UPSC-CMS 2009 — Obstetrics and Gynecology
24 Previous Year Questions with Answers & Explanations
The maximum chances of HIV infection being transmitted to the fetus/infant in an HIV infected mother are during
Which one of the following statements is not correct about obstetric cholestasis ?
What is the most commonly observed fetal effect in women receiving magnesium sulphate therapy for pre-eclampsia/eclampsia ?
Spiegelberg's criteria for diagnosis of ovarian pregnancy include the following except
Consider the following markers: 1. Nuchal translucency 2. PAPP-A 3. GTT 4. Inhibin A Which of the above markers are included in the first trimester screening of Down's syndrome?
The following changes may be seen in pre-eclampsia except
"Variable decelerations" on an electronic fetal heart rate monitor imply
What is the maternal risk of using misoprostol for ripening of cervix during induction of labour?
A 25 year old patient who has had an abortion four months ago has come with the history of profuse vaginal bleeding. On examination uterus is bulky, both the ovaries are enlarged, pregnancy test is positive. What is the probable clinical diagnosis ?
Uterine rupture is most commonly encountered after which one of the following surgeries?
UPSC-CMS 2009 - Obstetrics and Gynecology UPSC-CMS Practice Questions and MCQs
Question 1: The maximum chances of HIV infection being transmitted to the fetus/infant in an HIV infected mother are during
- A. During labour (Correct Answer)
- B. Third trimester
- C. First trimester
- D. During breast feeding
Explanation: ***During labour*** - The **highest risk** of mother-to-child HIV transmission occurs during labor and delivery due to the infant's exposure to maternal blood and genital secretions. - The process of passing through the **birth canal** can lead to inoculation with HIV-infected cells and viral particles. *Third trimester* - While some transmission can occur in the third trimester, the risk is significantly **lower** than during labor. - The placenta generally provides a barrier, though there's a risk of **transplacental passage** if the placental integrity is compromised. *First trimester* - The **lowest risk** of HIV transmission occurs during the first trimester. - The developing fetus is relatively protected by the placenta, and the viral load in maternal blood might be lower compared to later stages without intervention. *During breast feeding* - **Breastfeeding** is a known route of HIV transmission, but its risk is generally **lower per exposure** compared to labor and delivery, especially if the mother is on antiretroviral therapy. - The risk is **cumulative** over the duration of breastfeeding.
Question 2: Which one of the following statements is not correct about obstetric cholestasis ?
- A. It results in pruritus without rash
- B. Associated with markedly high bilirubin and raised liver enzymes (Correct Answer)
- C. It is an indication of termination of pregnancy at 37 weeks
- D. Risk of recurrence is high in future pregnancies
Explanation: ***Associated with markedly high bilirubin and raised liver enzymes*** - While **elevated liver enzymes** (aminotransferases) and slightly **raised bilirubin** can occur in obstetric cholestasis, a **markedly high bilirubin** level is more characteristic of other severe liver conditions or acute liver failure, not typical obstetric cholestasis. - The primary biochemical markers for diagnosis are **elevated serum bile acids** (usually >10 μmol/L), with secondary increases in liver enzymes, but bilirubin levels are rarely "markedly high." *It results in pruritus without rash* - **Pruritus without a rash** is the hallmark symptom of obstetric cholestasis, often worsening at night and affecting the palms and soles. - This symptom is due to the accumulation of **bile acids** in the skin. *It is an indication of termination of pregnancy at 37 weeks* - **Planned delivery** at 37-38 weeks is a common management strategy for obstetric cholestasis to reduce the risk of **fetal complications**, such as stillbirth. - This timing is chosen to balance fetal maturity with the risk of ongoing exposure to elevated bile acids. *Risk of recurrence is high in future pregnancies* - Obstetric cholestasis has a significant **recurrence rate**, often exceeding 60-70%, in subsequent pregnancies. - This high recurrence rate suggests a genetic predisposition to the condition.
Question 3: What is the most commonly observed fetal effect in women receiving magnesium sulphate therapy for pre-eclampsia/eclampsia ?
- A. Intestinal obstruction
- B. Variability in fetal heart rate pattern
- C. Cerebral palsy
- D. Respiratory depression (Correct Answer)
Explanation: ***Respiratory depression*** - Magnesium sulfate readily crosses the placenta, leading to elevated magnesium levels in the fetus, which can cause **central nervous system depression** and **respiratory depression** at birth. - This is the **most commonly observed fetal effect**, manifesting as neonatal hypermagnesemia with respiratory compromise, hypotonia, and decreased reflexes. - The effect is due to magnesium's role as a **neuromuscular blocker**, reducing acetylcholine release at the neuromuscular junction. *Intestinal obstruction* - There is no direct link between maternal magnesium sulfate therapy and an increased risk of **fetal intestinal obstruction**. - Intestinal obstruction in neonates is typically associated with **structural anomalies** or conditions like meconium ileus, not magnesium exposure. *Variability in fetal heart rate pattern* - While magnesium sulfate can cause **decreased fetal heart rate variability** as a monitoring finding, this is not the "most commonly observed fetal effect." - Decreased variability is a **transient monitoring change** during therapy, whereas respiratory depression is a direct clinical effect observed at birth. - The question asks for the most common **fetal effect**, and respiratory depression at delivery is more clinically significant and commonly encountered. *Cerebral palsy* - Magnesium sulfate is actually used as a **neuroprotective agent** in preterm births to **reduce the risk of cerebral palsy**. - It does not cause cerebral palsy; rather, it provides fetal neuroprotection when given for preterm labor <32 weeks gestation.
Question 4: Spiegelberg's criteria for diagnosis of ovarian pregnancy include the following except
- A. Gestational sac must occupy the position of ovary
- B. Gestational sac is connected with infundibulopelvic ligament (Correct Answer)
- C. Ovarian tissue should be present in the wall of gestational sac on histopathology
- D. Tube on the affected side must be intact
Explanation: ***Gestational sac is connected with infundibulopelvic ligament*** - Spiegelberg's criteria define specific conditions for diagnosing **ovarian pregnancy**, and a connection to the infundibulopelvic ligament is **not one of them**. - This criterion is associated more with **tubal pregnancies** or other ectopic locations rather than an ovarian implantation. *Gestational sac must occupy the position of ovary* - This is a key criterion by Spiegelberg, indicating that the **pregnancy is located within the ovary** itself, which is essential for diagnosis. - The macroscopic observation of the gestational sac within the ovarian borders is crucial in differentiating it from other ectopic sites. *Ovarian tissue should be present in the wall of gestational sac on histopathology* - This is also a fundamental Spiegelberg criterion, confirming the ovarian origin through **histopathological examination**. - The presence of **ovarian stroma** or **follicular structures** within the sac wall histologically proves ovarian implantation. *Tube on the affected side must be intact* - This criterion ensures that the **fallopian tube is not involved** in the pregnancy, ruling out a tubal ectopic pregnancy. - An intact tube supports the diagnosis of an ovarian pregnancy by excluding the most common site of ectopic gestation.
Question 5: Consider the following markers: 1. Nuchal translucency 2. PAPP-A 3. GTT 4. Inhibin A Which of the above markers are included in the first trimester screening of Down's syndrome?
- A. 2, 3 and 4
- B. 1 and 4
- C. 2 and 3 only
- D. 1 and 2 (Correct Answer)
Explanation: ***1 and 2*** - **Nuchal translucency (NT)** measurement and **Pregnancy-associated plasma protein A (PAPP-A)** are the key components of first-trimester screening for Down syndrome (combined test at 11-14 weeks). - Increased NT thickness (≥3.5 mm) and low PAPP-A levels are associated with higher risk of **trisomy 21 (Down syndrome)**. - This is typically combined with free β-hCG for the complete first-trimester combined screening. *2, 3 and 4* - This option incorrectly includes **GTT (Glucose Tolerance Test)**, which screens for **gestational diabetes mellitus**, not chromosomal abnormalities. - **Inhibin A** is a marker used in **second-trimester screening** (quadruple test at 15-20 weeks), not first trimester. - It correctly includes PAPP-A but omits the essential NT measurement. *1 and 4* - This option correctly includes **Nuchal translucency** but incorrectly adds **Inhibin A**. - **Inhibin A** is elevated in Down syndrome but is measured in the **second trimester** as part of the quad screen (AFP, hCG, uE3, Inhibin A). - It omits **PAPP-A**, which is the crucial biochemical marker for first-trimester screening. *2 and 3 only* - This option correctly includes **PAPP-A** but incorrectly includes **GTT**, which is completely unrelated to aneuploidy screening. - It omits **Nuchal translucency**, the most important ultrasound marker in first-trimester Down syndrome screening. - GTT is performed at 24-28 weeks for gestational diabetes screening.
Question 6: The following changes may be seen in pre-eclampsia except
- A. Thrombocytopenia
- B. Decreased antithrombin III
- C. Hemodilution (Correct Answer)
- D. Elevated uric acid
Explanation: ***Hemodilution*** - Pre-eclampsia is characterized by generalized **vasoconstriction** and **reduced plasma volume**, leading to **hemoconcentration**, not hemodilution. - The elevated hematocrit sometimes observed is a consequence of this reduced plasma volume. *Thrombocytopenia* - **Thrombocytopenia** (platelet count < 100,000/µL) is a common finding in severe pre-eclampsia and is part of the HELLP syndrome criteria. - It results from increased platelet consumption and destruction due to widespread endothelial dysfunction. *Decreased antithrombin III* - **Decreased antithrombin III** levels are characteristic of pre-eclampsia, reflecting disseminated intravascular coagulation (DIC) and increased consumption of coagulation factors. - This contributes to the procoagulant state often seen in severe pre-eclampsia. *Elevated uric acid* - **Elevated uric acid** is a common and early biochemical marker in pre-eclampsia, often correlating with disease severity. - It results from reduced renal clearance and increased production, reflecting renal impairment and widespread endothelial dysfunction.
Question 7: "Variable decelerations" on an electronic fetal heart rate monitor imply
- A. Fetal head compression
- B. Umbilical cord compression (Correct Answer)
- C. Utero-placental insufficiency
- D. Fetal anemia
Explanation: ***Umbilical cord compression*** - **Variable decelerations** are characterized by an **abrupt decrease** in fetal heart rate, which varies in timing, depth, and duration relative to uterine contractions. - This pattern is most commonly caused by **umbilical cord compression**, which temporarily reduces blood flow to the fetus, leading to immediate baroreceptor-mediated bradycardia. *Fetal head compression* - **Early decelerations** are typically associated with **fetal head compression** during contractions. - These are characterized by a gradual decrease in fetal heart rate that mirrors the contraction, with the nadir coinciding with the peak of the contraction. *Utero-placental insufficiency* - **Late decelerations** are associated with **utero-placental insufficiency**, indicating inadequate oxygen delivery to the fetus. - These are characterized by a gradual decrease in fetal heart rate that begins after the peak of the contraction and recovers after the contraction has ended. *Fetal anemia* - **Fetal anemia** can lead to a variety of fetal heart rate abnormalities, including **sinusoidal patterns** or **tachycardia**, as the fetus attempts to compensate for reduced oxygen-carrying capacity. - It does not typically present as isolated variable decelerations.
Question 8: What is the maternal risk of using misoprostol for ripening of cervix during induction of labour?
- A. Tachysystole/hyperstimulation of uterus (Correct Answer)
- B. Bradycardia
- C. Hypotension
- D. Tachycardia
Explanation: ***Tachysystole/hyperstimulation of uterus*** - Misoprostol, a **prostaglandin E1 analog**, increases uterine contractility to ripen the cervix and induce labor. - This heightened uterine activity can lead to **tachysystole** (more than 5 contractions in 10 minutes) or **uterine hyperstimulation**, posing risks to both mother and fetus. *Bradycardia* - **Maternal bradycardia** is not a direct or common maternal side effect of misoprostol; however, **fetal bradycardia** can occur secondary to uterine hyperstimulation and reduced placental perfusion. - Misoprostol's primary effect is on uterine smooth muscle, not directly on maternal heart rate regulation. *Hypotension* - While some prostaglandins can have vasodilatory effects, significant **maternal hypotension** is not a typical or well-known adverse effect of misoprostol used for cervical ripening. - The doses used for cervical ripening usually do not lead to systemic circulatory collapse. *Tachycardia* - **Maternal tachycardia** is not a primary or direct side effect of misoprostol; however, it could indirectly occur due to **maternal stress** or other complications. - The drug's mechanism of action primarily involves uterine contractility and cervical changes, not direct cardiac stimulation.
Question 9: A 25 year old patient who has had an abortion four months ago has come with the history of profuse vaginal bleeding. On examination uterus is bulky, both the ovaries are enlarged, pregnancy test is positive. What is the probable clinical diagnosis ?
- A. Ectopic pregnancy
- B. Incomplete abortion
- C. Choriocarcinoma (Correct Answer)
- D. Malignant ovarian tumor
Explanation: ***Choriocarcinoma*** - The combination of a history of **recent abortion** (four months prior), **profuse vaginal bleeding**, a **bulky uterus**, **enlarged ovaries**, and a positive **pregnancy test** strongly suggests choriocarcinoma. The enlarged ovaries are often due to **theca-lutein cysts** formed in response to very high hCG levels produced by the tumor. - Choriocarcinoma is a highly aggressive form of **gestational trophoblastic neoplasia** that typically arises after a molar pregnancy, abortion, or term pregnancy, and it secretes high levels of **hCG**, which accounts for the positive pregnancy test. *Ectopic pregnancy* - While an ectopic pregnancy can present with vaginal bleeding and a positive pregnancy test, it is unlikely to cause a **bulky uterus** or **bilateral enlarged ovaries**. - Symptoms usually appear earlier in pregnancy, and the hCG levels would typically not be as high as to cause theca-lutein cysts or persist four months post-abortion with profuse bleeding without rupture. *Incomplete abortion* - An incomplete abortion could cause vaginal bleeding and a bulky uterus, but it would typically occur much sooner after the abortion event (not four months later) and is generally associated with a declining or low plateau of hCG, not persistently high levels causing enlarged ovaries. - Retained products of conception would be the primary cause of bleeding, not a rapidly growing tumor with systemic effects. *Malignant ovarian tumor* - While a malignant ovarian tumor can cause an **enlarged ovary** (or ovaries) and vaginal bleeding, it would not result in a **positive pregnancy test** unless it was a very rare hCG-producing germ cell tumor, and even then, its presentation with a bulky uterus post-abortion is not typical. - The clinical picture here, particularly the positive pregnancy test and bulky uterus, points more specifically towards a **trophoblastic disease**.
Question 10: Uterine rupture is most commonly encountered after which one of the following surgeries?
- A. Hysterotomy
- B. Classical cesarean (Correct Answer)
- C. Metroplasty
- D. Myomectomy
Explanation: ***Classical cesarean*** - A **classical cesarean section** involves a vertical incision in the **upper uterine segment**, which contains fewer muscle fibers and heals less strongly than the lower segment. - This weaker scar is more prone to rupture in subsequent pregnancies or during labor, leading to a significantly higher risk compared to other uterine surgeries. *Hysterotomy* - **Hysterotomy** is a surgical incision into the uterus, often performed for fetal surgery, but **uterine rupture** risk is heavily dependent on the type and location of the incision. - While it creates a uterine scar, the risk of rupture varies with the depth and extent of the incision, and it is generally associated with a lower rupture risk than a single, full-thickness classical incision. *Metroplasty* - **Metroplasty** is a reconstructive surgery of the uterus, typically performed to correct uterine anomalies like a **septate uterus**, improving reproductive outcomes. - While it involves cutting and suturing uterine tissue, the goal is to create a more functional and robust uterus, and if performed meticulously, the risk of subsequent rupture is relatively low. *Myomectomy* - **Myomectomy** involves the surgical removal of **fibroids** (leiomyomas) from the uterus while preserving the uterus. - The risk of **uterine rupture** after myomectomy is proportional to the number, size, and depth of the fibroids removed, especially if the uterine cavity is entered; deep intramural fibroids pose a higher risk, but generally less than a classical cesarean.