FMGE 2025 Practice Questions

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: A 12-year-old girl has developed breast and pubic hair. The mother wants to know which sign of puberty will typically occur next?

Peak height. ***Peak height*** - **Peak Height Velocity (PHV)**, representing the maximal growth rate, is the **next major pubertal milestone** after the onset of **thelarche** (breast budding) and **pubarche** (pubic hair development). - In the typical sequence of female puberty, PHV occurs at Tanner stage 2-3, approximately **1 year before menarche**. - This is a highly predictable, measurable milestone that serves as a clinical marker of pubertal progression. *Vaginal discharge* - Mild physiologic **vaginal discharge** (leukorrhea) due to increasing estrogen often begins very early in puberty, frequently concurrent with or shortly after initial breast budding. - While it may already be present or developing, it is a **subtle, less predictable sign** compared to the major milestone of Peak Height Velocity. - It is not taught as a primary pubertal milestone in standard medical texts. *Menarche* - **Menarche** (first menses) is a **late pubertal event** occurring at Tanner stage 4, typically **2-2.5 years after thelarche**. - It follows Peak Height Velocity by approximately 1 year and signals the deceleration phase of the growth spurt. - This occurs well after the clinical scenario described. *Axillary hair development* - Axillary hair typically develops at **Tanner stage 4**, relatively late in puberty, closer to the time of menarche. - It follows both pubic hair development and Peak Height Velocity in the pubertal sequence.

Q: Identify the type of suture?

Simple Interrupted suture. ***Simple Interrupted suture*** - The image displays multiple, separate sutures, each individually placed and tied, which is characteristic of the **simple interrupted** technique. - This is the most common suturing method, providing good **wound apposition** and allowing for selective removal of single sutures if a localized infection develops. *Vertical Mattress* - A **vertical mattress suture** involves a 'far-far, near-near' stitching pattern in a plane perpendicular to the wound, which is not depicted in the image. - This technique is specifically used for everting wound edges and closing wounds under tension, creating a different surface appearance. *Horizontal mattress* - A **horizontal mattress suture** runs parallel to the wound edge on the skin surface, creating a box-like stitch to distribute tension. - It is primarily used for wounds under high tension or for providing **hemostasis**, and its appearance is distinctly different from the simple loops shown. *Subcuticular suture* - A **subcuticular suture** is placed entirely within the dermis, leaving no visible suture material on the skin surface except for the entry and exit points. - This method is used for optimal cosmetic results, whereas the image clearly shows external knots for each individual stitch.

Q: A 46-year-old male had a tumor in his left lobe of liver, so left sided hemi hepatectomy was planned. Which of the following segments of the liver will be resected in this procedure?

2, 3 & 4. ***2, 3 and 4***- **Left hemi hepatectomy** involves the surgical removal of the entire **left functional lobe** of the liver, which contributes to approximately 40% of the total liver volume.- In the **Couinaud segmental classification**, the left functional lobe includes segments **II** (left lateral superior), **III** (left lateral inferior), and **IV** (left medial segment/quadrate lobe). *1, 2 & 3*- Segment **I** is the **caudate lobe**, which is typically considered functionally distinct and often preserved during a standard left hemi hepatectomy, unless the tumor involves this segment. - Resecting only segments II and III is known as a **left lateral sectionectomy** or left bisegmentectomy (corresponding to the anatomical left lobe). *5, 6, 7 & 8*- These segments constitute the **right functional lobe** of the liver (segments **V** and **VIII** are anterior; **VI** and **VII** are posterior). - Resection of these four segments would be classified as a **right hemi hepatectomy** (right lobectomy). *2, 3, 4 & 5*- This combination includes the entire left functional lobe (2, 3, 4) plus segment **V**, which is the **anterior inferior segment** of the right lobe. - Removing the left lobe plus segment V constitutes an **extended left hemi hepatectomy** (or left trisectionectomy), exceeding the definition of a standard left hemi hepatectomy.

Q: Given below are the steps of Damage control surgery. What is the correct sequence? 1. Control of hemorrhage and contamination 2. Temporary abdominal closure 3. Resuscitation in ICU 4. Definitive surgical repair

1,2,3,4. ***Correct Sequence: 1,2,3,4*** The correct sequence of Damage Control Surgery follows a systematic approach: **Step 1: Control of hemorrhage and contamination** - Initial abbreviated laparotomy to control life-threatening bleeding - Control contamination from hollow viscus injuries - Pack bleeding sites, ligate vessels, staple or resect perforated bowel - Goal: Stop bleeding and contamination rapidly **Step 2: Temporary abdominal closure** - Use temporary closure techniques (vacuum-assisted closure, Bogota bag, towel clip closure) - Prevents abdominal compartment syndrome - Avoids tension on abdominal wall in edematous/swollen abdomen - No attempt at definitive repairs **Step 3: Resuscitation in ICU** - Correct the "lethal triad": **hypothermia, acidosis, coagulopathy** - Optimize physiology with warming, volume resuscitation, blood products - Typically requires 24-48 hours of intensive care - Patient must be physiologically stable before returning to OR **Step 4: Definitive surgical repair** - Return to OR once hemodynamically stable and coagulopathy corrected - Perform definitive anastomoses, vascular repairs, reconstructions - Formal abdominal closure - May require multiple staged operations *Incorrect Option 3,1,2,4:* Starting with ICU resuscitation before controlling hemorrhage would be fatal *Incorrect Option 1,3,2,4:* Performing ICU resuscitation before temporary closure risks abdominal compartment syndrome *Incorrect Option 2,1,4,3:* Performing temporary closure before controlling hemorrhage is illogical **Clinical Pearl:** Damage control surgery is indicated in patients with physiologic exhaustion (hypothermia <35°C, pH <7.2, coagulopathy) where prolonged definitive surgery would be fatal.

Q: What is the most appropriate treatment for an 8cm chylolymphatic mesenteric cyst?

Enucleation. ***Enucleation*** - This is the standard surgical treatment for most **mesenteric cysts**, as it allows for complete removal of the cyst while preserving the adjacent bowel and its vital blood supply. - Successful **enucleation** has a very low recurrence rate and provides a definitive tissue diagnosis to rule out rare cases of malignancy. *Aspiration* - Aspiration is associated with a very high **recurrence rate** (50-100%) because the cyst-secreting lining is left behind. - It also carries risks of **infection**, **hemorrhage**, and leakage of cystic fluid causing chemical peritonitis, and it fails to provide a histological diagnosis. *Resection of the cyst along with the adjacent bowel* - This is an overly aggressive approach for a typically benign condition and should be avoided unless necessary to preserve **bowel viability**. - **Bowel resection** is reserved for cases where the cyst cannot be separated from the bowel wall or when the mesenteric blood supply is irrevocably compromised. *Conservative* - Conservative management is generally not recommended for symptomatic or large cysts (like this 8cm one) due to the risk of complications. - Potential complications include **intestinal obstruction**, **volvulus**, **torsion** of the cyst, **hemorrhage** into the cyst, or infection.

Question 1

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 2

OCPs can be given in which of the following conditions?

Accepted Answer

HIV

Answer

DM

Answer

Hyperlipidemia

Answer

HTN

Question 3

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 4

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 5

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 6

A 12-year-old girl has developed breast and pubic hair. The mother wants to know which sign of puberty will typically occur next?

Accepted Answer

Peak height

Answer

Vaginal discharge

Answer

Axillary hair development

Answer

Menarche

Question 7

Identify the type of suture?

Accepted Answer

Simple Interrupted suture

Answer

Horizontal mattress

Answer

Vertical Mattress

Answer

Subcuticular suture

Question 8

A 46-year-old male had a tumor in his left lobe of liver, so left sided hemi hepatectomy was planned. Which of the following segments of the liver will be resected in this procedure?

Accepted Answer

2, 3 & 4

Answer

1, 2 & 3

Answer

5, 6, 7 & 8

Answer

2, 3, 4 & 5

Question 9

Given below are the steps of Damage control surgery. What is the correct sequence?

1. Control of hemorrhage and contamination
2. Temporary abdominal closure
3. Resuscitation in ICU
4. Definitive surgical repair

Accepted Answer

1,2,3,4

Answer

3,1,2,4

Answer

1,3,2,4

Answer

2,1,4,3

Question 10

What is the most appropriate treatment for an 8cm chylolymphatic mesenteric cyst?

Accepted Answer

Enucleation

Answer

Aspiration

Answer

Conservative

Answer

Resection of the cyst along with the adjacent bowel

FMGE 2025

Obstetrics and Gynecology

Pediatrics

Surgery