UPSC-CMS 2016 Practice Questions

Q: Which of the following is not a characteristic of Mayer-Rokitansky-Küster-Hauser syndrome?

Cardiac anomalies. ***Cardiac anomalies*** - While other systemic abnormalities can be associated with MRKH syndrome, **cardiac anomalies** are generally not considered a characteristic feature. - MRKH syndrome primarily affects the **Müllerian ducts** and is often linked to renal and skeletal issues due to common developmental origins. *Skeletal abnormalities* - **Skeletal abnormalities**, particularly of the **vertebral column** (e.g., scoliosis, fused vertebrae), are commonly associated with MRKH syndrome. - This association is thought to arise from defects in the paraxial mesoderm during embryonic development, which affects both skeletal and Müllerian structures. *Renal abnormalities* - Around 30-50% of individuals with MRKH syndrome also have **renal anomalies**, such as **unilateral renal agenesis**, horseshoe kidney, or renal ectopia. - These abnormalities are due to the close developmental proximity and shared mesodermal origin of the Müllerian ducts and the **urogenital system**. *Mullerian duct aplasia* - **Müllerian duct aplasia** is the **defining characteristic** of MRKH syndrome, leading to the absence or hypoplasia of the uterus and upper vagina. - Individuals typically present with **primary amenorrhea** despite having normal secondary sexual characteristics and functioning ovaries.

Q: The following are used in the staging of carcinoma of the cervix except:

Hydroureter. ***Hydroureter*** - While hydroureter (ureteral dilatation) can occur in advanced cervical cancer due to ureteral compression, **hydroureter alone is not a FIGO staging criterion**. - The FIGO staging system specifically uses **hydronephrosis or non-functioning kidney** as a criterion for Stage IIIB, not isolated hydroureter. - Hydronephrosis represents kidney involvement, whereas hydroureter refers only to ureteral dilatation, which may not always lead to renal compromise. - This distinction is important: the staging criterion requires **renal involvement/compromise**, not just ureteral changes. *Parametrial involvement* - **Parametrial involvement** is a crucial staging criterion indicating at least **FIGO Stage IIB** disease. - This is assessed by palpation during bimanual examination or confirmed by imaging studies. - Represents lateral extension of the tumor beyond the cervix. *Pelvic lymph node involvement* - **Pelvic lymph node involvement** is a key staging criterion in the **FIGO 2018 staging system**, classified as **Stage IIIC1**. - Assessed through imaging (CT, MRI, PET-CT) or surgical staging. - Significantly impacts prognosis and treatment planning. *Vaginal involvement* - The extent of **vaginal involvement** is a direct FIGO staging criterion. - Involvement of the upper two-thirds indicates **Stage IIA**, while extension to the lower third indicates **Stage IIIA**. - Assessed by careful pelvic examination and imaging.

Q: A 58 year old woman, post menopausal for last 8 years comes with history of spotting per vaginum. What is the most likely cause?

Atrophic vaginitis. ***Atrophic vaginitis*** - **Most common cause** of postmenopausal bleeding, accounting for **60-70% of cases**. - Due to **decreased estrogen levels** after menopause, the vaginal epithelium and endometrium become thin, dry, and fragile. - This leads to **easy bleeding** from minimal trauma, presenting as spotting. - In a woman 8 years postmenopausal, atrophic changes are the statistically most likely cause. *Endometrial carcinoma* - **Must always be ruled out** in any woman with postmenopausal bleeding - this is the golden rule. - Accounts for approximately **10% of postmenopausal bleeding cases**. - While statistically less common than atrophy, requires investigation with **endometrial biopsy or transvaginal ultrasound**. - Risk factors include obesity, nulliparity, late menopause, and unopposed estrogen exposure. *Endometrial hyperplasia* - Results from **unopposed estrogen stimulation** causing excessive endometrial growth. - More commonly presents with **heavier or prolonged bleeding** rather than spotting. - Less likely in a woman 8 years postmenopausal without hormone therapy. - Can be a precursor to endometrial carcinoma if left untreated. *Estrogen replacement therapy* - Can cause **breakthrough bleeding or spotting** if used. - The question stem does not mention the patient is on hormone replacement therapy. - If present, would be an important consideration in the differential diagnosis.

Q: A diabetic obese patient comes with history of post-menopausal bleeding. On examination, there is a supra pubic mass and per vagina there is purulent discharge. The probable diagnosis is:

Carcinoma endometrium. ***Carcinoma endometrium*** - **Postmenopausal bleeding** is the hallmark symptom, and the patient's **diabetes** and **obesity** are significant risk factors for endometrial carcinoma. - The combination of a **suprapubic mass** (indicating an enlarged uterus or advanced disease) and **purulent vaginal discharge** (suggesting **pyometra** secondary to cervical stenosis caused by tumor) strongly supports this diagnosis. *Ovarian carcinoma* - Ovarian carcinoma primarily presents with vague symptoms like **abdominal distension**, **bloating**, and **pelvic pain**, not typically postmenopausal bleeding as the initial symptom. - While it can cause an abdominal mass, **purulent vaginal discharge** and direct bleeding are not common primary presentations. *Uterine myoma* - **Uterine myomas (fibroids)** are common benign tumors that can cause bleeding, but typically in premenopausal women and characterized by **menorrhagia** or intermenstrual bleeding. - While large fibroids can present as a mass, **postmenopausal bleeding** and especially **purulent discharge** point away from a simple fibroid in this context. *Carcinoma cervix* - **Cervical carcinoma** often presents with **postcoital bleeding** or irregular intermenstrual bleeding, and can cause a mass and discharge. - However, the strong risk factors of **diabetes** and **obesity** are more directly linked to **endometrial cancer** than cervical cancer, and the description of a suprapubic mass suggests a uterine origin rather than primarily cervical.

Q: An adolescent girl with stage 1a dysgerminoma is managed by:

Unilateral salpingo-oophorectomy alone. ***Unilateral salpingo-oophorectomy alone*** - For **stage 1a dysgerminoma**, which is confined to one ovary, **fertility-sparing surgery** with unilateral salpingo-oophorectomy is the standard treatment, especially in young patients. - This approach aims to preserve reproductive function while effectively treating the localized tumor, given the **high radiosensitivity** and **chemosensitivity** of dysgerminomas. *Chemotherapy* - While dysgerminomas are sensitive to chemotherapy, it is typically reserved for **advanced stages** (stage 1c or higher), **recurrent disease**, or cases with **residual disease** after surgery. - It is not the primary treatment for **stage 1a disease** when complete surgical resection is achievable, especially when fertility preservation is desired. *Bilateral salpingo-oophorectomy alone* - This procedure would remove both ovaries and fallopian tubes, leading to **sterility and premature menopause**. - It is an **over-treatment** for stage 1a dysgerminoma, as the disease is localized to one ovary, and it is not fertility-sparing. *Total abdominal hysterectomy with unilateral salpingo-oophorectomy* - This extensive surgery involves the removal of the uterus and one ovary/fallopian tube, rendering the patient **infertile**. - It is an **overly aggressive** approach for stage 1a dysgerminoma in an adolescent girl, as the uterus is not involved, and fertility preservation is a crucial consideration.

Q: Which of the following conditions is best treated by a posterior colpotomy?

Pelvic abscess. ***Pelvic abscess*** - A **posterior colpotomy** allows for direct access and drainage of a pelvic abscess located in the **cul-de-sac** (pouch of Douglas). - This minimally invasive surgical approach provides effective relief for loculated pelvic infections. - **Most definitive indication** for posterior colpotomy as it allows complete drainage of purulent material. *Pyosalpinx* - Refers to a pus-filled fallopian tube, which is typically located **laterally to the uterus** and not easily accessible via a posterior colpotomy. - Drainage of a pyosalpinx usually requires a **laparoscopic or open abdominal approach**. *Pyometra* - Characterized by **pus accumulation within the uterine cavity**, which is drained via the cervix, not the posterior vaginal fornix. - **Cervical dilation** and drainage are the primary treatment, not colpotomy. *Pelvic haematocele* - Involves a collection of **blood in the pelvic cavity**, often within the cul-de-sac. - While technically accessible via colpotomy, **pelvic haematoceles are usually managed conservatively** or require laparoscopy to identify and control the bleeding source. - Colpotomy drainage alone is insufficient as it doesn't address the underlying cause of bleeding.

Q: Presence of signet-ring cells in a cellular or myxomatous stroma is diagnostic of:

Krukenberg tumour. ***Krukenberg tumour*** - **Krukenberg tumours** are characterized by mucin-filled **signet-ring cells** within a fibrous or myxomatous stroma. [1] - They represent metastatic adenocarcinomas, commonly originating from the **gastrointestinal tract**, particularly the stomach. [1] *Gynandroblastoma* - This is a rare **sex cord-stromal tumour** of the ovary that contains both female **(granulosa/theca cells)** and male **(Sertoli/Leydig cells)** components. - It does not typically feature signet-ring cells. *Hilus cell tumour* - **Hilus cell tumours** are **Leydig cell tumours** found in the ovarian hilum, characterized by cells containing **Reinke crystals**. - These tumours are associated with **androgen production** and virilization, and do not contain signet-ring cells. *Struma ovarii* - **Struma ovarii** is a specialized form of **ovarian teratoma** in which **thyroid tissue** is the predominant component (more than 50%). - While it can be functional and cause hyperthyroidism, it is not characterized by the presence of signet-ring cells. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 779.

Q: Which one of the following is not a contraindication for prescribing combined oral contraceptive pills?

Pelvic inflammatory disease. ***Pelvic inflammatory disease*** - **Pelvic inflammatory disease (PID)** is NOT a contraindication for combined oral contraceptive pills (COCs). - According to **WHO Medical Eligibility Criteria**, PID is classified as **Category 1** (no restriction) for COC use. - COCs do not worsen PID and may actually provide some **protective effect** against ascending genital tract infections. - PID concerns are primarily relevant for **IUD insertion**, not oral contraceptive use. *Viral hepatitis* - **Active viral hepatitis** is a contraindication (WHO Category 3-4) for COCs. - COCs are metabolized in the **liver**, and use during active hepatitis can exacerbate liver damage. - **Severe or acute liver disease** impairs hormone metabolism, increasing risks of adverse effects. *Well-controlled hypertension* - **Hypertension** is generally a contraindication for COCs depending on severity and vascular complications. - **Well-controlled hypertension without vascular disease** is WHO Category 3 (risks usually outweigh benefits). - **Uncontrolled hypertension** (≥160/100 mmHg) or hypertension with vascular disease is **Category 4** (absolute contraindication). - Estrogen in COCs can further elevate blood pressure and increase cardiovascular risks. *Thromboembolic disease* - History of **thromboembolic disease** (DVT, PE, stroke) is an **absolute contraindication** (WHO Category 4) for COCs. - Estrogen in COCs increases synthesis of **clotting factors** (I, VII, X) and decreases anticoagulant proteins, significantly raising **venous thromboembolism risk**.

Q: Which of the following suture materials has the least tissue reaction?

Stainless steel. ***Stainless steel*** - **Stainless steel** is a **monofilament** suture with the **lowest tissue reactivity** due to its inert nature. - It is often used in situations requiring maximal strength and minimal biological interaction, such as abdominal wall closure or orthopedic procedures. *Silk* - **Silk** is a **multifilament, natural, non-absorbable** suture and is known for its **moderate tissue reactivity** due to its braided structure and organic origin. - While it provides good knot security, its reactivity makes it unsuitable for areas where minimal foreign body reaction is paramount. *Cotton / Linen* - **Cotton and linen** sutures are **natural, multifilament, non-absorbable** materials that exhibit significant **tissue reactivity**. - Their fibrous nature can lead to considerable inflammatory response and are rarely used in modern surgical practice. *Chromic catgut* - **Chromic catgut** is a **natural, absorbable** suture treated with chromium salts to prolong its absorption time, but it still triggers a **significant inflammatory response** as it is absorbed by enzymatic digestion. - Its high tissue reactivity makes it less ideal for situations requiring minimal foreign body reaction compared to synthetic or metallic sutures.

Question 1

Regarding hypertensive disorders of pregnancy, the following are true except:

Accepted Answer

Urinary dipstick result of +1 is equivalent to urinary protein concentration of 300 mg/dl

Answer

Significant proteinuria is more than/equal to 0.3 g/24hr

Answer

Eclampsia may present in the absence of hypertension

Answer

A protein:creatinine ratio more than 30 mg/mmol is considered significant

Question 2

Which of the following is not a characteristic of Mayer-Rokitansky-Küster-Hauser syndrome?

Accepted Answer

Cardiac anomalies

Answer

Skeletal abnormalities

Answer

Renal abnormalities

Answer

Mullerian duct aplasia

Question 3

The following are used in the staging of carcinoma of the cervix except:

Accepted Answer

Hydroureter

Answer

Parametrial involvement

Answer

Pelvic lymph node involvement

Answer

Vaginal involvement

Question 4

A 58 year old woman, post menopausal for last 8 years comes with history of spotting per vaginum. What is the most likely cause?

Accepted Answer

Atrophic vaginitis

Answer

Endometrial hyperplasia

Answer

Endometrial carcinoma

Answer

Estrogen replacement therapy

Question 5

A diabetic obese patient comes with history of post-menopausal bleeding. On examination, there is a supra pubic mass and per vagina there is purulent discharge. The probable diagnosis is:

Accepted Answer

Carcinoma endometrium

Answer

Ovarian carcinoma

Answer

Uterine myoma

Answer

Carcinoma cervix

Question 6

An adolescent girl with stage 1a dysgerminoma is managed by:

Accepted Answer

Unilateral salpingo-oophorectomy alone

Answer

Chemotherapy

Answer

Bilateral salpingo-oophorectomy alone

Answer

Total abdominal hysterectomy with unilateral salpingo-oophorectomy

Question 7

Which of the following conditions is best treated by a posterior colpotomy?

Accepted Answer

Pelvic abscess

Answer

Pyosalpinx

Answer

Pyometra

Answer

Pelvic haematocele

Question 8

Presence of signet-ring cells in a cellular or myxomatous stroma is diagnostic of:

Accepted Answer

Krukenberg tumour

Answer

Gynandroblastoma

Answer

Hilus cell tumour

Answer

Struma ovarii

Question 9

Which one of the following is not a contraindication for prescribing combined oral contraceptive pills?

Accepted Answer

Pelvic inflammatory disease

Answer

Viral hepatitis

Answer

Well-controlled hypertension

Answer

Thromboembolic disease

Question 10

Which of the following suture materials has the least tissue reaction?

Accepted Answer

Stainless steel

Answer

Silk

Answer

Cotton / Linen

Answer

Chromic catgut

UPSC-CMS 2016

Obstetrics and Gynecology

Pathology

Pharmacology

Surgery