OB&G-AIM4PG

1. Post-menopausal endometrial thickness is 1-3 mm. 2. Selective serotonin reuptake inhibitors (SSRIs) is most useful for the treatment of premenstrual syndrome. 3. Endometriosis is commonly associated with bilateral chocolate cyst of ovary. 4. Red degeneration of fibroid occurs most commonly in 2nd trimester. 5. In a pregnant woman with red degeneration, management is conservative treatment. 6. Drug not helpful in induction of ovulation is progesterone. 7. Spinnbarkeit phenomenon is due to elasticity of cervical mucus. 8. The commonest Indication of IVF is abnormality of fallopian tube. 9. Most common cause of VVF in India is obstetrical trauma. 10. Stress incontinence is a common symptom of prolapse of uterus. 11. Retention of urine in a pregnant woman with a retroverted uterus is seen at 12-16 weeks. 12. Stress incontinence is best corrected by bladder neck suspension. 13. Retention of urine in a pregnant woman with retroverted uterus is seen in 12-16 weeks. 14. Most common site of injury to ureter is where it crosses uterine A . 15. Burch colposuspension for Stress incontinence has highest success rate at the end of 5 yrs. 16. Most useful investigation for VVF is Cystoscopy. 18. The most common malignant change seen In an ovarian tumour is serous cyst adenoma. 19. The ovarian tumor which is most likely to be associated with virilization is sertoli-Leydig cell tumor. 20. Bilateral ovarian carcinoma with breach in capsular wall with ascites, peritoneal metastasis & positive cytology belongs to stage Ic. 21. Largest tumour of the ovary is mucinous cystadenoma. 22. Tumor marker in dysgerminoma is LDH. 24. LDH is raised in dysgerminoma. 25. Pap smear in pregnancy is routine as a part of screening. 26. Carcinoma cervix extends to the lateral pelvic wall in Stage III. 27. Long-term use of tamoxifen causes endometrial carcinoma.

Q. Most state of the ART serum pregnancy test have a sensitivity of detection of beta hcg upto 25mLu/ml. Such tests would diagnose pregnancy as early as which of the following? A. 5 days after fertilization B. 24 hrs after implantation C. Day of the expected (missed) menses D. 5 weeks gestation age by menstrual dating E. 6 weeks gestation age by menstrual dating Ans. C Beta hcg in early pregnancy @ 25mLu/ml is detected in women by 12-13 days after LH peak. So the test should be positive by the expected date of the menses.

◼️Risks of intrauterine grawth restriction and small for gestational age: ▪️Antepartum : 1- hypoxia 2- intrauterine death ▪️peripartum 1-hypoxia 2-intrauterine death 3- meconium aspiration ▪️postpartum : 1- Neonatal hypoglycemia 2- Hypocalcaemia 3- Hypothermia 4- Polycythaemia 5- Hypoxic-ischemic encephalopathy ☑️N.B Hypoxia during the antenatal and intrapartum period can result in developmental delay and cerebral palsy.

🔵Differential diagnosis of big baby: 1-Constitutionally large for dates 2-Macrosomia (e.g. secondary to diabetes) 3-Wrong date 4-Polyhydraminos 5-Multiple pregnancy 6-Hydrops

#mneumonics Dil Mein Ppaar (read as pyaar) Dil • Drug ( Prostaglandin Synthetase inhibitors and ACE inhibitors). IUGR Leaking of fluid following amniocentesis or chorionic villus sampling. Mein • Maternal conditions like hypertension and preeclampsia. Ppaar • Post-term pregnancy • Premature rupture of membrane • Abruptiochronic • Amnion Nodosum and chromosomal anomaly like triploidy • Renal anomalies of fetus (leading to decreased urine production): – Renal agenesis – Urethral obstruction (posterior urethral valve) – Prune-Belly syndrome – Bilateral multicystic dysplastic kidneys.

Q. The patient reports that she is going to continue the medication because she would be too embarrassed to go to work if her acne were to return. You counsel the patient about the possible risks of this approach but she desires to proceed. You counsel the patient that her best option may be to terminate the pregnancy and continue the medication. Allowing her to make this decision is an example of which of the following? A. Beneficence B. Autonomy C. Breach of confidentiality D. Malfeasance E. Justice Ans. B The pregnancy risk factor category assists the physician and patient to understand the safety of the use of a medication during pregnancy. The summary of the categories is as follows: category A—controlled human studies demonstrate no risk to a fetus. Category B—animal-reproduction studies have not demonstrated fetal risk but there are no controlled human studies to assess the risk. Category C—animal-reproduction studies have demonstrated risk to a fetus and no controlled human studies are available. Category D—evidence of human teratogenic risk exists but in some cases the known risks may be outweighed in serious situations, such as lifethreatening disease. Class X—this drug should never be used by a pregnant female under any circumstances. The principle of autonomy states that the patient has the right and capability to control the course of her medical care and to participate in the decision-making process.

Medical management of induced abortion (latest WHO guideline) This recommendation has been updated from the WHO 2012 safe abortion guidance and presents recommendations related to medical management of induced abortion at < 12 weeks and at ≥ 12 weeks.  Recommendation for induced abortion for < 12 weeks of gestation: *Combined Regimen (Recommended): 200 mg of oral Mifepristone followed 1-2 days later by 800 mcg of buccal, vaginal or sublingual Misoprostol *Misoprostol only regimen (Alternative): 800 mcg misoprostol administered vaginal, sublingual, or buccal routes. This updated recommendation applies to pregnancies up to 12 weeks of gestation, whereas, in the previous guidelines, different regimens were recommended for pregnancies up to 7 weeks, 9 weeks, and 12 weeks.  For the recommended misoprostol-only regimen, the buccal route of administration has been added and the maximum number of doses has been removed.  Recommendation for induced abortion for >12 weeks of gestation: *Recommended Combined Regimen: 200 mg of oral Mifepristone followed 1-2 days later by 400 mcg of buccal, vaginal, or sublingual Misoprostol, every 3 hours. *Misoprostol only regimen (Alternative): 400 mcg misoprostol administered vaginally, sublingually or buccally, every 3 hours. In pregnancies, more than 12 weeks of gestation the combined regimen (mifepristone and misoprostol) does not have the loading dose of 800 mcg misoprostol as in the prior guidance.  For both the combination regimen and the misoprostol-only regimen, the buccal route has been added as an option. The maximum number of doses has been removed and the time period between mifepristone and misoprostol dosing is given in days.

Q. Apoptosis can occur by change in hormone levels in the ovarian cycle. When there is no fertilization of the ovum, the endometrial cells die because: a. The involution of corpus luteum causes estradiol and progesterone levels to fall dramatically b. LH levels rise after ovulation c. Estradiol levels are not involved in the LH surge phenomenon d. Estradiol inhibits the induction of the progesterone receptor in the endometrium Ans. A The involution of corpus luteum causes estradiol and progesterone levels to fall dramatically

Q. A15-year-old female presents to the emergency room (ER) with acute onset right lower quadrant pain and nausea. She recently became sexually active and is “in the middle” of her menstrual cycle. Physical examination is notable for generalized guarding, rebound, and 8/10 pain in both lower quadrants. A pelvic examination shows no vaginal discharge, a normal appearing cervix, and general pelvic tenderness, but the examination is limited by the patient’s guarding. Her complete blood count is notable for a borderline elevated white blood cell (WBC) count, and a urinary β-hCG is negative. Pelvic ultrasound shows a 2-cm simple appearing cyst on the right ovary and a mild amount of fluid in the cul-de-sac. A computed tomographic (CT) scan cannot definitively visualize the appendix, confirms the presence of a 2-cm cystic structure in the right ovary, and otherwise notes normal anatomy. Which of the following is the most appropriate next step? A. Diagnostic laparoscopy B. I.V antibiotics C. Pelvic MRI D. Discharge home on oral antibiotics E. Admissions for serial physical examination and pain control Ans. A Acute pelvic pain is a difficult diagnostic dilemma. An acute abdomen can result from appendicitis, ovarian torsion, ruptured ovarian cyst, ectopic pregnancy, PID, diverticular abscess, and other causes. Misdiagnosis of PID is common and the most likely diagnosis confused with PID is appendicitis. In the setting where the etiology of the acute abdomen is not certain, a laparoscopy is indicated both for diagnostic and, in many cases, therapeutic purposes. A pelvic MRI or serial examinations would further delay the diagnosis. In the case of ovarian torsion or appendicitis, rapid diagnosis and treatment is critical to optimize outcomes.

Q. With regards to the nerve supply of the pelvis all are correct except A. Sensory component of the pudendal nerve supplies skin of vulva, clitoris, perineum and lower vagina B. Motor component of pudendal nerve supplies all pelvic floor muscles C. Anterior half of the vulva is supplied by ilioinguinal and genitofemoral nerves D. Posterior half of the vulva is supplied by ilioinguinal nerve only Ans. D Both the motor and sensory part of the somatic supply to the pelvic organs are through: • Pudendal nerve—S2, S3, S4. • Ilio-inguinal nerve—L1, L2. • Genital branch of genitofemoral nerve—L1, L2. • Posterior cutaneous nerve of thigh. Pudendal nerve The sensory component supplies the skin of the vulva, external urethral meatus, clitoris, perineum and lower vagina. The motor fibers supply all the voluntary muscles of the perineal body, levator ani and sphincter ani externus. Levator ani, in addition, receives direct supply from S3 and S4 roots. While the anterior half of vulval skin is supplied by the ilioinguinal and genital branch of genitofemoral nerves, the posterior part of the vulva, including the perineum is supplied by the posterior cutaneous nerve of thigh.

🔴Endometriosis🔴 ➡️Endometriosis develops in 15% of females during active menstrual life ➡️Location 1) Ovary 2) Uterine ligaments 3) Rectovaginal septum, including sigmoid colon 4) Pelvic peritoneum 5) Umbilicus 6) Laparotomy and hernia scars 7) Appendix ➡️More common in nulliparous women ➡️More common in women who become pregnant later in life 🔹Symptoms🔹 ➡️Dysmenorrhea ➡️Menorrhagia ➡️Chronic pelvic pain worsened by menstruation 🔹Signs🔹 ➡️Most have no physical findings ➡️GI involvement in 12-25% of cases of endometriosis 🔹Imaging Findings🔹 ➡️Characteristic lesion is scalloping along the anti-mesenteric side of the colon ➡️Anterior scalloping of the rectum seen best on a lateral BE film is very suggestive of endometriosis of the recto- vaginal septum ➡️Polypoid lesion ➡️Long, narrowed segment like inflammatory bowel disease ➡️Short, narrow segment like carcinoma except the mucosa is intact. By Dr Ganesh For more notes join www.aim4pg.com/study-group

Branches of uterine artery to uterus: U = Uterine artery A = Arcuate artery—supplies outer 1/3rd of myometrium R = Radial artery—supplies inner 2/3rd of myometrium B = Basal artery—supplies basal endometrium S = Spiral artery—supplies superficial endometrium

Q. A 17-year-old female presents with primary amenorrhea. On physical examination, she has normal secondary sexual characteristics, scant pubic and axillary hair, and a blind ending vaginal pouch. Apelvic MRI indicates inguinal gonads and no uterus. Her karyotype is 46,XY. Which of the following is the most likely etiology of primary amenorrhea in this patient? A. Mullerian agenesis (mayer rokitansky kuster hauser syndrome) B. Turner mosaic C. Klinefelters syndrome D. Androgen insensitivity E. Kallmann syndrome Ans. D Androgen insensitivity is an inherited disease resulting from the lack of functional androgen receptors. Gonadal function is that of normal testicles; however, there is no end-organ effect due to the lack of any functional receptors. Because the gonads produce Müllerian inhibiting substance (MIS), the Müllerian structures regress. Primary amenorrhea is therefore a common cause for presentation to a physician. Normal female secondary sexual characteristics and external genitalia result due to the absence of any effect of endogenous androgens and the production of small, but adequate, amounts of estrogen, mostly from peripheral conversion of androstenedione.

Q. A 19-year-old patient came with C/o primary amenorrhea. she had well developed breasts and pubic hair. However there was absence of vagina and uterus. Likely diagnosis is: A. Gonadal agenesis B. Turner's syndrome C. Mullerian agenesis D. Klinefelters syndrome (xxy) Ans. C The questions clearly mentions: i. Phenotype of the patient is female: This rules out Kleinefelter syndrome (47 X XY) as in kenefelters syndrome phenotype of the patient resembles a male and not female. ii. Presence of well developed breast and pubic hair and absence of uterus and vagina rules out Turners syndrome and gonadal agenesis because in both these conditions gonads (ovary) although present is streak. Hence levels of estrogen are low and so secondary sexual characteristics are not developed or less developed. Here the internal genital organs are present but not well developed due to lack of deficancy of estrogen. Thus by exclusion our answer is mullerian agenesis. Rest all of you know so much about mullerian agenesis.

Q. A pregnant lady had no complaints but mild cervical lymphadenopathy in first trimester. She was prescribed spiramycin but she was noncompliant. Baby was born with hydrocephalous and intracerebral calcification. Which of these is likely cause? A. Toxoplasmosis B. CMV C. Rubella D. Cryptococcus Ans. A A disease that results from infection with the Toxoplasma gondii parasite. Toxoplasmosis results from infection with a common parasite found in cat faeces and contaminated food. It can cause serious complications for pregnant women and people with weakened immune systems.

Q. A 39-year-old obese female presents with irregular menstrual periods, mild acne and hirsutism, and acanthosis nigricans on the nuchal fold, axilla, and intertriginous areas (inner upper thighs). You suspect PCOS. Which of the following laboratory tests would be most important to perform to rule out a likely confounding diagnosis? A. 2 hr oral glucose tolerance test B. Prolactin C. DHEAS D. LH & FSH E. Testosterone Ans. A PCOS is the most common endocrine disorder of reproductive age women. Common symptoms include oligo- or amenorrhea, acne, hirsutism, infertility, and weight gain. Common tests used to support the diagnosis of PCOS include LH to FSH ratio, testosterone, DHEAS, and pelvic ultrasound. Acanthosis nigricans is a raised, velvety, tan skin lesion commonly seen on the back of the neck, in the axilla, and the intertriginous areas. Acanthosis nigricans is associated with hyperinsulinemia and is a sign that the patient is at significant risk for prediabetes and frank diabetes. Up to 30% of patients with suspected PCOS have prediabetes, and 8% are frank type II diabetics. PCOS is a diagnosis of exclusion and requires ruling out other possible confounding diagnoses. Given the obesity and acanthosis nigricans in this patient, a 75-g, 2-hour oral glucose tolerance test would be recommended. Other common confounding diagnoses in patients with PCOS include late-onset congenital adrenal hyperplasia (screened with a serum 17-hydroxyprogesterone), Cushing syndrome (screened with a 24 hour urinary free cortisol, or overnight dexamethasone suppression test), and thyroid disease.

Q. An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30 year old, gravida 5, para 4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. The most appropriate course of action is to: A. Leave the IUD in place without any further treatment B. Remove the IUD to decrease the risk of any malformation C. Remove the IUD to decrease the risk of any infection D. Terminate the pregnancy because of high risk of malformation Ans. C A woman with an IUCD in place, with amenorrhea should have a pregnancy test and pelvic examination. An intrauterine pregnancy can occur and continue successfully to term with an IUCD in place. A. If an intrauterine pregnancy is diagnosed and IUCD strings are visible: IUCD should be removed as soon as possible in order to prevent septic abortion, premature rupture of membranes, and premature birth. Also do an USG to know whether it is intrauterine or ectopic pregnancy B. If an intrauterine pregnancy is diagnosed and IUCD strings are not visible: • An ultrasound examination should be performed to localize the IUCD and determine whether expulsion has occured. • If the IUCD is present there are 3 options for management. i. Therapeutic abortion ii. If IUCD is not fundal in location: ultrasound guided intrauterine removal of IUCD. iii. If IUCD is present in fundus of uterus: it should be left in place and pregnancy continued with the device left in place. • If pregnancy continues with the device in place, the patient should be warned of the symptoms of intrauterine infection like fever or flue like symptoms, abdominal cramping or bleeding. • At the earliest sign of infection, high dose intravenous antibiotic therapy should be given and the pregnancy evacuated promptly. By Dr Antiva For more notes join www.aim4pg.com/study-group

Book Online Consultation www.CLINO.in Cheapest Online Clinic By the Doctors Also 10% Off On Consultation For Limited Period www.CLINO.in A Online Doctors Consultation Platform By www.AIM4PG.com Team

Q. A couple complains of primary infertility inspite of staying together for 4 year and having unprotected intercourse, all tests in wife are normal. Semen analysis shows a volume of 0.8 ml/sperm count is 0, fructose is absent what is done next? A. Karyotyping B. Ultrasound for obstruction C. Testicular FNAC D. Local palpation of vas Ans. B Absent fructose in semen indicates either there is congenital absence of seminal vesicle or there is obstruction in the ejaculatory duct system. The best way to detect obstruction is to perform a transrectal ultrasound. (Also know: Role of Transrectal ultrasound in male infertility)

Q. A 5-year-old girl presents for evaluation of breast development, history of multiple bone fractures, and vaginal bleeding. Physical examination is notable for “café au lait” spots on her skin, tanner stage 2 breasts, and she appears tall for her age. What is the most likely cause of precocious puberty in this child? A. Acromegaly B. Mccune alright syndrome C. Ovarian cyst D. Ingestion of her mother's oral contraceptive E. Hyperparathyroidism Ans. B The McCune-Albright syndrome is due to a G-protein mutation in the alpha-subunit that causes constitutive stimulatory activity of the tissues. Affected tissues are autonomously active. McCune-Albright syndrome classically consists of a triad of café au lait skin spots, cystic bone lesions (polyostotic fibrous dysplasia), and autonomous endocrine hyperfunction resulting in sexual precocity. Adominant ovarian cyst develops independent of stimulation by gonadotropins and it secretes estradiol, resulting in sexual precocity and skeletal maturity. Therefore, the finding of elevated estradiol levels and suppressed or undetectable gonadotropins is diagnostic. Affected individuals also may have hyperthyroidism, hypercortisolism, pituitary gigantism, or acromegaly.