FMGE 2019 — Obstetrics and Gynecology
29 Previous Year Questions with Answers & Explanations
A 32-year-old pregnant woman presents with mild bleeding and pain. On examination, the uterus is tender, and fetal heart sounds are absent. What is the most likely diagnosis?
What is the dose of mifepristone in medical abortion?
A 32-year-old lady with intrauterine fetal death after normal vaginal delivery has continuous passage of urine from the vagina. What is the most probable diagnosis?
A woman comes after 96 hours post coitus. Best contraceptive of choice is?
A 34-year-old lady with 4 children, after her 5th normal vaginal delivery, experiences excessive bleeding after the placenta is removed. What is the cause for this?
A 67-year-old female with hypertension and diabetes presents with heavy vaginal bleeding. What is the next step in management?
A 16-year-old girl with acute vaginal bleeding presents to the clinic. What is the immediate management?
Angle of cut in episiotomy is?
A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?
Most common organism causing the pelvic inflammatory disease?
FMGE 2019 - Obstetrics and Gynecology FMGE Practice Questions and MCQs
Question 1: A 32-year-old pregnant woman presents with mild bleeding and pain. On examination, the uterus is tender, and fetal heart sounds are absent. What is the most likely diagnosis?
- A. Abruptio placenta (Correct Answer)
- B. Uterine rupture
- C. Ectopic pregnancy
- D. Placenta previa
Explanation: ***Abruptio placenta*** - This condition involves the **premature detachment of the placenta** from the uterine wall, leading to bleeding and severe abdominal pain due to uterine contractions and irritation. - The **tender uterus** is a characteristic finding, often described as a "woody hard" uterus in severe cases. - The absence of fetal heart sounds suggests **fetal demise**, which is a common and severe complication of placental abruption due to oxygen deprivation. *Uterine rupture* - **Uterine rupture** can present with abdominal pain, vaginal bleeding, and loss of fetal heart tones, making it an important differential. - However, it typically occurs during **active labor**, especially in women with previous cesarean sections or uterine surgery. - The presentation usually includes **sudden severe pain**, loss of uterine contractions, and the fetus may be palpable abdominally if completely extruded. *Ectopic pregnancy* - This occurs when the **fertilized egg implants outside the uterus**, most commonly in the fallopian tube. - Symptoms typically appear much earlier in pregnancy **(first trimester)** and the pain is usually localized, often presenting with a smaller, non-tender uterus. - Not consistent with the clinical picture of an obviously pregnant uterus. *Placenta previa* - **Placenta previa** is characterized by the placenta covering the cervical opening, leading to **painless vaginal bleeding**, often bright red. - The uterus is typically **soft and non-tender**, in contrast to the tender uterus described in the case. - This is the key differentiating feature from placental abruption.
Question 2: What is the dose of mifepristone in medical abortion?
- A. 400 mg
- B. 100 mg
- C. 200 mg (Correct Answer)
- D. 600 mg
Explanation: ***200 mg*** - The standard dose of **mifepristone** for **medical abortion** in various protocols, including those up to 10 weeks of gestation, is **200 mg orally**. - This dose effectively blocks **progesterone receptors**, leading to endometrial breakdown and sensitization of the uterus to prostaglandins. - **WHO-recommended dose** with optimal efficacy and safety profile. *400 mg* - **400 mg is not a standard or recommended dose** for medical abortion in any established protocol. - The evidence-based regimens use either **200 mg** (current standard) or 600 mg (older protocol), but not 400 mg. - No clinical advantage has been demonstrated for this intermediate dose. *100 mg* - A dose of **100 mg of mifepristone is considered suboptimal** and less effective for inducing medical abortion compared to the standard 200 mg dose. - It may not sufficiently block progesterone receptors, potentially leading to **incomplete abortion** or treatment failure. - Not recommended in any standard medical abortion protocol. *600 mg* - Although **600 mg was an older protocol** for medical abortion, it has largely been replaced by the **200 mg dose**. - Research has demonstrated that **200 mg is equally effective** while resulting in a better side effect profile and lower cost. - The dose reduction from 600 mg to 200 mg represents evidence-based protocol optimization.
Question 3: A 32-year-old lady with intrauterine fetal death after normal vaginal delivery has continuous passage of urine from the vagina. What is the most probable diagnosis?
- A. Urge incontinence
- B. Stress incontinence
- C. Bladder rupture
- D. Vesicovaginal fistula (Correct Answer)
Explanation: ***Vesicovaginal fistula*** - The continuous passage of urine from the vagina following delivery, especially in the context of an intrauterine fetal death where prolonged or difficult labor might occur, is highly suggestive of a **vesicovaginal fistula**. - A fistula creates an abnormal connection between the **bladder** and the **vagina**, leading to continuous urine leakage. *Urge incontinence* - Characterized by an **involuntary loss of urine** associated with a sudden, strong desire to void. - This is typically due to an **overactive detrusor muscle** and would not cause continuous leakage, especially not through the vagina itself after a delivery. *Stress incontinence* - Defined by the leakage of urine with activities that **increase intra-abdominal pressure**, such as coughing, sneezing, or laughing. - It results from weakness of the **pelvic floor muscles** or urethral sphincter, not continuous drainage from the vagina. *Bladder rupture* - While a bladder rupture can cause urinary leakage, it usually presents with **acute abdominal pain**, abdominal distension, and possibly **hematuria**, along with urine accumulating in the peritoneal cavity, rather than continuous passage solely from the vagina. - A rupture would likely be an acute, more severe event with systemic symptoms, distinct from the described continuous vaginal leakage of urine.
Question 4: A woman comes after 96 hours post coitus. Best contraceptive of choice is?
- A. Progesterone only pills
- B. OCP
- C. IUCD (Correct Answer)
- D. Mifepristone
Explanation: ***IUCD*** - An **intrauterine contraceptive device (IUCD)** can be inserted up to **5 days (120 hours)** after unprotected intercourse or within 5 days of the earliest estimated ovulation. - It is the **most effective form of emergency contraception**, offering approximately **99% efficacy**. - Provides **immediate ongoing contraception** after insertion, making it the optimal choice at 96 hours post-coitus. *Progesterone only pills* - **Progesterone-only emergency contraceptive pills** (e.g., levonorgestrel) are most effective when taken within **72 hours (3 days)** of unprotected intercourse. - At **96 hours**, their efficacy is **significantly reduced**, making them suboptimal compared to IUCD. *OCP* - **Combined oral contraceptive pills (OCPs)** used for emergency contraception (Yuzpe method) are less effective and have more side effects than other emergency contraceptive methods. - Their effectiveness also significantly declines after **72 hours** post-coitus. *Mifepristone* - **Mifepristone** is an **anti-progestin** that can be used for emergency contraception within **120 hours (5 days)** of unprotected intercourse. - While effective within this timeframe at **96 hours**, the **IUCD remains superior** due to its higher efficacy (>99% vs ~98%) and provision of ongoing contraception.
Question 5: A 34-year-old lady with 4 children, after her 5th normal vaginal delivery, experiences excessive bleeding after the placenta is removed. What is the cause for this?
- A. Uterine atony (Correct Answer)
- B. Genital tract trauma
- C. Retained placental tissue
- D. Coagulation disorders
Explanation: ***Uterine atony*** - The most common cause of **postpartum hemorrhage (PPH)**, accounting for 70-80% of cases - **Multiparity** (Grand multipara with 5 deliveries) is a major risk factor, as repeated pregnancies lead to **overdistension and decreased uterine muscle tone** - Uterine atony is the failure of the myometrium to contract adequately after placental delivery, preventing compression of spiral arteries - Part of the **"4 Ts" mnemonic** for PPH causes: **Tone** (atony), Trauma, Tissue, Thrombin *Genital tract trauma* - Second most common cause of PPH (approximately 20% of cases) - Includes cervical lacerations, vaginal tears, or perineal trauma - However, the question specifically mentions **"normal vaginal delivery"** and bleeding **"after placenta removal"**, making trauma less likely - Trauma-related bleeding typically occurs **during or immediately after delivery**, not specifically post-placental *Retained placental tissue* - Accounts for approximately 10% of PPH cases - The question states the placenta **"is removed"**, suggesting complete placental delivery - If placental fragments were retained, bleeding would persist due to inability of the uterus to contract fully - Less likely given the clinical scenario described *Coagulation disorders* - Least common cause of primary PPH (1-2% of cases) - Includes conditions like **DIC, thrombocytopenia, or inherited coagulopathies** - No clinical history suggesting coagulopathy (e.g., no bleeding during pregnancy, no family history) - Would typically present with **oozing from multiple sites**, not just uterine bleeding
Question 6: A 67-year-old female with hypertension and diabetes presents with heavy vaginal bleeding. What is the next step in management?
- A. Endometrial biopsy (Correct Answer)
- B. Pelvic ultrasound
- C. Detailed history and physical examination
- D. Complete blood count and coagulation studies
Explanation: ***Endometrial biopsy*** - **Postmenopausal bleeding is endometrial cancer until proven otherwise** - this is a fundamental principle in gynecology requiring immediate tissue diagnosis. - **Endometrial biopsy is the first-line investigation** for any postmenopausal woman presenting with vaginal bleeding, as per **ACOG, RCOG, and WHO guidelines**. - An office endometrial biopsy (using **Pipelle sampler**) can be performed quickly and has **90-97% sensitivity** for detecting endometrial cancer and hyperplasia. - In this 67-year-old patient with risk factors (hypertension, diabetes), direct tissue sampling is mandatory to rule out **endometrial carcinoma**, which is the most concerning etiology. - If office biopsy is inadequate or negative but bleeding persists, proceed to **hysteroscopy with directed biopsy** or **dilatation and curettage (D&C)**. *Pelvic ultrasound* - While transvaginal ultrasound can assess **endometrial thickness** (cancer unlikely if <4-5mm in postmenopausal women), it **cannot replace histological diagnosis**. - Ultrasound may be used as an **adjunct** or for **triage in resource-limited settings**, but in established postmenopausal bleeding, **tissue diagnosis takes priority**. - Some protocols use ultrasound first, but the definitive diagnostic step remains biopsy, and many guidelines recommend proceeding directly to biopsy in postmenopausal bleeding. *Detailed history and physical examination* - History and examination are **always performed initially** when a patient presents, but the question asks for the "next step in management" after the presentation is established. - These would have already been completed to confirm postmenopausal status, exclude obvious causes (trauma, atrophic vaginitis), and assess hemodynamic stability. - The "next step" implies the specific diagnostic or therapeutic intervention to identify the cause. *Complete blood count and coagulation studies* - **CBC** helps assess the degree of anemia from blood loss and guides need for transfusion. - **Coagulation studies** may identify bleeding disorders but are not routinely indicated unless clinical suspicion exists. - These investigations are **supportive** but do not identify the **anatomical source** or **histological cause** of bleeding, which is essential for management of postmenopausal bleeding.
Question 7: A 16-year-old girl with acute vaginal bleeding presents to the clinic. What is the immediate management?
- A. Administer high-dose estrogen
- B. Perform dilation and curettage
- C. Start tranexamic acid
- D. Stabilize the patient and investigate the cause of bleeding (Correct Answer)
Explanation: ***Stabilize the patient and investigate the cause of bleeding*** - In a patient with acute bleeding, the **immediate priority** is to stabilize their hemodynamic status, which may involve intravenous fluids or blood transfusion, followed by a thorough investigation to identify the underlying cause of bleeding. - A 16-year-old presenting with acute vaginal bleeding requires a **comprehensive medical evaluation** to rule out trauma, pregnancy-related complications, coagulation disorders, or structural abnormalities before specific treatments are initiated. *Administer high-dose estrogen* - High-dose estrogen can be used to **acutely stop uterine bleeding** by promoting rapid endometrial proliferation, but it is not the *immediate* management without patient stabilization and identifying the cause, especially in an acute setting. - While effective for some types of dysfunctional uterine bleeding, it is a **therapeutic intervention**, not the primary step for initial stabilization or diagnosis. *Perform dilation and curettage* - Dilation and curettage (D&C) is a **surgical procedure** used to remove tissue from the uterus and is typically performed for diagnostic or therapeutic reasons after initial assessment and stabilization, or if medical management fails. - It carries risks and is not the first-line immediate management for acute vaginal bleeding in an adolescent without a clear indication, such as severe, uncontrolled bleeding resistant to medical therapy or suspected retained products of conception. *Start tranexamic acid* - Tranexamic acid is an **antifibrinolytic** that helps reduce bleeding by inhibiting fibrinolysis, making it useful for managing menstrual bleeding or other bleeding disorders. - While it can be part of medical management once the patient is stabilized, it is not the *immediate* initial step before hemodynamic stabilization or diagnostic workup to determine the cause of bleeding.
Question 8: Angle of cut in episiotomy is?
- A. 45 degrees at the midline
- B. 30 degrees at the midline
- C. 60 degrees at the midline (Correct Answer)
- D. 15 degrees at the midline
Explanation: ***60 degrees at the midline*** - A **mediolateral episiotomy** is recommended at a **60-degree angle** from the midline, directed towards the ischial tuberosity. - This angle is based on **RCOG guidelines** and standard obstetric practice, providing optimal protection against **third- and fourth-degree perineal tears**. - The 60-degree angle effectively directs the incision away from the **anal sphincter** and **rectum**, while maintaining adequate surgical access. *45 degrees at the midline* - While sometimes used, this angle is **less protective** than 60 degrees against anal sphincter injuries. - Studies show that angles less than 60 degrees have a **higher risk** of extension into the anal sphincter complex compared to the recommended 60-degree angle. *30 degrees at the midline* - This angle is **too shallow** and provides insufficient protection against tearing towards the anal sphincter. - The risk of uncontrolled extension into the **anal sphincter complex** is significantly increased with such a small angle. *15 degrees at the midline* - This angle is **far too shallow** and would provide minimal expansion of the vaginal outlet. - It offers virtually no protection from extension into the **anal sphincter** and would likely result in an uncontrolled tear, making it an impractical choice for episiotomy.
Question 9: A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?
- A. Clotting factor deficiency
- B. Atony (Correct Answer)
- C. Traumatic PPH
- D. Retained tissues
Explanation: ***Atonic*** - **Uterine atony** is the most common cause of **postpartum hemorrhage (PPH)**, accounting for approximately 70-80% of cases. The uterus fails to contract adequately after placental delivery, leading to continuous bleeding from the placental bed. - Risk factors for uterine atony include multiparity, prolonged labor, rapid labor, polyhydramnios, and multiple gestations, which can lead to overdistension and fatigue of the uterine muscle. *Clotting factor deficiency* - While **coagulopathies** (clotting factor deficiencies) can cause PPH, they are a less common primary cause than uterine atony. - This cause would be suspected if there is a history of bleeding disorders, liver disease, or if PPH persists despite a well-contracted uterus. *Traumatic PPH* - **Traumatic PPH** results from lacerations of the cervix, vagina, or perineum, or from uterine rupture. These are less common than uterine atony. - This cause is typically suspected when the uterus feels firm but bleeding continues, or when visible trauma is present. *Retained tissues* - **Retained placental tissue** can prevent the uterus from contracting effectively, leading to PPH. However, it is less common than atony. - This cause is usually identified by the presence of placental fragments or membranes in the uterine cavity upon examination.
Question 10: Most common organism causing the pelvic inflammatory disease?
- A. Gardnerella Vaginalis
- B. Bacteroides
- C. Neisseria gonorrhoeae
- D. Chlamydia (Correct Answer)
Explanation: ***Chlamydia*** - **Chlamydia trachomatis** is the most common bacterial cause of **pelvic inflammatory disease (PID)**, often leading to subtle or asymptomatic infections [1]. - Untreated chlamydial infections can ascend from the lower genital tract, causing inflammation and scarring in the fallopian tubes and other pelvic organs [1]. *Gardnerella Vaginalis* - **Gardnerella vaginalis** is primarily associated with **bacterial vaginosis (BV)**, a common cause of vaginal discharge. - While BV can sometimes predispose to PID, *Gardnerella* itself is not considered a primary causative agent of ascending PID. *Bacteroides* - **Bacteroides species** are anaerobic bacteria that are part of the normal vaginal flora and can be found in some cases of PID, particularly in **tubo-ovarian abscesses** [1]. - However, they are typically considered secondary invaders or coinfecting organisms rather than the initial causative agent of PID. *Neisseria gonorrhoeae* - **Neisseria gonorrhoeae** is a common and significant cause of **pelvic inflammatory disease (PID)**, historically being the most recognized pathogen [1]. - While still prevalent and capable of causing severe PID, **Chlamydia trachomatis** has surpassed it in overall incidence as the leading cause of PID [1].