cells drop precipitously. Most oogonia die during this period, while the remaining oogonia enter the first meiotic division (Pinkerton et al. 1961). These latter cells, called the primary oocytes, progress through the first meiotic prophase until the diplotene stage, at which point they are maintained until puberty. With the onset of adolescence, groups of oocytes periodically resume meiosis. Thus, in the human female, the first part of meiosis begins in the embryo, and the signal to resume meiosis is not given until roughly 12 years later. In fact, some oocytes are maintained in meiotic prophase for nearly 50 years. As Figure 19.19 indicates, primary oocytes continue to die even after birth. Of the millions of primary oocytes present at birth, only about 400 mature during a woman’s lifetime.
Ref: http://www.ncbi.nlm.nih.gov/books/NBK10008/
Q.11. The most likely diagnosis in a 28-year obese female presenting with oligomenorrhoea, hirsutism and infertility is (NHMC/MD/Ent/2014):
a) Polycystic ovarian syndrome
b) Chronic pelvic inflammatory disease
c) Serous uterine myoma
d) Gonadal dysgenesis
Answer: (a)
Note The most suitable choice among above-given variables suggested is (a) Polycystic Ovarian Syndrome.
Stem: ‘Oligomenorrhoea, hirsutism and infertility’
Recall
Above features point to ‘Polycystic Ovarian Syndrome’
