FMGE 2025 - Obstetrics and Gynecology Practice Questions

Q: A patient with a known marginal placenta presents for follow-up. On ultrasound, a 4 x 4 cm placental mass is noted invading into the urinary bladder. What is the most likely diagnosis?

Placenta percreta. ***Placenta percreta*** - This is the most severe form of the **placenta accreta spectrum**, where the placental villi penetrate through the entire uterine wall, including the **serosa**, and invade adjacent organs. - The ultrasound finding of a placental mass invading the **urinary bladder** is the classic presentation of **placenta percreta**. *Placenta previa* - This term describes the location of the placenta, where it partially or completely covers the **internal cervical os**. It does not describe the depth of invasion. - Although **placenta previa** is a significant risk factor for placenta accreta spectrum disorders, the invasion into the bladder points to a specific diagnosis of abnormal adherence, not just location. *Placenta increta* - In **placenta increta**, the placental villi invade into the **myometrium** (uterine muscle) but do not penetrate through to the serosa or adjacent organs. - This represents the intermediate form of the accreta spectrum, more severe than accreta but less severe than percreta. *Placenta accreta* - In **placenta accreta**, the placental villi are abnormally attached to the **myometrium**, but they do not invade the uterine muscle itself. This is the least invasive form of the spectrum. - The finding of invasion into the **urinary bladder** rules out simple accreta, as this requires penetration through the entire myometrium and serosa, which is characteristic of percreta.

Q: A patient develops profuse uterine bleeding after a lower segment cesarean section (LSCS). Despite administration of oxytocin and other uterotonics, the bleeding continues. What is the 1st line conservative surgical management?

Uterine balloon tamponade. ***Uterine balloon tamponade*** - This is the **first-line conservative surgical intervention** when uterine atony persists despite maximum medical management (oxytocin, methylergometrine, carboprost, misoprostol). - Devices like the **Bakri balloon** are inserted rapidly to apply counter-pressure to the uterine walls, effectively halting bleeding in 80-90% of cases while preserving the uterus. - This is a **Tier 2 intervention** that bridges medical management and invasive surgical procedures. *Uterine artery embolization* - This specialized technique requires immediate availability of an **interventional radiology suite** and hemodynamically stable patient for transport. - It is typically pursued after conservative mechanical procedures (tamponade or compression sutures) have failed, or in specialized centers where it's immediately available. - Considered a **Tier 3 intervention**. *Internal iliac artery ligation* - This complex invasive surgical procedure is performed when simpler techniques like **balloon tamponade** or **B-Lynch compression sutures** have failed. - It is typically reserved as a step before hysterectomy, aimed at reducing pelvic blood flow. - Also a **Tier 3 intervention**. *Hysterectomy* - **Hysterectomy** is the **last-resort, life-saving measure** (Tier 4) when all conservative mechanical, surgical, and medical options have failed to control massive hemorrhage. - The goal is to implement conservative measures rapidly to **preserve fertility** before resorting to definitive surgery.

Q: A patient's fetal heart rate tracing is shown in the image. The tracing shows variable deceleration. What does that indicate?

Umbilical cord compression. ***Umbilical cord compression*** - Variable decelerations are characterized by an **abrupt decrease** in fetal heart rate with a variable onset, duration, and shape, which is the classic sign of **umbilical cord compression**. - The compression of the umbilical cord causes a reflex **baroreceptor-mediated** slowing of the heart rate, which resolves when the compression is relieved. *Fetal head compression* - This causes **early decelerations**, which are gradual, uniform in shape, and mirror the uterine contraction. - Early decelerations are a result of a **vagal response** to increased intracranial pressure during contractions and are generally considered benign. *Uteroplacental insufficiency* - This leads to **late decelerations**, where the nadir of the deceleration occurs after the peak of the contraction. - Late decelerations signify impaired oxygen exchange at the placenta and are associated with fetal **hypoxemia**. *Maternal hypotension* - Maternal hypotension can reduce blood flow to the placenta, causing **uteroplacental insufficiency**. - This would result in **late decelerations** or potentially a **prolonged deceleration**, not the characteristic variable pattern.

Q: In a case of face presentation during labor, which diameter is seen?

Submentobregmatic. ***Submentobregmatic*** - In a **face presentation**, the fetal head is completely extended (deflexed), causing the face to present first in the birth canal. - The presenting diameter is the **submentobregmatic**, which measures approximately **9.5 cm** and extends from the junction of the neck and chin to the anterior fontanelle (bregma). *Mentobregmatic* - This term is sometimes used, but the precise engaging diameter in a face presentation is the **submentobregmatic** diameter. - The **mento-vertical** diameter (**14 cm**), which is the largest, is associated with a **brow presentation** and is too large for a vaginal delivery. *Suboccipitobregmatic* - This is the presenting diameter in a normal, **well-flexed vertex presentation**, which is the most common and favorable presentation. - It measures approximately **9.5 cm** and extends from the nape of the neck (subocciput) to the bregma. *Occipitofrontal* - This diameter is seen when the head is in a **military attitude** (partially deflexed), where neither flexion nor extension is complete. - It measures about **11.5 cm**, which is larger than the ideal presenting diameter and can prolong labor.

Q: What is the best diagnostic test for evaluating endometrial pathology?

Hysteroscopy-guided endometrial biopsy. ***Hysteroscopy-guided endometrial biopsy*** - This is considered the **gold standard** for evaluation as it allows for **direct visualization** of the endometrial cavity, facilitating the targeted biopsy of focal lesions such as polyps or localized carcinoma. - Targeting specific areas significantly improves **diagnostic yield** and accuracy, minimizing the risk of missing pathology compared to blind procedures. *Pipelle endometrial biopsy* - This is an effective, **office-based suction procedure** often used for initial screening of diffuse pathology (e.g., endometrial hyperplasia or carcinoma) due to its ease and tolerability. - It is a **blind procedure** and may fail to adequately sample or completely miss **focal lesions** like small polyps or carcinoma situated in the cornua. *Dilatation and curettage (D&C)* - D&C is also a **blind scraping procedure** that often yields incomplete tissue sampling, particularly of the **uterine cornua**, leading to potential false negatives. - While useful therapeutically (e.g., managing abortions), it is less accurate for **diagnostic evaluation** than hysteroscopy. *Transvaginal sonography* - TVS is an **initial screening test** used to measure **endometrial thickness** (ET), which can indicate the *need* for, but cannot replace, histological diagnosis. - It provides **structural information** (e.g., presence of fluid, fibroids) but cannot definitively diagnose the nature of the cellular pathology, requiring subsequent biopsy for **histological confirmation**.

Q: In which of the following conditions would the use of an intrauterine contraceptive device (IUCD) require the most careful consideration due to contraindication concerns?

HIV infection. ***HIV infection*** - According to WHO Medical Eligibility Criteria (MEC), HIV infection presents varying levels of concern depending on disease status: - **Stable HIV on ART**: MEC Category 2 (benefits generally outweigh risks) - **Severe/Advanced HIV (AIDS)**: MEC Category 3 (risks usually outweigh benefits) - The primary concern is the increased risk of **pelvic inflammatory disease (PID)** in immunocompromised patients - Among the options provided, HIV infection represents the **strongest relative contraindication** requiring careful clinical assessment before IUCD insertion - Recent guidelines emphasize individualized decision-making based on immune status, viral load, and ART adherence *Hypertension* - **Hypertension** is NOT a contraindication for IUCD use (MEC Category 1) - Neither copper IUDs nor levonorgestrel-releasing IUDs (LNG-IUD) affect blood pressure - IUCDs are safe contraceptive options for women with controlled or uncontrolled hypertension - No cardiovascular risk associated with IUD use *Hyperlipidemia* - **Hyperlipidemia** is NOT a contraindication for IUCD use (MEC Category 1) - IUDs do not affect lipid metabolism or lipid levels - Both copper and hormonal IUCDs can be safely used in women with abnormal lipid profiles *Diabetes mellitus* - **Diabetes mellitus** is NOT a contraindication for IUCD use (MEC Category 1/2) - Both copper and hormonal IUDs are safe and effective for diabetic patients - IUCDs are often preferred over combined hormonal contraceptives, which may affect **glycemic control** - No increased risk of complications with proper insertion technique

Q: A 12-year-old female presents with Tanner stage II breast development and white, odorless vaginal discharge. This discharge is most likely due to the action of which hormone?

Estrogen. ***Estrogen*** - **Estrogen** levels rise during the initial phases of puberty (Tanner stage II), primarily driving secondary sexual characteristics like **breast development** and maturation of the vaginal epithelium. - Increased estrogen levels lead to enhanced mucus production by cervical glands and increased desquamation of vaginal epithelial cells, resulting in the normal, odorless, white discharge known as **physiologic leukorrhea** seen premenarche. *GnRH* - **Gonadotropin-releasing hormone (GnRH)** is the hypothalamic hormone that initiates puberty by stimulating the pituitary to release **FSH** and **LH**. - While GnRH initiates the hormonal cascade, it is the downstream production of **estrogen** by the ovaries that directly causes the changes in the genital tract mucosa resulting in vaginal discharge. *Inhibin B* - **Inhibin B** is predominantly produced by the **granulosa cells** of the developing ovarian follicles. - Its main function is to provide negative feedback to the pituitary gland, selectively inhibiting the secretion of **Follicle-Stimulating Hormone (FSH)**, and is not directly implicated in causing vaginal discharge. *Progesterone* - **Progesterone** is primarily produced by the corpus luteum after ovulation and plays a key role in preparing the endometrium for implantation. - In early puberty (Tanner stage II), progesterone levels are typically low as ovulatory cycles have not yet been established, and it does not directly cause the vaginal discharge seen at this stage.

Q: A 36-year-old P2L2 patient diagnosed with severe endometriosis shows pelvic adhesions on laparoscopy. She has undergone tubal ligation and adhesiolysis previously. What is the most appropriate management during laparoscopy?

Total hysterectomy and bilateral salpingo-oophorectomy. ***Total hysterectomy and bilateral salpingo-oophorectomy***- This is the **definitive surgical treatment** for symptomatic **severe endometriosis** (Grade IV) in patients who have completed childbearing, offering the highest chance of cure and symptom relief.- Removing both the uterus and the ovaries eliminates the sources of **menstruation** and **estrogen**, which fuel the remaining endometriotic lesions, thereby minimizing the risk of recurrence.*Observation only, no intervention*- This approach is inappropriate for **severe, symptomatic endometriosis**, especially given the history of failed prior intervention (adhesiolysis) and chronic symptoms.- Failing to intervene surgically can lead to persistent **chronic pelvic pain** and potential organ dysfunction due to extensive adhesions and deep infiltrating endometriosis.*Total laparoscopic hysterectomy*- While removing the uterus addresses pain related to menses and potential adenomyosis, leaving the ovaries intact ensures continued **estrogen production**.- Continued estrogen stimulation significantly increases the risk of endometriosis recurrence (up to 50%) from any residual deposits, contraindicating ovarian preservation in this severe case.*Oophorectomy*- Simple oophorectomy (unilateral or bilateral) without concomitant **hysterectomy** is generally inadequate for severe endometriosis.- If the uterus is left behind, the patient may still experience cyclical bleeding and pain related to **adenomyosis** or pain fibers, and surgical staging remains incomplete for definitive care.

Q: After an initial serum $\beta$-hCG test in a patient with suspected pregnancy, when should the repeat $\beta$-hCG level ideally be checked to assess viability or progression?

48 hours. ***Correct: 48 hours*** - In a viable, intrauterine pregnancy, serum β-hCG levels typically **double approximately every 48 hours** (or show a rise of at least 35% in 48 hours) during the initial weeks. - This standard **48-hour interval** is critical as it provides the most timely and appropriate benchmark to determine if the required doubling is occurring, aiding in the assessment of viability. - This is the **gold standard timing** for repeat β-hCG testing in early pregnancy monitoring. *Incorrect: 24 hours* - This interval is generally **too short** to observe the significant rise needed to confidently distinguish a normal, viable doubling rate from an abnormal or insufficient rate. - Due to natural variations in hormone secretion, a 24-hour reading often yields an overlapping range, making interpretation of the trend difficult. *Incorrect: 72 hours* - Although a check at 72 hours is sometimes used (as doubling can take up to 72 hours), waiting this long can **delay critical diagnosis** of urgent conditions like a non-ruptured **ectopic pregnancy** or ongoing miscarriage. - The 48-hour check remains the standard benchmark providing the earliest necessary data for management decisions. *Incorrect: 96 hours* - Waiting 96 hours (4 days) is generally **too long** and could significantly delay necessary intervention or further management for a non-viable or **ectopic pregnancy**. - While β-hCG doubling slows down significantly after approximately 6 weeks of gestation, the initial assessment requires the tighter 48-hour timeframe.

Q: A pregnant woman with a short cervix undergoes a cervical cerclage procedure. The image shows a key step during the procedure. What is the most likely procedure being performed?

Modified Shirodkar. ***Modified Shirodkar*** - The image displays the dissection of the **vesicocervical mucosa** (bladder flap) which is a crucial step in the Shirodkar procedure, allowing the suture to be placed high on the cervix near the **internal os**. - This technique involves a submucosal placement of a non-absorbable suture (like Mersilene tape) which is then buried, providing better support for an incompetent cervix compared to lower-placed sutures. *Modified McDonald's* - The McDonald's procedure and its modifications are simpler techniques that place a **purse-string suture** around the cervix without any dissection of the cervical mucosa. - This procedure is less invasive but the suture is placed lower on the cervix, which might offer less support than a high cerclage like the Shirodkar. *McDonald's* - This is a transvaginal **purse-string suture** placed around the body of the cervix, cinching it closed. It is a common and relatively simple method of cerclage. - Crucially, it does not involve the **bladder dissection** shown in the image, which is the key differentiating feature of the Shirodkar technique. *Shirodkar* - While the procedure shown is a Shirodkar type, the **Modified Shirodkar** is the version most commonly performed today and is therefore the most precise answer. - The original Shirodkar technique often involved a permanent suture requiring a **cesarean delivery**, whereas the modified version uses a suture that can be removed to allow for a trial of vaginal delivery.

Question 1

A patient with a known marginal placenta presents for follow-up. On ultrasound, a 4 x 4 cm placental mass is noted invading into the urinary bladder. What is the most likely diagnosis?

Accepted Answer

Placenta percreta

Answer

Placenta accreta

Answer

Placenta previa

Answer

Placenta increta

Question 2

A patient develops profuse uterine bleeding after a lower segment cesarean section (LSCS). Despite administration of oxytocin and other uterotonics, the bleeding continues. What is the 1st line conservative surgical management?

Accepted Answer

Uterine balloon tamponade

Answer

Hysterectomy

Answer

Internal iliac artery ligation

Answer

Uterine artery embolization

Question 3

A patient's fetal heart rate tracing is shown in the image. The tracing shows variable deceleration. What does that indicate?

Accepted Answer

Umbilical cord compression

Answer

Maternal hypotension

Answer

Fetal head compression

Answer

Uteroplacental insufficiency

Question 4

In a case of face presentation during labor, which diameter is seen?

Accepted Answer

Submentobregmatic

Answer

Mentobregmatic

Answer

Occipitofrontal

Answer

Suboccipitobregmatic

Question 5

What is the best diagnostic test for evaluating endometrial pathology?

Accepted Answer

Hysteroscopy-guided endometrial biopsy

Answer

Transvaginal sonography

Answer

Pipelle endometrial biopsy

Answer

Dilatation and curettage (D&C)

Question 6

In which of the following conditions would the use of an intrauterine contraceptive device (IUCD) require the most careful consideration due to contraindication concerns?

Accepted Answer

HIV infection

Answer

Diabetes mellitus

Answer

Hypertension

Answer

Hyperlipidemia

Question 7

A 12-year-old female presents with Tanner stage II breast development and white, odorless vaginal discharge. This discharge is most likely due to the action of which hormone?

Accepted Answer

Estrogen

Answer

Inhibin B

Answer

GnRH

Answer

Progesterone

Question 8

A 36-year-old P2L2 patient diagnosed with severe endometriosis shows pelvic adhesions on laparoscopy. She has undergone tubal ligation and adhesiolysis previously. What is the most appropriate management during laparoscopy?

Accepted Answer

Total hysterectomy and bilateral salpingo-oophorectomy

Answer

Observation only, no intervention

Answer

Total laparoscopic hysterectomy

Answer

Oophorectomy

Question 9

After an initial serum $\beta$-hCG test in a patient with suspected pregnancy, when should the repeat $\beta$-hCG level ideally be checked to assess viability or progression?

Accepted Answer

48 hours

Answer

96 hours

Answer

24 hours

Answer

72 hours

Question 10

A pregnant woman with a short cervix undergoes a cervical cerclage procedure. The image shows a key step during the procedure. What is the most likely procedure being performed?

Accepted Answer

Modified Shirodkar

Answer

Shirodkar

Answer

Modified McDonald's

Answer

McDonald's

FMGE 2025 — Obstetrics and Gynecology