UPSC-CMS 2014 Practice Questions

Q: A G6 P5 L5 with 4 1/2 MA comes to you requesting a medical termination of pregnancy after sex determination. Then,

you will not do it, as it is against the law.. **you will not do it, as it is against the law.** - **Sex determination** followed by an MTP based on fetal sex is **illegal** under the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994, in India. - Performing such an abortion is an **ethical violation** and carries severe legal penalties for the medical practitioner. *you will do the termination because continuation of pregnancy will affect the mental health of the patient and it is a clause in the M.T.P. Act.* - While mental health is a valid ground for MTP under the M.T.P. Act, 1971, this clause cannot be invoked when the primary reason is **illegal sex determination**. - The M.T.P. Act exists to protect women's health, but it does not supersede the **PCPNDT Act**, which strictly prohibits sex-selective abortions. *you will consult another medical practitioner because it is a mid-trimester pregnancy.* - Consulting another medical practitioner is required for MTPs beyond 12 weeks according to the M.T.P. Act. - However, this procedural requirement does not make the underlying *reason* for the termination (due to **illegal sex determination**) permissible. *you will do both (a) and (b) above.* - This option incorrectly combines an illegal act (MTP after sex determination) with a procedural step (consulting another practitioner). - The foundational issue remains the **illegality** of the reason for termination, rendering both (a) and (b) inappropriate in this context.

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.

Q: During Pomeroy’s method of female sterilization, which portion of tube is ligated?

Isthmo-ampullary. ***Isthmo-ampullary*** - In **Pomeroy's method** of female sterilization, a loop of fallopian tube is picked up at the **isthmo-ampullary junction** (junction of middle and outer third of the tube). - This mid-portion of the tube is elevated into a knuckle, ligated at its base with absorbable suture, and the loop above the ligature is excised. - The **isthmo-ampullary junction** is the classic site described in standard texts for Pomeroy's technique, as it provides adequate length for creating a loop while maintaining sufficient distance from the uterine cornua. *Isthmus* - While the isthmus may be partially involved in the loop, **Pomeroy's method specifically targets the isthmo-ampullary junction**, not the pure isthmic segment. - Ligation of the isthmus alone (too close to the uterus) would not be the standard Pomeroy's technique and could increase risk of complications. *Cornual* - The **cornual portion** refers to the interstitial part of the fallopian tube located within the uterine wall. - This segment is not targeted in Pomeroy's method due to increased risk of uterine injury and bleeding. - Cornual resection is a different surgical approach used in other sterilization techniques. *Ampullary* - The **ampulla** is the wider, lateral portion of the fallopian tube where fertilization typically occurs. - While the ampulla may form part of the loop in Pomeroy's method, the **ligation point** is specifically at the isthmo-ampullary junction, not in the pure ampullary segment. - Ligation too far laterally in the ampulla would not be standard Pomeroy's technique.

Q: Which one of the following causes the greatest risk of ectopic pregnancy?

Previous ectopic pregnancy. ***Previous ectopic pregnancy*** - A history of prior ectopic pregnancy significantly increases the risk of a **recurrent ectopic pregnancy** due to potential **tubal damage** from the previous event. - This is considered the **highest risk factor** among the choices provided because it indicates a pre-existing vulnerability in the reproductive system. *Intrauterine contraceptive devices use* - While IUDs do not cause ectopic pregnancies, they **prevent intrauterine pregnancies** more effectively than ectopic ones, leading to a higher proportion of pregnancies being ectopic if conception occurs. - The absolute risk of an ectopic pregnancy with an IUD in place is still **lower than in women not using contraception** but the ratio of ectopic to intrauterine pregnancies is higher. *Previous normal delivery* - A history of previous normal delivery is generally **protective against ectopic pregnancy**, as it suggests healthy tubal function and uterine environment. - This factor has **no association** with an increased risk of ectopic pregnancy. *Previous medical termination of pregnancy* - There is generally **no significant increased risk** of ectopic pregnancy associated with a single medical termination of pregnancy, especially when performed early in gestation. - Repeated or complicated terminations, especially surgical, *could* theoretically increase risk due to **tubal damage or inflammation**, but medical termination typically carries little to no added risk.

Q: Which of the following is not true regarding ‘no scalpel’ vasectomy?

Scrotal skin is cut with LASER to expose the vas.. ***Scrotal skin is cut with LASER to expose the vas.*** - The "no-scalpel" technique specifically avoids cutting the scrotal skin with a **scalpel** or **LASER**. - Instead, a **small puncture** is made using a specialized instrument to access the vas deferens. *The failure rate is same as that of conventional vasectomy.* - The failure rate for no-scalpel vasectomy is generally very low and comparable to, or even slightly lower than, conventional vasectomy. - This is due to the precise identification and handling of the **vas deferens** through the small puncture. *Special instruments are used to deliver the vas instead of cutting the skin.* - This statement is true; the no-scalpel technique utilizes **specialized forceps** to puncture and stretch the scrotal skin. - This creates a small opening to access the vas deferens without needing a traditional incision. *It is a very popular method in China.* - The no-scalpel vasectomy technique was developed in China in 1974 by Dr. Li Shunqiang, where it gained widespread adoption. - Its popularity in China significantly contributed to its global recognition as a minimally invasive and effective method for male contraception.

Q: Which one of the following is the safest gas for creating pneumoperitoneum in operative laparoscopy?

Carbon dioxide. ***Carbon dioxide*** - **Carbon dioxide (CO2)** is the gold standard for creating **pneumoperitoneum** because it is rapidly absorbed from the **peritoneal cavity** and excreted by the lungs, minimizing the risk of gas embolism. - Its **high solubility in blood** (20x more soluble than nitrogen) reduces the risk of serious complications if inadvertently injected intravascularly. - **Non-combustible** and does not support combustion, making it safe to use with electrocautery and other heat sources during surgery. *Oxygen* - **Oxygen** is highly **combustible** and would create a significant fire hazard in the presence of electrocautery or other heat sources during surgery. - It could also cause **gas emboli** if it enters the bloodstream, as it is less soluble than CO2. - Risk of **oxidative tissue damage** with prolonged exposure. *Carbon monoxide* - **Carbon monoxide** is extremely **toxic** and binds irreversibly to hemoglobin with 200-250 times greater affinity than oxygen, forming **carboxyhemoglobin**, which impairs oxygen transport. - Even minimal exposure can be life-threatening due to systemic hypoxia. - Absolutely contraindicated for clinical use. *Nitrous oxide* - **Nitrous oxide** can diffuse into gas-filled spaces (bowel loops) 30x faster than nitrogen, potentially causing **bowel distension** and increased intra-abdominal pressure during prolonged procedures. - Although less of a fire risk than oxygen, it can **support combustion** at high concentrations. - Less rapidly absorbed than CO2, posing higher embolism risk if intravascular injection occurs.

Question 1

A G6 P5 L5 with 4 1/2 MA comes to you requesting a medical termination of pregnancy after sex determination. Then,

Accepted Answer

you will not do it, as it is against the law.

Answer

you will do the termination because continuation of pregnancy will affect the mental health of the patient and it is a clause in the M.T.P. Act.

Answer

you will consult another medical practitioner because it is a mid-trimester pregnancy.

Answer

you will do both (a) and (b) above.

Question 2

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

Accepted Answer

Multiparity

Answer

Hypertension

Answer

Obesity

Answer

Diabetes

Question 3

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 4

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 5

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 6

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

Question 7

During Pomeroy’s method of female sterilization, which portion of tube is ligated?

Accepted Answer

Isthmo-ampullary

Answer

Cornual

Answer

Ampullary

Answer

Isthmus

Question 8

Which one of the following causes the greatest risk of ectopic pregnancy?

Accepted Answer

Previous ectopic pregnancy

Answer

Intrauterine contraceptive devices use

Answer

Previous normal delivery

Answer

Previous medical termination of pregnancy

Question 9

Which of the following is not true regarding ‘no scalpel’ vasectomy?

Accepted Answer

Scrotal skin is cut with LASER to expose the vas.

Answer

The failure rate is same as that of conventional vasectomy.

Answer

Special instruments are used to deliver the vas instead of cutting the skin.

Answer

It is a very popular method in China.

Question 10

Which one of the following is the safest gas for creating pneumoperitoneum in operative laparoscopy?

Accepted Answer

Carbon dioxide

Answer

Oxygen

Answer

Carbon monoxide

Answer

Nitrous oxide

UPSC-CMS 2014

Forensic Medicine

Obstetrics and Gynecology

Surgery