2.

C
3. A
4. C

Batch 21 – MCQ ANSWERS 5. B

OBG CA SET
6. B
1. C
7. D
2. D
8. D
3. B
9. C
4. B
10. A
5. A
11. A
6. C
12. C
7. A
13. B
8. C
14. D
9. C
15. B
10. B
16. A
11. A
17. A
12. C
18. B
13. A
19. B
14. B
20. A
15. D
21. A
16. A
22. B
17. C
23. C
18. B
24. B
19. C
25. B
20. D
26. B
21. D
27. B
22. A
28. C
23. A
29. A
24. A
30. C
25. A
31. D
26. D
32. A
27. C
33. C
28. C
34. B
29. D
35. D
30. C
31. A
32. B OBG SET 2
33. D 1. B

34. D 2. A

35. B 3. B
4. C
OBG SET 1 5. A
1. A
 6. B 10. D
7. A
11. B
8. B
12. B
9. A
13. D
10. D
14. B
11.
15. C
12. B
16. C
13. D
17. B
14. D
18. B
15. D
19. C
16. B
20. B
17. D
21. B
18. C
22. D
19. C
23. D
20. A
24. D
21. C
25. B
22. B
26. D
23. C
27. C
24. B
28. D
25. B
29. A
26. B
30. C
27. A
31. B
28. C
32. A
29. A
33. B
30. C
34. A
31. D
35. B
32. C
33. A
34. B LIST OF TOPICS DISCUSSED
CA SET
35. D
1 VBAC
2 PUERPERIUM
PUERPERAL PYREXIA
PUERPERAL SEPSIS
3 NAEGELE RULE
OBG SET 3 BRANDT-ANDREWS MANEUVER
1. C BIMANUAL COMPRESSION OF UTERUS
MC ROBERTS MANEUVER
2. B
AMNIOCENTESIS
3. D 4 IRON DEFICIENCY ANEMIA
5 MENOPAUSE
4. D
6 OVARIAN CARCINOMA
5. D 7 ENDOMETRIOSIS
6. A SET 1
1 POLYHYDRAMNIOS
7. C 2 PPROM
8. B 3 INDUCTION OF LABOUR
4 GESTATIONAL DIABETES MELLITUS
9. B
5 CERVICAL CARCINOMA • Abnormal CTG— (abnormal FHR, bradycardia, variable and late
6 MISCARRIAGE decelerations)—most consistent finding (55–87%)
7 FIBROID UTERUS
• suprapubic pain if severe and especially persisting in between contractions
SET 2
1 TRANSVERSE LIE • shoulder tip pain or chest pain or sudden onset of shortness of breath
2 PLACENTA PRIVEA • acute onset of scar tenderness
3 DIABETES MELLITUS • abnormal vaginal bleeding or haematuria
4 PRENATAL GENETIC SCREENING
5 CERVICAL CANCER • cessation of uterine contractions which were previously adequate
6 POST MENOPAUSAL BLEEDING • maternal tachycardia, hypotension or shock
7 TUBAL FACTOR SUBFERTILITY • loss of station of the presenting part
SET 3
1 HYPERTENSIVE DISORDER IN PREGNANCY
2 TWIN PREGNANCY 2a. Define puerperium.
Puerperium is the period following childbirth during which the body tissues,
3 WATERY DISCHARGE FROM VAGINA
especially the pelvic organs revert back approximately to the pre- pregnant state both
4 PRETERM LABOUR anatomically and physiologically.
5 ABNORMAL UTERINE BLEEDING It occurs after the expulsion of placenta and lasts around 6 weeks.
6 CERVICAL CARCINOMA b. Define puerperal pyrexia.
7 ENDOMETRIOSIS A rise of temperature reaching 38°C or more (measured orally) on two separate
occasions at 24 hours apart (excluding first 24 hours) within first 10 days following
delivery is called puerperal pyrexia.
c. List 4 causes of puerperal pyrexia.

d. Outline the management of puerperal sepsis.

OBG SAQ for Batch 21 CA Set
1. 25 years G3 P2, with history of spontaneous vaginal delivery 6 years ago
• INVESTIGATION
followed by emergency caesarean section for foetal distress later, seeks o High vaginal and endocervical swabs for culture in aerobic and anaerobic
counselling for delivery options for present pregnancy. media and sensitivity test to antibiotics.
a) List any four (4) suitable factors for successful vaginal birth after caesarean
section (VBAC).
o “Clean catch” midstream specimen of urine for analysis and culture
including sensitivity test
• One or two previous lower segment transverse scars
o Blood for total and differential white cell count, haemoglobin estimation. A
• Nonrecurring indication for prior caesarean section low platelet count may indicate septicaemia or DIC. Thick blood film should
• Pelvis adequate for the foetus be examined for malarial parasites.
• Continued labour monitoring possible o Blood culture, if fever is associated with chills and rigor.
• Availability of resources (anaesthesia, blood transfusion and theatre) for o Pelvic ultrasound is helpful—
emergency caesarean section within 30 minutes of decision (i) to detect any retained bits of conception within the uterus
(ii) to locate any abscess within the pelvis
• Informed consent of the woman (iii) to collect samples (pus or fluid) from the pelvis for culture and
b) List any 4 advantages and 4 disadvantages of vaginal birth after caesarean sensitivity
section (VBAC). (iv) for colour flow Doppler study to detect venous thrombosis.
Advantages
o Use of CT and MRI is needed especially when diagnosis is in doubt or there
• Decreased maternal morbidity (infection and others) is pelvic vein thrombosis.
• Reduced length of hospital stays o X-ray chest (CXR) should be taken in cases with suspected pulmonary
• Decreased need for blood transfusion Koch’s lesion and also to detect any lung pathology like collapse and
atelectasis (following inhalation anaesthesia).
• Decreased risk of abnormal placentation and need for successive caesarean
delivery in next pregnancy
o Blood urea and electrolytes
Disadvantages
• Patient have higher possibility of undergoing emergency caesarean section • PROPHYLAXIS
during labour.
o Antenatal prophylaxis includes improvement of nutritional status (to raise
• Higher risk of blood transfusion
haemoglobin level) of the pregnant woman and eradication of any septic focus
• Higher risk of uterine rupture (skin, throat, tonsils) in the body.
• Higher possibility of patient undergoing assisted vaginal birth using ventouse o Intranatal prophylaxis includes
or forceps ▪ Full surgical asepsis during delivery
c) List any 4 clinical diagnostic sign/symptoms of uterine rupture.
▪ Screening for Group B Streptococcus in a high-risk patient.
 Prophylactic use of antibiotic is not recommended as a routine
▪ Prophylactic use of antibiotic at the time of caesarean section has
significantly reduced the incidence of wound infection,
endometritis, urinary tract infection and other serious infections.
o Postpartum prophylaxis includes aseptic precautions for at least 1
week, following delivery until the open wounds in the uterus,
perineum, vagina is healed up. Too many visitors are restricted.
Sterilized sanitary pads are to be used. Infected babies and mothers
should be in isolated room.
• TREATMENT
General care
(i) Isolation of the patient is preferred especially when haemolytic Streptococcus is
obtained
on culture
(ii) Adequate fluid and calorie are maintained by intravenous infusion (IV)
(iii) Anaemia is corrected by oral iron or blood transfusion,
(iv) An indwelling catheter is used to relieve any urine retention due to pelvic
abscess. It also helps to record urinary output
(v) A chart is maintained by recording pulse, respiration, temperature, lochia
discharge, and fluid intake and output.
(vi) Antibiotics: Ideal antibiotic regimen should depend on the culture and sensitivity
report.
Pending the report, gentamicin (2 mg/kg IV loading dose, followed by 1.5 mg/kg IV
every 8 hours) and clindamycin (900 mg IV every 8 hours) should be started.
Metronidazole 0.5 g IV is given at 8 hours interval to control the anaerobic group.
The treatment is continued until the infection is controlled for at least 7–10 days.
Antibiotic Regimens: Severe sepsis. A combination of either piperacillin-
tazobactam or carbapenem plus clindamycin has broadest range of antimicrobial
coverage. Women with MRSA infection should be treated with vancomycin or
teicoplanin.
Surgical treatment
There is little role of major surgery in the treatment of puerperal sepsis.
• Perineal wound—+e stitches of the perineal wound may have to be removed to
facilitate drainage of pus and relieve pain. +e wound is to be cleaned with sitz
bath several times a day and is dressed with an antiseptic ointment or powder.
After the infection is controlled, secondary suture may be given.
• Retained uterine products with a diameter of 3 cm or less may be disregarded
and left alone. Otherwise surgical evacuation after antibiotic coverage for 24
hours should be done to avoid the risk of septicaemia. Cases with septic pelvic
thrombophlebitis are treated with IV heparin for 7–10 days
• Pelvic abscess should be drained by colpotomy under ultrasound guidance.
• Wound dehiscence: Dehiscence of episiotomy or abdominal wound following
caesarean section is managed by scrubbing the wound twice daily,
debridement of all necrotic tissue and then closing the wound with secondary
suture. Appropriate antimicrobials are used following culture and sensitivity.
• Laparotomy has got limited indications. Maintenance of electrolyte balance by
intravenous fluids along with appropriate antibiotic therapy usually controls
the peritonitis. However, in unresponsive peritonitis, laparotomy is indicated.
Even if no palpable pathology is found, drainage of pus may be elective.
• Hysterectomy is indicated in cases with rupture or perforation, having multiple
abscesses, gangrenous uterus or gas gangrene infection. Ruptured tubo-
ovarian abscess should be removed.
3. Describe the following:
a. Naegele’s rule
Naegele's rule is a standard way of calculating the due date for a pregnancy when
assuming a gestational age of 280 days at childbirth.
The rule estimates the expected date of delivery (EDD) by adding a year, subtracting
three months, and adding seven days to the origin of gestational age. (+1yr – 3 months
+ 7 days)
b. Brandt- Andrews manoeuvre
Modified Brandt-Andrews method, also known as
controlled cord traction. It is a technique for
expressing the placenta from the uterus during the
third stage of labour. The procedure is to be adopted
only when the uterus is hard and contracted.
The palmar surface of the fingers of the left hand is
placed (above the symphysis pubis) approximately at
the junction of upper and lower uterine segment. The
body of the uterus is pushed upward and backward,
toward the umbilicus while by the right-hand steady
tension (but not too strong traction) is given in
downward and backward direction holding the clamp
until the placenta comes outside the introitus. It is
thus more a uterine elevation which facilitates expulsion of the placenta.
c. Bimanual compression of the uterus
In a case of Postpartum haemorrhage, bimanual uterine compression is an
intervention performed by a skilled birth attendant, where one hand is placed in the
vagina and pushed against the body of the uterus, while the other hand compresses the
uterine fundus above through the abdominal wall. If a PPH occurs after vaginal birth,
and is due to uterine atony, bimanual uterine compression can act as a temporizing
measure until definitive treatment is available.
d. McRoberts manoeuvre
McRoberts’ manoeuvre is done in a case of shoulder dystocia. The McRoberts’
manoeuvre is flexion and abduction of the maternal hips, positioning the maternal
thighs on her abdomen. It straightens the lumbosacral angle, rotates the maternal
pelvis towards the mother’s head and increases the relative anterior-posterior diameter
of the pelvis.
e. Amniocentesis
A process in which amniotic fluid is sampled using a hollow needle inserted into the
uterus, to screen for abnormalities in the developing foetus.
4. 20-year-old primigravida at 34 weeks of gestation is detected to have
haemoglobin of 8 gm%.
a. Explain why iron deficiency anaemia is common in pregnancy.
Total iron requirement during pregnancy is estimated approximately 1,000 mg. This is
distributed in foetus and placenta 300 mg and expanded red cell mass 400 mg. (Total
increase in red cell volume—350 mL and 1 mL contains 1.1 mg of iron.) There is
obligatory loss of about 200 mg through normal routes. The iron in the foetus and
placenta is permanently lost and a variable amount of iron in the expanded RBC
volume is also lost due to blood loss during delivery (45 mg/100 mL) and the rest is
returned to the store.
However, there is saving of about 300 mg of iron due to amenorrhea for 10 months.
(Iron loss in menstrual bleeding per cycle is 30 mg.) Iron need during lactation is 1
mg/day. This iron need is not squarely distributed throughout the pregnancy but
mostly limited to the third trimester. (Daily iron requirement in non-menstruating
women to compensate the average daily loss is 1 mg.) Thus, in the second half, the
daily requirement actually becomes very much increased to the extent of about 6–7
mg.
The amount of the iron absorbed from the diet and that mobilized from the store are
inadequate to meet the demand. In the absence of iron supplementation, there is drop
in haemoglobin, serum iron and serum ferritin concentration at term pregnancy. Thus,
pregnancy is an inevitable iron deficiency state.
b. List 4 complications of anaemia in pregnancy.
• Preeclampsia
• Intercurrent infection
• Heart Failure
• Preterm labour
c. Discuss the treatment options for this patient.
Prophylactic
• Avoidance of frequent child-births with minimum interval of 2 years between
each pregnancy
 • Supplementary iron therapy • Increasing age
• Diet rich in iron and protein (E.g. egg, green vegetables, green peas, beans, • Genetics
whole wheat b) State the aetiology of ovarian carcinoma
• Adequate treatment to eradicate hookworm, dysentery, malaria, bleeding piles Incessant ovulation hypothesis. There is disruption of ovarian surface epithelium
during ovulation leading to accumulation of genetic alterations leading to ovarian
and urinary tract infection
cancer.
Curative
c) List 4 tumour markers for ovarian carcinoma
• Hospitalization for all patients with Hb levels 7.5gm/dL and below • CA-125
• General treatment: Diet rich in proteins, iron and vitamins • Alpha fetoprotein
• Specific treatment • Beta HCG
o Oral therapy: ferrous gluconate, ferrous fumarate or ferrous • Inhibin
succinate
o Parenteral therapy: iron sucrose compound, sodium ferric
• Oestradiol
gluconate or iron dextran • CEA
5. a) Define menopause and perimenopause
Menopause – permanent cessation of menstruation at the end of reproductive life due
to loss of ovarian follicular activity
Perimenopause – it is a part of climeteric when menstrual cycle is irregular.
Climeteric – it is when a woman goes from reproductive to non-reproductive. It
d) List 4 ultrasound findings suggestive of malignant ovarian carcinoma.
covers 5 to 10 years on either side of menopause.
b) List any 8 signs/symptoms of menopause • Multilocular cysts
• vasomotor – hot flushes, sweating • Solid areas of metastasis
• psychological • Ascites
• skin and hair • Bilateral lesion
• sexual dysfunction 7. A 24-year woman with primary subfertility and congestive dysmenorrhea was
detected on pelvic examination to have nodular and thickened uterosacral
• dementia ligaments.
• urogenital a) State the probable diagnosis
• osteoporosis The most likely diagnosis is endometriosis.
• cardiovascular b) List 2 investigations with expected outcomes to confirm diagnosis
Ultrasonography – it is the first line investigation tool and helps find any cysts
and fibroids
c) Describe hormonal and non-hormonal treatment of menopause Direct visualization with laparoscopy and biopsy of endometriotic lesion and
Non hormonal histology has been regarded as the gold standard for diagnosis.
• Lifestyle modification c) Discuss the medical management of the probable diagnosis.
• Nutritional diet Treatment for pain – combined progestin and oestrogen therapy
• Vitamin D supplement Oral progestin therapy – dienogest (2 mg once daily),

• Calcium supplement GnRH agonist – leuproline, buserelin

Aromatase inhibitor – letrozole, tamoxifen
• Bisphosphonates Analgesia – NSAIDS
• Fluorides Paracetamol
• SERMS Antidepressants
• Clonidine Opioids
• Thiazide
• Paroxetine
• Gabapentin
Hormonal
Hormones are given exogenously to replace the loss of endogenous hormones.
• Oral oestrogens
• Oestrogens and cyclic progestin
• Continuous oestrogen and progestin
6.a) List 4 risk factors of ovarian carcinoma
• Early menarche and late menopause
• Tubal ligation and hysterectomy OBG SAQ for Batch 21 Set 1
1. a) Define polyhydramnios
• Family history of ovarian cancer in first degree relatives Defined as excessive amount of amniotic fluid of 2000 ml or more.
(Amniotic Fluid Index of > 25 cm or Single Deepest Pool of > 8 cm)
b) List 4 causes of polyhydramnios
• Idiopathic
• Congenital anomalies – oesophageal or duodenal atresia, cardiovascular defect,
neural tube defect, microcephaly or anencephaly.
• Maternal diabetes
• Multiple pregnancy
• Foetal anaemia.
• Congenital infections (e.g., toxoplasmosis, parvovirus, rubella,
cytomegalovirus).
• Hydrops fetalis
• Maternal substance abuse.
• Maternal metabolic abnormalities such as hypercalcaemia.
c) Outline the management of polyhydramnios
Mild polyhydramnios can be simply monitored and treated conservatively.
• Perform Glucose Tolerance Test (OGTT)
Abnormal OGTT: refer to the Diabetes Specialist
Normal OGTT: repeat scans 4 weekly
Mild polyhydramnios resolves: stop scanning
Mild polyhydramnios persists: refer to Obstetric specialist after 34 weeks
If polyhydramnios progresses to moderate / severe: refer to FMU
Mild polyhydramnios:
The Obstetric team should individualise care
Timing of delivery:
Consider delivery at term [in view of the possible increase in risk of late foetal
demise]
Hospital delivery [Community delivery should not be recommended]
An NG tube should be passed at delivery prior to first feed to exclude oesophageal
anomaly
Moderate / severe POLYHYDRAMNIOS
Refer to FMU:
Arrange a GTT: if abnormal: refer to the Diabetes Specialist
Detailed ultrasound assessment is done
If no abnormality is detected and the polyhydramnios is thought to be idiopathic:
perform scan 2-4 weekly and refer to the Consultant Obstetric Clinic
Plan mode and timing of delivery.: delivery at term may be considered. [an increase in
late foetal demise]
Factors to consider include: severity of the polyhydramnios, maternal symptoms,
foetal size, lie and stability and previous obstetric history
Labour and delivery require extra vigilance for complications including
malpresentation, cord prolapse, abruption and atony
A nasogastric tube should be passed at delivery, prior to first, feed to exclude
oesophageal anomaly
If an abnormality is detected, identify if there is an underlying cause [FMU should
provide individualised on-going care]
Identified causes are treated as appropriate.
Foetal hydrops anaemia is treated with intra uterine transfusion.
If gestational diabetes is diagnosed, tight glycaemic control should be maintained.
This may involve dietary manipulation, oral medication or insulin.
Preterm labour is common due to overdistension of the uterus, and measures should
be taken to minimise this complication.
This includes regular antenatal checks and inspection of the uterus.
Serial ultrasound scans should be carried out to monitor the AFI and foetal growth.
Induction of labour should be considered if foetal distress develops.
Induction by artificial rupture of the membranes (ARM) should be controlled,
performed by an obstetrician and with consent to proceed to lower-segment caesarean
section if
required.
Corticosteroids should be given to the mother antenatally if preterm delivery is
imminent or considered.
Prostaglandin synthetase inhibitors, particularly indomethacin, may be used.
Sulindac has also been used but there are no trials to confirm efficacy and safety.
Amnioreduction (drainage of amniotic fluid under ultrasound guidance) is also used
in cases where indomethacin is contra-indicated, in severe polyhydramnios, or in
patients who are symptomatic
2a) Define PPROM (Premature preterm rupture of membrane)
PPROM is spontaneous rupture of foetal membranes that occurs before 37 completed
weeks and after 24 weeks but before the onset of labour.
b) List 4 causes and 4 complications of PPROM
Causes
• vaginal infection (ascending infection) in most cases
• bleeding: APH – abruptio placentae, placenta praevia
• Uterine over distension: Multiple pregnancy, poly hydramnios
• uterine abnormality, cervical insufficiency
Complications
Foetal – prematurity, sepsis, cord prolapse, pulmonary hypoplasia
Maternal – chorioamniotis, placental abruption
c) Outline the management of PPROM
All are admitted / transferred to a hospital well equipped with neonatal care facilities.
All patients are given parenteral corticosteroids (between 24-34 weeks and once
only).
All are given broad spectrum antibiotics e.g. Tab Erythromycin [250mg qid x
10days.]
At or near term (> 34 weeks) Induction and delivery is usually preferred;
< 34 weeks, Expectant management
PPROM expectant management [ < 34 weeks]
DAILY PHYSICAL EXAM
Maternal fever (tachycardia and pyrexia)
Abdominal pain & Uterine tenderness
Offensive vaginal discharge
FHR –tachycardia sign of chorioamnionitis
Investigations done weekly - FBC, C reactive protein, HVS C/S, Urine C/S, Foetal
wellbeing monitoring using CTG, NST, USG for AFI (oligohydramnios) and foetal
wellbeing monitoring
Antibiotic prophylaxis in labour
Intrapartum antibiotic prophylaxis with iv benzylpenicillin (or clindamycin if
penicillin allergic)
should be offered as prematurity and prolonged rupture of membranes are both risk
factors for GBS disease.
The neonatal guideline advocates blood cultures and intravenous antibiotics for the
preterm neonate if rupture of membranes occurred more than 18 hours prior to
delivery and intrapartum antibiotics were not administered more than 2 hours prior to
delivery
Begin IV broad spectrum antibiotics and deliver immediately
There is no place for expectant management in clinically overt chorioamnionitis.
The route of delivery should be determined by standard obstetric considerations.
Immediate caesarean delivery increases maternal morbidity and does not improve
neonatal outcome.
However, the caesarean delivery rate is high in pregnancies complicated by clinical
chorioamnionitis because of poor progress in labour, non –reassuring foetal heart rate
patterns, and malpresentations.
3a) Define induction of labour
initiation of uterine contraction by any method for the purpose of vaginal delivery.
b) List 2 indications and 2 contraindications of induction of labour
Indication – post maturity, abruptio placenta, pre-eclampsia, eclampsia, intra uterine
foetal death, PROM
Contraindication – Cephalopelvic disproportionate, malpresentation, active genital
infection
c) Describe briefly any 3 methods of induction of labour
 • medical – prostaglandins, oxytocin, mifepristone • Early sexual intercourse (less than 16 years)
• surgical – artificial rupture of membrane, stripping of membrane • STD
• combined – amniotomy and oxytocin • Early age of first pregnancy
4. A 27-year-old G3P2 presented at 10 weeks of gestation. At booking • High parity
investigations her MOGTT is positive for gestational diabetes.
a) List the diagnostic criteria for gestational diabetes. • Too many and too frequent births
The current WHO diagnostic criteria for diabetes– Fasting plasma glucose ≥ • Low socioeconomic status
7.0mmol/ l (126mg/dl) or
OR • Multiple sexual partners
2–h plasma glucose ≥ 11.1mmol/ l (200mg/dl). • HIV positive individuals
Diagnostic criteria [after OGTT]: a fasting plasma glucose level of 5.6 mmol / litre or
above [<7mmol] • Husband with multiple sexual partners
OR • Increasing age
a 2hour plasma glucose level of 7.8 mmol / litre or above. [<11.1mmol]
b) List 4 high risk factors for MOGTT at booking period • Dietary deficiency (vitamin A, C, E, folic acid)
• BMI >27 kg/m2 • Oral pill users
• Previous history of GDM
• First degree relative with DM • Smoking habits
• History of big baby (>4 kg)
• Bad obstetric history
b) List any 4 clinical features of carcinoma of cervix
• Glycosuria ≥2+ on two occasions
• Current obstetric problems (essential hypertension, pregnancy-induced • Irregular vaginal bleeding
hypertension, polyhydramnios and current use of steroids) • Pelvic pain
c) List 4 maternal, foetal and neonatal complications of diabetes in pregnancy.
Maternal • Leg oedema
• Aggravation of end organ disease: eye (retinopathy), renal disease • Offensive vaginal discharge – whitish coloured
(nephropathy) cardiac disease [vasculopathy], neuropathy • Bladder symptoms – dysuria, haematuria, incontinence
• Recurrent vaginal infections e.g. candida • Rectal involvement – diarrhoea, rectal pain, bleeding per rectum
• PIH
• Polyhydramnios
c) Define management of stage Ib of carcinoma cervix
• ↑↑ Obstructed labour The management of cervical carcinoma involves a team approach. Both the
• ↑↑ Shoulder dystocia gynaecologist and radio oncologist should review the patient together and give the
patient an individualized plan.
• ↑↑Operative deliveries It should be based on:
Foetal o General condition of the patient
• Congenital anomalies o Stage of the disease
• Miscarriage o Facilities available
• Macrosomia o Wish of the patient
• Delayed foetal lung maturity
• Preterm labour/prematurity
• Increased incidence of IUD or stillbirth
• IUGR if mother has end-organ damage(vascular) or PE The management of stage Ib carcinoma of cervix includes the following:
• radical hysterectomy
• pelvic lymphadenectomy (type iii) with paraaortic lymph nodes evaluation
• external radiation if the nodes are positive or primary radiation with
Neonatal concomitant platinum-based chemotherapy (chemoradiation)
• Birth trauma, 6a) Define miscarriage.
Abortion is the expulsion or extraction from its mother of an embryo or foetus
• Hypoglycaemia, weighing 500g or less when it is not capable of independent survival.
• Hyperbilirubinemia and jaundice, (500g is usually attained at 22 weeks)

• Hypocalcaemia,
b) List any 4 types of miscarriages
• Polycythaemia • complete
• Infections • incomplete
• threatened
5a) List any 4 predisposing factors for carcinoma of cervix
• Infection – HPV (16,18,31,33), HSV2, HIV, Chlamydia • missed
 • septic • Sarcomatous change
• inevitable • Torsion of subserous pedunculated fibroid
• Haemorrhage
c) Describe clinical features and management of incomplete miscarriage • Polycythaemia
Clinical features
Life threatening complications of fibroids
History of expulsion of fleshy mass per vagina followed by:
• continuation of pain in the lower abdomen o Persistent menorrhagia leading to severe anaemia
• persistent vaginal bleeding o Severe intraperitoneal haemorrhage due to rupture of veins over subserous
fibroid
Internal examination reveals
• uterus smaller than period of amenorrhea o Severe infection leading to peritonitis or septicaemia

• patulous cervical os often admitting tip of finger o Sarcoma

d) Describe conservative surgical treatment of fibroid uterus.
• varying amount of bleeding Myomectomy
Ultrasound shows echogenic material within cavity It is the enucleation of myotomata from the uterus leaving behind a potentially
Management functioning organ capable of future reproduction.
Resuscitate the patient and make sure she is stable before Evacuation of the retained Myomectomy may be done by laparotomy, laparoscopy and hysteroscopy. It is
products of conception (ERCP). indicated in cases of:
o Persistent uterine bleeding
Early abortion – dilation and evacuation under analgesia or anaesthesia o Excessive pain or pressure symptoms
Later abortion – evacuate the uterus under anaesthesia and remove blunt curette. In
late cases, dilatation and curettage is done to remove bits of tissues left behind. The o Size of more than 12 weeks
removed materials are sent for histological examination. o Distortion of the uterine cavity
o Recurrent pregnancy loss
Medical management – tablet misoprostol 200µg vaginally every 4 hours.
o Rapidly growing myoma during follow up
7a) Define fibroid uterus and three types of fibroid uterus o Subserous pedunculated fibroid.
Definition OBG SAQ for Batch 21 Set 2
Fibroid is the most common benign tumour of the uterus.
Histologically it is a tumour composed of smooth muscle and fibrous connective
1. A 32-year-old G3P2 at 36 weeks of gestation presents to the clinic with an
ultrasound report indicating transverse lie.
tissues.
a) List 4 causes of transverse lie
• Multiparity
Types • Prematurity
• intramural • Twins
• submucosal • Hydramnios
• subserosa • Contracted pelvis
• Placenta previa
b) List any 4 typical clinical features of fibroid uterus • Pelvic tumour
It is usually asymptomatic
• menorrhagia • Congenital malformation of the uterus
• irregular bleeding • Intrauterine death
• dysmenorrhea
• dyspareunia b) Enumerate the findings on obstetric examination of this patient
Inspection – the uterus looks broader and often asymmetrical not maintaining
• subfertility pyriform shape.
• pressure symptoms Palpation
Fundal height – less than period of amenorrhea
• recurrent abortions Fundal grip – foetal pole (breech or head) is not palpable
• lower abdominal pain Lateral grip – soft, broad and irregular breech on one side of the midline and smooth,
hard and globular head is felt on the other side. The head is usually at the lower level
• abdominal enlargement of one iliac fossa.
The back is felt anteriorly across the long axis in dorsoanterior or the irregular small
parts are felt anteriorly in dorsoposterior.
c) List any 4 complications of fibroid uterus Pelvic grip – the lower pole of the uterus is found empty.
• Degeneration Auscultation – FHS is heard at a higher level.
• Necrosis c) List any 2 complication of transverse lie
• Infection • Arm prolapse / cord prolapse
 • Premature birth
• Uterine rupture

d) Outline the plan of management of this patient

c) Describe the management of patient if her bleeding stops and she is
hemodynamically stable.

3. A 22-year woman with pre-existing diabetes mellitus is married and planning

2. A G2P1 woman reports to the A&E with 32 weeks of pregnancy and history
of sudden onset painless and causeless bleeding
a) State the most likely diagnosis
Antepartum haemorrhage – placenta previa
b) State the required investigation with its expected findings to confirm the
diagnosis
Ultrasound – it can be used to identify the location of the placenta.
Maternal
• Aggravation of end organ disease: eye (retinopathy), renal disease
her first pregnancy.
a) Describe preconception counselling for her
• Monitor her blood sugar and try to keep it within normal levels.
• Have regular follow up to check her medications and change them if it is not
effective.
• Give counselling on diet
• Educate her on how she should try to keep her weight within normal BMI.
• Educate the patient about the complications of diabetes to her and her child.
• Suggest caesarean section in case complications such as macrosomia occurs.
• She should do genetic testing in case she had uncontrolled DM before
conception.
b) List any 4 maternal and 4 foetal complications for pregnancy with
diabetes mellitus
(nephropathy) cardiac disease [vasculopathy], neuropathy
 • Recurrent vaginal infections e.g. candida weeks to term. Diagnosis can be obtained by 24 hours.
Its studies trophoblast cells.
• PIH • Amniocentesis
• Polyhydramnios Genetic amniocentesis is done after 15 weeks under ultrasound guidance. The foetal
• ↑↑ Obstructed labour cells obtained in this procedure are subjected for cytogenic analysis.
5a) State the Bethesda classification of pap smear cytology
• ↑↑ Shoulder dystocia
1. Squamous cell abnormalities
• ↑↑Operative deliveries
Foetal
a. Atypical squamous cell
• Congenital anomalies i. ASC of undetermined significance
• Miscarriage ii. ASC, cannot exclude high grade lesion
• Macrosomia b. Low grade squamous intraepithelial lesion (LSIL)
• Delayed foetal lung maturity c. High grade squamous intraepithelial lesion (HSIL)
• Preterm labour/prematurity d. Squamous cell carcinoma
• Increased incidence of IUD or stillbirth 2. Glandular cell abnormalities
• IUGR if mother has end-organ damage(vascular) or PE a. Atypical glandular cells – endocervical, endometrial or not specified
b. Atypical glandular cell favors neoplastic endocervical or not specified
4. A 35-year old lady conceives and approaches you at the clinic with an early c. Adenocarcinoma in situ
positive pregnancy test. d. Adenocarcinoma
b) Describe the screening criteria for pap smear test
a) List any 4 risk factors of prenatal genetic screening
Maternal risk factors • Women aged 21–29 years should have a Pap test alone every 3 years. HPV
• Maternal age more than 35 years testing is not recommended.

• Family history of neural tube defect • Women aged 30–65 years should have a Pap test and an HPV test (co-testing)
every 5 years (preferred). It also is acceptable to have a Pap test alone every 3
• Previous baby born with neural tube defect years.
• One or both parents is known to carry a balanced translocation c) List any four risk factors for cervical neoplasia

• History of recurrent miscarriage • Infection – HPV (16,18,31,33), HSV2, HIV, Chlamydia

Prenatal risk factors • Early sexual intercourse (less than 16 years)
• Oligohydramnios • STD
• Polyhydramnios • Early age of first pregnancy
• Severe symmetrical foetal growth restriction • High parity
• Abnormal ultrasound findings • Too many and too frequent births
• Uncontrolled DM in preconceptionally period • Low socioeconomic status
• Contact with infection – TORCHES • Multiple sexual partners
• Presence of soft tissue markers of chromosomal anomaly of ultrasound • HIV positive individuals
b) List the expected outcomes of any 2 prenatal genetic screening tests in the • Husband with multiple sexual partners
first trimester and 2 prenatal genetic screening tests in the second • Increasing age
trimester.
First trimester • Dietary deficiency (vitamin A, C, E, folic acid)
• Ultrasound measurement of nuchal translucency - increased • Oral pill users
• Free B- hCG - increased • Smoking habits
• Pregnancy associated plasma protein A – decreased
Findings of trisomy 21 6. A 56-year-old lady reports with a history of menopause since the past 4 years
Second trimester and vaginal bleeding in the past 7 days.
• MSAFP - done between 15 to 20 weeks. To detect neural tube detect a) List 4 causes of post-menopausal bleeding

• Triple test – MSAFP, hCG, Ue3. To detect Down’s syndrome • Endometrial hyperplasia
• Quadruple test – MSAFP. hCG, Ue3 and dimeric inhibin A • Senile endometritis
• Genital malignancy
• Dysfunctional uterine bleed
c) List and describe any 2 invasive procedures for prenatal genetic
diagnosis. • Ovarian neoplasm
• Chorionic villus sampling • Uterine polyp
It is done trans cervically between 10 to 13 weeks and transabdominally from 10

b) List and describe any 3 important investigations
• Saline infusion sonography – can be used to diagnose endometrial polyps,
submucosal fibroids and intrauterine abnormalities.
• Hysteroscopy – to have better evaluation of the endometrium and take biopsy
• Endometrial sampling – to diagnose endometrial carcinoma
• Diagnostic dilatation and curettage – to exclude organic lesions in the end of
the endometrium.
c) Outline the treatment of one of the causes of post-menopausal bleeding.
Treatment of polyps
• It can be removed by doing hysteroscopy and resection. It can be removed by
uterine curettage or using ring or ovum forceps.
• Hysteroscopy can be used to locate the position, size, and base of the polyp.
• Endometrial polyp can be removed hysteroscopic ally.
• The removal of polyp can be by morcellement followed by the trans fixation
suture on the pedicle and removal of the redundant pedicle distal to the
ligature.
• Hysterectomy is indicated if the polyp is infected. Antibiotics will be given too.
• The polyp should be sent for histological examination after its removal.
7a) List and explain the 3 causes of tubal factor subfertility
• Pelvic infections causing
o Pelvic adhesions
o Endosalpingeal damage
o Previous tubal surgery or sterilization
o Salpingitis
o Tubal endometriosis
o Polyps within the tubal lumen
o Tubal spasm
• Altered tubal motility
• Distortion of normal tube and ovarian relationship
• Impaired pick up of oocyte by the fimbria
b) List and explain the 3 diagnostic tests to confirm tubal factor subfertility
• Dilatation and insufflation test – the push of air or CO2 into peritoneal cavity
when pushed trans cervically under pressure, gives evidence of tubal patency.
• Hysterosalpingography – similar to insufflation test except dye is instilled
transcervical.
• Saline infusion sonography
• Falloposcopy – study of the entire length of tubal lumen with the help of fine
and flexible fiberoptic device.
• Salpingoscopy – tubal lumen is studied with a rigid endoscope through the
fimbrial end of the tube.
• Laparoscopy and chromopertubation – gold standard.
c) Outline the treatment of tubal factor subfertility.
Tubal factors for infertility are corrected only by surgery. The different surgical
methods are:
i. Peri tubal adhesions: Correction is done by salpingo-ovariolysis either by
laparoscopy or by laparotomy.
ii. Proximal tubal block: Salpingography under fluoroscopy may be helpful to remove
any block due to mucus plugging. Otherwise proximal tubal cannulation with a guide
wire under hysteroscopic guidance is done. In about 85 percent cases, tubal patency
can be restored and over all pregnancy rate of about 45–60 percent is reported.
Cannulation and balloon tuboplasty can avoid the need of ART which is expensive.
iii. Distal tubal block:
(a) Fimbrioplasty/fimbriolysis— release of fimbrial adhesions and/or dilatation of
fimbrial phimosis.
(b) Neosalpingostomy—to create a new tubal opening in an occluded tube.
iv. Mid tubal block: Reversal of tubal ligation— pregnancy rates after this procedure
varies between 50–82 percent. Success rate depends on—
(a) age,
(b) the method of sterilization (Pomeroy’s, Fallope rings, Diathermy, etc.),
(c) site of anastomosis (isthmic-isthmic or isthmic-cornual),
(d) final length of reconstructed tube.
Tuboplasty operation
Adhesiolysis Separation or division of adhesions
Fimbrioplasty Separation of the fimbria adhesions to open up the
abdominal ostium
Salpingostomy That creates a new opening in a completely occluded
tube. It is called terminal or ‘cuff’ at the abdominal
ostium. The eversion of the neo-ostium is maintained
by few stitches of 6-0 Vicryl.
Tubotubal anastomosis When the segment of the diseased tube following
tubectomy operation is resected and end to end
anastomosis is done.
Tubocornual anastomosis When there is cornual block, the remaining healthy
tube is anastomosed to the patent interstitial part of the
tube.
OBG SAQ for Batch 21 Set 3
1a) List and describe the classification of hypertensive disorders in pregnancy
• Hypertension – blood pressure of more than 140/90 mmHg with at least 6-
hour interval
• Gestational hypertension - blood pressure of more than 140/90 mmHg for the
first time in pregnancy after 20 weeks without proteinuria
• Pre-eclampsia – gestational hypertension with proteinuria
• Eclampsia – woman with pre-eclampsia complicated with grand mal seizures
and/or coma
• HELLP Syndrome – hemolysis, elevated enzymes, low platelet count
• Chronic hypertension – known hypertension before pregnancy or
hypertension diagnosed first time before 20 weeks of pregnancy
• Superimposed preeclampsia or eclampsia – occurrence of new onset of
proteinuria in women with chronic hypertension
• Chronic hypertension with superimposed preeclampsia and eclampsia
b) List any 8 signs/ symptoms of severe pre-eclampsia
• A persistent systolic BP above or equal to 160 mmHg or diastolic above
110mmHg
• Protein excretion more than 5g/24 hour
 • Oliguria (less than 400ml/24hr)
• Platelet count less than 100 000/mm3
• HELLP Syndrome
• Cerebral or visual disturbance
• Persistent severe epigastric pain
• Retinal hemorrhages, exudates or papilledema
• Intrauterine growth restriction
• Pulmonary edema

c) List 4 signs/lab findings to monitor magnesium sulphate toxicity

• Loss of deep tendon reflex
• Decreased respiratory rate
• Urine output less than 30ml/hr.
• Chest pain, heart block

2a) Describe the 3 outcomes of monozygotic twinning process depending on when

the zygote division occurs
3. A 23-year-old primigravida presents at 33 weeks with watery discharge from
• Division at morula will result in dichorionic diamniotic twins vagina of 4 hours duration.
a) List the probable causes
• Division at blastocyst with result in monochorionic diamniotic twins • Show
• Division of implanted blastocyst will result in monochorionic monoamniotic • Preterm rupture of membrane
twins
• Genital infection
b) List 6 complications associated with twin pregnancy • Urinary incontinence

Antenatal – anemia, pre-eclampsia, abruptio placenta, polyhydramnios, increased b) List and justify investigations to confirm the diagnosis.
symptoms of pregnancy, preterm labor, antepartum hemorrhage

• Abdominal palpation – measurement of symphysio-fundal height to assess loss

Intrapartum – prolonged labor, cord prolapse, post-partum hemorrhage
of amniotic fluid

Fetal – congenital malformation, miscarriage, intrauterine growth restriction

• Per vaginal examination to determine the origin of the discharge, determine
cervical dilatation
c) Describe the method of delivery if the first twin is vertex and second is non
vertex presentation.
• High vaginal swab for culture and sensitivity to determine any genital infection

• Fetal fibronectin testing to determine if patient is in preterm labor.

• Ultrasound to measure the length of cervical length

c) Outline the management of this patient.

PRELIMINARIES:

(1) Aseptic examination with a sterile speculum is done not only to confirm the
diagnosis but also to note the state of the cervix and to detect any cord prolapse;

(2) Vaginal digital examination is generally avoided;

(3) Patient is put to bed rest and sterile vulval pad is applied to observe any further
leakage.

Once the diagnosis is confirmed, management depends on—

 (i) Gestational age of the fetus; negative then it reassures that delivery will not occur within the next 7 days.
if fetal fibronectin testing is positive (concentration more than 50 ng/ml), view the
woman as being in diagnosed preterm labor and
(ii) Whether the patient is in labor or not; offer treatment

(iii) Any evidence of sepsis and Or

(iv) Prospect of fetal survival in that institution, if delivery occurs. If the clinical assessment suggests that the woman is in suspected preterm labor and
Maternal pulse, temperature and fetal heart rate are monitored 4 hourly. she is 30+0 weeks pregnant or more,

Term PROM: If the patient is not in labor and there is no evidence of infection or
fetal distress, she is observed carefully in the hospital. Generally, in 90% of cases
spontaneous labor ensue within 24 hours. If labor does not start within the stipulated
time or there are reasons not to wait, induction of labor with oxytocin is commenced
forthwith. Cesarean section is performed with obstetric indications.
Preterm PROM: The main concern is to balance the risk of infection in expectant
management (while pregnancy is continued) versus the risk of prematurity in active
intervention. Ideally the patient should be transferred with the “fetus in utero” to a
unit able to manage preterm neonates effectively.
If the gestational age is 34 weeks or more, perinatal mortality from prematurity is
less compared to infection (GBS). Labor generally starts spontaneously within 48
hours, otherwise induction with oxytocin is instituted. Presentation other than
cephalic merits cesarean section. When gestational age is less than 34 weeks,
conservative attitude generally followed in absence of any maternal or fetal
indications. On rare occasion with bed rest, the leak seals spontaneously and
pregnancy continues.
Consider TVS measurement of cervical length as a diagnostic test to determine
likelihood of birth within 48 hours.
if cervical length is more than 15 mm:
it is unlikely that she is in preterm labor
advise her that if she does decide to go home, she should return if symptoms
suggestive of preterm labor persist or recur
if cervical length is 15 mm or less,
view the woman as being in diagnosed preterm labor and offer treatment
c) Describe the surgical treatment recommended for prevention of preterm labor.
Prophylactic cervical cerclage can be done. It is considered ed as 'rescue' cervical
cerclage for women between 16+0 and 27+6 weeks of pregnancy with a dilated cervix
and exposed, unruptured fetal membranes. The cerclage is removed at 36 weeks or
when the patient is in labor

USE OF ANTIBIOTICS: Prophylactic antibiotics are given to minimize maternal

and perinatal risks of infection. Intravenous ampicillin, amoxicillin or erythromycin 5a) Classify abnormal uterine bleeding (AUB) according to PALM- COEIN
for 48 hours followed by oral therapy for 5 days or until delivery is recommended. P – polyps
Pelvic rest and antibiotics help to seal the leak spontaneously and reduce infection. A – adenomyosis
L – leiomyoma
Use of corticosteroids to stimulate surfactant synthesis against RDS in preterm M – malignancy and hyperplasia
neonates is advised. As such PROM alone may accelerate fetal lung maturation. C – coagulopathy
However, combined use of antibiotics and corticosteroids (see p. 367) has reduced the O – ovulatory disfunction
risks of neonatal RDS, IVH and NEC, BPD and PDA E – endometrial
I – iatrogenic
Tocolysis, progesterone therapy, cervical cerclage in the management of PROM is N – unknown
not recommended. b) Outline the plan of medical management of abnormal uterine bleeding in a
woman of 35-years of age.
Medical
4a) List any 8 causes of preterm labor Non- hormonal
• Pregnancy complication – pre eclampsia, antepartum hemorrhage, o Prostaglandin synthase inhibitor – Mefenamic acid
polyhydramnios o Antifibrinolytic agents – Tranexamic acid
• Uterine anomalies – cervical incompetence, malformation of uterus Hormonal
• Medical and surgical illness – acute fever, acute pyelonephritis, diarrhea, acute o Progestin
appendicitis o Medroxyprogesterone acetate
• Chronic disease – hypertension, nephritis, severe anemia, low BMI o Combined estrogen and progesterone (contraceptive pills)
• Genital tract infection o Mifepristone
• Fetal causes – multiple pregnancy, intrauterine death o GnRH analogs
• Placental causes – infarction, thrombosis, placenta previa o Desmopressin
• Iatrogenic Surgical
• Idiopathic o Uterine curettage
o Endometrial ablation/ resection
b) List and describe any one recommended investigation to confirm the diagnosis o Hysterectomy
of preterm labor. o Uterine artery embolization
Fetal fibronectin.
It is a glycoprotein that binds the fetal membrane to the decidua. It is normally found o Transcervical resection of endometrium
in the cervicovaginal discharge before 22 weeks and after 37 weeks. Presence of 6a) List any 4 predisposing factors for carcinoma of cervix
fibronectin between 24 weeks and 34 weeks is a predictor of preterm labor. If
 • Infection – HPV (16,18,31,33), HSV2, HIV, Chlamydia ❖ Direct implantation
• Early sexual intercourse (less than 16 years) The endometrial tissue starts to grow susceptible to individual when implanted to new
sites. Such sites are abdominal scars following hysterectomy, at the episiotomy scar,
• STD vaginal or cervical site.
• Early age of first pregnancy ❖ Lymphatic theory
• High parity Normal endometrium metastasizes the pelvic lymph nodes through draining of the
lymphatic channels of the uterus.
• Too many and too frequent births
❖ Vascular theory
• Low socioeconomic status It explains endometriosis at distant sites such as lungs, arms or thighs.
• Multiple sexual partners b) List any 3 symptoms and 3 signs of endometriosis
Symptoms
• HIV positive individuals • Dysmenorrhea
• Husband with multiple sexual partners • Abnormal menstruation – menorrhagia
• Increasing age • Infertility
• Dietary deficiency (vitamin A, C, E, folic acid) • Dyspareunia
• Oral pill users • Chronic pelvic pain
• Smoking habits • Abdominal pain
Signs
b) List any 4 clinical features of carcinoma of cervix
•
• Irregular vaginal bleeding c) Outline medical and surgical treatment of endometriosis.
• Pelvic pain Medical
• Leg oedema • Combined oestrogen and progesterone pills
• Offensive vaginal discharge – whitish coloured • Progesterone
• Bladder symptoms – dysuria, haematuria, incontinence o Oral
• Rectal involvement – diarrhoea, rectal pain, bleeding per rectum o Intramuscular
o IUCD – levonorgestrel releasing IUCD
c)Define management of stage Ib of carcinoma cervix • Danazol
The management of cervical carcinoma involves a team approach. Both the
gynaecologist and radio oncologist should review the patient together and give the
• GnRH analogues
patient an individualized plan. Surgical
It should be based on: Conservative surgery
o General condition of the patient • Laparoscopy
o Stage of the disease o Cauterization

o Facilities available o Laser vaporization

o Wish of the patient o Adhesiolysis

o Laparoscopic uterosacral nerve ablation (LUNA)
The management of stage Ib carcinoma of cervix includes the following: Definitive surgery
• radical hysterectomy • Laparoscopy/ laparotomy
• pelvic lymphadenectomy (type iii) with paraaortic lymph nodes evaluation o Hysterectomy with bilateral salphingo-oopherectomy
• external radiation if the nodes are positive or primary radiation with o Resection of bowel or ureter may be needed
concomitant platinum-based chemotherapy (chemoradiation)
7a) List and describe 3 main etiological theories of endometriosis
❖ Retrograde Menstruation
There is retrograde flow of menstrual blood through uterine tubes during
menstruation. The endometrial fragments get implanted in the peritoneal surface of
pelvic organs. Subsequently, cyclic growth and shedding of endometrium at the
ectopic sites occur under the influence of endogenous ovarian hormones.
Probably a genetic factor or favourable hormonal milieu is necessary for successful
implantation and growth of the fragments of endometrium.
❖ Coelomic Metaplasia
Chronic irritation of the pelvic peritoneum by the menstrual blood may cause
coelomic metaplasia which results in endometriosis. Alternatively, the Mullerian
tissue remnants may be trapped within the peritoneum. They could undergo
metaplasia and be transferred into endometrium.