UPSC-CMS 2014 - Obstetrics and Gynecology Practice Questions

Q: The causes for subinvolution of uterus are the following except:

Established breast feeding. ***Established breast feeding*** - **Breastfeeding** promotes the release of **oxytocin**, which aids in uterine contractions and thus helps the uterus return to its pre-pregnancy size and state, preventing subinvolution. - Therefore, it is a protective factor against subinvolution, not a cause. *Retained placental fragments* - **Retained placental tissue** prevents the uterus from contracting effectively, leading to continued bleeding and an enlarged, soft uterus. - This physical obstruction interferes with the normal process of **involution**. *Multiple pregnancy* - A uterus stretched significantly by a **multiple pregnancy** (e.g., twins or triplets) may have difficulty contracting efficiently after birth. - The increased uterine size and distension can impair the myometrial fibers' ability to involute properly. *Pelvic infection* - **Infection** within the uterus (e.g., **endometritis**) can interfere with uterine contractions and tissue repair. - The inflammatory process can delay or prevent the normal physiological reduction in uterine size, contributing to subinvolution.

Q: Treatment of choice in 28 year old nullipara with third degree cervical descent is:

Abdominal cervicopexy. ***Abdominal cervicopexy (Sacrohysteropexy)*** - For a **28-year-old nullipara**, **fertility preservation is paramount** as she may desire future pregnancies. - **Abdominal cervicopexy** (or sacrohysteropexy) suspends the uterus to the sacral promontory using mesh, effectively correcting third-degree uterine prolapse while **preserving the uterus and fertility potential**. - This is the **treatment of choice** in young women with significant pelvic organ prolapse who wish to maintain reproductive capability. - Has high success rates (>90%) with good anatomical outcomes and allows for future vaginal delivery in most cases. *Vaginal hysterectomy with PFR* - While this provides definitive surgical correction of prolapse, it **permanently eliminates fertility**. - This would be inappropriate as first-line treatment for a 28-year-old nulliparous patient unless she explicitly declines uterine preservation. - Reserved for patients who have **completed childbearing** or have additional indications for hysterectomy. *Fothergill's repair (Manchester repair)* - Involves cervical amputation, cardinal ligament shortening, and anterior colporrhaphy. - Although it preserves the uterus, it is **less effective for high-grade prolapse** (third degree) and may compromise fertility due to cervical amputation. - Has largely been replaced by modern uterine suspension procedures like sacrohysteropexy. *Anterior and posterior colporrhaphy* - Repairs **cystocele and rectocele** (vaginal wall defects) but **does not address uterine/cervical descent**. - Would be inadequate as sole treatment for third-degree uterine prolapse, though may be performed as adjunctive procedures.

Q: A G 2 P 1 A 0 presents with full term pregnancy with transverse lie in the first stage of labour. On examination, cervix is 5 cm dilated, membranes are intact and foetal heart sounds are regular. The appropriate management would be:

Caesarean section. ***Caesarean section*** - A **transverse lie** at term in the first stage of labor is a contraindication to vaginal delivery due to the high risk of **cord prolapse**, **uterine rupture**, and fetal distress. - **Caesarean section** is the safest mode of delivery for both mother and fetus in this scenario, as it prevents these complications. *External cephalic version* - **External cephalic version** is typically attempted in cases of **breech presentation** in the late third trimester (around 36-37 weeks) to convert it to a cephalic presentation. - It is **contraindicated** in transverse lie during active labor, especially with cervical dilation, as it has a low success rate and can lead to complications such as **placental abruption** or **cord prolapse**. *Internal podalic version* - **Internal podalic version** is a procedure typically reserved for the delivery of the second twin in a **transverse or oblique lie**, or in some cases of breech presentation. - It carries significant risks, including **uterine rupture** and fetal injury, and is generally not performed for a singleton pregnancy with cervical dilation. *Wait for spontaneous evolution and expulsion* - **Spontaneous evolution** (where the fetus rotates to a longitudinal lie) is extremely rare in a transverse lie presentation at term, especially once labor has started. - Waiting for spontaneous rotation would lead to **prolonged labor**, increased risk of **uterine rupture**, and severe fetal compromise due to obstruction.

Q: Rokitansky-Küster-Hauser syndrome is associated with:

All of the options. ***All of the options*** Rokitansky-Küster-Hauser (MRKH) syndrome is associated with **all three features** listed, making this the correct answer. **Primary amenorrhea with Müllerian agenesis:** - This is the **hallmark feature** of MRKH syndrome - Müllerian agenesis leads to **absent or underdeveloped uterus and upper two-thirds of vagina** - Patients present with **primary amenorrhea** despite normal pubertal development - The external genitalia and lower vagina are normal **Normal hormone profile:** - MRKH syndrome patients have **functioning ovaries** with normal oogenesis - **Normal 46,XX karyotype** - **Normal FSH, LH, estrogen, and progesterone levels** - Normal development of **secondary sexual characteristics** (breast development, pubic hair, normal height) - This distinguishes MRKH from androgen insensitivity syndrome **Renal abnormalities:** - Present in **15-30% of MRKH type 1** cases - Present in **up to 50% of MRKH type 2** (MURCS association - Müllerian, Renal, Cervicothoracic Somite abnormalities) - Common anomalies include **renal agenesis** (unilateral or bilateral), **ectopic kidney**, **horseshoe kidney**, and **hydronephrosis** - Renal ultrasound is recommended as part of initial evaluation **Why "All of the options" is correct:** All three features—primary amenorrhea with Müllerian agenesis, normal hormone profile, and renal abnormalities—are characteristic associations of MRKH syndrome, making this the most complete and accurate answer.

Q: The level of external cervical os in a second degree utero vaginal prolapse is:

Introitus. ***Introitus*** - In a **second-degree uterovaginal prolapse**, the external cervical os descends to the level of the introitus (hymenal ring). - The cervix reaches the vaginal opening but does not extend beyond it, typically becoming visible during straining or examination. - This is the defining characteristic of second-degree prolapse. *Between ischial spines and introitus* - This description refers to a **first-degree uterovaginal prolapse**, where the cervix descends into the lower vagina but remains above the introitus. - The external os has not yet reached the **introitus** and remains within the vaginal canal. *3 cm outside introitus* - This indicates a **third-degree uterovaginal prolapse (procidentia)**, where the cervix and entire uterus descend completely outside the vagina. - The measurement of 3 cm outside the introitus represents significant prolapse beyond the vaginal opening. *At the level of ischial spines* - The **ischial spines** serve as the anatomical zero point in the POP-Q (Pelvic Organ Prolapse Quantification) staging system. - If the external cervical os is at the level of the ischial spines, this represents minimal or no prolapse, as the cervix is in its normal anatomical position high in the vagina.

Q: Carcinoma of endometrium is associated with the following risk factors except:

Multiparity. ***Multiparity*** - **Multiparity**, defined as having given birth to multiple children, is generally considered a protective factor or to have no significant association with endometrial cancer. - Reduced exposure to unopposed **estrogen** due to more frequent anovulation or hormonal changes during and after pregnancy may contribute to this protective effect. *Hypertension* - **Hypertension** is a known risk factor for endometrial cancer, possibly due to its association with **obesity** and metabolic syndrome, which increase endogenous estrogen levels. - The exact mechanism is not fully understood, but it is thought to be part of the complex interplay of metabolic factors. *Obesity* - **Obesity** is a strong and well-established risk factor for endometrial cancer, as adipose tissue converts androgens into **estrogens** (via aromatase), leading to unopposed estrogen stimulation of the endometrium. - Higher levels of **insulin-like growth factors** in obese individuals may also promote endometrial cell proliferation. *Diabetes* - **Diabetes mellitus**, particularly type 2, is associated with an increased risk of endometrial cancer, largely due to **hyperinsulinemia** and insulin resistance. - **Insulin** acts as a growth factor, promoting endometrial cell proliferation and potentially contributing to malignant transformation.

Q: Female sterilization is contraindicated in which of the following well-controlled conditions?

None of the above. ***None of the above*** - **Well-controlled** chronic conditions like diabetes mellitus, heart disease, or hypertension generally do **not contraindicate female sterilization** according to WHO Medical Eligibility Criteria (MEC). - Sterilization is a **permanent contraception method** that is often the most appropriate option for women with stable medical conditions who have completed their families. - The key principle is that these conditions must be **well-controlled** and stable at the time of the procedure. *Diabetes mellitus* - **Well-controlled diabetes** is WHO MEC Category 1-2 (no restriction or advantages generally outweigh risks) for female sterilization. - Women with **poorly controlled diabetes** should have their condition optimized before surgery to minimize perioperative risks, but this is not an absolute contraindication. - The risks of pregnancy in diabetic women typically exceed the minimal surgical risks of sterilization. *Heart disease* - **Well-managed stable heart disease** does not preclude female sterilization, though cardiac function should be assessed pre-operatively. - Most stable cardiac conditions are WHO MEC Category 2-3, with individualized assessment based on functional status. - For women with significant heart disease, avoiding pregnancy (which carries substantial cardiovascular burden) is often more important than avoiding a brief surgical procedure. *Hypertension* - **Controlled hypertension** is WHO MEC Category 1-2 for female sterilization and is not a contraindication. - Blood pressure should be optimized before surgery, and anesthetic management adjusted accordingly. - The cardiovascular stress of pregnancy far exceeds that of a sterilization procedure in hypertensive women.

Q: Laparoscopic sterilization is not recommended during the period of:

Immediate post partum. ***Immediate post partum*** - The **uterus** is significantly enlarged and **hypervascular** in the immediate postpartum period, increasing the risk of **hemorrhage** and organ injury during laparoscopic sterilization. - The **bowel can be dilated and edematous**, making visualization and manipulation difficult, further complicating the procedure. *Post menstrual* - This period is generally considered **safe and even ideal** for sterilization procedures as the risk of pregnancy is minimal and the uterus is small. - The **uterine size** is at its baseline, which facilitates easier access and manipulation during laparoscopy. *Post first trimester MTP* - This period is considered a suitable time for sterilization, as the **uterus is still relatively small**, and the risks associated with the procedure are low. - It allows for the patient to combine two procedures, thereby reducing the need for multiple hospital visits. *Interval* - The **interval period** (any time not immediately postpartum or post-abortion) is the **most common and often most recommended time** for sterilization. - At this time, the **uterus is non-gravid**, at its baseline size, and easily accessible, leading to a lower risk of complications.

Q: The highest incidence of ectopic pregnancy amongst contraceptive users is observed with:

Progestasert intrauterine device. ***Progestasert intrauterine device*** - The **Progestasert IUD** (progesterone-releasing) has the **highest failure rate** among IUDs (2-3% per year), meaning more pregnancies occur in users. - When pregnancy does occur with Progestasert, approximately **5-6% are ectopic**, and due to the higher overall failure rate, this results in the **highest absolute incidence** of ectopic pregnancy among contraceptive users. - The progesterone released locally is less effective at preventing pregnancy compared to copper or levonorgestrel-releasing devices. - **Key concept**: The question asks about "highest incidence" (absolute rate among all users), not the highest proportion among pregnancies that occur. *Copper T intrauterine contraceptive device* - While the **proportion** of pregnancies that are ectopic is relatively high with Copper T (3-4% of pregnancies that occur are ectopic), the **absolute incidence** is lower. - Copper T has a very low failure rate (<1% per year), so fewer total pregnancies occur, resulting in fewer ectopic pregnancies overall among users. - Highly effective at preventing intrauterine implantation but not ovulation. *Levonorgestrel intrauterine system* - The **levonorgestrel IUS** has the **lowest failure rate** among IUDs (0.1-0.2% per year). - It suppresses ovulation in some users, thickens cervical mucus, and thins the endometrium. - Results in the **lowest absolute incidence** of ectopic pregnancy due to excellent contraceptive efficacy. *Combined contraceptive pills* - Highly effective at preventing pregnancy by **inhibiting ovulation**. - Very low incidence of ectopic pregnancy because ovulation is suppressed in most users. - When taken correctly, overall pregnancy rates are very low (0.3% per year with perfect use).

Q: Which one of the following is the most suitable situation for prescribing progestin only pill?

Lactating mother. ***Lactating mother*** - Progestin-only pills (POPs) are preferred for **breastfeeding mothers** as they do not affect **milk supply** or composition, unlike combined oral contraceptives containing estrogen. - They also eliminate the risk of estrogen exposure to the infant, which is generally avoided during **lactation**. *Young patients* - While young patients can use POPs, there isn't a specific indication making them "most suitable" compared to other contraceptive methods. - Often, combined oral contraceptives are also an appropriate choice for young patients, depending on their individual health profile. *Emergency contraception* - Progestin-only pills are a type of contraception, but they are not the primary or most effective form of **emergency contraception**; dedicated high-dose progestin pills (like levonorgestrel) or copper IUDs are used for this purpose. - Regular POPs are designed for daily use and are not formulated for a single, high-dose emergency contraceptive effect. *Woman with unexplained vaginal bleeding* - **Unexplained vaginal bleeding** is a **contraindication** for starting any hormonal contraceptive, including POPs, until the cause is identified. - It is crucial to rule out serious conditions like **endometrial cancer** or other gynecological pathologies before initiating hormonal therapy.

Question 1

The causes for subinvolution of uterus are the following except:

Accepted Answer

Established breast feeding

Answer

Retained placental fragments

Answer

Multiple pregnancy

Answer

Pelvic infection

Question 2

Treatment of choice in 28 year old nullipara with third degree cervical descent is:

Accepted Answer

Abdominal cervicopexy

Answer

Fothergill’s repair

Answer

Anterior and posterior colporrhaphy

Answer

Vaginal hysterectomy with PFR

Question 3

A G 2 P 1 A 0 presents with full term pregnancy with transverse lie in the first stage of labour. On examination, cervix is 5 cm dilated, membranes are intact and foetal heart sounds are regular. The appropriate management would be:

Accepted Answer

Caesarean section

Answer

External cephalic version

Answer

Internal podalic version

Answer

Wait for spontaneous evolution and expulsion

Question 4

Rokitansky-Küster-Hauser syndrome is associated with:

Accepted Answer

All of the options

Answer

Normal hormone profile

Answer

Primary amenorrhoea with mullerian agenesis

Answer

Renal abnormalities

Question 5

The level of external cervical os in a second degree utero
vaginal prolapse is:

Accepted Answer

Introitus

Answer

Between ischial spines and introitus

Answer

3 cm outside introitus

Answer

At the level of ischial spines

Question 6

Carcinoma of endometrium is associated with the following risk factors except:

Accepted Answer

Multiparity

Answer

Hypertension

Answer

Obesity

Answer

Diabetes

Question 7

Female sterilization is contraindicated in which of the following well-controlled conditions?

Accepted Answer

None of the above

Answer

Diabetes mellitus

Answer

Heart disease

Answer

Hypertension

Question 8

Laparoscopic sterilization is not recommended during the period of:

Accepted Answer

Immediate post partum

Answer

Post menstrual

Answer

Interval

Answer

Post first trimester MTP

Question 9

The highest incidence of ectopic pregnancy amongst contraceptive users is observed with:

Accepted Answer

Progestasert intrauterine device

Answer

Combined contraceptive pills

Answer

Levonorgestrel intrauterine system

Answer

Copper T intrauterine contraceptive device

Question 10

Which one of the following is the most suitable situation for prescribing progestin only pill?

Accepted Answer

Lactating mother

Answer

Young patients

Answer

Emergency contraception

Answer

Woman with unexplained vaginal bleeding

UPSC-CMS 2014 — Obstetrics and Gynecology