FMGE 2025 - Obstetrics and Gynecology Practice Questions

Q: Fetal anaemia is monitored by?

MCA-PSV. ***MCA-PSV*** - **Middle Cerebral Artery-Peak Systolic Velocity (MCA-PSV)** is a non-invasive Doppler ultrasound method to assess for fetal anemia. It measures the peak velocity of blood flow in the fetal middle cerebral artery. - In anemic fetuses, blood viscosity decreases, leading to increased cardiac output and higher cerebral blood flow velocity. A value greater than **1.5 Multiples of the Median (MoM)** for gestational age is highly predictive of moderate to severe fetal anemia. *Maternal blood* - Maternal blood testing, such as the **Indirect Coombs Test (ICT)**, is used to detect maternal antibodies against fetal red blood cells, indicating maternal sensitization and risk of fetal hemolysis. - While a rising titer suggests an increased risk, it does not directly quantify the severity of anemia in the fetus itself; it serves as a screening tool to identify pregnancies needing closer surveillance. *Fetal blood* - Fetal blood sampling, performed via **cordocentesis**, is the gold standard for diagnosing and quantifying the degree of fetal anemia by directly measuring fetal hemoglobin. - However, it is an invasive procedure with significant risks (e.g., fetal loss, hemorrhage) and is reserved for confirming severe anemia indicated by non-invasive tests like MCA-PSV, or for therapeutic intervention like intrauterine transfusion. *Amniocentesis* - Historically, amniocentesis was used to measure the level of bilirubin in the amniotic fluid (spectrophotometry at ΔOD450) as an indirect marker of hemolysis. - This invasive method has been largely replaced by the non-invasive, safer, and more accurate MCA-PSV Doppler assessment for monitoring fetal anemia.

Q: A woman had a difficult labour. She complains of dribbling of urine 7 days after delivery. What is the diagnosis?

VVF. ***VVF***- **Vesicovaginal fistula (VVF)** is the most common genitourinary fistula following obstetrical trauma, often resulting from pressure necrosis due to **prolonged obstructed labor**. The typical presentation is continuous **dribbling of urine** from the vagina, starting several days (often 3-7 days) after the event when the necrotic tissue sloughs off.*UVF*- **Ureterovaginal fistula (UVF)** typically results from injury during **gynecological surgery** (like hysterectomy) rather than primarily from complicated labor itself.- While it also causes continuous urinary leakage, the diagnosis usually requires advanced imaging (IV Urography) to confirm ureteric involvement.*Rectovaginal fistula*- This fistula connects the **rectum** and the **vagina**, leading to the passage of **flatus** and **fecal matter** through the vagina.- It is directly related to damage to the perineum (3rd or 4th-degree lacerations) and does **not** cause urinary leakage.*VUF*- **Vesicouterine fistula (VUF)** involves communication between the bladder and the uterine cavity, almost exclusively occurring after a **Cesarean section**.- While urine can leak into the vagina, classic differentiating features often include secondary **amenorrhea** and **cyclic hematuria (Menouria)**.

Q: A woman, a few weeks after delivery, complains of bloody discharge from nipple and fever. On examination, diffuse lump under areola. What is the diagnosis?

Lactational mastitis. ***Lactational mastitis***- This condition is common during the **puerperium** (a few weeks after delivery) and is typically caused by retrograde infection (usually *Staphylococcus aureus*) entering through damaged nipples.- The classic presentation includes **fever**, warmth, pain, and a painful, diffuse, indurated area in the breast (the lump). **Bloody discharge** can occur due to severe inflammation or coexisting bleeding/damage related to the infection.*Galactocele*- This is a retention cyst resulting from an *obstructed lactiferous duct*, characterized by a firm, discrete, and movable lump.- It is usually **painless** and **afebrile**, and the discharge, if present, is typically milky or oily, not bloody and associated with fever.*Mondor disease*- This is a rare, benign condition, involving **thrombophlebitis of the superficial veins** of the breast or chest wall.- It presents as a palpable, painful, **cord-like structure** but is not associated with fever, systemic symptoms, or nipple discharge.*Fibrocystic disease*- This is a benign condition characterized by **lumpiness** and often cyclical pain, typically *before* menstruation.- It does not present acutely post-delivery with fever and bloody discharge, and it lacks the acute inflammatory signs characteristic of infection.

Q: The ureter is safe in which type of hysterectomy?

Vaginal. ***Vaginal*** - The lack of deep **lateral pelvic dissection** in a vaginal approach minimizes the surgical field near the area where the **ureter** crosses the **uterine artery**. - The main approach is through the vaginal cuff and supporting structures, placing the ureter at the **lowest risk** of **ligation** or **transection** compared to abdominal routes. - This is the **safest approach** for the ureter among all hysterectomy types. *Open laparotomy* - This approach requires extensive dissection of the **cardinal ligaments** and **parametrium**, placing the ureter (which runs under the uterine artery) in close proximity to the operative field, increasing the risk of injury. - The ureter can be easily inadvertently clamped or ligated during securement of the **uterine pedicles**. *Laparoscopy* - Despite magnified visualization, laparoscopic dissection requires the use of energy devices (e.g., electrocautery) near the **uterine vessels**, potentially exposing the ureter to a higher risk of **thermal injury**. - Deep lateral dissection near the cervix increases the risk of mechanical injury, often compounded by difficulty in **depth perception** during pedicle clamping. *Robotic* - Similar to laparoscopy, robotic assistance involves deep dissection of the broad and **cardinal ligaments** where the **ureter** is vulnerable as it passes near the **uterine artery**. - Although visualization and dexterity are improved, the instruments still operate close to the ureter during securing of the **uterine pedicles**, maintaining a significant risk of injury.

Q: A 30-year-old female presents with a painful red granular lesion on the vulva accompanied by bilateral lymphadenopathy. What is the most likely diagnosis?

Chancroid. ***Chancroid***- Caused by ***Haemophilus ducreyi***, it presents classically as a **painful, ragged, deep vulvar ulcer** (soft chancre) often described as having an erythematous or granular base.- The condition is characteristically associated with large, sometimes suppurative, **painful unilateral or bilateral inguinal lymphadenopathy** (**buboes**), which fits the combined clinical presentation of pain and lymphadenopathy.*Neisseria Gonorrhoeae Infection*- This infection primarily causes **mucopurulent urethritis** or **cervicitis** and is not typically associated with primary, ulcerative, or granular vulval lesions.- While regional lymphadenopathy may occur, it is usually not a prominent, painful finding defining the clinical presentation.*Granuloma Inguinale*- The characteristic lesion is a **painless, highly vascular, 'beefy red' ulcer** which bleeds easily, consistent with the term "granular" but contradicting the crucial feature of being **painful**.- True regional lymphadenopathy is rare; instead, subcutaneous granulomas may mimic lymph nodes (**pseudo-buboes**).*Lymphogranuloma Venereum*- The primary genital lesion is typically a small, **painless, transient papule** or vesicle that is often overlooked.- While it causes severe, painful inguinal lymphadenopathy, the initial vulval lesion is usually not a prominent, painful, granular ulcer as described.

Q: A 29-year-old woman presents with abdominal pain, vaginal bleeding, and a history of amenorrhea for 6 weeks. Transvaginal ultrasound does not show an intrauterine gestational sac or features suggestive of ectopic pregnancy. Her serum $\beta$-hCG is 1,200 IU/L, which is below the discriminatory zone. What is the next step in management?

Repeat $\beta$-hCG after 48 hours. ***Repeat $\beta$-hCG after 48 hours*** - In a pregnancy of unknown location (PUL) with **β-hCG below the discriminatory zone** (1,500-2,000 IU/L), ultrasound cannot reliably visualize an intrauterine pregnancy - **Serial β-hCG monitoring at 48-hour intervals** is the standard approach to determine pregnancy viability and location - Expected β-hCG patterns help guide management: - **Rise >53% in 48 hours**: Suggests viable intrauterine pregnancy → repeat ultrasound when β-hCG reaches discriminatory zone - **Rise 50% in 48 hours**: Suggests spontaneous miscarriage → monitor to zero - Patient is **hemodynamically stable**, so expectant management with close monitoring is appropriate *Dilatation and curettage* - Premature intervention without knowing β-hCG trend - Reserved for cases where β-hCG plateaus or rises abnormally, suggesting either ectopic or abnormal intrauterine pregnancy - May be used for histological diagnosis (presence of chorionic villi confirms intrauterine pregnancy) *Methotrexate therapy* - Cannot be administered without **confirmed diagnosis of ectopic pregnancy** - Requires meeting specific criteria: hemodynamic stability, unruptured ectopic, β-hCG typically <5,000 IU/L, no fetal cardiac activity - Inappropriate when pregnancy location is unknown *Laparoscopy* - Too invasive as initial management for a **stable patient** - Reserved for hemodynamically unstable patients with suspected ruptured ectopic pregnancy - May be indicated later if ectopic pregnancy is confirmed and meets surgical criteria

Q: All of the following are protected by OCPs except?

Carcinoma breast. ***Carcinoma breast*** - OCPs do not protect against **breast cancer**; large meta-analyses suggest a small, transient increase in risk, particularly with **current or recent use**, which generally dissipates 10 years after stopping. - This marginal increase in risk is attributed to the **estrogen component**, which promotes proliferation in hormone-sensitive breast tissue. *Carcinoma endometrium* - OCPs offer significant long-term protection against **endometrial cancer**, mediated primarily by the **progestin component**, which induces endometrial atrophy. - Protection lasts for many years after discontinuing OCPs and is one of the most prominent non-contraceptive benefits. *Colonic cancer* - OCP use is associated with a reduced risk of **colorectal cancer**, a benefit that appears to be related to the duration of use. - This protective effect is thought to be mediated by the actions of estrogen on bile acid metabolism and subsequent modulation of cell proliferation in the **colonic mucosa**. *Ovarian cancer* - OCPs provide robust, durable protection against **ovarian cancer**, with the risk reduction correlating significantly with the duration of intake. - The primary protective mechanism is the **suppression of ovulation**, which reduces trauma and proliferation of the ovarian surface epithelium.

Q: A 30-year-old female who delivered a healthy term baby one week ago is now presenting to the OBG clinic with complaints of fishy-smelling pale brownish vaginal discharge. What is the nature of this discharge?

Lochia Serosa. ***Lochia Serosa***- This stage of postpartum discharge typically begins around **day 4** and lasts until **day 10** postpartum, aligning perfectly with the patient’s presentation at one week (7 days) after delivery.- It is characterized by a **pale brownish** or pinkish, watery discharge, consisting of old blood, serum, and leukocytes. The described "fishy smell" likely results from bacterial colonization, common in this stage, but the timing dictates the stage.*Lochia Rubra*- This is the initial, heavy stage of lochia, which occurs during the first **1 to 3 days** postpartum.- The discharge is predominantly **bright red** and bloody, containing large amounts of decidua and tissue fragments, not pale brownish.*Lochia Alba*- This is the final stage of lochia, usually beginning after **day 10** (or even two weeks) and may persist for several weeks.- It is typically **creamy, white, or yellowish** in color, containing predominantly leukocytes, epithelial cells, and mucus.*Leukorrhea*- This is a broad term for **non-bloody vaginal discharge** related to normal physiological changes (like ovulation) or pathological conditions (like vaginitis).- While lochia contains many components of leukorrhea (white cells), **lochia** is the specific and correct term for the expected postpartum discharge composed of blood, serum, and tissue.

Q: Shoulder dystocia is diagnosed when the anterior shoulder fails to deliver after what time following delivery of the head?

60 sec. ***60 sec*** - Shoulder dystocia is generally defined as the failure of the shoulders to deliver spontaneously after the head is already delivered, requiring additional obstetrical maneuvers. - Using a time criterion, the condition is classified when the interval between the delivery of the fetal head and the delivery of the shoulders exceeds **60 seconds (1 minute)**. - The definition is established at **60 seconds** because delays exceeding this time significantly elevate the risk of fetal injury, particularly **brachial plexus injury**. *15 sec* - This time interval is typically too short to define true shoulder dystocia, as spontaneous delivery of the shoulders often occurs within the first 30 seconds. - A delay of **15 seconds** usually reflects normal variation in the second stage of labor. *30 sec* - While a delay greater than **30 seconds** is sometimes cited as an *increased risk* indicator, it is not the standard, universally endorsed cutoff for formally diagnosing shoulder dystocia. - Most major obstetric guidelines (ACOG and RCOG) use the **60-second** criterion. *45 sec* - Although indicative of a slower process, **45 seconds** falls short of the critical **60-second** mark used by most major obstetric guidelines to classify the complication. - Using 45 seconds could lead to over-diagnosis, while the 60-second rule ensures appropriate identification of high-risk cases.

Question 1

Fetal anaemia is monitored by?

Accepted Answer

MCA-PSV

Answer

Amniocentesis

Answer

Maternal blood

Answer

Fetal blood

Question 2

A woman had a difficult labour. She complains of dribbling of urine 7 days after delivery. What is the diagnosis?

Accepted Answer

VVF

Answer

Rectovaginal fistula

Answer

UVF

Answer

VUF

Question 3

A woman, a few weeks after delivery, complains of bloody discharge from nipple and fever. On examination, diffuse lump under areola. What is the diagnosis?

Accepted Answer

Lactational mastitis

Answer

Fibrocystic disease

Answer

Galactocele

Answer

Mondor disease

Question 4

The ureter is safe in which type of hysterectomy?

Accepted Answer

Vaginal

Answer

Robotic

Answer

Laparoscopy

Answer

Open laparotomy

Question 5

A 30-year-old female presents with a painful red granular lesion on the vulva accompanied by bilateral lymphadenopathy. What is the most likely diagnosis?

Accepted Answer

Chancroid

Answer

Neisseria Gonorrhoeae Infection

Answer

Lymphogranuloma Venereum

Answer

Granuloma Inguinale

Question 6

A 29-year-old woman presents with abdominal pain, vaginal bleeding, and a history of amenorrhea for 6 weeks. Transvaginal ultrasound does not show an intrauterine gestational sac or features suggestive of ectopic pregnancy. Her serum $\beta$-hCG is 1,200 IU/L, which is below the discriminatory zone. What is the next step in management?

Accepted Answer

Repeat $\beta$-hCG after 48 hours

Answer

Dilatation and curettage

Answer

Methotrexate therapy

Answer

Laparoscopy

Question 7

A 32 y/o pregnant woman presents for her routine antenatal check-up at 28 weeks gestation. She has a history of obesity but no previous history of diabetes. Her fasting plasma glucose level is 104 mg/dL, and her 2-hour plasma glucose level after a 75g Oral Glucose Tolerance Test (OGTT) is 167 mg/dL. Based on these findings, what is the most appropriate next step?

Accepted Answer

Diagnose her with GDM and initiate dietary modifications with close monitoring of blood glucose levels.

Answer

Start lifestyle modifications and repeat OGTT at 32 weeks gestation.

Answer

Monitor her closely without intervention since her glucose levels are borderline.

Answer

Diagnose her with pre-existing diabetes and initiate insulin therapy.

Question 8

All of the following are protected by OCPs except?

Accepted Answer

Carcinoma breast

Answer

Colonic cancer

Answer

Carcinoma endometrium

Answer

Ovarian cancer

Question 9

A 30-year-old female who delivered a healthy term baby one week ago is now presenting to the OBG clinic with complaints of fishy-smelling pale brownish vaginal discharge. What is the nature of this discharge?

Accepted Answer

Lochia Serosa

Answer

Leukorrhea

Answer

Lochia Rubra

Answer

Lochia Alba

Question 10

Shoulder dystocia is diagnosed when the anterior shoulder fails to deliver after what time following delivery of the head?

Accepted Answer

60 sec

Answer

15 sec

Answer

45 sec

Answer

30 sec

FMGE 2025 — Obstetrics and Gynecology