clinical MCQ discussion Done on High yielding topics

1. Diabetes
2. Detection of pregnancy
3. Molar pregnancy
4. MTP
5. Biochemical markers in Pregnancy
6. Liver disease in Pregnancy
7. CTG tracing
8. Umbilical Artery doppler
9. COVID-19 in Pregnancy
10. Pregnancy induced hypertension
11. HPV vaccine
12. Primary amenorrhea
13. Hirsutism

14. Abnormal Uterine Bleeding

1. 25 year old, G2P1 patient visits the antenatal clinic for the first time at 12 weeks and
obstetrician plans to de 2 hr OGTT test. The following instructions should be given to the
patient with respect to test except.

a. Patient has to take 75 gms of oral glucose irrespective of her previous meal

b. glucose can be mixed with water and should be consumed within 10 mins

c. if she vomits the glucose within 30 mins, she should take the same amount of
glucose again and continue with the test
d. If she vomits within 30 mins, she should come next day for the test

Answer :- “ C “

• DIPSI criteria :- OGTT should be done at first Antenatal visit, if normal it is repeated at
24-26 weeks
• Give 75 gm of glucose with 250-300 ml of Water (Lime can be added)
• If vomiting occurs
‣ Within 30 minutes :- Call her next day
‣ After 30 minutes :- Do the Test
• 2 hour OGTT value
‣ 120-140 mg/dl :- Deranged glucose tolerance
‣ ≥ 140 mg/dl :- Gestational diabetes
‣ ≥ 200 mg/dl :- overt diabetes

R1. A 30 year old G2P1, known case of diabetes for 2 years, conceives and visits you at 10
weeks of pregnancy, worried about the risk of GCA in her fetus. You ask her to get her
HbA1c levels checked. Her Ab A1C is 9%. Looking at this the next logical step is

a. advise her to get karyotyping done

b. advise her for USG in 1st trimester

c. advise her level 2 scan at 18 weeks

d. advise her to get serum AFP levels checked

Answer :- “B”

• No risk of chromosomal anomalies in diabetes; Karyotyping not done

• Anencephaly can be earliest detected @ 10 weeks on USG; in this case Next step should be
to do USG
• Best step in this scenario would be TIFFA (targeted imaging for fetal anomaly) but it is best
done @ 18 weeks
• Now-a-days; TIFFA has replaced Biochemical markers (AFP) for detection of fetal anomalies
• Gestational diabetes
‣ No risk of Gross Congenital anomalies
‣ Can present in 2nd and 3rd trimester
• Overt diabetes
‣ Risk of GCA (Due to Hyperglycemia)
‣ Can present in 1st, 2nd, 3rd trimester
• Correlation between HbA1c and GCA risk
‣ < 6.5 % :- No increased risk
‣ ≥ 6.5 % :- 3% risk
‣ 7.5 % :- 4% risk
‣ 8.5 % :- 7% risk
‣ ≥9 % :- 10-15 % risk

1. A 34 weeks pregnant female on MNT (Medical Nutrition therapy) has FBS 97 mg/dl and 2
B
hr PP :140 mg/dl. She was advised 8U of mixtard insulin by the obstetrician before
breakfast. Now Patient complains of tremors, sweating and palpitations. What is the next
logical step in management

a. Advise her to get her HbA1c levels

b. Advise her to have 6tsp of sugar

c. Advise her to increase her insulin to 10 IU

d. Advise her to get an echo done

Answer :- “B”

• Symptoms (tremors, sweating and palpitations) are suggestive of hypoglycemia (< 70 mg/dl),
Next step should be
‣ 3 Tsp of Glucose or
‣ 6 Tsp of Sugar
• Management of Overt diabetes
‣ Weight Gain counselling (How much wt they should gain)
‣ Start MNT
‣ Start Insulin along with MNT
‣ Start low dose Aspirin (They are at risk of PIH)
• Management of Gestational diabetes
‣ Weight gain counseling
‣ MNT for 2 weeks and Target
• FBS < 95 mg/dl
• 1 hour PP < 140 mg/dl
• 2 hour PP < 120 mg/dl
• Avg. Capillary glucose < 100 mg/dl
• HbA1c < 6.0
 ‣ Start insulin if the targets are not met
• Mixtard insulin (70 : 30 = intermediate : short acting) (40 IU/ml)
• Store @ 4 - 8 degrees C
• Route :- S/C before Breakfast
• Dose depends on 2 hour PP
‣ 120-160 mg/dl :- 4 IU
‣ 160-200 mg/dl :- 6 IU
‣ ≥ 200 mg/dl :- 8 IU
• Target
‣ FBS < 95
‣ 2hour PP < 140
• If target are not met
‣ Add 2 IU before dinner
‣ Still not met; Add 2 IU before Breakfast

1. A 32 year old G1 at 10 weeks gestation presents for her routine obstetrical visit. She is
M
worried about her pregnancy because she has history of insulin dependant diabetes since
the age of 18. Prior to becoming pregnant her endocrinologist diagnosed her with
microalbuminaria. She has had photo laser ablation of retinopathy in the past. What
diabetic complication is most likely worsened by pregnancy?

a. gastroparesis

b. Nephropathy

c. Neuropathy

d. Retinopathy

Answer:- “D”

• Diabetic complication Is not common in Pregnancy, But if it occurs then MC is vasculopathy

• Vasculopathy
‣ Retinopathy
‣ Placental Vasculopathy Results in oligohydramnios (MC in Diabetes is polyhydroamnios)

B1. A patient comes to your office with her last menstrual period 4 weeks back. She denies
any symptoms like nausea, fatigue, urinary frequency or breast tenderness. She thinks she
may be pregnant because she has not had her periods yet. She is very anxious to find out
because she has a history of previous ectopic pregnancy. Which of the following is the
most appropriate action

a. order a serum quantitative pregnancy test

b. Listen to the fetal heart sounds by hand held doppler

c. perform abdominal scan

d. Do a urine pregnancy test

Answer :- “A”

• Earliest detection of Pregnancy by USG is by TVS @ 4 weeks 3 days

• USG abdomen detect 1 week later than TVS (5 weeks 3 days)
• Fetal heart sound is heard at 10 weeks by Hand held doppler
• Urine pregnancy test
‣ Method :- 2 site sandwich immunoassay
‣ +ve when HCG level is 10-20 mIU/ml
‣ Earliest +ve by Missed period
‣ In some women it is +ve by 7 days after missed period
• Serum / Blood HCG test
‣ Method :- FIA > RIA
‣ Earliest +ve by 8 days after fertilization / 5-6 days before missed period / Day 22

1. The marker of development of invasive mole after treatment of complete mole by suction
Or
evacuation are all except

a. persistent theca lutein cysts

b. rising hcg levels after initial fall

c. suburethral nodule
d. subinvolution of uterus

Answer :- “c”

• After suction and evacuation; Gestational Trophoblastic Neoplasia (Invasive mole and
choriocarcinoma) is Diagnosed by
‣ Lab values
• Beta-HCG Value Is increased for 3 weeks
• Plateau in Beta-HCG value ( ± 10 %)
• HCG level remains high even after 3 months of evacuation
• On HPE :- GTN
‣ Clinical features
• Persistent bleeding after suction and evacuation
• Subinvolution of uterus
• Shock
• Metastasis (Only for Choriocarcinoma not Invasive mole)
‣ Lungs (Cannon ball metastasis)
‣ Vagina (Sub-urethral nodules)
• Persistence of theca lutein cyst)
• Note :- Metastasis is a sign of choriocarcinoma (not invasive mole)
1.
I A patient present to your office for her first prenatal visit. By her last menstrual period she
is 11 weeks pregnant. This is the first pregnancy for this 36 yr old woman. She has no
medical problems. At the visit you observe that her uterus is palpable midway between the
pubic symphysis and umbilicus. No fetal heart tones are audible with the Doppler
stethoscope. Which of the following is the best next step in the management of this
patient?

a. Reassure her that fetal heart tones are not audible with the Doppler at this
gestational age.

b. Schedule genetic amniocentesis right away because of her advanced maternal age.

c. Schedule her for a suction evacuation because she has a molar pregnancy since
her uterus is too large and the fetal herat tones are not audible.

d. Schedule her USG as soon as possible to determine the gestational age and
viability of fetus.

Answer :- “D”

• Uterine height > POG

• Molar pregnancy is suspected as FHS is not heard
• We Can’t proceed for suctioning without confirming diagnosis
• Next best step in this case is to confirm the diagnosis by USG

1. A 21 year old female at 22 weeks of pregnancy for MTP .She cites contraceptive failure as
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the indication for getting MTP done. In context of the amendament proposed which of the
following statement is true.

a. MTP can be done in this case till 24 weeks of pregnancy

b. MTP cannot be done as her gestational age is 22 weeks

c. MTP can be done at 22 weeks with consent of her husband

d. MTP can be done at 22 weeks without consent of her husband.

Answer :- “B”

• MTP amendment 2021

‣ Eugenic indication (Congenital anomaly); MTP allowed upto 24 weeks
‣ Humanitarian indication (Incest, Rape); MTP allowed upto 24 weeks
‣ Medical indication (Heart failure in mother); MTP allowed upto 24 weeks
‣ Contraceptive failure; MTP allowed upto 20 weeks
‣ For Gross congenital malformations (Anencephaly, Caudal regression syndrome) MTP
can be done after 24 weeks only if GCA is certified by team of doctors
• Consent is needed only in case of Minor (<18 years); given by guardian / parents
• 1 doctor needed for MTP uptill 20 weeks
• 2 doctors needed for MTP uptill 24 weeks
11. A 37 year old G1 undergoes a triple screen test at 16 weeks of pregnancy to evaluate
her risk of having a baby with Down syndrome because she is worried about coming into
the high risk category of increased maternal age. Her maternal serum AFP levels come
out to be raised. The patient is extremely concerned and comes into your office to get
additional counselling and recommendations. All of the following are true statements that
you can tell her except

a. An elevated serum AFP level indicates that she is at risk for having a baby with
down syndrome and she should undergo chorionic villí sampling to determine the
karyotype
b. An USG should be performed to confirm the gestational age of the fetus and
rule out fetal anomalies (done to Rule out Abdominal wall defects, NTDs)
c. fetal neural tube defects, multiple gestation and fetal abdominal wall defects are
possible etiologies of elevated MSAFP

d. Unexplained elevated MSAFP levels have been associated with adverse pregnancy
outcomes such as placental abruption, oligohydramnios, or fetal death in utero

Answer :- “A”

• Alpha-fetoprotein level are said to be raised if

‣ ≥ 2.5 MOM in singleton pregnancy
‣ ≥ 3.5 MOM in twins
• Best time to Do AFP @ 16-18 weeks
• Cause of Raised AFP
‣ NTDs
‣ Abdominal wall defect in fetus
‣ Pilonidal sinus in fetus
‣ Underestimated gestational age
• Causes of Decreased AFP
‣ Gestational Trophoblastic diseases
‣ Obesity
‣ Overestimated GA
‣ Abortion
‣ Trisomy (Down syndrome)
1. A 36-year-old G1P0 at 35 weeks gestations presents with several days H/O generalized
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malaise, anorexia, nausea emesis and abdominal discomfort. She has loss of apetite and loss
of several pounds weight in 1 week. Fetal movements are good. There is no headache, visual
changes, no vaginal bleeding, no regular uterine contractions or rupture of membranes. She
is on prenatal vitamins. No other medical problem. On examination she is mild jaundiced and
little confused. Her temperature is 100 degree F, PR is 70/min, BP-100/62 mmHg, no
significant edema, appears dehydrated. FHR is 160/min and is nonreactive but with good
variability. Her WBC is 25000, Hct is 42.0, platelets is 51000, SGOT/SGPT :- 287/350,
GLUCOSE :- 43, Creatinine :-2.0, fibrinogen :-135, PT/aPTT :- 16/50, Serum Ammonia
level :- 90mmol/L. Urine is 3+ proteins with large amount of ketones. What is the most
likely diagnosis.

a. Hepatitis B

b. AFLP (Acute Fatty liver of pregnancy)

c. Intrahepatic cholestasis

d. HELLP syndrome

Answer :- “B”

• Findings
‣ Confused (Due to Raised Urea)
‣ Normal BP
‣ Hypoglycemia
‣ LFT and KFT is abnormal
‣ Abnormal coagulation profile
• Hepatitis B will not have Renal dysfunction, and SGOT/SGPT will be very high
• Intrahepatic cholestasis will have
‣ Pruritis
‣ Raised Bile Acids
‣ Raised Direct billirubin but ( < 5)
‣ SGOT/SGPT raised but < 250
• HELLP syndrome will have
‣ Raised BP
‣ Hemolysis
• Increased indirect billirubin
• Raised LDH
• Schistocytes / Helmet cells on PBS
• Dec Haptoglobin
‣ Elevated liver enzymes
‣ Low platelet count
‣ Normal Coagulation profile
‣ No Uremic encephalopathy features
• AFLP (Acute fatty liver of pregnancy)
‣ Male Fetal Have LCHAD deficiency that leads to Accumulation of fatty acids
‣ Fatty acids damages Maternal hepatocytes
‣ Liver failure will occur leading to
• Hypoglycemia
• Raised NH3
• Abnormal coagulation profile
• Hepato-renal syndrome (Raised Creatinine and Urea)
• Termination of pregnancy
‣ AFLP :- Immediately
‣ Intrahepatic cholestasis(DOC :- Deoxycholic acid) :- 37 weeks
‣ HELLP :- Immediately

1. A healthy 30 year old G1P0 at 41 weeks gestational age presents to labor and delivery at
i 11 pm because she is concerened that her baby has not been moving as much as usual for
the past 24 hrs. On arrival to labor and delivery, her BP is initially 140/90 but decreases
with rest to 120/75. Her prenatal chart indicates that her baseline BP was 100 to 120/60
to 70 mmHg. She denies any complications during the pregnancy. She denies headache,
rupture of membranes, regular uterine contractions and vaginal bleeding. The patient is
placed on an external fetal monitor. The fetal heart rate baseline is 80 bpm with absent
variability. There are uterine contractions every 3 min accompanied by late fetal heart rate
decelearations. Physical examination indicates that the cervix is long/closed/-2. The
patient's urinanlysis shows no proteinuria. Which of the following is the appropriate plan for
Mx for this patient?

a. Proceed with emergent CS.

b. administer I/V MgSO4 and induce labor with Pitocin.

c. Ripe cervix overnight with PGE2 and proceed with Pitocin induction in the morning

d. Induce labor with misoprostol.

Answer :- “A”

• Findings on CTG suggestive of Grade III FHR tracing are

‣ Decreased / Absent Baseline variablity along with Any of the following three
• Fetal bradycardia
• Late deceleration
• Variable deceleration
‣ Sinusoidal FHR pattern
• Management :- Immediately termination of pregnancy; No role of induction of labor
 1. A 26 yr old G1PO patient at 31 weeks of gestation is being evaluated with Doppler USG
studies of fetal umbilical arteries. The patient is a heavy smoker. Her fetus has shown
evidence of IUGR on previous USG. The Doppler studies currently shows that the systolic to
diastoloic ratio (S/D) in the umbilical arteries is much higher than it was on her last USG 3
weeks ago and there is absent diastolic flow. The next step in management is

a. immediate Induction of labor

b. immediate termination of pregnancy by caesarean

c. admit patient, give corticosteroids, do fetal monitoring and caesarean at 34 weeks

d. admit patient, give corticosteroids, do fetal monitoring and vaginal delivery at 32
weeks

Answer:- “c”

Very important for INICET

i 1. Regarding breast feeding of a baby by a mother with covid 19 disease, true statement is

a. Babies are immune to infection from SARS-CoV2

b. COVID-19 mother should withhold breast feeding her infant till her report comes
negative

c. COVID-19 mother can breast feed if she practises hand hygiene and respiratory
hygiene
d. CDC recommends against breast feeding by infected mother because the virus is
easily transmitted through breast milk.
Answer :- “C”

• Breast feeding is allowed during Lactation in COVID-19 +ve Mother because It is believed that
Antibodies against SARS CoV2 virus is transmitted to Baby
• In India Vaccination of lactating mother is also allowed
• Virus is not transmitted through breast milk
• Vaginal delivery can be done in COVID-19 during pregnancy; LSCS is reserved for Obstetrical
indications

1. A 25 year old primigravida at 28 weeks of pregnancy has BP of 160/110 mm of hg. Her 24

I hours urine albumin level of 220 mg. She has family history of hypertension in mother. Her
previous record show normal BP at 12 weeks and normal investigations. She has developed
headache, blurring of vision since one day. What is your diagnosis.

a. gestational hypertension

b. severe preeclampsia
c. chronic hypertension

d. chronic hypertension with superimposed pre eclampsia

Answer :- “B”

• Chronic Hypertension is ruled out as BP is normal at 12 weeks

• Pre-eclampsia :-
‣ Raised BP (> 160/110 mmHg) along with
‣ S/S of End organ Damage (or)
• Platelet count < 1 lakh
• Raised liver enzyme > 2 twice the normal
• S. creatinine > 1.1
• Headache, Visual symptoms
• Pulmonary edema
• Significant proteinuria :- >300mg/day
1. Your patient has had an ultrasound examination today at 38 weeks gestation for size less
1 than dates. The ultrasound showed AFI 1.5 cms. Patients cervix is unfavorable. Which of the
following is the next best step in management of this patient.

a. Admit for caesarean section

b. admit for cervical ripening followed by induction of labor

c. Perform stripping of membranes and perform a BPP in 2 days

d. Write a prescription for misoprost to take home every 4 hourly till she goes into
labor

Answer :- “B”
• USG criteria for Oligohydroamnios
‣ AFI < 5 cm
‣ SVP < 2 cm
• Causes of Oligohydroamnios in 3rd trimester
‣ PIH
‣ IUGR
‣ PROM
• Management of Oligohydroamnios :- Termination of pregnancy ≥ 37 weeks
• Oligohydroamnios In 3rd trimester Has high Risk of Cord compression

1. A 27 year old P1L1 has sensation of heaviness in lower abdomen. Her periods are regular
I
and normal . She undergoes ultrasound and on ultrasound a huge intramural fibroid is seen
which can be palpated till the umbilicus. What should be the best management in this case

a. Expectant management
b. GnRH analogues

c. Myomectomy

d. Hysterectomy

Answer :- “ A”

• Repeatedly Asked in AIIMS

• Management
‣ If fibroid is asymptomatic :- Expectant Management
‣ Intervention is done if fibroid is Causing
• Recurrent Abortion (Pedunculated fibroid)
• Infertility
• Rapidly enlarging in post menopausal women (suggestive of malignant changes)

1. With respect to administration the vaccine shown in the image, all of the following are
p
guidelines issued by ACOG except

a. If a female had sexual assault in childhood can be given at age < 9 years
b. the vaccine can be given to females aged 27 -45 years who were unvaccinated
earlier and have risk of HPV infection

c. vaccine is recommended for females ≤ 26 years even if person is tested positive

for HPV DNA

d. Vaccine can be and should be given to breast feeding females ≤ 26 years of age

Answer :- “A”

• The American College of Obstetricians and Gynecologists (ACOG) makes the following
recommendations and conclusions :-
‣ Routine human papillomavirus (HPV) vaccination for girls and boys at the target age
of 11-12 years (but it may be given from the age of years)

‣ Obstetrician-gynecologists should assess and vaccinate adolescent girls and young

women with the HPV vaccine during the catch-up period (ages 13-26 years),
regardless of sexual activity, prior exposure to HPV, or sexual orientation, if they
were not vaccinated in the target age of 11-12 years.

‣ For some women aged 27-45 years who are previously unvaccinated, consider the
patient's risk for acquisition of a new HPV infection and whether the HPV vaccine
may provide benefit.

‣ An individual who received the quadrivalent HPV vaccine should not be revaccinated
with 9-valent HPV vaccine

‣ Vaccination is recommended for women through age 26 years even if the patient is
tested for HPV DNA and the results are positive. Testing for HPV DNA is not
recommended before vaccination.

‣ Human papillomavirus vaccination is not recommended during pregnancy, however,

routine pregnancy testing is not recommended before vaccination

‣ The HPV vaccine can and should be given to breastfeeding women age 26 years and
younger who have not previously been vaccinated

‣ In children with a history of sexual abuse or assault, the HPV vaccine should be given
as early as possible, starting at age 9 years
1. A 18 year old female visits your office with C/o primary amenorrhea. Her breast
p development corresponds to Tanner stage 1. The consulting doctor informs the female that
she has strong probability of her gonads turning malignant. Which of the following is the
most likely diagnosis

a. Mullerian agenesis

b. Androgen insensitivity syndrome

c. Swyers syndrome
d. Turners syndrome

Answer :- “c”
• Patient has
‣ Primary amenorrhea
‣ Female phenotype
‣ Risk of Gonadal malignancy i.e. Presence of Y-chromosome in gonads
• XX karyotype :- Mullerian agenesis
• XO karyotype :- Turners syndrome
• XY karyotype :-
‣ Androgen insensitivity syndrome (Breast developed; tanner stage IV or V)
‣ Swyers syndrome
• Gonadectomy timing
‣ AIS :- After 14-15 years (After pubertal development)
‣ Swyers :- At time of diagnosis
• MC cancer in Dysgenetic Gonadal :- Gonadoblastoma
1. A 13 year old femal presents with complain of primary amenorrhea. On examination
p
secondary sexual characteristics are absent and pubic hair and axillary hair are sparse.
Next step in management is

a. Karyotyping

b. IVP

c. Per rectal examination

d. Ultrasound pelvis

Answer :- “D”

• Cause of primary amenorrhea with absence of secondary sexual characteristics

‣ Turner syndrome
‣ Pure Gonadal dysgenesis
• 46 XX
• 46 XY (Swyer syndrome)
‣ Kallman syndrome
• Investigations
‣ Ist :- USG
• Streak gonads in Turner and pure Gonadal dysgenesis (46XX)
• Testis in Swyers syndrome
• Normal ovaries in Kallman syndrome
‣ FSH levels
• Raised in Turner and Pure gonadal dysgenesis
• Low in kallman syndrome
• IVP is done in Mullerian agenesis
• DRE is done to palpate uterus in Cryptomenorrhea
1. 16 year old girl with primary amenorrhea, and breast development tanner stage1, with
pubic and axillary hair present and uterus present. FSH levels are low. USG is normal. MRI
brain is normal. Her stature is also short. What is the most likely diagnosis?

a. Kallman syndrome

b. Turner syndrome

c. Constitutional
d. Swyer syndrome

Answer :- “C”

• Delayed puberty and Low FSH (Hypogonadotropic Hypogonadism)

‣ Kallman syndrome
‣ Constitutional
‣ Prolactinoma
• Hypogonadotropic hypergonadism
‣ Turner syndrome
‣ Swyer syndrome
• To differentiate between causes of Hypogonadotropic Hypogonadism; Do MRI-BRAIN
‣ Absent olfactory tract :- Kallman syndrome
‣ Pituitary Mass :- Prolactinoma
‣ Normal In constitutional delay
• In constitutional delay there is Also Delayed Adrenarche; Hence do DHEA-S
‣ Normal in Kallman syndrome
‣ Low levels in Constitutional delay
• Kallman syndrome also has Anosmia

1. A 23 year old nulliparous female complains of secondary amenorrhea. UPT is negative and
her estrogen-progesterone challenge test is negative. What is the next best line of
management

a. Serum FSH levels

b. hysteroscopy

c. GnRh stimulation test

d. karyotype

Answer :- “B”

• -ve Estrogen-progesterone challenge test means that problem lies at level of uterus, MCC
being Ashermann syndrome (Diagnosed by Hysteroscopy)
1. A 22 year old female, G0P0 visits your clinic with chief complaint of being too hairy. Her
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menarche was at the age of 13 and her menses have always been very irregular. She has
acne and is currently under the treatment of dermatologist for the condition. On physical
examination there is sparse hair around the nipples, chin and upper lip. No galactorrhea,
thyromegaly, or temporal balding is noted. Pelvic examination is normal and there is no
evidence of clitoromegaly. All of the following should be included in the differential
diagnosis based on patients history and physical examination except

a. Idiopathic hirsutism

b. PCOS
c. late onset congenital adrenal hyperplasia

d. Sertoli Leydig tumor

Answer :- “D”

• Patient is suffering from Hirsutism

‣ Idiopathic Hirsutism :- Hirsutism with Normal serum Testosterone levels
‣ PCOS :- MCC of Hirsutism, Diagnosis by Rotterdam criteria
‣ Late onset CAH :- Do 17-OH progesterone level
• Sertoli-leydig cell tumour is a d/d of hirsutism but it also has
‣ Virilisation (Clitoromegaly, Hoarseness of voice)
‣ S. Testosterone > 200 mg/dl

1. 55 year old post menopausal female presents to your office for evaluation of post
menopausal bleeding. She is morbidly obese, has chronic hypertension and adult onset
diabetes. An endometrial sampling done in the office shows complex atypical hyperplasia
with atypia and a pelvic ultrasound shows large fibroid. Which of the following is the next
step in management

a. Oral combined pills

b. TAH with BSO

c. Myomectomy

d. Dilation and Curettage with hysteroscopy

Answer :- ”B”

• Investigations in PMB :- Endometrial sampling (If USG ET ≥ 4mm)

• Corpus cancer syndrome
‣ Obesity
‣ Hypertension
‣ Diabetes
• Risk of cancer in
‣ Complex hyperplasia with atypia :- 30%
‣ Simple hyperplasia without atypia :- 8%
• After Atypia is Seen on Endometrial Biopsy; Do fractional curettage with Hysteroscopy
followed to confirm the diagnosis
• Management of Endometrial Atypia (Simple & Complex) :- TAH ± BSO

q1. 48 year old female with history of fibroid. presents to you with irregular vaginal bleeding.
Until last month she has not had a period in over 6 months. She thought she was
menopausal but started bleeding again. Over the past month she had irregular spotty
vaginal bleeding. The last time she bled was 1 month ago She doesnot have any significant
medical history or drug intake history. Her recent ultrasound showed an intramural fibroid
of 10 x 8 mm. The next step in management of the patient

a. Insert LNG IUCD

b. Perform an endometrial biopsy

c. TAH with BSO

d. OCP for 3 cycles

Answer :- “B”

• Indication of Endometrial biopsy

‣ Post-menopausal women :- If Endometrial Thickness ≥ 4mm on USG
‣ Peri-Menopausal (45 years) with AUB; Irrespective of USG findings

1. 22 year old obese female comes to your office for routine gynecological examination. She is
single but has history of 4 partners in the past and became sexually active at the age of
17 years. She denies use of any alcohol or cigratte smoking. Her physical examination is
normal. Her PAP smear is done and report shows HSIL Which of the following is the next
step in mgt.

a. perform a cone biopsy

b. repeat pap smear after 4-6 months

c. Order HPV DNA testing

d. perform colposcopy

Answer :- “D”

• Management of Abnormal PAP smear

‣ Age < 25 years
• HSIL & ASC-H :- Do Colposcopy
• LSIL & ASCUS :- Repeat PAP smear
‣ Age 25-30 years
• HSIL, ASC-H & LSIL :- Colposcopy
• ASCUS :- Do HPV-DNA testing
‣ AGUS :- Colposcopy, Endocervical curettage, Endometrial Biopsy