INI-CET 2023 — Obstetrics and Gynecology
12 Previous Year Questions with Answers & Explanations
A 15-year-old girl child with primary amenorrhea has pubic hair, prepubertal breast, blind vagina, clitoromegaly, and normal testosterone. Karyotype given is 46 XY , what is the cause?
Least chances of perinatal transmission are seen in?
Which of the following is an established benefit of Hormone Replacement Therapy (HRT)?
A woman presents with painless ulcers on the vulva, she gives a history of having multiple sexual partners and has had a stillbirth at 28 weeks in the past. What is the next best step of investigation?
All are the causes of non-immune hydrops except?
A patient has dyspareunia, and dysmenorrhea with adnexal tenderness. What is the first step of investigation?
After delivering a baby boy, a 25 -year-old mother developed acute PPH and hypovolemic shock, and major blood transfusion occurred. All of the following are complications of blood transfusion except?
Least chance of perinatal transmission?
A 30-year-old pregnant female diagnosed with fibroid presented with fever, mild leukocytosis, and pain at 28 weeks. What is the likely cause?
A patient complained of whitish discharge from the vagina and yellow staining on their clothes. There is no itching, no redness, and pH is acidic. What is the likely cause?
INI-CET 2023 - Obstetrics and Gynecology INI-CET Practice Questions and MCQs
Question 1: A 15-year-old girl child with primary amenorrhea has pubic hair, prepubertal breast, blind vagina, clitoromegaly, and normal testosterone. Karyotype given is 46 XY , what is the cause?
- A. 17 hydroxylase deficiency
- B. 5-alpha reductase deficiency (Correct Answer)
- C. Swyer syndrome
- D. Complete AIS
Explanation: ***5-alpha reductase deficiency*** - The presence of **primary amenorrhea**, **pubic hair**, **clitoromegaly**, **blind vagina**, and a **46 XY karyotype** with **normal testosterone** levels points to 5-alpha reductase deficiency. In this condition, the body cannot convert testosterone to the more potent dihydrotestosterone (DHT) needed for external male genitalia development in utero. - Individuals with this condition are typically raised as girls, but at puberty, they develop **virilization** (e.g., clitoromegaly, deepening voice, pubic hair) due to an increase in testosterone, which can still exert some androgenic effects. *17 hydroxylase deficiency* - This deficiency affects both adrenal and gonadal steroid synthesis, leading to **hypertension**, **hypokalemia**, and **primary amenorrhea** in 46 XY individuals. - It would also result in **low testosterone levels**, which contradicts the normal testosterone mentioned in the case. *Swyer syndrome* - Swyer syndrome (46 XY pure gonadal dysgenesis) is characterized by a **46 XY karyotype** but rudimentary or streak gonads, leading to **primary amenorrhea** and an **absence of secondary sexual characteristics** (no breast development, no pubic hair). - These individuals have **low testosterone** and high gonadotropins, and they present with a **female phenotype** and a **uterus**, which contradicts the features of pubic hair and clitoromegaly. *Complete AIS* - Complete Androgen Insensitivity Syndrome (CAIS) also presents with a **46 XY karyotype**, **primary amenorrhea**, and a **blind vagina**. - However, individuals with CAIS have **undescended testes** that produce testosterone, but their cells cannot respond to it due to defective androgen receptors, resulting in **breast development** at puberty (due to peripheral conversion of testosterone to estrogen) and **absent or sparse pubic/axillary hair** (since androgen receptors are non-functional). - The presence of **pubic hair** and **clitoromegaly** in this case rules out CAIS.
Question 2: Least chances of perinatal transmission are seen in?
- A. Rubella
- B. Hepatitis B
- C. HSV (Correct Answer)
- D. CMV
Explanation: ***HSV*** - **Perinatal transmission of HSV** is rare, occurring in approximately 1 in 3,000 to 1 in 20,000 live births, primarily from contact with maternal genital lesions during vaginal delivery. - Transmission rates are lowest when the mother has **recurrent herpes lesions** due to the presence of maternal antibodies offering some fetal protection. *Rubella* - **Congenital rubella syndrome** carries a high risk of transmission (up to 90%) if the mother contracts rubella in the first trimester. - It can lead to severe birth defects such as **heart abnormalities**, **cataracts**, and **deafness**. *Hepatitis B* - The risk of **vertical transmission of Hepatitis B** is significant, especially if the mother is HBeAg-positive (up to 90%). - Without intervention, chronic infection develops in 70-90% of infected infants, often leading to **liver disease** later in life. *CMV* - **Congenital CMV infection** is the most common congenital viral infection, with a transmission rate of 30-40% in primary maternal infection. - It can cause severe neurological deficits, **sensorineural hearing loss**, and **developmental delays** in affected infants.
Question 3: Which of the following is an established benefit of Hormone Replacement Therapy (HRT)?
- A. Decreased risk of endometrial cancer
- B. Decreased risk of breast cancer
- C. Decreased risk of colon cancer
- D. Decreased risk of vertebral fracture (Correct Answer)
Explanation: ***Decreased risk of vertebral fracture*** - HRT is **one of the most well-established benefits** for **prevention of osteoporosis and fractures**, including vertebral fractures. - Estrogen plays a crucial role in maintaining **bone mineral density** by inhibiting osteoclast activity and promoting osteoblast function. - Multiple studies, including the **Women's Health Initiative (WHI)**, have demonstrated a **significant reduction in hip, vertebral, and other osteoporotic fractures** in women taking HRT. - This benefit is recognized by **ACOG, NAMS, and international menopause societies** as a primary indication for HRT in appropriate candidates. *Decreased risk of endometrial cancer* - **Unopposed estrogen therapy** actually **increases the risk of endometrial cancer** due to hyperplasia of the endometrium. - To counteract this, **progestin is added** in women with a uterus receiving HRT, which reduces but does not eliminate the risk increase. - Combined HRT does not provide a net decreased risk below baseline. *Decreased risk of breast cancer* - Combined **estrogen-progestin HRT** has been consistently associated with an **increased risk of breast cancer**, especially with longer durations of use (>5 years). - This was clearly demonstrated in the **WHI trial** and remains a major consideration when prescribing HRT. - Estrogen-only HRT might have a neutral or slightly increased risk, but never a decreased risk. *Decreased risk of colon cancer* - While some observational studies and the **WHI trial** initially showed a reduced incidence of colorectal cancer with HRT, this is **not considered an established or primary indication** for HRT. - Subsequent analyses have shown **inconsistent results**, and any benefit is offset by increased risks. - Current guidelines do **not recommend HRT** for colorectal cancer prevention.
Question 4: A woman presents with painless ulcers on the vulva, she gives a history of having multiple sexual partners and has had a stillbirth at 28 weeks in the past. What is the next best step of investigation?
- A. PCR
- B. VDRL (Correct Answer)
- C. Vaginal swab and culture
- D. NAT
Explanation: ***VDRL*** - The presentation of **painless vulvar ulcers**, a history of **multiple sexual partners**, and a past **stillbirth at 28 weeks** are highly suggestive of **syphilis**. - A **VDRL (Venereal Disease Research Laboratory) test** is a non-treponemal serologic test used for screening and monitoring the treatment of syphilis. *PCR* - While **PCR** can be used to detect the genetic material of *Treponema pallidum*, it is not the primary diagnostic test for syphilis, especially given the classic clinical picture. - It is more commonly used for detecting other sexually transmitted infections (STIs) or for specific situations where direct detection of the organism from a lesion is preferred. *Vaginal swab and culture* - A **vaginal swab and culture** would be appropriate for diagnosing bacterial vaginosis, candidiasis, or certain bacterial STIs, but it is not suitable for diagnosing syphilis. - Syphilis is caused by a spirochete (*Treponema pallidum*) that cannot be cultured on standard media. *NAT* - **Nucleic Acid Amplification Tests (NATs)** are a broad category of tests that include PCR. - Like PCR, while potentially applicable for *Treponema pallidum* detection, they are not the standard or first-line diagnostic investigation for syphilis given the strong clinical indicators.
Question 5: All are the causes of non-immune hydrops except?
- A. Thalassemia
- B. Cardiovascular causes
- C. Parvovirus
- D. ABO incompatibility (Correct Answer)
Explanation: ***ABO incompatibility*** - **ABO incompatibility** is a common cause of **immune hydrops fetalis** due to antibody-mediated hemolytic anemia. - Immune hydrops involves red blood cell destruction caused by maternal antibodies crossing the placenta, which is not characteristic of non-immune hydrops. *Thalassemia* - **Alpha-thalassemia major (Hb Barts hydrops fetalis)** is a severe form of thalassemia frequently leading to **non-immune hydrops** due to profound anemia. - The severe chronic anemia leads to **high-output cardiac failure**, diffuse edema, and ascites. *Cardiovascular causes* - **Structural heart defects** and **arrhythmias** can impair fetal circulation and cardiac function, leading to **non-immune hydrops**. - Conditions like **hypoplastic left heart syndrome** or **supraventricular tachycardia** can cause fluid overload and edema. *Parvovirus* - **Parvovirus B19 infection** in the fetus can cause severe **anemia** by targeting erythroid progenitor cells, resulting in bone marrow suppression. - This severe fetal anemia frequently leads to **non-immune hydrops** as a consequence of heart failure.
Question 6: A patient has dyspareunia, and dysmenorrhea with adnexal tenderness. What is the first step of investigation?
- A. Colposcopy
- B. Diagnostic laparoscopy
- C. Transvaginal USG (Correct Answer)
- D. Transabdominal pelvic ultrasound
Explanation: ***Transvaginal USG*** - This is the **first-line investigation** for evaluating pelvic pain, dyspareunia, dysmenorrhea, and adnexal tenderness due to its ability to provide **high-resolution images** of the uterus, ovaries, and surrounding structures to identify potential pathology like **endometriomas** or other adnexal masses. - It allows for detailed assessment of **ovarian cysts**, fibroids, and other pelvic abnormalities, which can explain the patient's symptoms. *Colposcopy* - This procedure is primarily used to closely examine the **cervix, vagina, and vulva** for abnormal cells, often following an abnormal Pap test. - It is not the initial step for investigating generalized pelvic pain, dyspareunia, or adnexal tenderness. *Diagnostic laparoscopy* - While a **diagnostic laparoscopy** can provide a definitive diagnosis for conditions like **endometriosis**, it is an **invasive surgical procedure** and typically reserved for cases where non-invasive imaging, such as transvaginal ultrasound, has not yielded a clear diagnosis or when conservative management has failed. - It is not considered the first-step investigation due to its **invasive nature** and associated risks. *Transabdominal pelvic ultrasound* - A **transabdominal pelvic ultrasound** provides a broader view of the pelvic organs but often has **lower resolution** and is less accurate for detailed assessment of the uterus, ovaries, and adnexa compared to transvaginal ultrasound, especially in obese patients. - It is often used if a transvaginal ultrasound is not feasible or for assessing larger pelvic masses, but the **transvaginal approach** is superior for detailed evaluation of the female reproductive organs.
Question 7: After delivering a baby boy, a 25 -year-old mother developed acute PPH and hypovolemic shock, and major blood transfusion occurred. All of the following are complications of blood transfusion except?
- A. Hypothermia
- B. Hypocalcemia
- C. Hypokalemia (Correct Answer)
- D. Hypomagnesemia
Explanation: ***Hypokalemia*** - **Hypokalemia is NOT a typical complication of massive blood transfusion**. In fact, massive transfusion is characteristically associated with **hyperkalemia**, not hypokalemia. - **Stored blood** contains high levels of extracellular potassium due to **red blood cell lysis** during storage (potassium levels can reach 30-50 mEq/L in units stored >21 days). - Rapid transfusion of multiple units delivers a significant **potassium load**, making **hyperkalemia** the expected electrolyte abnormality. - While hypokalemia could theoretically occur later due to **alkalosis from citrate metabolism** or during the **rewarming/correction phase**, this is **indirect, uncommon, and not a recognized acute complication** of the transfusion itself. - Therefore, hypokalemia is the exception among the listed options. *Hypothermia* - **Direct and common complication** when cold blood products (stored at 1-6°C) are rapidly infused without adequate warming. - Can cause **coagulopathy**, cardiac arrhythmias, decreased drug metabolism, and leftward shift of oxygen-hemoglobin dissociation curve. - Prevention requires use of **blood warmers** during massive transfusion. *Hypocalcemia* - **Very common complication** of massive transfusion due to **citrate toxicity**. - **Citrate** (anticoagulant in stored blood) chelates ionized calcium in the recipient's circulation. - Normally metabolized by the liver, but rapid transfusion overwhelms hepatic metabolism, leading to **symptomatic hypocalcemia**. - Can cause **cardiac dysfunction, hypotension, and prolonged QT interval**. *Hypomagnesemia* - Can occur with massive transfusion as **magnesium is also chelated by citrate**, similar to calcium. - Less commonly recognized than hypocalcemia but documented in massive transfusion protocols. - Can contribute to **cardiac arrhythmias and neuromuscular irritability**.
Question 8: Least chance of perinatal transmission?
- A. Hepatitis A (Correct Answer)
- B. HSV
- C. Rubella
- D. CMV
Explanation: ***Hepatitis A*** - Perinatal transmission of **hepatitis A virus (HAV)** is rare because it's primarily transmitted via the **fecal-oral route**. - While HAV can be present in blood during the viremic phase, the risk of maternal-fetal transmission is negligible due to the short duration of viremia and antibodies usually present in immune mothers. *HSV* - **Herpes simplex virus (HSV)** has a significant risk of perinatal transmission, especially during **vaginal delivery** if the mother has active genital lesions. - Neonatal herpes can lead to severe disseminated disease, central nervous system involvement, or skin, eye, and mouth disease. *Rubella* - **Rubella virus** can cause congenital rubella syndrome (CRS) if the mother is infected during pregnancy, leading to severe birth defects. - This highly teratogenic virus readily crosses the **placenta**, particularly in the first trimester. *CMV* - **Cytomegalovirus (CMV)** is the most common cause of congenital viral infection, with often asymptomatic mothers transmitting the virus to the fetus. - Perinatal transmission can occur *in utero*, during **delivery**, or through **breastfeeding**.
Question 9: A 30-year-old pregnant female diagnosed with fibroid presented with fever, mild leukocytosis, and pain at 28 weeks. What is the likely cause?
- A. Fibroid infection
- B. Red degeneration of fibroid (Correct Answer)
- C. Fibroid torsion
- D. Labor pain
Explanation: ***Red degeneration of fibroid*** - **Red degeneration** (also known as carneous degeneration) is common in pregnancy due to rapid fibroid growth outstripping its blood supply, leading to **ischemic necrosis** and causing pain, fever, and leukocytosis. - This complication typically occurs during the **second and third trimesters** due to hormonal changes and increased vascularity, consistent with the 28-week presentation. *Fibroid infection* - While possible, **fibroid infection** is a rarer complication, often secondary to other procedures or prolonged degeneration. - It would likely present with more pronounced signs of infection, such as higher fever, significant leukocytosis, and possibly discharge or septic symptoms, which are not explicitly stated as severe here. *Fibroid torsion* - **Torsion** usually occurs with pedunculated fibroids when the stalk twists, leading to acute, severe pain and potentially necrosis. - This presentation does not specifically mention a pedunculated fibroid or the sudden, sharp, localized pain typically associated with torsion of an appendage. *Labor pain* - At 28 weeks, **labor pain** would indicate preterm labor, which would typically involve regular, escalating uterine contractions and cervical changes. - The symptoms of fever and leukocytosis are not characteristic of uncomplicated labor pain, suggesting an underlying inflammatory or degenerative process with the fibroid.
Question 10: A patient complained of whitish discharge from the vagina and yellow staining on their clothes. There is no itching, no redness, and pH is acidic. What is the likely cause?
- A. Trichomoniasis
- B. Candidiasis
- C. Bacterial vaginosis
- D. Increased normal vaginal discharge (Correct Answer)
Explanation: ***Increased normal vaginal discharge*** - The presence of a whitish discharge and yellow staining on clothes, without **itching** or **redness**, and with an **acidic pH**, is characteristic of a **normal physiological discharge**. - Normal vaginal discharge can vary in color and consistency, and its volume can increase due to hormonal changes (e.g., during ovulation or pregnancy) or sexual arousal. *Trichomoniasis* - This infection typically causes a **frothy, greenish-yellow discharge** with a **foul odor**, often accompanied by **itching**, redness, and a **pH greater than 4.5**. - The absence of itching and the acidic pH rule out trichomoniasis in this scenario. *Candidiasis* - **Candidiasis** (yeast infection) presents with a **thick, white, 'cottage cheese' like discharge**, accompanied by **intense itching**, burning, and redness, with a **normal to acidic pH (less than 4.5)**. - The lack of itching and redness, along with a simple whitish discharge, does not align with candidiasis. *Bacterial vaginosis* - **Bacterial vaginosis** is characterized by a **thin, grayish-white discharge** with a **"fishy" odor**, especially after intercourse, and a **vaginal pH greater than 4.5**. - The absence of a fishy odor and the acidic pH make bacterial vaginosis an unlikely diagnosis.