FMGE 2025 - Obstetrics and Gynecology Practice Questions

Q: A patient presents with obstructed labor, and on abdominal examination, a groove or band is palpable across the uterus. What is the most likely diagnosis?

Bandl’s ring. ***Bandl’s ring***- This is the **pathological retraction ring** that forms in cases of prolonged **obstructed labor**, separating the thick, upper, contracted uterine segment from the thin, distended lower uterine segment.- Its presence as a palpable groove or band across the abdomen is a critical sign of **impending uterine rupture** and mandates immediate intervention.*Constriction ring*- This is a localized persistent contraction or **spasm of the circular uterine muscle fibers** occurring at any level, hindering the passage of the fetus but not necessarily indicating imminent rupture.- Unlike Bandl's ring, it is usually not a high, visible, or palpable abdominal band indicating severe obstruction and **uterine overdistention**.*Schroeder's ring*- This term is not the standardized term used to describe the **pathological retraction ring** visible externally in severe obstructed labor.- While it may sometimes be confused with terms related to cervical changes, **Bandl's ring** is the definitive diagnosis for the palpable groove in this clinical context.*Contraction ring*- This term is often used synonymously with the normal **physiological retraction ring** which forms between the active and passive segments during normal labor.- Although it involves muscle contraction, it lacks the specific **pathological significance** and height within the abdomen characteristic of Bandl’s ring in severe obstruction.

Q: A pregnant woman is being assessed for induction of labor. On vaginal examination: Cervical dilation: 2 cm, Effacement: 20%, Cervical consistency: Soft, Position: Midline, Station: -2. What is the modified Bishop Score?

Score 5 - Unfavorable. ***Score 5 - Unfavorable*** - This score is calculated by assigning points based on cervical parameters: **Dilation 2 cm (1 pt)**, **Effacement 20% (0 pts)**, **Consistency Soft (2 pts)**, **Position Midline (1 pt)**, and **Station -2 (1 pt)**, totaling **5 points**. - A Bishop Score of 5 or less indicates an **unfavorable cervix**, suggesting a low likelihood of successful vaginal delivery following induction without prior cervical ripening. *Score 7 - Favorable* - A score of 7 or higher is generally considered highly **favorable** for successful induction, meaning the cervix is likely to respond well to oxytocin. - To reach a score of 7, the patient would need two additional points, such as effacement of 60% (2 points) instead of 20% (0 points), or improved station. *Score 6 - Borderline* - A score of 6 is considered **borderline** or marginally favorable, but many clinicians still prefer cervical ripening before proceeding with oxytocin. - This would require an improvement in one parameter, such as the fetal station moving from -2 (1 pt) to -1 or 0 (2 pts). *Score 3 - Highly unfavorable* - A score of 3 indicates a very **unripe cervix** (e.g., firm consistency, posterior position, minimal dilation and effacement) with very low chance of successful induction. - The current patient scores 5 points with favorable features (soft consistency, midline position), making a score as low as 3 impossible with the given findings.

Q: During the management of shoulder dystocia in childbirth, which of the following is the earliest and first maneuver typically attempted?

McRoberts maneuver. ***McRoberts maneuver***- This is universally considered the **first-line** and **least invasive** procedure for shoulder dystocia management.- It involves sharply flexing the mother's hips against her abdomen (knees-to-chest), which rotates the **pubic symphysis** cephalad and flattens the lumbar lordosis, increasing the functional AP diameter of the pelvis.*Woods corkscrew maneuver*- This is a **second-line** rotational maneuver attempted if McRoberts and suprapubic pressure fail.- It involves applying pressure to the posterior aspect of the anterior shoulder to rotate the fetal shoulders 180 degrees.*Rubin maneuver*- This is a **second-line** rotational maneuver where the physician places fingers behind the anteriorly impacted shoulder.- The goal is to push the shoulder towards the fetal chest, rotating the shoulders into the oblique diameter.*Delivery of posterior arm*- This is a highly invasive maneuver usually reserved for when less invasive positional and rotational techniques have failed.- Successfully extracting the posterior arm significantly reduces the **bisacromial diameter**, facilitating delivery.

Q: OCPs can be given in which of the following conditions?

HIV. ***HIV***- HIV infection itself is **not a contraindication** to the use of Oral Contraceptive Pills (OCPs).- OCPs are a safe and highly effective contraceptive method for women living with HIV, though potential interactions with certain **Antiretroviral Therapy (ART)** regimens must be considered.*HTN*- OCPs can cause or exacerbate **hypertension** by activating the renin-angiotensin-aldosterone system through increased **angiotensinogen** production.- The use of OCPs is strongly discouraged in women with **uncontrolled** or **severe hypertension** due to increased risk of stroke and myocardial infarction.*DM*- OCPs are relatively contraindicated in women with diabetes mellitus who have **associated vascular complications** (e.g., retinopathy, nephropathy, neuropathy) or long-standing disease (>20 years).- While modern low-dose OCPs are generally safe for *uncomplicated* DM, they can transiently worsen **glucose tolerance** and require careful monitoring.*Hyperlipidemia*- OCPs, particularly those with higher estrogen content, can significantly increase serum **triglyceride levels**, which dramatically raises the risk of **pancreatitis**.- They are relatively contraindicated in individuals with severe or uncontrolled **hyperlipidemia** due to concerns about accelerating cardiovascular disease risks.

Q: A woman sustains a perineal tear during delivery. Examination reveals that less than 50% of the external anal sphincter is involved. Based on the classification system, what is the most appropriate description of this injury?

Grade 3a. ***Grade 3a*** - This is the correct classification for perineal tears involving **less than 50% of the external anal sphincter (EAS) thickness** - Grade 3 tears are classified as **Obstetric Anal Sphincter Injuries (OASI)** and require immediate recognition, specialized repair by an experienced obstetrician, and structured follow-up - The key differentiating factor is the **percentage of EAS involvement** *Grade 2* - Grade 2 tears involve the **perineal muscles** and vaginal mucosa but specifically **exclude the anal sphincter complex** - This is less severe than the scenario described, as no sphincter involvement occurs *Grade 3b* - Grade 3b represents a more severe injury with **more than 50% of the EAS thickness** torn - The clinical scenario specifies "less than 50%," making this classification incorrect *Grade 4* - Grade 4 is the most severe perineal tear, involving the **entire anal sphincter complex (both EAS and IAS)** plus disruption of the **anal epithelium or rectal mucosa** - This creates direct communication between the vagina and rectum, which is not described in this scenario

Q: A 12-year-old girl presents with primary amenorrhea. She has been raised as a girl, has not developed breast tissue, and ultrasound reveals absence of the uterus. Karyotyping shows a 46 XY chromosomal pattern. What is the most likely diagnosis?

Androgen insensitivity syndrome. ***Androgen Insensitivity Syndrome (AIS)*** - **46,XY karyotype with absent uterus** is the key diagnostic feature - testes produce Anti-Müllerian Hormone (AMH) which causes regression of Müllerian structures (uterus, fallopian tubes, upper vagina) - **Phenotypically female appearance** due to inability of tissues to respond to androgens, despite normal testosterone production - At **12 years of age**, breast development may not have occurred yet, though in complete AIS, breast development typically occurs at puberty due to peripheral conversion of testosterone to estrogen - **Testes are typically located in abdomen or inguinal canal** - must be removed due to malignancy risk after puberty - This is the **most common cause of 46,XY DSD presenting with female external genitalia** *Incorrect: MRKH Syndrome* - Mayer-Rokitansky-Küster-Hauser syndrome presents with **absent uterus but normal 46,XX karyotype** - These patients have **normal ovarian function** with normal breast development and secondary sexual characteristics - The **46,XY karyotype rules out MRKH** *Incorrect: 17-hydroxylase deficiency* - This enzyme deficiency affects both **glucocorticoid and sex steroid synthesis** - Classically presents with **hypertension and hypokalemia** due to excess mineralocorticoids (DOC, corticosterone) - In 46,XY individuals, causes undervirilization but does not explain the **absent uterus** - Müllerian regression still occurs from testicular AMH - **Does not fit the clinical picture** of absent uterus in 46,XY individual *Incorrect: Swyer Syndrome* - Pure gonadal dysgenesis with **46,XY karyotype but streak gonads** - Key differentiating feature: **uterus is PRESENT** because streak gonads do not produce AMH - These patients have **female external genitalia with normal Müllerian structures** - The **absent uterus in this case rules out Swyer syndrome**

Q: During assisted vaginal delivery, where is the vacuum device typically applied?

3 cm anterior to the posterior fontanelle. ***3 cm anterior to the posterior fontanelle***- This exact point is known as the **flexion point** (or optimum traction point), which is essential for ensuring that traction causes the fetal head to flex, thus presenting the smallest diameter for delivery.- Applying the vacuum cup at the flexion point ensures that the pull is along the axis of the **fetal head**, minimizing cephalhematoma and increasing the efficacy of the vacuum pull.*At 3 cm behind the anterior fonatnelle*- This position corresponds to the **sinciput** and is too far forward on the fetal head.- Applying traction here could lead to **extension** of the fetal head, making delivery more difficult and increasing the risk of fetal injury or cap detachment.*On the posterior fontanelle*- Placing the cup directly on the **posterior fontanelle** is incorrect as it is a small, soft area and the application would be off-center from the optimal traction point.- This off-center placement could result in **deflecting** the fetal head upon traction, making the pull less effective and potentially causing scalp damage.*Between the anterior and posterior fontanelle*- While the ideal position lies along the sagittal suture between the fontanelles, this description is too vague and does not pinpoint the specific **flexion point** (3 cm anterior to the posterior fontanelle).- Vague placement often results in applied traction that is not fully conducive to optimal **head flexion** and descent.

Q: What is the co-test in cervical cancer screening?

HPV and PAP smear. ***HPV and PAP smear*** - **Co-testing** is the simultaneous use of the **hrHPV DNA test** (to detect oncogenic virus presence) and the **Papanicolaou (PAP) smear** (to detect cytological abnormalities). - This combination provides the highest sensitivity for detecting high-grade cervical intraepithelial neoplasia (**CIN 2/3**) and is recommended for screening women aged 30-65 years in many guidelines. *Pap smear and VIA* - **Visual Inspection with Acetic acid (VIA)** is typically used as a primary screening method in settings where laboratory infrastructure for cytology or HPV testing is limited, not as a standard co-test. - The combination of **PAP smear** (cytology) and **HPV testing** (molecular) offers a superior and more risk-stratified approach than combining cytology with simple visual inspection. *HPV and VIA* - This combination lacks the necessary **specificity** provided by the PAP smear, as VIA relies on subjective visual assessment of acetowhite changes rather than objective cytological classification. - Standard screening protocols often require detailed cytological results (e.g., **ASCUS, LSIL, HSIL**) from the PAP smear to guide subsequent triage and management decisions when HPV is positive. *PAP smear and colposcopy* - **Colposcopy** is a **diagnostic and evaluation procedure** performed *after* an abnormal screening result (e.g., abnormal PAP or positive HPV), not a screening test to be paired with the PAP smear. - Colposcopy allows for directed biopsy and is crucial for definitive diagnosis and staging of **cervical intraepithelial neoplasia (CIN)**.

Q: Which of the following is a contraindication to subdermal contraceptive implant?

Undiagnosed genital bleeding. ***Undiagnosed genital bleeding*** - Undiagnosed abnormal genital bleeding is a key contraindication because hormonal methods, including the implant, may mask potentially serious underlying causes such as **endometrial or cervical cancer**. - Comprehensive evaluation must be completed and a definitive diagnosis established before initiating the implant to ensure patient safety. *Hypertension* - **Mild to moderate hypertension** is generally not a contraindication for progestin-only methods like the contraceptive implant, which has minimal effect on blood pressure. - Progestin implants are often a good alternative for women with hypertension who have contraindications to **estrogen-containing contraceptives**. *Diabetes mellitus* - **Diabetes mellitus** (uncomplicated by vascular disease) is not a contraindication for progestin-only contraceptives, which are safe for diabetic management. - The implant has minimal adverse effects on **glucose metabolism** and is classified as a Category 2 (benefits generally outweigh risks) method by WHO MEC criteria. *PID* - A **history of Pelvic Inflammatory Disease (PID)** is not a contraindication for the contraceptive implant, as it is a systemic hormonal method and not an intrauterine device. - Unlike IUDs, the subdermal implant does not interact with the uterine cavity or tubes, thus posing no risk of inducing or exacerbating **pelvic infection**.

Q: A patient with a previous history of cesarean section is in labor and has contractions of 3/10, no fetal distress and membranes are intact. What is the next step in management?

Perform artificial rupture of membranes (ARM) and monitor. ***Perform artificial rupture of membranes (ARM) and monitor*** - In a patient undergoing **Trial of Labor After Cesarean (TOLAC)**, with adequate contractions (3/10) and intact membranes, **ARM may be performed** to assess amniotic fluid and facilitate closer monitoring of fetal well-being - ARM allows for **placement of internal monitors** (fetal scalp electrode and intrauterine pressure catheter) if needed for more accurate assessment during TOLAC - **Continuous electronic fetal monitoring (EFM)** is mandatory during TOLAC to detect early signs of **uterine rupture** (fetal heart rate abnormalities) or fetal distress - Once ARM is performed, close observation of labor progress and fetal status continues *Oxytocin* - While labor augmentation may be needed later, **oxytocin should be used cautiously** in TOLAC due to increased risk of **uterine hyperstimulation** and **uterine rupture** - Current contractions at 3/10 are adequate; oxytocin is reserved for **inadequate uterine contractions** or **labor dystocia** - If used, oxytocin should be at **lower doses** with careful titration in patients with prior cesarean section *Proceed with instrumental delivery* - Instrumental delivery (vacuum or forceps) is indicated only during the **second stage of labor** for specific indications such as **prolonged second stage**, **maternal exhaustion**, or **non-reassuring fetal status** - This patient is in the **first stage of labor**; instrumental delivery is not applicable at this stage *Perform a repeat cesarean section* - The patient is successfully undergoing **TOLAC** with adequate contractions and no fetal distress; immediate cesarean section is **not indicated** - Repeat cesarean section is reserved for **failed TOLAC** (arrested labor), **non-reassuring fetal heart rate patterns**, or **suspected uterine rupture** - Approximately 60-80% of appropriate TOLAC candidates achieve successful vaginal delivery

Question 1

A patient presents with obstructed labor, and on abdominal examination, a groove or band is palpable across the uterus. What is the most likely diagnosis?

Accepted Answer

Bandl’s ring

Answer

Constriction ring

Answer

Contraction ring

Answer

Schroeder's ring

Question 2

A pregnant woman is being assessed for induction of labor. On vaginal examination: Cervical dilation: 2 cm, Effacement: 20%, Cervical consistency: Soft, Position: Midline, Station: -2. What is the modified Bishop Score?

Accepted Answer

Score 5 - Unfavorable

Answer

Score 7 - Favorable

Answer

Score 6 - Borderline

Answer

Score 3 - Highly unfavorable

Question 3

During the management of shoulder dystocia in childbirth, which of the following is the earliest and first maneuver typically attempted?

Accepted Answer

McRoberts maneuver

Answer

Delivery of posterior arm

Answer

Woods corkscrew maneuver

Answer

Rubin maneuver

Question 4

OCPs can be given in which of the following conditions?

Accepted Answer

HIV

Answer

DM

Answer

Hyperlipidemia

Answer

HTN

Question 5

A woman sustains a perineal tear during delivery. Examination reveals that less than 50% of the external anal sphincter is involved. Based on the classification system, what is the most appropriate description of this injury?

Accepted Answer

Grade 3a

Answer

Grade 4

Answer

Grade 2

Answer

Grade 3b

Question 6

A 12-year-old girl presents with primary amenorrhea. She has been raised as a girl, has not developed breast tissue, and ultrasound reveals absence of the uterus. Karyotyping shows a 46 XY chromosomal pattern. What is the most likely diagnosis?

Accepted Answer

Androgen insensitivity syndrome

Answer

MRKH syndrome

Answer

17-hydroxylase deficiency

Answer

Swyer syndrome

Question 7

During assisted vaginal delivery, where is the vacuum device typically applied?

Accepted Answer

3 cm anterior to the posterior fontanelle

Answer

Between the anterior and posterior fontanelle

Answer

On the posterior fontanelle

Answer

At 3 cm behind the anterior fontanelle

Question 8

What is the co-test in cervical cancer screening?

Accepted Answer

HPV and PAP smear

Answer

PAP smear and colposcopy

Answer

HPV and VIA

Answer

Pap smear and VIA

Question 9

Which of the following is a contraindication to subdermal contraceptive implant?

Accepted Answer

Undiagnosed genital bleeding

Answer

PID

Answer

Diabetes mellitus

Answer

Hypertension

Question 10

A patient with a previous history of cesarean section is in labor and has contractions of 3/10, no fetal distress and membranes are intact. What is the next step in management?

Accepted Answer

Perform artificial rupture of membranes (ARM) and monitor

Answer

Perform a repeat cesarean section

Answer

Proceed with instrumental delivery

Answer

Oxytocin

FMGE 2025 — Obstetrics and Gynecology