UPSC-CMS 2012 Practice Questions

Q: A 30-year-old third gravida, who has a 3-year-old child and had undergone a MTP one year ago, has presented with 30-weeks pregnancy. She complains of having vaginal bleeding 2 hours ago. She has not received any antenatal care. Her pulse is 78 beats per minute, and the BP is 102/58 mmHg. The most appropriate management will include: 1. Ultrasonographic evaluation 2. Watch for labour 3. Hospitalisation and bed rest 4. Speculum examination of vagina and cervix 5. I.V. fluid drip Select the appropriate combination:

1, 3 and 5. ***1, 3 and 5*** - This patient presents with **third-trimester vaginal bleeding** without prior antenatal care, which is a significant red flag requiring immediate investigation and management. An **ultrasonographic evaluation** is crucial to determine the cause of bleeding, especially to rule out **placenta previa** or **abruptio placentae**, which dictate further management. - **Hospitalization and bed rest** are essential to stabilize the patient, monitor the bleeding, and prepare for potential complications. Initiating an **I.V. fluid drip** is critical for maintaining **hemodynamic stability**, especially given her low blood pressure of 102/58 mmHg, and for providing immediate venous access. *2, 3 and 4* - **Watching for labor** without first establishing the cause of bleeding is inappropriate and potentially dangerous, as active management might be needed. - A **speculum examination** should *not* be the initial step before an ultrasound, as a digital or speculum exam in cases of undiagnosed placenta previa can provoke severe hemorrhage. *1 and 2* - While an **ultrasound (1)** is necessary to diagnose the cause of bleeding, **watching for labor (2)** without further intervention or stabilization is insufficient for a woman with third-trimester bleeding, especially with no prior antenatal care. - This option misses crucial components like hospitalization, bed rest, and IV fluids, which are part of initial stabilization. *1, 4 and 5* - **Ultrasonographic evaluation (1)** and **I.V. fluid drip (5)** are appropriate, but **speculum examination of the vagina and cervix (4)** should be avoided until placenta previa is ruled out by ultrasound. - A digital or speculum exam could exacerbate bleeding if **placenta previa** is present, making this a potentially harmful step in the initial management.

Q: A 35-year-old woman presents with complaints of profuse vaginal bleeding. She also has a history of abortion 4 months ago. On examination, the uterus is soft and bulky, both ovaries are enlarged and cystic, and the pregnancy test is positive. The probable diagnosis is

Persistent trophoblastic disease. ***Persistent trophoblastic disease*** - The history of **abortion 4 months ago** followed by **profuse vaginal bleeding**, a **positive pregnancy test**, and a **bulky uterus** strongly suggests persistent trophoblastic disease (PTD). - The presence of **bilaterally enlarged cystic ovaries** (theca-lutein cysts) is also characteristic, resulting from ovarian stimulation by persistently high levels of hCG. *Malignant ovarian tumour* - While it can cause vaginal bleeding, a **positive pregnancy test** and the finding of a **bulky uterus** are generally not primary features of most ovarian malignancies. - Ovarian tumours are less likely to present with the rapid development of bilateral, **cystic enlargement** associated with a recent pregnancy and persistent hCG. *Incomplete abortion* - While it causes **vaginal bleeding** and a **bulky uterus**, it typically occurs much more acutely and closer to the time of the abortion itself, not four months later. - An incomplete abortion would usually result in a **negative or rapidly declining pregnancy test** due to the absence of viable trophoblastic tissue. *Dysfunctional uterine bleeding* - This diagnosis usually implies bleeding without a clear organic cause and would not be associated with a **positive pregnancy test** or **enlarged, cystic ovaries**. - DUB is a diagnosis of exclusion after other causes, including **gestational** trophoblastic disease, have been ruled out.

Q: An elderly gravida with 36-weeks pregnancy presents with severe pregnancy induced hypertension (PIH), severe abdominal pain, per vaginal bleeding and loss of foetal movements. The diagnosis is

Abruptio placenta. ***Abruptio placenta*** - The combination of **severe abdominal pain**, **vaginal bleeding**, **loss of fetal movements**, and **severe pregnancy-induced hypertension (PIH)** in an elderly gravida at 36 weeks is a classic presentation of **abruptio placenta** (placental abruption). - Severe PIH is a significant **risk factor for placental abruption**, and the pain, bleeding, and fetal distress are due to premature separation of the placenta from the uterine wall. *Vasa praevia* - Characterized by **painless, bright red vaginal bleeding** of fetal origin that typically occurs when the membranes rupture, associated with **fetal distress** or bradycardia. - While there is bleeding and fetal distress mentioned in the question, the presence of **severe abdominal pain** and **PIH** is not typical of vasa praevia, which presents with painless bleeding. *Rupture of uterus* - Uterine rupture usually presents with sudden, **excruciating abdominal pain**, **loss of uterine contractions**, **cessation of labor progress**, and often a **palpable fetal part** outside the uterus if the rupture is complete. - While severe pain and loss of fetal movements are present, the absence of prior uterine surgery (like a C-section) or high parity as risk factors, and the specific association with **severe PIH** pointing strongly to abruption, makes this less likely. *Placenta praevia* - Typically presents with **painless, bright red vaginal bleeding** in the second or third trimester, without associated abdominal pain. - The presence of **severe abdominal pain** and **loss of fetal movements** rules out placenta previa, as these are not characteristic symptoms.

Q: A young female patient presents with a history of two months amenorrhoea and complaints of severe lower abdominal pain, syncopal attacks and minimal per vaginal bleeding. On examination, she has tachycardia and appears pale. The clinical diagnosis is

Ectopic pregnancy. ***Ectopic pregnancy*** - The combination of **amenorrhoea**, severe **lower abdominal pain**, **syncopal attacks**, and signs of **hypovolemic shock** (tachycardia, pallor) strongly indicates a ruptured ectopic pregnancy. - Minimal per vaginal bleeding is common, and the syncopal episodes are due to **hemoperitoneum** and resulting hypovolemia. *Missed abortion* - A missed abortion typically involves **no symptoms of acute distress** or shock. Patients often present with absent fetal heart tones on ultrasound, but without acute pain or significant bleeding initially. - There would be no signs of hypovolemia such as tachycardia or syncopal attacks, as the bleeding is usually contained within the uterus or minimal. *Molar pregnancy* - While a molar pregnancy can present with amenorrhoea and vaginal bleeding, it typically causes symptoms like **excessive nausea and vomiting**, and a **grape-like vesicular discharge**. - It does not usually cause acute, severe abdominal pain or hypovolemic shock unless there is a rare complication like uterine perforation, which is not the primary presentation. *Inevitable abortion* - An inevitable abortion presents with **vaginal bleeding** and **cervical dilatation**, often accompanied by abdominal cramping. - While there can be significant bleeding, it is usually not associated with acute, severe pain or rapid onset of **hypovolemic shock** and syncopal attacks as seen with a ruptured ectopic pregnancy.

Q: A 30-year-old woman with history of previous three abortions, has been found to have antiphospholipid antibodies. What will be the treatment of choice in the subsequent pregnancy?

Aspirin and Heparin. ***Aspirin and Heparin*** - A history of recurrent abortions with positive **anti-phospholipid antibodies** indicates **antiphospholipid syndrome (APS)**. The combination of **aspirin** and **heparin (low molecular weight heparin is preferred)** is the treatment of choice to prevent further thrombotic events, including miscarriage, in pregnant women with APS. - Aspirin helps **reduce platelet aggregation**, while heparin **anticoagulates** by inhibiting clotting factors, thereby improving pregnancy outcomes. *Corticosteroids* - Corticosteroids like **prednisone** may be used in specific autoimmune conditions where inflammation is a primary concern, but they are not the primary treatment for preventing thrombotic events in APS and can have significant side effects in pregnancy. - They are generally reserved for cases with refractory symptoms or other autoimmune comorbidities. *Aspirin* - While **low-dose aspirin** is part of the treatment regimen for APS in pregnancy, it is **insufficient on its own** to prevent recurrent pregnancy losses associated with the thrombotic complications of the syndrome. - Aspirin primarily inhibits **platelet aggregation**, but **heparin** is crucial for its additional anticoagulation effects to address the hypercoagulable state. *Heparin* - **Heparin (low molecular weight)** is a critical component of treatment for APS in pregnancy to prevent thrombosis. However, it is optimally used in combination with **low-dose aspirin**. - Using heparin alone might not fully address all aspects of the prothrombotic state in APS, especially those related to platelet activation.

Q: In the rhesus-negative mothers, the factors which influence the development of rhesus incompatibility include all except

Maternal age >35 years. ***Maternal age >35 years*** - **Maternal age** is not a direct factor influencing the development or severity of Rh incompatibility. The immune response to fetal Rh antigens is independent of the mother's age. - Rh sensitization occurs due to fetal-maternal hemorrhage, causing the mother's immune system to produce **antibodies** against Rh-positive red blood cells, which is not age-dependent. *Amniocentesis* - **Amniocentesis** can lead to **fetal-maternal hemorrhage** by puncturing the placental or fetal vessels, introducing fetal red blood cells into the maternal circulation. - This exposure can trigger the formation of **anti-D antibodies** in an Rh-negative mother if the fetus is Rh-positive, thereby increasing the risk of sensitization. *Incoordinate uterine action* - **Incoordinate uterine action**, especially during labor, can increase the risk of **fetal-maternal hemorrhage** due to increased uterine manipulation, trauma, or prolonged labor, leading to greater placental surface disruption. - Greater exposure to fetal red blood cells then enhances the likelihood of **Rh sensitization** in an Rh-negative mother carrying an Rh-positive fetus. *Placental abruption* - **Placental abruption**, the premature separation of the placenta from the uterine wall, significantly increases the risk of **fetal-maternal hemorrhage**. - A larger volume of fetal blood entering the maternal circulation substantially elevates the chances of an Rh-negative mother becoming **sensitized** and developing **anti-D antibodies**.

Q: A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is

Perform LSCS (Lower Segment Caesarean Section). ***Perform LSCS (Lower Segment Caesarean Section)*** - The presence of a **tonically contracted uterus** with **Bandl's ring**, unengaged presenting part, and the patient being in **shock** (pulse 150 bpm) are all signs of **imminent uterine rupture** due to obstructed labor. - An **emergency LSCS** is immediately indicated to deliver the baby and manage the uterine obstruction, prioritizing the mother's and baby's lives. *Do internal podalic version and extraction* - This procedure is contraindicated in cases of **obstructed labor** with a tonically contracted uterus and Bandl's ring, as it significantly increases the risk of **uterine rupture**. - Internal podalic version is typically performed for malpresentations in the absence of obstruction, often in a less critical maternal condition. *Deliver the baby by vaginal route using a vacuum extractor* - **Vacuum extraction** requires a dilated cervix, engaged head, and the absence of mechanical obstruction. - With an **unengaged presenting part**, tonically contracted uterus, and Bandl's ring, a vaginal instrumental delivery is impossible and highly dangerous, risking uterine rupture. *Augment labour with oxytocin* - **Oxytocin augmentation** is used for hypotonic uterine dysfunction to strengthen contractions. - In a case of **obstructed labor** with a tonically contracted uterus and Bandl's ring, adding oxytocin would further exacerbate the uterine stress and dramatically increase the risk of **uterine rupture**, making it absolutely contraindicated.

Q: A second gravida, whose first baby is alive, has been in the second stage of labour for more than one hour. On examination, her cervix is fully dilated. The pelvis is adequate and the station of the vertex is +2. The occiput is in right, occipito-posterior position and the fetal heart rate is 120/min. The most appropriate management will be

Forceps application. ***Forceps application*** - With a fully dilated cervix, adequate pelvis, and **vertex at +2 station**, instrumental delivery is indicated to expedite delivery, especially given the **prolonged second stage of labor** (>1 hour in a multigravida). - **Occipito-posterior position** can be managed with rotational forceps (Kielland's forceps) to correct the malposition and facilitate delivery. - The fetal heart rate of 120/min is at the lower end of normal, and combined with the prolonged second stage, instrumental delivery is warranted to prevent further delay and potential complications. *Vacuum extraction* - While vacuum extraction is an option for instrumental delivery, **forceps are generally preferred in cases of occipito-posterior position** as they offer greater control for rotation and extraction. - Rotational maneuvers are more controlled with forceps compared to vacuum extraction. - The risk of **failed extraction** is higher with vacuum in occipito-posterior positions. *Wait and watch policy* - This is inappropriate given the **prolonged second stage** of labor (over one hour in a multigravida with good uterine contractions). - Modern guidelines allow up to 2 hours for second stage in multiparas, but with malposition (occipito-posterior) and lack of progress, active intervention is preferred. - Delaying intervention could lead to **fetal distress**, maternal exhaustion, or obstructed labor. *Caesarean section* - A Caesarean section is too invasive given the favorable conditions for vaginal delivery, including a **fully dilated cervix**, **adequate pelvis**, and **low station of the vertex (+2)**. - Instrumental delivery is the preferred approach with lower maternal morbidity in this scenario. - LSCS in second stage carries higher risks of hemorrhage and bladder injury.

Q: The anticonvulsant of choice in the treatment of generalized tonic-clonic seizures is

Phenytoin. ***Phenytoin*** - **Historical Context (2012):** Phenytoin was traditionally considered a first-line anticonvulsant for **generalized tonic-clonic seizures** due to its ability to stabilize neuronal membranes and prevent seizure propagation by **blocking voltage-gated sodium channels**. - **Current Guidelines:** While phenytoin remains effective, it is now generally considered a **second-line agent** due to its narrow therapeutic index, significant side effects (gingival hyperplasia, hirsutism, osteomalacia), and multiple drug interactions. **Valproate, levetiracetam, and lamotrigine** are now preferred first-line options per modern ILAE guidelines. - **Note:** This question reflects the 2012 exam standards when phenytoin was still widely taught as first-line therapy. *Diazepam* - **Diazepam** is a **benzodiazepine** primarily used for the **acute termination of seizures** (status epilepticus), not as long-term maintenance therapy for generalized tonic-clonic seizures. - It acts by enhancing **GABA-A receptor** activity, leading to rapid CNS depression and seizure termination. *Phenobarbital* - **Phenobarbital** is a **barbiturate** that can be used for generalized tonic-clonic seizures but is generally a **second or third-line agent** due to significant sedative effects, cognitive impairment, and potential for drug interactions. - Its mechanism involves increasing **GABA-mediated chloride influx**, causing neuronal hyperpolarization. *Magnesium sulphate* - **Magnesium sulfate** is specifically indicated for the prevention and treatment of seizures in **eclampsia and preeclampsia**, not for generalized tonic-clonic seizures in other contexts. - It exerts anticonvulsant effects by acting as an **NMDA receptor antagonist** and reducing neuronal excitability.

Question 1

A 30-year-old third gravida, who has a 3-year-old child and had undergone a MTP one year ago, has presented with 30-weeks pregnancy. She complains of having vaginal bleeding 2 hours ago. She has not received any antenatal care. Her pulse is 78 beats per minute, and the BP is 102/58 mmHg.

The most appropriate management will include:

1. Ultrasonographic evaluation
2. Watch for labour
3. Hospitalisation and bed rest
4. Speculum examination of vagina and cervix
5. I.V. fluid drip

Select the appropriate combination:

Accepted Answer

1, 3 and 5

Answer

2, 3 and 4

Answer

1 and 2

Answer

1, 4 and 5

Question 2

A 35-year-old woman presents with complaints of profuse vaginal bleeding. She also has a history of abortion 4 months ago. On examination, the uterus is soft and bulky, both ovaries are enlarged and cystic, and the pregnancy test is positive. The probable diagnosis is

Accepted Answer

Persistent trophoblastic disease

Answer

Malignant ovarian tumour

Answer

Incomplete abortion

Answer

Dysfunctional uterine bleeding

Question 3

An elderly gravida with 36-weeks pregnancy presents with severe pregnancy induced hypertension (PIH), severe abdominal pain, per vaginal bleeding and loss of foetal movements. The diagnosis is

Accepted Answer

Abruptio placenta

Answer

Vasa praevia

Answer

Rupture of uterus

Answer

Placenta praevia

Question 4

A young female patient presents with a history of two months amenorrhoea and complaints of severe lower abdominal pain, syncopal attacks and minimal per vaginal bleeding. On examination, she has tachycardia and appears pale. The clinical diagnosis is

Accepted Answer

Ectopic pregnancy

Answer

Missed abortion

Answer

Molar pregnancy

Answer

Inevitable abortion

Question 5

A 30-year-old woman with history of previous three abortions, has been found to have antiphospholipid antibodies. What will be the treatment of choice in the subsequent pregnancy?

Accepted Answer

Aspirin and Heparin

Answer

Corticosteroids

Answer

Aspirin

Answer

Heparin

Question 6

In the rhesus-negative mothers, the factors which influence the development of rhesus incompatibility include all except

Accepted Answer

Maternal age >35 years

Answer

Amniocentesis

Answer

Incoordinate uterine action

Answer

Placental abruption

Question 7

A vaginal examination conducted during the second stage of labour reveals occipito-posterior position of the vertex. This occipito-posterior position of the vertex was diagnosed on the basis of which of the following findings ?

Accepted Answer

Posterior fontanelle positioned posteriorly with the sagittal suture anteroposterior

Answer

Anterior fontanelle not reached

Answer

Posterior fontanelle in the subpubic area

Answer

Sagittal suture in transverse in the pelvic cavity

Question 8

A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is

Accepted Answer

Perform LSCS (Lower Segment Caesarean Section)

Answer

Do internal podalic version and extraction

Answer

Deliver the baby by vaginal route using a vacuum extractor

Answer

Augment labour with oxytocin

Question 9

A second gravida, whose first baby is alive, has been in the second stage of labour for more than one hour. On examination, her cervix is fully dilated. The pelvis is adequate and the station of the vertex is +2. The occiput is in right, occipito-posterior position and the fetal heart rate is 120/min. The most appropriate management will be

Accepted Answer

Forceps application

Answer

Vacuum extraction

Answer

Wait and watch policy

Answer

Caesarean section

Question 10

The anticonvulsant of choice in the treatment of generalized tonic-clonic seizures is

Accepted Answer

Phenytoin

Answer

Diazepam

Answer

Phenobarbital

Answer

Magnesium sulphate

UPSC-CMS 2012

Obstetrics and Gynecology

Pharmacology