UPSC-CMS 2009 Practice Questions

Q: Contraindications to epidural analgesia include the following except

Hypertension. ***Hypertension*** - While careful monitoring is needed, **uncontrolled hypertension** is not an absolute contraindication to epidural analgesia. - Epidural analgesia can sometimes even help to lower blood pressure, which might be beneficial in certain hypertensive patients. *Infection over the back* - This is a significant contraindication due to the risk of introducing bacteria into the **epidural space**, leading to severe infections like **epidural abscess** or **meningitis**. - A local infection could spread to the central nervous system, causing grave complications. *Raised intracranial pressure* - This is a contraindication because a sudden decrease in **cerebrospinal fluid pressure** from epidural needle insertion can exacerbate herniation in patients with **raised ICP**. - The procedure itself can further alter intracranial dynamics, posing a significant risk. *Coagulopathy* - **Coagulopathy**, whether due to medication (e.g., anticoagulants) or a pre-existing medical condition, is a major contraindication. - There is an increased risk of **epidural hematoma**, which can compress the spinal cord and lead to permanent neurological damage.

Q: 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?

1 and 2. ***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.

Q: The following changes may be seen in pre-eclampsia except

Hemodilution. ***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.

Q: "Variable decelerations" on an electronic fetal heart rate monitor imply

Umbilical cord compression. ***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.

Q: What is the maternal risk of using misoprostol for ripening of cervix during induction of labour?

Tachysystole/hyperstimulation of uterus. ***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.

Q: 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 ?

Choriocarcinoma. ***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**.

Q: Uterine rupture is most commonly encountered after which one of the following surgeries?

Classical cesarean. ***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.

Q: Most common newborn rash which presents at 24-48 hours of life is

Erythema toxicum neonatorum. ***Erythematous papular pustular lesions*** - This description is characteristic of **Erythema toxicum neonatorum**, which is the **most common benign transient rash in newborns.** - It typically appears between **24 and 48 hours of life** and presents with discrete **erythematous macules**, papules, and pustules on a red base. *Milia* - Milia are **tiny, pearly white cysts** that are present from birth and are due to trapped keratin. - While common, they are **not typically red or pustular** and do not usually have a delayed onset at 24-48 hours specifically. *Transient neonatal pustular melanosis* - This rash is present at **birth** and consists of **non-erythematous pustules** that rupture to leave collarettes of scale and dark macules. - Unlike erythema toxicum, it **lacks the erythematous base** and is usually present earlier. *Erythematous maculopapular rash* - This is a **general description** that could fit several conditions but **lacks the specific pustular component** that is key to identifying erythema toxicum neonatorum. - While erythema toxicum has macules and papules, the **presence of pustules** is a hallmark.

Q: Neural tube defects have which one of the following inheritance patterns ?

Multi-factorial. ***Multi-factorial*** - Neural tube defects (NTDs) are considered **multi-factorial**, meaning they result from a complex interaction between multiple genetic predispositions and environmental factors. - While there are genetic components, no single gene mutation typically explains the recurrence risk, and external factors like **folic acid deficiency** play a significant role. *X-linked recessive* - This inheritance pattern typically affects males more severely and exclusively, with females often being carriers, which is not the primary pattern observed in NTDs. - Conditions like **Duchenne muscular dystrophy** exhibit X-linked recessive inheritance. *Autosomal dominant* - A single copy of an altered gene on a non-sex chromosome is sufficient to cause the condition, resulting in a 50% chance of transmission to offspring, which does not match the observed inheritance pattern for NTDs. - Examples include **Huntington's disease** and **Marfan syndrome**. *Autosomal recessive* - Both copies of a gene on a non-sex chromosome must be altered for the condition to manifest, meaning parents are often carriers but unaffected, which isn't the primary inheritance pattern for NTDs. - Conditions like **cystic fibrosis** and **sickle cell anemia** follow autosomal recessive inheritance.

Q: Post coital contraception is achieved by all except

High degree of progesterone. ***High degree of progesterone*** - A *high degree of progesterone* is associated with **maintaining pregnancy**, not preventing it. - Progesterone supports the endometrium and maintains the corpus luteum, which are essential for pregnancy continuation. - While synthetic progestins (like levonorgestrel) are used in emergency contraception, they work through different mechanisms (ovulation inhibition, altered cervical mucus) at specific low doses, not as "high degree of progesterone" [2]. - High progesterone levels are NOT used for post-coital contraception. *By administration of RU 486* - **RU 486 (mifepristone)** is a progesterone receptor antagonist effective for post-coital contraception and medical abortion [1]. - It blocks progesterone action, causing decidual necrosis and preventing implantation or terminating early pregnancy [1]. - Commonly used as emergency contraception and for early medical abortion [1]. *Administration of prostaglandins* - **Prostaglandins** (like misoprostol) cause uterine contractions and cervical ripening [1]. - Used in combination with mifepristone for medical abortion [1]. - Can prevent implantation or induce abortion when administered post-coitally [1]. *High dose estrogens* - **High-dose estrogens** were historically used for post-coital contraception (Yuzpe regimen combined estrogen-progestin). - Work by inhibiting or delaying ovulation, interfering with corpus luteum function, and altering the endometrium to prevent implantation. - Effective when administered within 72 hours of unprotected intercourse.

Question 1

Contraindications to epidural analgesia include the following except

Accepted Answer

Hypertension

Answer

Infection over the back

Answer

Raised intracranial pressure

Answer

Coagulopathy

Question 2

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?

Accepted Answer

1 and 2

Answer

2, 3 and 4

Answer

1 and 4

Answer

2 and 3 only

Question 3

The following changes may be seen in pre-eclampsia except

Accepted Answer

Hemodilution

Answer

Thrombocytopenia

Answer

Decreased antithrombin III

Answer

Elevated uric acid

Question 4

"Variable decelerations" on an electronic fetal heart rate monitor imply

Accepted Answer

Umbilical cord compression

Answer

Fetal head compression

Answer

Utero-placental insufficiency

Answer

Fetal anemia

Question 5

What is the maternal risk of using misoprostol for ripening of cervix during induction of labour?

Accepted Answer

Tachysystole/hyperstimulation of uterus

Answer

Bradycardia

Answer

Hypotension

Answer

Tachycardia

Question 6

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 ?

Accepted Answer

Choriocarcinoma

Answer

Ectopic pregnancy

Answer

Incomplete abortion

Answer

Malignant ovarian tumor

Question 7

Uterine rupture is most commonly encountered after which one of the following surgeries?

Accepted Answer

Classical cesarean

Answer

Hysterotomy

Answer

Metroplasty

Answer

Myomectomy

Question 8

Most common newborn rash which presents at 24-48 hours of life is

Accepted Answer

Erythema toxicum neonatorum

Answer

Milia

Answer

Transient neonatal pustular melanosis

Answer

Erythematous maculopapular rash

Question 9

Neural tube defects have which one of the following inheritance patterns ?

Accepted Answer

Multi-factorial

Answer

X-linked recessive

Answer

Autosomal dominant

Answer

Autosomal recessive

Question 10

Post coital contraception is achieved by all except

Accepted Answer

High degree of progesterone

Answer

By administration of RU 486

Answer

Administration of prostaglandins

Answer

High dose estrogens

UPSC-CMS 2009

Anesthesiology

Obstetrics and Gynecology

Pediatrics

Pharmacology