OB&G-AIM4PG

Q. In order to prevent unintended pregnancy following an episode of unprotected intercourse, by what time is it recommended to initiate the emergency oral contraception? A. 12 hrs B. 24 hrs C. 48 hrs D. 72 hrs E. 1 wk Ans. D The U.S. Food and Drug Administration (FDA) has approved the use of oral contraceptives as an effective method of postcoital contraception, often termed emergency contraception. The most common regimens involve two to four oral contraceptive tablets, depending on the dosage of the brand used, repeated 12 hours later. Progestin-only regimens are also highly effective. Initiating treatment greater than 72 hours after the event of unprotected intercourse is associated with a lower success rate.

Q. You are called to the operating room. The general surgeons have operated on a woman to rule out appendicitis and the signs of an abdominal pregnancy with an 18 week fetus and placenta attached to the omentum. The best course of action in the case is: A. Removal of the fetus & placenta B. Laproscopic ligation of the umbilical cord C. Removal of the fetus only D. Closely follow until viability and then deliver by laprotomy Ans. C Abdominal pregnancy • Management includes urgent laparotomy irrespective of period of gestation. • The ideal surgery is to remove the entire sac, fetus, placenta and membrane. This can be done if placenta is attached to a removable organ like uterus or broad ligament. • If placenta is attached to some vital organs, it is better to take out the fetus and leave behind the placenta and the sac after tying and cutting the cord with its placental attachment. • Absorption of placenta occurs by aseptic autolysis. • If placenta is left, its involution is monitored by serum hCG and USG. Dangers related to leaving placenta attached: • Infection and abscess • Adhesions • Intestinal obstruction • Wound dehiscence

Q. A 40-year-old primiparous woman suspected to be suffering from endometriosis is subjected to diagnostic laparoscopy. Findings indicate - uterus normal, both the ovaries show presence of chocolate cysts; endometriotic deposits are seen on the round ligament right side, both the fallopian tubes and the pouch of Douglas; moderately dense adhesions are present between the fallopian tubes and the pouch of Douglas. The treatment of choice in this case is: A. Total hysterectomy with bilateral salpingoophorectomy B. Danazol therapy C. Progesterone therapy D. Fulgration of endometriotic deposits Ans. D In the question it is given, dense adhesions and chocolate cyst are present which cannot be fully treated by medical therapy and so, some form of surgery is required.Main question is whether we would like to go for conservative surgery or radical surgery (i.e. TAH with BSO) Remember: mostly in endometriosis conservative surgery is done. Conservative surgery: The clinical situations involving conservative surgery include ovarian endometrioma, pelvic adhesions, peritoneal implants and deep infiltrative rectovaginal septum disease. In addition, laser laparoscopy can be used in order to perform uterine nerve ablation. By: Dr Anvita For more notes join www.aim4pg.com/study-group

Ans. A Numerous causes lead to delayed puberty. Common features of Turner syndrome include short stature, sexual infantilism, “shield” chest, “webbed” neck, high arched palate, increased carrying angle of the arms (cubitus valgus), short fourth metacarpal, and streak gonads. The diagnosis of Turner syndrome requires the presence of typical phenotypic features and the complete or partial absence of a second X chromosome. Diagnosis should be considered in individuals with primary or secondary amenorrhea and in adult women with unexplained infertility, particularly when such individuals also are short in stature. Although the FSH would be elevated in Turner syndrome, it would not differentiate among the many causes of ovarian failure. In childhood, GH therapy is standard to prevent short stature as an adult. Estrogen replacement therapy usually is required, but starting too early can compromise adult height. Estrogen usually is started from age 12 to 15 years.

Q. A 17-year-old female presents with delayed puberty. Her mother reports her daughter has never menstruated. On examination, the patient is 59 in. (4 ft 11 in.) tall and is shown in Figure . Which of the following tests is most likely to confirm the diagnosis? A. Karyotype B. FSH C. LH D. cranial MRI E. Growth hormone

Q. A 35-year-old pregnant female at 40 weeks gestational age presents with pain and regular uterine contractions every 4-5 min. ON arrival, the patient is in a lot of pain and requesting relief immediately. Her cervix is 5 cm dilated. What is the most appropriate method of pain control for this patient? A. Pudendal block B. Local block C. Intramuscular morphine D. Epidural block Ans. D When complete relief of pain is needed throughout labor, epidural analgesia is safest and simplest.

Q. You are called to a maternity ward to see a 23 year old primi patient who had delivered a 2.7 kg baby boy 2 days back.She had a normal vaginal delivery and placenta delivered spontaneously. Now she complains of bloody vaginal discharge with no other signs. O/E you notice a sweetish odour bloody discharge on the vaginal walls and introitus.Sterile pelvic examination shoes a soft non tender uterus.Her P/R-78/min, B/P-110/76 mm of hg, temp-37°C,R/R-16/min. Her WBC count =10,000 with predominant granulocytes. What is the most appropriate step? A. Curettage B. Oral antibiotics C. Reassurance D. Order urinalysis E. Vaginal culture Ans. C This patient is a purperal female who is complaining of bloody vaginal discharge with no other significant abnormal signs. On examination there is a sweetish odour bloody discharge on the vaginal walls and introitus.Her vitals are normal suggesting that this cannot be PPH (The most common cause of secondary PPH is retained bits of placenta for which curettage is done, but here it is not required). Slight amount of bloody discharge called as lochia is absolutely normal for the first 15 days after delivery and does not require any treatment, so we will reassure the patient and do nothing. Do not get confused with the finding of WBC count 10,000 with predominant granulocytes as this is a normal finding in the puerperal period. Note- leucocytes can rise to as high as 25000 during puerperium probably as a response to the stress of labor). Since lochia has no foul smell it means no infection and so no need for culture or antibiotics.

Q. An 80-year-old female who has never taken estrogen, develops pink vaginal discharge. An endometrial biopsy shows an adenocarcinoma of the endometrium. Papanicolaou smear is negative. Of the following what is the most important indicator of prognosis? A. Body habitus B. Level of CA - 125 C. Nutritional status D. Histologic type of tumour Ans. D A description of a tumor based on how abnormal the cancer cells and tissue look under a microscope and how quickly the cancer cells are likely to grow and spread. Low-grade cancer cells look more like normal cells and tend to grow and spread more slowly than high-grade cancer cells.

Q. Thirty years old G4P3L3 with 32 weeks pregancy with single live fetus in cephalic presentation, Patient complains of easy fatiguability and weakness since last 3 months which has gradually increased over last 15 days to an extent that she gets tired on doing household activities. Patient also complaints of breathlessness on exertion since last 15 days. Patient gets breathless on climbing 2 flight of stairs. It is not associated with palpitations or any chest pain. There is no history of pedal edema, sudden onset breathlessness, cough or decreased urine output. There is no history of asthma or chronic cough. There is no history of chronic fever with chills or rigors. There is no history of passage of worms in stool nor blood loss from any site. There is no history of easy bruisability or petechiae. There is no history of yellow discoloration of urine, skin or eyes. She did not take iron folate prophylaxis throughout her pregnancy. • She is suspected to be anemic and her blood sample was ordered for examination which showed. • Hb 7.4 gm% (12–14 gm%) • Hct 22% (36–44%) • MCV 72 fL (80–97 fL) • MCH 25 pg (27–33 pg) • MCHC 30% (32–36%) • Peripheral smear shows microcytic hypochromic RBCs with anisopoikilocytosis • Naked eye single tube red cell osmotic fragility test (NESTROFT) is negative. What is the most probable diagnosis? A. Thalessemia B. Iron deficiency anemia C. Megaloblastic anemia D. Vitamin B12 deficiency anemia Ans. B In the question patient has Hb 7.4 gm%, hematocrit 22% and symptoms of early fatigue, which indicate she is anemic. Her complete blood picture shows MCV and MCH are low indicating microcytic anemia. Thus differential diagnosis could either be be Iron deficiency anemia or thalassemia.

Q. A G2 P1+0+0 diabetic mother present at 32 weeks pregnancy, there is history of full term fetal demise in last pregnancy. Her vitals are stable, sugar is controlled and fetus is stable. Which among the following will be the most appropriate management? A. To induce at 38 wks B. To induce at 40 wks C. C-section at 38 wks D. To wait for spontaneous delivery Ans. A The most common time of IUD in a diabetic patient is last two weeks of pregnancy, since in this patient there is history of a full term demise as well, so logically speaking we should terminate her pregnancy at 38 weeks.This is what logic says, now let us see what references have to say High risk gestational diabetes: ▫️History of stillbirth ▫️History of neonatal death ▫️History of fetal macrosomia ▫️Concomitant obesity and/or hypertension ▫️Development of oligohydramnios, polyhydramnios preeclampsia or fetal macrosomia ▫️Inadequate metabolic control with diet alone. “High risk gestational diabetic patients should have their labor induced when they reach 38 weeks with exception of those with a macrosomia fetus (Efw > 4000 g) who should be delivered by cesarean section because of the increased risk of shoulder dystocia”. —Ref. Fernando Arias 3/e, p 449 Induction of labor: The indications are— (i) Diabetic women controlled on insulin (GDM or class B diabetes) are considered forinductionoflaborafter38completedweeks(ii)Womenwithvascularcomplications(pre-eclampsia,IUGR)oftenrequire induction after 37 weeks. Also know: In case of low risk gestational diabetes - patient may be allowed to go into spontaneous labour. In any case, the pregnancy should not be allowed to overrun the expected date. Route of Delivery: Diabetes per se is not an indication for caesarean section. Vaginal delivery may be allowed if there are no maternal or fetal complications, the cervix is favourable, the baby is of average size and the presentation is vertex with no cephalopelvic disproportion. In such cases, labour may be induced. Continuous CTG monitoring in labour is mandatory. Shoulder dystocia must be anticipated in labour. Macrosomic fetus with weight > 4500 g at term cesarean section is indicated. If weight is between 4000 g–4500 g vaginal delivery or cesarean section, the decision depends on the obstetrician (According to ACOG)

A23-year-old female presents to her obstetrician/ gynecologist (OB/GYN) complaining of inability to conceive. She has regular menstrual cycles, and her husband’s semen analysis is normal. She undergoes a hysterosalpingogram that shows evidence of bilateral distal tubal obstruction. Which of the following is the most likely cause of acquired tubal damage? A. Appendicitis B. Pelvic inflammatory disease C. Ruptured ovarian cyst D. Salpingitis isthimica nodosa E. Asherman's syndrome Ans. B PID is the most common cause of Fallopian tube damage. It is a polymicrobial infection that originates from upward spread of infecting organisms through the cervix and into the uterus, Fallopian tubes, or peritoneal cavity. The two most common pathogens are Neisseria gonorrhea and Chlamydia trachomatis; however, microorganisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae) also have been associated with PID. Symptoms of PID include lower abdominal pain, dyspareunia, fever, back pain, and vomiting, as well as symptoms of lower genital tract infection such as abnormal vaginal discharge or bleeding, itching, and odor. In some women, symptoms are mild or even absent. Risk factors for PID include the presence of a sexually transmitted infection, a previous episode of PID, sexual intercourse at an early age, high number of sexual partners, and alcohol use. Empiric treatment of PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination: cervical motion tenderness OR uterine tenderness OR adnexal tenderness. Other common causes of acquired tubal damage include endometriosis, previous pelvic surgery, and a ruptured appendix.

29) A34-year-old Black (G1 ) female presents to your clinic for an obstetric visit at 16 weeks estimated gestational age (EGA). She has a sure LMP and her estimated date of delivery (EDD) is in December. She is generally healthy and has not had any surgeries. She denies history of sexually transmitted diseases or abnormal pap smears. She has no significant family history. She does not smoke or use alcohol or illicit drugs. She works as an administrative assistant. Her prenatal labs are as follows: blood type O+, antibody screen negative; hepatitis B surface antigen negative; HIV antibody negative; Rubella nonimmune; rapid plasma regain (RPR) nonreactive; pap smear within normal limits; urine culture negative. Based on her laboratory results and history, you recommend that she receive which of the following injections during her pregnancy? A. MMR vaccine B. Influenza vaccine C. Hepatitis B vaccine series D. Poliomyelitis vaccine E. RhoGAM injection Ans. B Influenza vaccination is recommended to all women who will be in the second or third trimester of pregnancy during the flu season. Poliomyelitis vaccination is not recommended for women in the United States unless they have some increased risk due to travel or exposure. MMR vaccination is contraindicated in pregnancy secondary to a theoretic risk of teratogenicity from the rubella vaccine. MMR should be given to this patient postpartum. RhoGAM is recommended routinely during pregnancy in Rh negative women who are unsensitized to Rh factor. In this case the patient is Rh positive.

30) A23-year-old female presents to the emergency department (ED) with “abdominal cramping,” nausea, and vaginal bleeding. A human chorionic gonadotropin (hCG) level returns 5150 mIU/mL. Avaginal probe ultrasound is performed and notes no evidence of an intrauterine pregnancy, normal appearing ovaries, a mild amount of fluid in the cul-de-sac, and no evidence of ectopic gestation. The ED physician can exclude which diagnosis from the differential? A. Spontaneous abortion B. Ectopic pregnancy C. Single intrauterine pregnancy D. Ruptured ovarian cyst (corpus luteum) E. Molar pregnancy Ans. C Differentiating between an ectopic pregnancy, an early intrauterine pregnancy, or a miscarriage is a common dilemma for the ED physician. Transabdominal ultrasound (TAUS) requires a β-hCG level of 6500 mIU/mL before an intrauterine gestation can be confidently visualized. Transvaginal ultrasound (TVUS) is the most accurate means of confirming intrauterine pregnancy and gestational age during the early first trimester. TVUS can help detect signs of intrauterine pregnancy approximately 1 week earlier than TAUS because it has a lower discriminatory zone (β-hCG level between 1000 and 1500 mIU/mL). ATAUS that does not detect an intrauterine gestational sac with a β-hCG level higher than 6500 mIU/mLor a TVUS examination that does not detect an intrauterine gestational sac when the β-hCG level is higher than 1500 mIU/mL suggests an ectopic pregnancy. The literature provides a wide range of sensitivities and specificities for transvaginal ultrasonography in the detection of ectopic pregnancy. Sensitivities range from 69 to 99%, and specificities range from 84 to 99.6%.

Q.A 31-year-old female presents to her physician complaining of rapid onset of hirsutism, deepening of the voice, irregular menses, clitoral enlargement, and acne. Which of the following is the most likely cause of this clinical presentation? A. PCOS B. Type ll DM C. Cushing syndrome D. Androgen secreting Tumour E. Congenital adrenal hyperplasia Ans. D Androgen excess syndromes are common and usually characterized by one or more of the following problems: hirsutism, acne, weight gain, or irregular menses. PCOS is the most common disorder of androgen excess. Other syndromes that often result in signs and symptoms of androgen excess in adults include Cushing syndrome and late-onset congenital adrenal hyperplasia. The classic presentation of a patient with an androgen-secreting tumor of the ovary or adrenal gland involves the rapid onset of symptoms. Late-onset congenital adrenal hyperplasia and an androgen-secreting tumor are the only disorders of androgen excess usually resulting in clitoromegaly. By Dr Anvita For more notes join www.aim4pg.com/study-group

Management of shoulder dystocia (BE CALM)

HAPPY NEW YEAR 2022 A SMALL GIFT FROM AIM4PG www.aim4pg.com/calendar WISHING YOU A PROSPEROUS YEAR WITH YOUR DREAMS COME TRUE From AIM4PG Team

A 23 Yr old G1P0 woman at 38 wks gestation delivered a 7lb 4 oz baby boy vaginally. Upon delivery of the placenta, there was noted to be an inverted Uterus, which was successfully managed including replacement of the Uterus. Which of the following placental implantation sites would most likely predispose to an inverted uterus? A. fundal B. anterior C. posterior D. lateral E. lower segment Ans. A A fundally implanted Placenta predisposes to uterine inversion. A placenta implanted in either the anterior, posterior, lateral or lower segment of the uterus does not have the direct angle that a fundally implanted Placenta has through the cervix and out the vagina. The best method for preventing inversion is to await spontaneous separation of the placenta from the uterus before placing traction on the umbilical cord.

Measurements in the 1st trimester: 1. Mean sac diameter 2. Crown rump length Measurements in the 2nd and 3rd trimester. 1. Biparietal Diameter 2. Head Circumference 3. Abdominal Circumference 4. Femur Length Other important points: -   CRL (till 14 weeks): Most accurate determination of gestational age - In the 2nd trimester, the BPD most accurately reflects gestational age with a variation of 7 to 10 days. - If fetal head is dolichocephalic (flattened) or brachycephalic (rounded); HC is a more reliable parameter for gestational age determination -  AC has the greatest variation and hence least reliable for gestational age. By Dr Anvita For more notes join www.aim4pg.com/study-group