13
Gynecology
AIIMS NOVEMBER 2017
1. In confirmed case of Down’s syndrome, what will be finding
in 2nd trimester in triple test?
a. Low MSAFP, Low UE3 low, Low beta hCG
b. Low MSAFP, Low UE3 and High beta hCG
c. High MSAFP, High UE3 and Low beta hCG
d. High MSAFP, Low UE3 and High beta hCG high
2. A pregnant lady who is Nurse by profession needs how much
extra calories in first trimester of pregnancy?
a. 300 kcal b. 500 kcal
c. 600 kcal d. No extra calories
3. A Multigravida with cervical dilation 6 cm and contraction
Ea
every 10 min last for 20 sec. Which stage of labour she is in?
a. 1st stage b. 2nd stage
c. 3rd stage d. 4th stage
ed
4. First reading on partogram should be placed at?   b. Hypertension at 10 weeks of pregnancy
a. Left side of the action line
b. Right side of the action line
M
c. Left side of the alert line
d. Right side of the alert line
S
5. According to Naegele’s rule, calculate EDD of a patient with
LMP 9 January 2017.
IM
a. 16/09/2017 b. 16/10/2017
c. 16/11/2017 d. 9/10/2017
AI
6. A 18 year old female presents with an ovarian mass, her
serum biomarker are found to be normal except LDH,
which is found to be elevated. The most likely diagnosis is?
a. Dysgerminoma
b. Endodermal sinus tumor
c. Malignant teratoma
d. Mucinous cystadenocarcinoma
7. For effective protection after unprotected intercourse one
single tab of levonorgestrel 0.75 mg has already been taken,
when is next dose to be taken?
a. 1 tab after 24 hrs b. 1 tab after 12 hrs
c. 2 tab after 12 hrs d. 2 tab after 24 hrs
8. Nonavalent HPV vaccine protects against which subtypes of
HPV viruses?
a. 6, 11, 16, 18, 31, 33, 45, 48, and 52
b. 6, 11, 16, 18, 31, 33, 45, 52, and 58
c. 6, 11, 16, 18, 33, 45, 48, 52 and 58
d. 6, 11, 16, 18, 33, 38, 45, 52, and 58
Obstetrics and
9. A 60 year old postmenopausal woman presents with history
of bleeding PV. Biopsy showed Endometrial hyperplasia
with atypia. Next line of management is?
a. Mirena b. Type 1 hysterectomy
c. Oral progestins d. Dilatation and Curettage
10. Drug of choice for gonococcal as well as nongonococcal
/e
mucopurulent cervicitis and urethritis is?
a. Cefixime 400 mg single oral dose
,2
b. Ceftriaxone 250 mg IM single dose
c. Azithromycin 2 gm oral single dose
d. Ciprofloxacin 500 mg single oral dose
sy
11. A 26 year old pregnant lady is diagnosed to have
Hypertension during her pregnancy. How would you say that
Hypertension is systemic hypertension and not pregnancy
induced hypertension?
a. Hypertensive retinopathy
c. Episode of seizure d. Proteinuria
12. A 35 year old female comes with history of postcoital bleed.
What to do next?
a. PAP smear
b. Hysteroscopy and then take biopsy
c. Four quadrant biopsy
d. Conisation e. Cryotherapy
13. A couple with 2 children who are not able to conceive for
over an year now present to OPD. Male partner is diagnosed
to be having hypogonadotrophic hypogonadism. Which of
the following is not true?
a. Low LH and Low FSH b. Low testosterone
c. Oligospermia d. High prolactin levels
14. A  27 years old female comes with history of infertility and
she is being treated with Bromocriptine. What is disease she
could be suffering from?
a. Hypogonadotrophic hypogonadism
b. Hyperprolactinemia
c. Polycystic ovarian disease
d. Pelvic Inflammatory disease
15. A 18 year old female with primary amenorrhoea, infantile
uterus and genotype 45XO/46XX comes to you. How you
will treat her?
a. Bilateral gonadectomy
b. Hormone replacement therapy
c. Remove the clitoris d. Vulvoplasty
716 Section I  •  Subject-wise MCQs and Answers with Explanations
16. Identify the name of menuvure shown in the picture?
a. Pelvic grip b. Pawlick’s grip
c. Fundal grip d. Lateral grip
17. Identify the instrument shown below?
Ea
ed
OBG PLATE 15
M
a. Mayo scissor b. Episiotomy scissor
c. Suture remover d. Curved scissors
S
AIIMS MAY 2017
IM
18. A women with infertility and bilateral cornual block on
HSG. Best management?  (AIIMS May 2017, Nov 2011)
AI
a. Tuboplasty b. IVF
c. Hydrotubation d. Hysteroscopy and laparoscopy
19. A 59-year-old female with history of ovarian carcinoma in
the mother achieved menopause with smooth transition.
She is on hormone replacement therapy. She developed
abdominal pain and the right adnexal mass was palpable,
non tender. On routine examination she has a 3 × 3 cm
smooth cyst in her ovary. Which is the next step?
a. Do CA-125 levels, if normal advise regular check up
b. Confirm USG findings by ordering CT scan
c. Do an exploratory laparoscopy to visualise the nature of cyst
d. Reassure and advise regular follow-up once in 6 months
20. Which of the following fits into the criteria of severe variable
deceleration, variations less than?
a. 70 beats per minute lasting for 60 seconds
b. 80 beats per minute lasting for 60 seconds
c. 90 beats per minute lasting for 60 seconds
d. 100 beats per minute lasting for 60 seconds
AIIMS (Nov 2017–May 2014)
21. A 28-year-old female nearing her date has been admitted
following regular contractions. The resident doctor did
an examination and told the intern that the head is at +1
station. What is the exact position of head?
a. High up in the false pelvis b. Just above ischial spine
c. Just below ischial spine d. At the perineum
22. Which of the following is the best parameter to assess in case
of male infertility?
a. The number of sperm b. The morphology of sperms
c. Motility of sperms d. Quantity of semen
23. A patient close to her due date and she experienced
uterine contractions and was admitted in the hospital
for observation. The resident was instructed to plot the
partogram regularly. From what cm of cervical dilatation is
partogram plotted in regular intervals?
a. 4 cm b. 5 cm
c. 6 cm d. 8 cm
/e
24. A patient came to OPD with a twin pregnancy. She already
had 2 first trimester abortion and she has a 3-year-old female
,2
child who was born at the end of ninth month of gestation.
Which of the following is her accurate representation?
G = gravid, P = para
sy a. G4P1 1+2+1
c. G4P1 0+1+2
b. G5P1 2+0+1
d. G5P0 1+0+2
25. Ureteric injury is most commonly associated with which of
the following?
a. Anterior colporrhaphy b. Vaginal hysterectomy
c. Wertheim hysterectomy d. Abdominal hysterectomy
26. A 23-year-old female came with complaints of 4 months
amenorrhea. The FSH and LH were elevated above the
normal value, thyroid function test were normal. Which is
the next step in management?
a. Give progesterone and stop after 10 days for withdrawal
bleeding
b. Check USG for polycystic ovaries
c. Estimate serum estradiol values
d. Do a urine pregnancy test
27. A pregnant lady was admitted for pregnancy induced hyper­
tension for monitoring and bed rest. In supine position which
of the following is a complication of the below representation?
a. Abdominal aorta syndrome
b. Supine vena caval syndrome
c. Superior vena caval syndrome
d. Ascending aorta syndrome
AIIMS Nov 2013–May 2011
Questions with Explanations Covered in Volume II (Available Separately)
 OBSTETRICS AND GYNECOLOGY  •  Answers with Explanations 723

ANSWERS WITH EXPLANATIONS

AIIMS NOVEMBER 2017 2. Ans. (d)  No extra calories

1. Ans. (b)  Low MSAFP, Low UE3 and High beta hCG
Ref: Williams 24th ed page 290
Triple test can detect 60-70% cases of Down’s syndrome
Triple test
•• Also called triple screen, the Kettering test or the Bart’s
test.
•• It is a combined biochemical test which includes MS-
AFP, hCG and UE3 (unconjugated estriol).
Ref: With Text
At first look this question appears to be a repeat question from
Preventive and social medicine. Supplementary Nutrition is
given to the children (6 months – 6 years) and pregnant and
lactating mothers under the Integrated Child Development
Services (ICDS) Scheme. However since first trimester was
specifically mentioned in the question we had a second look.
PSM books including PARK and ICDS does not differentiate
on the basis of Trimester however Obstetric books do mention
trimester wise.  Going through the below text from Williams
it’s clear that the answer is (D) No extra calories
William’s obstetrics 24th ed page 51; Analysis by the World
Health Organization (2004) estimates that the additional total

/e
•• Maternal age in relation to confirmed gestation age is
also taken into account pregnancy energy demands associated with normal pregnancy
•• The test is for screening, not for diagnosis. are approximately 77,000 kcal or 85 kcal/day, 285 kcal/day,

,2
••  Usually done between 15-18 weeks (16 weeks and 475 kcal/day during the first, second, and third trimester,
optimum). respectively.
William obstetrics 24th ed page 178; Pregnancy requires an
Genetic diseases
Down’s syndrome
β-hCG MS-AFP UE3
↑ ↓ ↓ sy additional 80,000 kcal, mostly during the last 20 weeks. To
meet this demand, a caloric increase of 100 to 300 kcal per
Ea
Turner’s syndrome ↑ ↑ ↓ day is recommended during pregnancy (American Academy
of Pediatrics and the American College of Obstetricians and
Edward syndrome ↓ ↓ ↓
Gynecologists, 2012). This intake increase, however, should not
ed

be divided equally during the course of pregnancy. The Institute

of Medicine (2006) recommends adding 0, 340, and 452 kcal/
Tests for Down’s syndrome day to the estimated nonpregnant energy requirements in the
M

first, second, and third trimesters, respectively.

1st trimester ↑ hCG, ↓ MSAFP, ↓ PAPP
2 trimester
nd
•• Triple test (↓ MSAFP, ↓ UE3, ↑ Total
S

hCG) 3. Ans. (a)  1st Stage

•• Quadruple test (↓ MSAFP, ↓ UE3, ↑
IM

Ref: Danforth’s Obstetrics and Gynaecology 10th ed ch 2;

Total hCG, ↑ Inhibin A) William’s 24th Ed Pg 444-446, Dutta’s obstetrics 8th ed pg no 386
•• USG (sonographic marker/Soft sign)
The first stage begins when spaced uterine contractions of
•• ↑ nuchal fold thickness (Nuchal
AI

sufficient frequency, intensity, and duration are attained

translucency)
•• ↓ Femur length and humerus
•• Nasal bone absence or hypoplasia
•• Shortened frontal lobe or
brachycephaly
•• Short ear length
•• Echogenic bowel and intracardiac focus
•• Mild renal pelvis dilation
•• Widened iliac angle
•• Widened gap between first and second
toes- “sandal gap”
•• Clinodactyly, hypoplastic mid-phalanx
of fifth digit
•• Single transverse palmar crease
to bring about cervical thinning, or effacement. This labor
stage ends when the cervix is fully dilated—about 10 cm—to
allow passage of the term-sized fetus. The first stage of labor,
therefore, is the stage of cervical effacement and dilatation.
The second stage begins when cervical dilatation is complete
and ends with delivery. Thus, the second stage of labor is the
stage of fetal expulsion. Last, the third stage begins immediately
after delivery of the fetus and ends with the delivery of the
placenta. Thus, the third stage of labor is the stage of placental
separation and expulsion.
First Stage
Upto 10 cm dilation is called as full/ complete dilatation, which
is First Stage of Labour irrespective of parity

OBSTETRICS AND GYNECOLOGY

724 Section I  •  Subject-wise MCQs and Answers with Explanations

Stages and phases of labour

First stage Second stage Third stage Fourth stage
Description 0 to 10 cm dilatation (full dilatation) From complete dilatation Separation and 1-4 hour after
to birth of newborn, lasts delivery of the birth of newborn;
up to 1 hour placenta time of maternal
physiological
adjustment
Phases Latent phase: Pelvic phase: Placental
0-3 cm dilatation Period of fetal descent separation,
Effacement 0-40% placental expulsion
Nullipara – 9 hours Perineal phase:
Multipara – 5 to 6 hours Period of active pushing.
Contraction frequency every 5-6 min Nullipara -1 hour
Contraction duration 40-45 sec Multipara- 30 min
Contraction intensity mild Contraction frequency
Active phase: every 2-3 min or less
Contraction duration 60-

/e
4-7 cm dilatation
Effacement 40-80% 90 sec
Nullipara – 6 hours Contraction intensity

,2
Multipara – 4 hours strong
Contraction frequency every 2-5 min
Contraction duration 45- 60 sec
Contraction intensity moderate
Transition phase:
sy
Ea
8-10 cm dilatation
Effacement 80-100%
Nullipara – 1 hours
ed

Multipara – 30 min
Contraction frequency every 1-2 min
Contraction duration 60-90 sec
M

Contraction intensity strong

S
IM

4. Ans. (c)  Left side of the alert line months and 7 days to the first day of the last normal (28 day
Ref: Sheila Balakrishnan 2nd edition pg 121; William’s 24th ed cycle) period. Alternatively, one can count back 3 calendar
page 452, Dutta 6th ed p- 528 months from the first day of the last period and then add 7
AI

days to get the expected date of delivery; the former method is

See table of PARTOGRAPH in AIIMS NOV 2016
Prolonged labour is diagnosed, once the alert line is crossed
i.e shift to right. There is considered an indication for
intervention. If the patient is in peripheral hospital, once the
alert line is crossed from left to right, it is an indication for
referral to higher centre.
5. Ans. (b)  16/10/2017
Ref: Dutta’s 8th ed page 108 ,734, William’s 24th ed page 172
Naegele’s formula: Provided the periods are regular, it is
very useful and commonly practiced means to calculate the
expected date. Its prediction range is about 50% with 7 days on
either side of EDD. If the interval of cycles is longer, the extra
days are to be added and if the interval is shorter, the lesser
days are to be subtracted to get the EDD.
Calculation of the expected date of delivery (EDD): This
is done according to Naegele’s formula by adding 9 calendar
commonly employed.
Example: The patient had her first day of last menstrual period
on 9th January. By adding 9 calendar months it comes to 9th
October and then add 7 days, i.e. 16th October, which becomes
the expected date of delivery.
Note:
For IVF pregnancy date of LMP is 14 days prior to date of
embryo transfers (266 days).
Naegele’s rule is based on 28 days regular cycle.
If the interval of cycles is longer, the extra days are to be added and
if the interval is shorter, the lesser days are to be subtracted to get the
EDD. Examples: (1) If she is having 40days cycle regularly, to get
corrected EDD, add 12 days (40-28) with the EDD calculated
from LMP. (2) If she is having 21 days cycle regularly, to
get corrected EDD, subtract 7 days(28-21) with the EDD
calculated from LMP.

AIIMS (Nov 2017–May 2014)

 OBSTETRICS AND GYNECOLOGY  •  Answers with Explanations 725

6. Ans. (a)  Dysgerminoma Option (D)

Mucinous cystadenocarcinoma s epithelial tumor and is
Ref: Shaw’s Gynecology 16th ed page 821, Novak’s Gynecology
negative for all biomarkers including LDH and ALP
15th ed page 1223
Dysgerminoma 30–40% of Female counterpart of
See OBG PLATE 10 KEY
(MC malignant germ cell the seminoma
germ cell tumour, tumors Most radiosensitive
Option (B) MC malignant Unilateral (but surgery is the
Endodermal sinus tumor is AFP positive tumour diagnosed in 85–90% preferred treatment)
during pregnancy) of cases Tumour with
Option (C)
lymphocytic
Malignant Teratoma is AFP positive infiltration, LDH +ve,
ALP +ve

7. Ans. (b)  1 tab after 12 hrs

Ref: Shaw 16th ed page 609, William’s 24th ed page 1484, Dutta 7th ed page 551

Postcoital/ emergency contraceptives

/e
Drug Dose Pregnancy rate
(%)

,2
•• Levonorgestrel (Progesterone only pills) 0.75 mg stat and after 12 hrs Or 1.5 0-1
mg (2 Tab.stat dose)
•• Ethinyl estradiol 50 μg + Norgestrel 0.25 mg (Yuzpe method
or OCPs method) sy
2 tab stat and 2 after 12 hours 0–2
Ea
•• Ethinyl estradiol (Estrogen high dose), Now replaced by LNG 2.5 mg BD × 5 days 0–0.6

•• Mifepristone (RU-486) (Effective up to 49 days of LMP) 100 mg single dose 0-0.6

ed

•• Copper IUDs Insertion (Gold standard but now not within 5 days 0-0.1
M

recommended)
•• Ulipristal acetate (synthetic progesterone hormone receptor A 30 mg tablet should be taken 0-1
modular, attaches to progesterone receptor and prevents/ within 5 days
S

delays ovulation and suppresses endometrium, prevents

implantation)
IM

8. Ans. (b)  6, 11, 16, 18, 31, 33, 45, 52, and 58
AI

Ref: Shaw’s Gynecology 16th ed page 623, Novak’s Gynecology 15th ed page 1203

Cervarix vs gardasil
Cervarix Gardasil Gardasil- 9
Valency Bivalent vaccine Quadrivalent vaccine Nonavalent vaccine
Strains HPV viruses Types 16 and 18 HPV viruses 6, 11, 16, 18 HPV viruses 6, 11, 16, 18, 31, 33,
45, 52, and 58
Protection Types 16 and 18, 45 and 31 Types 6, 11, 16, 18 Types 6, 11, 16, 18, 31, 33, 45, 52,
and 58
Age group 9 to 26 years 9 to 26 years 9 to 26 years
Gender use Both male and females Both male and Female Both Males and females
Dose and Route 0.5 ml IM 0.5 ml IM 0.5 ml IM
Vaccine schedule 0, 2, 6 months 0, 2, 6 months 0, 2, 6 months
Immune response Stronger and longer Weaker and shorter Weaker and shorter
Contd…

OBSTETRICS AND GYNECOLOGY

726 Section I  •  Subject-wise MCQs and Answers with Explanations
Cervarix vs gardasil
Cervarix Gardasil
Pregnancy Category B- used during Category B- used during pregnancy
pregnancy only if clearly needed. only if clearly needed.
FDA Approval 2009 2006
Comments More effective for Ca cervix
AS04 adjuvant
9. Ans. (b)  Type 1 Hysterectomy
Ref: Shaw’s 16th ed page 826, Novak’s 15th ed page 1121, Novak’s
14th ed page 466, 1347
If not specifically mentioned at 60 years of age the patient does
not require fertility. Hence Type 1 Hysterectomy is the best
answer.
All postmenopausal women with unexpected uterine bleeding
patients should be evaluated for endometrial carcinoma.
Approximately 5 to 10 percent of women with postmenopausal
vaginal bleeding have endometrial cancer. For this reason,
atypical endometrial hyperplasia should be treated by
hysterectomy and not merely by ablative technique.
Progestin therapy is very effective in reversing endometrial
hyperplasia without atypia but is less effective for endometrial
hyperplasia with atypia.
Ea
•• For women with endometrial hyperplasia without atypia,
ovulation induction, cyclical progestin therapy (e.g.,
medroxyprogesterone acetate, 10-20 mg/day for 14 days per
ed
month), or continuous progestin therapy (e.g., megestrol
acetate, 20-40 mg/day) appear to be effective.
•• In a younger woman who wishes to retain her fertility
M
treatment of choice for endometrial hyperplasia is Medroxy
Progesterone Acetate 30-40 mg/day for 6-12 months or
MIRENA IUCD”. Surprisingly, Mirena is not effective
S
against endometrial hyperplasia caused by tamoxifen.
IM
Continuous progestin therapy with megestrol acetate (40-
160 mg/day) is probably the most reliable treatment for
reversing complex or atypical hyperplasia. Therapy should
AI
be continued for 2 to 3 months, and endometrial biopsy
should be performed 3 to 4 weeks after completion of
therapy to assess response. Periodic endometrial biopsy or
transvaginal ultrasonography is advisable in patients being
monitored after progestin therapy for atypical hyperplasia
because of the presence of undiagnosed cancer in 25% of
cases, the 29% progression rate to cancer, and the high
recurrence rate after treatment with progestins.
•• Oral, parenteral, or intrauterine delivery of progestins
may be used in selected women with atypical endometrial
hyperplasia who wish to maintain their fertility
•• For women with atypical complex hyperplasia who no
longer desire fertility, hysterectomy is recommended.
Normally a 1-year period of amenorrhoea after the age of
40 is considered as menopause. However, vaginal bleeding
occurring anytime after 6 months of amenorrhoea in a
menopausal age should be considered as postmenopausal
bleeding and investigated. In the majority of women, oestrogen
withdrawal at menopause causes endometrial atrophy,
AIIMS (Nov 2017–May 2014)
Gardasil- 9
Category B- used during pregnancy
only if clearly needed.
2014
and the endometrium is only 1-3 mm in thickness. The
postmenopausal endometrium measuring more than 4 mm is
considered abnormal
Classification of Endometrial Hyperplasias
Type of Hyperplasia Progression to Cancer (%)
Simple (cystic without atypia)  1
Complex (adenomatous without  3
/e
atypia)
Atypical
,2
Simple (cystic with atypia)  8
Complex (adenomatous with 29
sy
atypia)
10. Ans. (c)  Azithromycin 2 gm oral single dose
Ref: Park 23rd ed page 332, Novak 14th ed page 150, 151
This question is on Syndromic management of STI.
Option (A) and (B)
Ceftriaxone is not included by NACO in its syndromic
management KIT, however CDC recommends it to be used as
first line management.
Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1g
orally in a single dose
If ceftriaxone is not available: Cefixime 400 mg orally in a
single dose PLUS Azithromycin 1 g orally in a single dose
CDC states “A 400-mg oral dose of cefixime should only be
considered as an alternative cephalosporin regimen because
it does not provide as high, nor as sustained, bactericidal
blood levels as a 250-mg dose of ceftriaxone”
Option (C)
Monotherapy with azithromycin 2 g orally as a single dose has
been demonstrated to be 99.2% effective against uncomplicated
urogenital gonorrhea. However, monotherapy is no longer
recommended because of concerns over the ease with which
N. gonorrhoeae can develop resistance to macrolides, and
because several studies have documented azithromycin
treatment failures. However in absence of any other more
suitable option, Azithromycin 2 g Oral is the best answer.
Syndromic Management of STI
A woman is liable to several infections in the lower genital
tract most common of which are gonorrhoea, chlamydia,
trichomonal infection, monilial infection and bacterial
vaginosis. The tests and cultures take time, are costly and invite
 OBSTETRICS AND GYNECOLOGY  •  Answers with Explanations 727
more visits to the clinic, therefore, ‘syndrome management’ approach is implemented. This consists of giving multiple drug therapy in
one sitting and comprises 1 g azithromycin, 2 g metronidazole and 150 mg fluazide. Only those who fail to respond or those who are
resistant are subjected to detailed investigations. Advantages of this approach are
•• Single visit.
•• Cost-effective.
•• Quicker treatment.

Syndromic management of STI

STI/RTI Syndromic diagnosis Name of Colour Contents of the Kits(Name of the Drugs)
the Kit code of Kit
Urethral Discharge (UD) Cervicitis (CD) Ano-rectal Kit-1 Gray 1 tablet of Azithromycin ( 1 gram) / 2 tablets of
Discharge (ARD) Painful Scrotal Swelling (PSS) Azithromycin (500 mg) and 1 tablet of cefixme
Presumptive Treatment (PT) (400 mg)
Vaginitis / Vaginal discharge (VD)  (TV+BV+Candida) Kit-2 Green •• Tab. Secnidazole 2 gm orally, single dose
OR Tab. Metronidazole/ Tinidazole 500 mg
orally, twice daily for 5 days.

/e
•• Tab. Metoclopropramide 30 minutes
before Tab. Secnidazole, to prevent gastric

,2
intolerance.
•• Treat for candidiasis with Tab Fluconazole
150 mg orally single dose OR local

Genital Ulcer Disease Non Herpetic (GUD-NH) Kit-3 sy White

Clotrimazole 500 mg vaginal pessaries once.
Injection Benzathine penicillin (2.4 MU) + 1
Ea
tablet Azithromycin (1 gram) + distilled water
(10 ml) +
ed

Genital Ulcer Disease Non Herpetic (GUD-NH)- for Kit-4 Blue 28 tablets / capsules of Doxycycline (100 mg)
patients allergic to penicillin and 1 tablet of Azithromycin (1 gram) / 2
tablets of Azithromycin (500 mg)
M

Genital Ulcer Disease - Herpetic (GUD-H) Kit-5 Red 21 tablets of Acyclovir (400 mg)
Lower Abdominal Pain (LAP/PID) Kit-6 Yellow 1 tablet of cefixime (400 mg) 28 tablets
S

of Metronidazole (400 mg) 28 tablets of

Doxycycline (100 mg)
IM

Inguinal bubo (IB) Kit-7 Black 42 tablets of Doxycyline (100 mg ) and 1 tablet
of Azithromycin (1 gram)
AI

11. Ans. (b)  Hypertension at 10 weeks of pregnancy

Ref: William’s 24th ed page 729, 738, Dutta’s 7th ed page 219

Hypertensive disorders in pregnancy (NHBPEP 2000 classification)

Hypertension BP ≥ 140/90 mm Hg measured 2 times with at least a 6-hour interval
Proteinuria Urinary excretion of ≥ 0.3 gm protein/24 hours specimen or 0.1 gm/L

Gestational hypertension BP ≥ 140/90 mm Hg for the first time in pregnancy after 20 weeks, without proteinuria
Pre-eclampsia Gestational hypertension with proteinuria
Eclampsia Women with pre-eclampsia complicated with convulsions and/ or coma
Chronic hypertension Known hypertension before pregnancy or hypertension diagnosed first time before
20 weeks of pregnancy
Superimposed pre-eclampsia or Occurrence of new onset of proteinuria in women with chronic hypertension
eclampsia

OBSTETRICS AND GYNECOLOGY

728 Section I  •  Subject-wise MCQs and Answers with Explanations

The term, ‘Pregnancy-induced hypertension (PIH)’ is
defined as the hypertension that develops as a direct result of
the gravid state.
It includes—(i) gestational hypertension, (ii) preeclampsia,
and (iii) eclampsia
And gestational hypertension is hypertension detected after 20
weeks of pregnancy.
•• Hypertensive retinopathy- it is a complication of
hypertension that can be seen in pre eclampsia
•• Hypertension at 10 weeks of pregnancy-it is detected after
20 weeks hence hypertension at 10 weeks was already
present before pregnancy.
•• Episode of seizure-it is called as eclampsia which is
pregnancy induced
•• Proteinuria-gestational hypertension with proteinuria is
preeclampsia.
when microinvasion is suspected. Early invasion is characterized
by a protrusion of malignant cells from the stromal epithelial
junction. This focus consists of cells that appear better
differentiated than the adjacent noninvasive cells and have
abundant pink-staining cytoplasm, hyperchromatic nuclei, and
small- to medium-sized nucleoli (Novak 14th ed page 1406)
Option (E)
Cryotherapy destroys the surface epithelium of the cervix
by crystallizing the intracellular water using nitrous oxide or
carbon dioxide. Hence cryotherapy is indicated only for biopsy
proven cases of abnormal epithelium. Cryotherapy is ideal
only for small superficial lesions.
13. Ans. (d)  High prolactin levels
Ref: Shaw 16th ed page page 431

12. Ans.  (b)  Hysteroscopy and biopsy Hypogonado- Hypergonadotro- Normogonado-

/e
trophic hypogo- phic hypogonad- trophic hypogo-
Ref: With text
nadism ism nadism

,2
Option (A) Low LH, Low FSH High LH, High FSH Normal LH and
PAP Smear: The false negative rate of pap smear in the presence Low testosterone Low testosterone FSH, Normal
of invasive cancer is 50% and a negative pap test should never Low testicular Low testicular testosterone,
be relied on in a symptomatic patient
Option (B)
sy volume
(Oligospermia),
Low Prolactin
volume
(Oligospermia)
High prolactin
Normal testicular
volume and
Normal prolactin
Ea
Hysteroscopy and then take biopsy levels levels levels
Causes of post coital bleeding:
ed

•• Uterine - pregnancy, endometrial polyps, endometrial

hyperplasia, endometrial carcinoma, leiomyomata 14. Ans. (b)  Hyperprolactinemia
•• Cervical-polyps, cervicitis, cervical erosion,cervical Ref: Novaks 15th ed page 1107
M

dysplasia or neoplasia Bromocriptine is an ergot alkaloid, a strong dopamine agonist,

•• Vaginal- trauma, infection, atrophy decreases prolactin levels within hours. Dose : 1.25 to 2.5 mg
•• Perineal- vulvar lesions , hemorrhoids. (Netter’s obstetrics BD, Hence its given in Hyperprolactinemia.
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and gynaecology 3rd ed, pg no 120)

Also, Post coital bleeding is frequently associated with 15. Ans. (a)  Bilateral gonadectomy
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endocervical polyps.(Women’s health, American College of

Ref: Leon speroff endocrinology 8th ed page 461, Novak’s
Physicians-Menstrual disorders 2006) In a 35 year old women,
gynecology, 15th ed page 1040
polyps is a fair common occurrence(incidence 20-40%). We
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cannot be sure that the cause is cervical malignancy only. Doing
a hysteroscopy will detect any cause of the bleeding whether
vginal, cervical or uterine. But, Vaginal bleeding is the most
common symptom in cancer cervix, most often which is post
coital bleeding but may occur as irregular or post menopausal
bleeding.(Ref: Novak’s 15th ed pg 1365). So taking a biopsy is
an imperative step. The biopsy could be done after VIA or VILI.
Option (C)
Four quadrant biopsy-It is a type of cervical biopsy. The types
of cervical biopsy are punch biopsy, wedge biopsy, ring biopsy
(not done) and four quadrant biopsy from 3,6,9 and 12 o’clock
positions. (Practical manual of gynaecology 2nd edition by
amitava pal and rupali modak).  Cervical biopsy is done as a
diagnostic modality for cervical cancer.
Option (D)
Cervical conization is an invasive procedure and is required to
assess correctly the depth and the linear extent of involvement
See table of CAUSES OF PRIMARY AMENORRHEA in AIIMS
NOV 2016
This is a case of Mixed Gonadal Dysgenesis (Turner’s
syndrome). Hypergonadotropic hypogonadism- elevated
gonadotropins,  and low estrogens is seen. With Karyotyping
already done  45XO/46XX, there is no risk of gonadoblastoma
hece Hormone replacement is the best management.
Option (A)
Even in the presence of typical turner stigmata, a karyotype
is indicated to eliminate the presence of Y chromosome.
Presence of Y chromosome is associated with 12% risk of
gonadoblastoma. If Y chromosome is identified, laparoscopic
prophylactic gonadectomy is recommended to eliminate
the risk of malignancy. (Novak’s gynaecology 15th ed page
1008, 1009) Now since there is no Y chromosome in this
case as provided in the question that Karyotyping is done,
Gonadectomy is of no use.

AIIMS (Nov 2017–May 2014)


Option (B)
Hypergonadotropic hypogonadism.- elevated gonadotropins,  and low estrogens is seen in Turners syndrome. With Karyotyping al-
ready done  45XO/46XX, there is no risk of gonadoblastoma hece Hormone replacement is the best management.
Option (C) and (D)
Removing Clitoris and Valvuloplasty will solve no purpose and is totally unnecessary.
16. Ans. (b)  Pawlik’s grip
Ref: William’s 24th ed page 437
A B
Fig. 1: Abdominal palpation: Leopold’s maneuver (A) First maneuver (Fundal palpation); (B) Second maneuver (Lateral palpation); (C) Third
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maneuver (Pawlik’s grip/second pelvic grip); (D) Fourth maneuver (Pelvic palpation/first pelvic grip)
Purpose
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First maneuver: Fundal grip To determine fetal part lying
in the fundus
To determine presentation
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Second maneuver: Umbilical To identify location of fetal
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grip back
To determine position
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Third maneuver: Pawlik’s grip To determine engagement of
presenting part
Fourth maneuver: Pelvic grip To determine the degree of
flexion of fetal head
To determine attitude or
habitus
OBSTETRICS AND GYNECOLOGY  •  Answers with Explanations
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sy C D
Procedure
Using both hands, feel for the
fetal part lying in the fundus
One hand is used to steady
the uterus on one side of the
abdomen while the other
hand moves slightly on a
circular motion from top to
the lower segment of the
uterus to feel for the fetal
back and small fetal parts
Use gentle but deep pressure
Using thumb and finger, grasp
the lower portion of the
abdomen above symphisis
pubis, press in slightly and
make gentle movements from
side to side
Facing foot part of the
woman, palpate fetal head
pressing downward about
2 inches above the inguinal
ligament. Use both hands
OBSTETRICS AND GYNECOLOGY
729
Findings
Head is more firm, hard
and round that moves
independently of the body
Breech is less well defined
that moves only in
conjunction with the body
Fetal back is smooth, hard,
and resistant surface Knees
and elbows of fetus fell with a
number of angular nodulation
The presenting part is not
engaged if it is not movable. It
is not yet engaged if it is still
movable
Good attitude–if brow
correspond to the side (2nd
maneuver) that contained
the elbows and knees. Poor
atitude–if examining fingers
will meet an obstruction on
the same side as fetal back
(hyperextended head)
730 Section I  •  Subject-wise MCQs and Answers with Explanations

17. Ans. (b)  Episiotomy scissor

Ref: William’s 24th ed page 550
See OBG PLATE 15

Episiotomy Scissor
Angulation in the scissor: To prevent extension of pelvic tears in to the anal margins (OASIS/CPT) obstretic anal sphincter injuries/
complete perineal tear.

AIIMS MAY 2017

18. Ans. (d)  Hysteroscopy and Laparoscopy
Ref: Speroff 8th ed page 1108
HSG: Moderate sensitivity—65%
High specificity—83% in a typical infertile population
False negatives are much more common than false positives.

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False-negative Causes
•• Injection of contrast may cause “cornual spasm” misinterpreted as proximal tubal occlusion.

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•• Unilateral tubal patency and contralateral proximal occlusion may be due to catheter placement allowing contrast to take the path of
least resistance.
False-positive Causes

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•• When contrast entering a widely dilated hydrosalpinx is diluted to yield a blush that is misinterpreted as evidence of tubal patency.
•• Peritubular adhesions surrounding an otherwise normal and patent tube can sequester contrast as it escapes from the tube, resulting
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in a focal loculation that can be misinterpreted as distal obstruction.
The clinical implications are that when HSG reveals obstruction there is still a relatively high probability (approximately 60%) that the
tube is open, but when HSG demonstrates patency there is little chance the tube is actually occluded (approximately 5%).
ed

•• Laparoscopy is considered the gold standard for diagnosis of tubal and peritoneal diseases.
•• Abnormal findings on HSG can be validated by direct visualization on laparoscopy.
•• Chromopertubation involves the transcervical installation of a dye, such as methylene blue or indigo carmine. Tubal patency is assessed
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by direct laparoscopic visualization of the dye extruding through the fimbrial openings of the tubes.
•• Along with laparoscopy hysteroscopy should also be done in the same sitting because in a case of infertility this will complete the
examination.
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19. Ans. (a)  Do a CA 125 levels, if normal advise regular check up

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Ref: RCOG Green-top Guideline No. 34, www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg_34.pdf

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Note
Kindly do not get confused with that question because here the adnexal mass is a simple cyst and RCOG guidelines
deal specifically with it. So the answer will not be surgery but CA 125 measurement.
There was a question in AIIMS MAY 2016 asking about the management of ovarian cyst in a young women. Answer
given has a flowchart showing the management of adenexal mass in a post menopausal women as surgery. (Flowchart
reference : Novak’s gynae 15th ed pg 412).
 

AIIMS (Nov 2017–May 2014)


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20. Ans. (a)  70 beats per minute lasting for 60 seconds
Ref: William’s 24th Ed page 98, 995 Fetal monitoring interpreta-
tion by Micki L.Cabbanis, Michael. G. Ross 2nd ed pg no 80
See table of Fetal Monitor Pattern in OBG AIIMS NOV 2015
Variable deceleration is defined as (as per NICHD)
•• An apparent abrupt decrease in fetal heart rate.
•• An abrupt decrease is defined as from the onset of decelera-
tion to the beginning of fetal heart rate nadir of <0 seconds.
•• The decrease is calculated from onset to nadir of deceleration.
•• The decrease in fetal heart rate is >/= 15 bpm, lasting >/= 15
sec and <2 min in duration.
OBSTETRICS AND GYNECOLOGY  •  Answers with Explanations 731
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•• When it is associated with uterine contraction its duration,
onset and depth varies with each uterine contraction.
Note
Variable deceleration are based on shape (the
abruptness), not on timing. They can have any
timing which using coincides with contraction as
a result of uterus compressing the cord against
fetal head or body.
In early years of fetal monitoring variable deceleration was
defined as mild, moderate and severe which were misleading
terms. Severe implied something more ominous than deserved
for such variable deceleration.
OBSTETRICS AND GYNECOLOGY
732 Section I  •  Subject-wise MCQs and Answers with Explanations
  A variable pattern can be a compensatory mechanism of a
well oxygenated fetus. NICHD does not subcategorize variable
deceleration.
  But the categorisation is as follows according to the old no-
menclature.
•• Marked or formerly known as severe variable deceleration
is FHR drop to <70 bpm and last at least 60 seconds.
•• Moderate: >70 bpm and lasting 30 to 60 seconds or 70 to
80 bpm and lasting >/= 60 seconds.
•• Mild: >80 bpm irrespective of duration or <30 seconds,
irrespective of depth, or 70 to 80 bpm and lasting <60 sec.
21. Ans. (c)  Just below ischial spine
Ref: Dutta’s obs 7th ed pg no 133
Station of the Head in Relation to Ischial Spines
The level of ischial spines is the halfway between the pelvic inlet
and outlet. This level is known as station zero (0). The levels
above and below the spines are divided into fifths to represent
centimeters. The station is said to be ‘O’ if the presenting part is
at the level of the spines. The station is stated in minus figures,
if it is above the spines (–1 cm, –2 cm, –3 cm –4 cm, and
–5 cm) and in plus figures if it is below the spines (+1 cm,
+2 cm, +3 cm, +4 cm, and +5 cm).
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22. Ans. (b)  The morphology of sperms
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Ref: Speroff 8th ed pg no 1270-1271, Novak’s Gynaecology 15th
ed page 1142
See table of Normal Semen Analysis in OBG AIIMS May 2015
•• Strict sperm morphology remains the best available predictor
of sperm function (the capacity to fertilize a mature oocyte.
•• A number of studies have examined semen parameters
in couples with no known infertility factors who were
attempting pregnancy, or compared the semen parameters
of fertile and infertile men.
•• Whereas sperm concentration and progressive motility
had value for distinguishing fertile from infertile men,
strict sperm morphology (as determined by an individual
having extensive training and experience) was the one most
discriminating value.
AIIMS (Nov 2017–May 2014)
23. Ans. (a)  4 cm
Ref: Sheila Balakrishnan 2nd edition pg 121; William’s 24th
ed page 452, Dutta 6th ed p- 528, www.who.int, International
Journal of Gynecology and Obstetrics 107 (2009) S21–S45,
International Journal of Clinical Cases and Investigations 2011.
Volume 3 (Issue 1), 1:6, 6th August, 2011
Note
In Modified WHO Partograph (2000) cervical dila-
tation plotting starts at 4 cm.
Indirect repeat AIIMS NOV 2016 (See for details)
AIIMS is playing table tennis with this Partograph point.
Within one session they give 3 cm as answer and next very
session they give 4 cm. We need to understand the concept and
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tailor the answer according to need. In NOV 2016 option was
saying that partograph starts at 4 cm was the most incorrect
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statement because all other options were correct and in the
original partograph plotting started at 3 cm cervical dilatation
so 4 cm was chosen as the wrong statement. But here 3 cm is
sy not in option and 4 cm is one option so we need ti select 4 cm
as answer.
24. Ans. (c)  G4 P1 0+1+2
Ref: Dutta’s 7th ed pg 94-95, 131
•• Gravida: Gravida denotes a pregnant state both present and
past, irrespective of the period of gestation. A woman who
delivers twins in first pregnancy is still a gravida one and para
one.
•• Parity: Parity denotes a state of previous pregnancy beyond
the period of viability.
Note
The 28th week is taken arbitrarily as the lower
limit of fetal viability. (Dutta’s obs 7th ed pg 131)
•• Infants now considered to be at the threshold of viability
are those born at 22, 23, 24, or 25 weeks (American College
of Obstetricians and Gynecologists, 2012a,b). (Williams
obstetrics 24th ed pg no 1712).
•• For all purposes we will consider 28 weeks as the period of
viability being a developing country.
Past obstetric history is summarised by two methods.
Two digits (the first one relates with viable births and the
second one relates with abortion) connected with a plus sign
affixing the letter ‘P’.
Thus P2+1 denotes the patient had two viable births and
one abortion.
It is also expressed by four digits connected by dashes.

PA–B–C–D, where
A denotes number of term (37 to 42 weeks) pregnancies
B – Number of preterm (28 to <37 weeks) pregnancies
C – Number of miscarriages (<28 weeks)
D – The number of children alive at present.
The given patient is pregnant for the fourth time hence is
G4, and P1-0-2-1.
But, this option is not given and considering that the given
options are what were actually present, there is a general use
format called as G (gravida) P (para) L (live issues) A (abortions)
format used in history taking and is widely practiced.
Our patient is G4, P1 (one girl delivered at term) 0 (no
preterm deliveries)+1(one living issue)+2 (2 abortions).
25. Ans. (c)  Wertheim hysterectomy
Ref: Shaw 15th ed pg no 184, 414
•• 75% of ureteric injuries occur with gynaecological proce-
OBSTETRICS AND GYNECOLOGY  •  Answers with Explanations 733
Option (B)
Check USG for polycystic ovaries. It is not PCOS because in
it LH/FSH ratio is increased. Also progesterone challenge test
would be positive in anovulation cases, i.e. PCOS.
Option (C)
Women with hypo-oestrogenic amenorrhoea have either
ovarian failure or hypothalamic-pituitary dysfunction. Serum
concentrations of FSH and LH of more than 40-50 mIU/ml are
diagnostic of ovarian failure. Serial assessments may be necessary
because of the pulsatile nature of pituitary gonadotropin
secretion. Most women under the age of 40 years belonging to this
category have premature ovarian failure. Overt primary ovarian
insufficiency (POI) is defined as the presence of amenorrhea for
4 months or more accompanied by two serum FSH levels in the
menopausal range for a woman who is less than 40 years of age.
Serum estradiol values will be low in gonadal failure cases like
premature ovarian failure. (Novak’s 15th ed pg 1157)

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dures. Option (D)
•• 3/4th of which occur in abdominal procedures.
Urine pregnancy test is of no use because FSH and LH would
•• 1-2%- highest incidence is seen with extensive surgeries for

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be normal in that case. Although our diagnosis is made before
invasive carcinoma.
doing serum estradiol as FSH is high which would not be
•• Incidence is higher for abdominal (1-2%) than with vaginal
in PCOS still doing serum estradiol seems to be the most
(0.1%) hysterectomy.
•• The incidence of ureterovaginal fistula after laparoscopic
hysterectomy appears to be 1% to 4%. (Novak’s gynaec 15th sy appropriate answer of the given options which would be
normal in PCOS and low in premature ovarian failure.
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ed pg no 870).
27. Ans. (b)  Supine vena caval syndrome
Hence risk of ureteric injury.
Ref: Williams 24th ed page 1369, Dutta 6th Ed page 52
Laparoscopic hysterectomy (1-4%) > Abdominal (1-2 %) >
ed

Compression of vena cava by gravid uterus in supine position

Vaginal hysterectomy (0.1%)
leads to opening of collaterals, however in some people when
Also, the risk is high when the surgery is undertaken for pelvic they fail to open, it leads to compromised venous return and
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endometriosis, pelvic inflammatory disease, cervical and broad hence hypotension. It is treated by turning patient to lateral
ligament, Wertheim hysterectomy when the ureter anatomy is position. It is not abdominal aorta, or superior vena cava or
distorted. ascending aorta because we can see the uterus compressing the
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vessel which is inferior vena cava.

26. Ans. (c)  Estimate serum estradiol values
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Ref: Novak’s 15th ed pg 1036 28. Ans. (c)  Manual support to perineum with deflexion of head

World Health Organization (WHO) Classes of Amenorrhea Ref: WHO guidelines

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http://apps.who.int/iris/bitstream/10665/63167/1/WHO_
Group I Group II Group III FRH_MSM_96.24.pdf
No evidence of Evidence Elevated serum Option (A) Perform labor in lithotomy position
endogenous estrogen of estrogen FSH indicating The lithotomy position with the legs in stirrups was experi-
production, normal production and gonadal enced as less comfortable and more painful and restricted in
or low FSH levels, normal levels insufficiency or movement. Women who had given birth in that position would
normal prolactin levels, of prolactin and failure. prefer the option of an upright position in the future. (WHO
and no lesion in the FSH. guidelines http://apps.who.int/iris/bitstream/10665/63167/1/
hypothalamic-pituitary WHO_FRH_MSM_96.24.pdf)
region. “During second-stage labor, pushing positions may vary.
The given patient belongs to gonadal failure group. But for delivery, dorsal lithotomy position is the most widely
used and often the most satisfactory. For better exposure, leg
Option (A) holders or stirrups are used.” (Williams obs 24th ed pg 1080).
Give progesterone and stop after 10 days for withdrawal As understood it is not a guideline by WHO but is widely
bleeding and practised.

OBSTETRICS AND GYNECOLOGY

 Obstetrics and Gynecology

OBG PLATE 1
OBG PLATE 2 KEY
A Bakri Postpartum Balloon works on the principle of tampon-
ade (for uterine atony) to stop bleeding. Success rate approximately
85 percent.
Procedure: Insertion requires two or three team members. The first
performs abdominal sonography during the procedure. The second
places the deflated balloon into the uterus and stabilizes it. The third

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member instills fluid to inflate the balloon, rapidly infusing at least
150 mL followed by further instillation over a few minutes for a total

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of 300 to 500 mL to arrest hemorrhage.
Advantage: There is continuous drainage hence the risk of infection
is reduced.

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OBG PLATE 1 KEY

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Cusco’s speculum: Bivalved self retaining speculum. Its advantage

over Sim’s speculum is that no assistance is required to hold it in
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place. Hence, minor procedures like papsmear, IUCD insertions can

be performed independently. Its disadvantage is the limited visual-
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ization of vagina walls.

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OBG PLATE 2 OBG PLATE 3

 OBSTETRICS AND GYNECOLOGY  • Color Plates 1195

OBG PLATE 3 KEY OBG PLATE 4 KEY

Harvey Karman in the United States refined the technique of Vacuum
or suction aspiration in the early 1970s with the development of the
Karman cannula, a soft, flexible cannula that avoided the need for
initial cervical dilatation and so reduced the risks of puncturing the
uterus. The given instrument is karman cannula that comes in various
sizes mainly used for termination of pregnancy. The diameters of 4-6
are used for endometrial biopsy.
Material: Polypropylene
Sets of Manual Vacuum Aspiration
A. Mirena: Hormonal IUD Mirena with T shaped polyethelene
frame impregnated with barium sulphate for visibility during
X-rays (black arrow), hormone cylinder (red arrow) and removal
thread (yellow arrow)
B.  Nova T 380
ƒƒ T-shaped polyethelene frame impregnated with barium sulfate
for visibility during X-rays
ƒƒ 380 mm2 surface area copper, in the form of copper wire with a
silver core, wrapped around the vertical stem of the T
ƒƒ Two removal threads pigmented with iron oxide
ƒƒ Suffix number of the device signifies the amount of copper
C.  Multiload Cu 250/375
ƒƒ Flexible curved arms
ƒƒ Copper wrapped around the polyethelene frame impregnated

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with barium sulphate for visibility during X-rays
ƒƒ Two nylon thread

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ƒƒ Suffix number of the device signifies the amount of copper
D.  Copper T 380 A
ƒƒ T-shaped polyethelene frame impregnated with barium

sy sulphate for visibility during X-rays

ƒƒ Suffix number of the device signifies the amount of copper
ƒƒ 380 mm2 surface area copper, in the form of copper wire with a
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silver core, wrapped around the vertical stem of the T and also
the arms of the “T” hence the Suffix “a”
E.  Nuva Ring
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ƒƒ Combined hormonal contraceptive vaginal ring

ƒƒ It is a flexible plastic (ethylene-vinyl acetate copolymer) ring
that releases a low dose of a progestin and estrogen over three
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weeks.
ƒƒ The exact position of NuvaRing is not important for it to be
effective.
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OBG PLATE 4 OBG PLATE 5

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A B C

D E A

OBSTETRICS AND GYNECOLOGY

1196 Section II  •  Subject-wise Color Plates

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E

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C
F
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OBG PLATE 5 KEY

Hysterosalpingography is an important tool in the evaluation of
infertility. It provides information regarding the shape of the uterine
cavity and the patency of the tubes. Tubal factors, many of which
follow from sexually transmitted diseases, are an important cause of
infertility.
A. Normal hysterosalpingogram: Shows normal filling and spillage
of contrast media.
B. Endometrial polyps are seen as filling defects of various size
at the level of uterine cavity. This HSG shows a rounded fundal
polyp.
C. Displays bilateral hydrosalpinx and clubbing of the tubes with
no evidence of any spillage into the peritoneal cavity. The uterine
cavity in this HSG is normal.
D

AIIMS
 OBSTETRICS AND GYNECOLOGY  • Color Plates 1197
D. In the figure there is unilateral hydrosalpinx and evidence of F. Salpingitis isthmica nodosa: Characteristic “salt-and pepper”
adhesions within the uterine cavity consistent with Asherman pattern of tubal filling and evidence of a diverticulum of the tube
syndrome. There is no filling of the other tube. on one side.
E. One tube fills and has unilateral hydrosalpinx; the other shows
loculation and minimal fluid accumulation. The uterine cavity
here is normal.

OBG PLATE 6

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OBG PLATE 6 KEY

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A.  Normal early pregnancy on USG:

   Yolk sac (YS) and fetal pole (FP) in Gestational sac (GS)
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B. Double decidual sac sign (DDSS) is a useful feature on early pregnancy ultrasound in distinguishing between an early intrauterine
pregnancy (IUP) and a pseudogestational sac. It consists of the decidua parietalis (that lining the uterine cavity) and decidua capsularis
(lining the gestational sac) and is seen as two concentirc rings surrounding an anechoic gestational sac.
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OBG PLATE 7

A B C

OBSTETRICS AND GYNECOLOGY

1198 Section II  •  Subject-wise Color Plates

OBG PLATE 7 KEY OBG PLATE 8

Abortion is the termination of pregnancy, either spontaneously or

intentionally, before the fetus develops sufficiently to survive. By
convention, abortion is usually defined as pregnancy termination
prior to 20 weeks gestation or less than 500 g birth weight.
Hemorrhage into the decidua basalis, followed by necrosis of tis-
sues adjacent to the bleeding, usually accompanies abortion. If early,
the ovum detaches, stimulating uterine contractions that result in
its expulsion. When a gestational sac is opened, fluid is commonly
found surrounding a small macerated fetus, or alternatively no fetus
is visible—the so-called blighted ovum.
Miscarriage is classified as threatened, missed, incomplete and
complete based on the ultrasound findings:
A. Threatened abortion is usually diagnosed in women with a his-
tory of vaginal bleeding and in whom a live embryo can be visu-

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alized on the scan. In 15% of these women the pregnancy will
be lost. Threatened abortion can not be diagnosed radiologically.

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B. Missed abortion is defined as the retention of a gestational
sac within the uterus following embryonic or early fetal death.
The diagnosis is usually based on the absence of cardiac activ-
ity within the fetal pole. The terms ‘blighted ovum’ and ‘anem-
bryonic pregnancy’ have been used to describe a gestational sac
without a detectable fetalpole. The absence of cardiac activity in
sy OBG PLATE 8 KEY
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an embryo of crown–rump length (CRL) >6 mm, or the absence
of a yolk sac or embryo in a gestation sac of mean diameter
>20 mm (blighted ovum), enables conclusive diagnosis of a Polycystic Ovary
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missed abortion. In pregnancies in which the embryo and sac are Multiple hypoechoeic cystic leasions are seen in the ovary in pelvic
smaller than 6 mm or 20 mm, respectively, a repeat ultrasound USG.
examination 1 week later is necessary to clarify the diagnosis.
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OBG PLATE 9
N ote
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An anembryonic gestation (also known as a blighted ovum) is

a pregnancy in which the very early pregnancy appears normal
on an ultrasound scan, but as the pregnancy progresses a visible
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embryo never develops. See absent fetal pole with irregular ges-
tational sac (asterix)

C. Complete abortion is usually diagnosed when the endometrium

is very thin and regular with no retained products (red arrow).
The ultrasound appearances are therefore comparable to those of
the non-pregnant uterus in the early proliferative phase.
D. Incomplete abortion: Endometrial thickness vary between 5 and
15 mm, retained products are usually seen as a well-defined area
of hyperechoic tissue within the uterine cavity (yellow arrow) as
opposed to blood clots that are more irregular.

USG Diagnosis
Complete abortion Incomplete abortion
Endometrium Thin and regular Thickness between 5-15 mm
Retained Not seen Well defined hyperechoic
products area
Management Evacuation not Evacuation required
required

AIIMS