The contraceptive choice for a 38 year old woman with chronic hypertension and history of dysmenorrhea and menorrhagia (malignancy ruled out) is:
Tubectomy is commonly performed at which site of fallopian tube?
A 60 year old woman presents with postmenopausal bleeding. On endometrial curettage she is diagnosed as endometrial carcinoma. Which one of the following is a risk factor for endometrial cancer?
A 29 year old woman presents in emergency ward with amenorrhea of 6 weeks and pain. Urine pregnancy test shows positive. Examination shows diffuse significant lower abdomen tenderness. The pelvic examination is difficult to accomplish due to guarding. Her Beta-hCG level is 4000 mIU/ml. Transvaginal ultrasound shows no pregnancy in the uterus and no adnexal mass but moderate fluid in abdomen. Which of the following is the next best step?
Which one of the following is NOT done as screening test in pregnancy?
Amniocentesis is called for in all of the following circumstances EXCEPT:
LNG-20 (Mirena) is a third generation intra uterine device. What are the advantages of its use? 1. Low uterine pregnancy rates 2. Prevents anemia 3. Long effective life of 5 years 4. No effect on incidence of ectopic pregnancy Select the correct answer using the code given below:
UPSC-CMS 2019 - Obstetrics and Gynecology UPSC-CMS Practice Questions and MCQs
Question 31: The contraceptive choice for a 38 year old woman with chronic hypertension and history of dysmenorrhea and menorrhagia (malignancy ruled out) is:
- A. Copper intrauterine device
- B. Sterilization
- C. Combined oral contraceptive pills
- D. Levonorgestrel intrauterine device (Correct Answer)
Explanation: ***Levonorgestrel intrauterine device*** - The **Levonorgestrel IUD** is an excellent choice as it provides effective contraception while also treating menorrhagia and dysmenorrhea due to its local progesterone release. - It is safe for women with **hypertension** as it is a **non-estrogen-containing method**, avoiding the increased risk of thrombotic events associated with estrogen. *Copper intrauterine device* - While an effective non-hormonal contraceptive, the **copper IUD** can worsen **dysmenorrhea** and **menorrhagia**, which are existing concerns for the patient. - It does not offer any therapeutic benefits for her heavy and painful periods. *Sterilization* - Although it provides permanent and highly effective contraception, **sterilization** does not address the patient's symptoms of **dysmenorrhea** and **menorrhagia**. - It is an irreversible procedure and typically considered when no further childbearing is desired and symptomatic relief is not a primary concern for the contraceptive method itself. *Combined oral contraceptive pills* - **Combined oral contraceptive pills (COCs)** are generally contraindicated or used with caution in women with uncontrolled **hypertension** due to the estrogen component, which can increase the risk of cardiovascular events, including thrombosis. - While COCs can improve dysmenorrhea and menorrhagia, the cardiovascular risks in a 38-year-old with chronic hypertension outweigh these benefits.
Question 32: Tubectomy is commonly performed at which site of fallopian tube?
- A. Infundibulum
- B. Ampulla
- C. Cornua
- D. Isthmus (Correct Answer)
Explanation: ***Isthmus*** - The **isthmus** is the **most common site** for tubectomy (tubal ligation) procedures. - It is the preferred location because it is **narrow, straight, and easily accessible** during surgery, making ligation technically simpler. - The isthmus has **relatively less blood supply** compared to other parts of the tube, reducing the risk of bleeding. - Common techniques like the **Pomeroy method** and **Parkland technique** are typically performed at the isthmus. - The narrow diameter ensures **complete occlusion** and reduces the risk of recanalization. *Ampulla* - The **ampulla** is the widest and longest portion of the fallopian tube, located between the isthmus and infundibulum. - It is **rarely chosen** for tubectomy because its wider lumen makes complete occlusion more difficult. - The ampulla has **higher vascularity**, increasing the risk of bleeding during surgery. - Greater risk of **incomplete blockage** and potential for recanalization. *Infundibulum* - The **infundibulum** is the funnel-shaped distal end with fimbriae that opens into the peritoneal cavity. - This site is **almost never used** for tubectomy due to its proximity to the ovary and technical difficulty. - Risk of damage to the fimbriae and ovarian blood supply. *Cornua* - The **cornua** (interstitial portion) passes through the uterine wall. - While sometimes used, it is **less common** than the isthmus due to increased technical difficulty. - Cornual resection carries higher risk of **uterine perforation** and **bleeding** from the uterine vessels. - May be chosen in specific clinical scenarios but not the standard first choice.
Question 33: A 60 year old woman presents with postmenopausal bleeding. On endometrial curettage she is diagnosed as endometrial carcinoma. Which one of the following is a risk factor for endometrial cancer?
- A. Oral contraceptive use
- B. Multiparity
- C. Diabetes mellitus (Correct Answer)
- D. Smoking
Explanation: ***Diabetes mellitus*** - Diabetes is a significant risk factor for endometrial cancer, particularly due to its association with **obesity** and resulting increased **estrogen levels**. - **Insulin resistance** and elevated insulin-like growth factors can directly promote endometrial cell proliferation. *Oral contraceptive use* - Combined oral contraceptives (OCPs) are actually **protective** against endometrial cancer. - The progestin component in OCPs counteracts the unopposed estrogen effect that is a major driver of endometrial cancer. *Multiparity* - **Multiparity** (having had multiple pregnancies) is generally considered to be protective against endometrial cancer. - This protective effect is thought to be related to the hormonal changes during pregnancy, which involve a higher proportion of **progesterone**. *Smoking* - Smoking is generally associated with an **increased risk of certain cancers,** but it is **not considered a risk factor** for endometrial cancer. - Some studies suggest it might even slightly decrease risk due to anti-estrogenic effects, though this benefit is far outweighed by its many harms.
Question 34: A 29 year old woman presents in emergency ward with amenorrhea of 6 weeks and pain. Urine pregnancy test shows positive. Examination shows diffuse significant lower abdomen tenderness. The pelvic examination is difficult to accomplish due to guarding. Her Beta-hCG level is 4000 mIU/ml. Transvaginal ultrasound shows no pregnancy in the uterus and no adnexal mass but moderate fluid in abdomen. Which of the following is the next best step?
- A. Repeat Beta-hCG level in 48 hours
- B. Institution of methotrexate
- C. Wait and watch
- D. Emergency laparotomy (Correct Answer)
Explanation: ***Emergency laparotomy*** - The patient presents with **amenorrhea**, **positive pregnancy test**, significant lower **abdominal tenderness**, and **free fluid in the abdomen** without an intrauterine pregnancy on ultrasound, strongly suggesting a **ruptured ectopic pregnancy**, which is a life-threatening emergency requiring immediate surgical intervention. - The high **Beta-hCG level of 4000 mIU/ml** with no intrauterine pregnancy on ultrasound, combined with acute abdominal pain and tenderness, points to a rapidly progressing ectopic pregnancy that may have already ruptured, necessitating **emergency laparotomy** for hemorrhage control and removal of the ectopic gestation. *Repeat Beta-hCG level in 48 hours* - While serial Beta-hCG measurements are used to monitor early pregnancies, this patient's acute symptoms of severe abdominal pain, tenderness, and fluid in the abdomen, along with a high Beta-hCG and no intrauterine pregnancy, indicate an **urgent condition** that cannot wait 48 hours. - Waiting for repeat hCG levels would delay critical intervention for a potentially ruptured ectopic pregnancy, which could lead to **hemorrhagic shock** and death. *Institution of methotrexate* - **Methotrexate** is typically considered for **unruptured, stable ectopic pregnancies** with lower Beta-hCG levels and no signs of acute abdominal distress or rupture. - This patient's presentation with acute pain, tenderness, and free fluid strongly suggests rupture, making **methotrexate inappropriate** and dangerous as it would not address the active bleeding and could worsen her condition. *Wait and watch* - A "wait and watch" approach is inappropriate and extremely dangerous given the patient's acute abdominal pain, tenderness, and evidence of free fluid in the abdomen, which are all signs of a **ruptured ectopic pregnancy**. - Delaying intervention in cases of potential ruptured ectopic pregnancy can lead to **massive hemorrhage**, shock, and maternal death.
Question 35: Which one of the following is NOT done as screening test in pregnancy?
- A. Serum cholesterol (Correct Answer)
- B. Neural tube defects
- C. Syphilis-VDRL
- D. Diabetes
Explanation: ***Serum cholesterol*** - **Serum cholesterol** levels are not routinely measured as a screening test during pregnancy. - While lipid metabolism changes during pregnancy, monitoring cholesterol levels specifically for screening purposes is not standard practice. *Neural tube defects (NTDs)* - Screening for **neural tube defects** is a crucial part of antenatal care, typically involving maternal serum alpha-fetoprotein (**MSAFP**) screening and targeted ultrasound. - Early detection allows for counseling and management options for the pregnancy due to conditions like **spina bifida** or **anencephaly**. *Syphilis-VDRL* - Screening for **syphilis** using tests like **VDRL** (Venereal Disease Research Laboratory) or RPR (Rapid Plasma Reagin) is a mandatory part of antenatal screening in many regions. - This is done to prevent congenital syphilis, which can cause severe fetal and neonatal complications. *Diabetes* - All pregnant women are screened for **gestational diabetes mellitus (GDM)**, typically between 24 and 28 weeks of gestation, using a **glucose challenge test** followed by an oral glucose tolerance test if screening is positive. - Undiagnosed and untreated GDM can lead to adverse maternal and fetal outcomes, including macrosomia, pre-eclampsia, and neonatal hypoglycemia.
Question 36: Amniocentesis is called for in all of the following circumstances EXCEPT:
- A. Parents who are known to have chromosomal translocation
- B. A father aged 50 year or more (Correct Answer)
- C. Mother who had a child with Down's syndrome or other chromosomal anomalies
- D. A mother aged 35 years or more
Explanation: ***A father aged 50 year or more*** - Advanced paternal age (typically 40 years or more) may be associated with a slightly increased risk of certain **autosomal dominant disorders** (e.g., achondroplasia, Marfan syndrome) and **schizophrenia** due to an accumulation of de novo mutations in sperm. - However, it is not a direct indication for **amniocentesis** for chromosomal abnormalities in the same way advanced maternal age or a history of chromosomal issues is. *Parents who are known to have chromosomal translocation* - If either parent carries a **balanced chromosomal translocation**, there is a significant risk that the pregnancy could result in an **unbalanced translocation** in the fetus, leading to developmental abnormalities or miscarriage. - **Amniocentesis** is indicated to determine whether the fetus has inherited an unbalanced translocation. *Mother who had a child with Down's syndrome or other chromosomal anomalies* - A prior pregnancy affected by **Down syndrome (Trisomy 21)** or another **chromosomal anomaly** significantly increases the risk of recurrence in subsequent pregnancies. - **Amniocentesis** allows for prenatal diagnosis to detect if the current fetus is affected. *A mother aged 35 years or more* - Advanced maternal age, generally defined as 35 years or older at the time of delivery, is associated with an increased risk of **aneuploidies**, such as **Down syndrome**. - **Amniocentesis** is offered to these mothers for prenatal chromosomal analysis.
Question 37: LNG-20 (Mirena) is a third generation intra uterine device. What are the advantages of its use? 1. Low uterine pregnancy rates 2. Prevents anemia 3. Long effective life of 5 years 4. No effect on incidence of ectopic pregnancy Select the correct answer using the code given below:
- A. 1, 2 and 4
- B. 1, 2 and 3 (Correct Answer)
- C. 1, 3 and 4
- D. 2, 3 and 4
Explanation: ***1, 2 and 3*** - LNG-20 (Mirena) significantly reduces the risk of **uterine pregnancy** due to its local progestin release, which thins the endometrium and thickens cervical mucus. - It often leads to **reduced menstrual blood loss** or even amenorrhea, thereby preventing or improving **anemia** in many users. - Mirena is effectively contraceptive for **up to 5 years**, providing a long-acting reversible contraceptive option. *1, 2 and 4* - While LNG-20 offers low uterine pregnancy rates and can prevent anemia, it **does not eliminate the risk of ectopic pregnancy** and may slightly increase its relative incidence if pregnancy occurs. - Therefore, the statement "no effect on incidence of ectopic pregnancy" is incorrect. *1, 3 and 4* - Although LNG-20 provides low uterine pregnancy rates and a 5-year effective life, the claim of "no effect on incidence of ectopic pregnancy" is **inaccurate**. - LNG-IUDs reduce overall pregnancy risk but if conception does occur, it's more likely to be ectopic than with no contraception. *2, 3 and 4* - LNG-20 does prevent anemia and has a long effective life, but it **does not have no effect on ectopic pregnancy incidence**; rather, it shifts the proportion of pregnancies that are ectopic if contraception fails. - It also provides low uterine pregnancy rates, making the exclusion of statement 1 incorrect.