Q.

1 Identify the grip in the picture used for checking ballotability of head

A.pelvic grip

B.pawlick grip

C.fundal grip

D.umbilical grip

Ans.pawlick grip

Ref-Arul Kumaran labour management 6th edition p.633

Mudaliar and Menons clinical obstetrics 12th edition p.76

WILLIAMS obstretics p.453

Obstetric grips(leopold manoeuvrs)

1)fundal grip (first leopold)

2)lateral/umbilical grip(second leopold)

3)first pelvic grip(third leopold)/pawlick grip

4)second pelvic grip(fourth leopold)

Importance of Pawlick grip:

- To determine which part of the foetus occupies the lower part of uterus

1. head(independently ballotable)

2. breech(not independently ballotable)

3. empty lower pole(transverse lie) NEET PG

Q.2 Name the instrument seen in the picture

A.mayo scissor

B.episiotomy scissor

C.suture remover

D.curved scissor

Ans.episiotomy scissor

Ref-Arul Kumaran labour management 6th edition p.701

WILLIAMS obstretics p.203

Episiotomy scissor

Angulation in the scissor:

-To prevent extension of pelvic tears in to the anal margins(OASIS/CPT)obstretic

anal sphincter injuries / complete perineal tear.

Structures cut in episiotomy;

1)vaginal mucosa

2)superficial and deep transverse perineal muscles,bulbospongiosus,levator ani

muscles.

3)internal pudendal blood vessels

4)subcutaneous tissue and perineal skin

Degrees of perineal tear: NEET PG

1st degree: perineal skin

2nd degree:perineal muscles

(includes episiotomy)

3rd degree: second degree + anal sphincter complex

3a. <50% of thickness of external sphincter

3b. >50% thickness of external sphincter

3c. internal sphincter involved

4th degree: anal sphincter complex and rectal mucosa

Q3.In partogram first time of the initial markings are made in

A.left side of the action line

B.right side of the action line

C.left side of the alert line

D.right side of the alert line

Ans.left side of the alert line

Ref-Arul Kumaran labour management 6th edition p.467

Mudaliar and Menons clinical obstetrics 12th edition p.401

WILLIAMS obstretics p.1109

Partograph-

Principle changes in the modified WHO partograph

-Latent phase removed

Components of the partograph:
-Active phase begins from 4cm cervical dilatation
foetus:-
-2 squares in 1 hour.
-foetal heart rate

-colour of amniotic fluid

-moulding.

labour:-

-cervical dilation,

-descent of foetal head,

-uterine contraction.

mother:-

-pulse,

-BP,

-temperature,

-urine examination.

-Partograph should be potted from the left side of the alert line.

- when curve reaches right side of the alert line indicate delay in labour.
-there will be differance of 4 hrs between alert line and action line.

Q4.Fixative used in PAP smear

A.55% ethyl alchohol

B.95% formalin

C.95%ethyl alcohol

D.normal saline

Ans.95%ethyl alcohol & 5%ether

Ref- Shaws Gynecology 16th edition p.343

Novaks Gynecology 15th edition p.987

WILLIAMS gynecology 16th edition p.1123

new guidelines for PAP (screening guidelines):

American college of obstetrics and gynecology(ACOG)& US preventive services task

force(USPSTF):

1) begin at age 21

2)from age 21 to 29 :

a)screen every 3 years with pap smear

b)HPV testing should not be used

3)from age 30 to 65

a)screen every 5 years with pap smear and HPV co testing

b)screen every 3 years with pap smear alone

4)stop screening at 65 if previous smears are negative

5)no screening done after hysterectomy unless done for CIN 2&3

6)continue screening for women treated for CIN2&3

-liquid based cytology are used now a days. Here fixative used is METHANOL

Q5.Nanovalent vaccine offers protection against which type of HPV virus

A.types 6,8,10,11,31,33,45,52,&58

b.types 6,11,16,18,31,33,45,52,58

C.types 6,11,16,18,31,35,45,52,58

D.types 6,11,16,18,19,31,32,33,34

Ans.b.types 6,11,16,18,31,33,45,52,58

Ref- Shaws Gynecology 16th edition p.623

Novaks Gynecology 15th edition p.1203

WILLIAMS gynecology p.1002

bivalent vaccine:

16&18

CERVARIX

only for girls.

quadrivalent vaccine:

6,11,16,18

GARDASIL

both for boys and girls

Nanovalent vaccine:

6,11,16,18,31,33,45,52,58

GARDASIL 9

both for boys and girls

3 doses -0,2&6 months

0.5 ml given IM.

Q6. According to Naegele's rule, calculate EDD of a patient with LMP 9/01/2017

A.16/10/2017

B.16/09/2017

C.16/11/2017

D.9/10/2017

Ans.16/10/2017

Ref-Arul Kumaran labour management 6th p.153

WILLIAMS obstretics p.423

EDD is calculated by Naegele's rule

-Adding 7 days to the date of first day LMP and counting back 3 months or
forwarding 9 months.

Naegele's rule is based on 28 days regular cycle.

If the cycle is shorter or longer than 28 days, EDD will be corrected and written as
corrected EDD.

Examples:

A) If she is having 40days cycle regularly, to get corrected EDD, add 12 days
(40-28) with the EDD calculated from LMP.

B) if she is having 21 days cycle regularly, to get corrected EDD, subtract 7

days(28-21) with the EDD calculated from LMP.

Q7. A 18 year old female presents with an ovarian mass, her serum bio marker are
found to be normal except for LDH, which is found to be elevated. The most likely
diagnosis is

A.Dysgerminoma

B.Endodermal sinus tumor

C.Malignant terratoma

D.Mucinous cystadeno carcinoma

Ans.A.Dysgerminoma

Ref- Shaws Gynecology 16th edition p.821

 Novaks Gynecology 15th edition p.1223

WILLIAMS gynecology 16th edition p.987

Germ Cell Tumors(GCT) are most common ovarian tumors in the reproductive age
group.

DYSGERMINOMA:

-Most common malignant GCT of ovary

-Most radio sensitive GCT

-GCT with best prognosis

-Most common tumor seen in dysgenetic gonads along with

gonadoblastoma.

Tumour marker: LDH and ALP

-Found in both gonad and extra gonadal sites.

-Cut section is fleshy in nature

-80% unilateral and 15-20% cases are bilateral.

TUMOR MARKERS:

1)Dysgerminoma-

-LDH

-ALP

2)Endodermal sinus tumor-

-ALPHA FETO PROTEIN

-ALPHA 1 ANTITRYPSIN
3)GRANUOSA CELL TUMOUR

-INHIBIN B

4)SEROUS CYSTADENOCARCINOMA

-CA125

5)MUCINOUS CYSTADENOCARCINOMA

-CEA

-CA19-9

HISTOLOGICAL MARKERS:

1)Endodermal sinus tumor- Schiller duval body

2)Granulosa cell tumour- call-exner bodies/coffee bean nuclei

3)Serous epithelial tumours- psammomma body

4)Brenner tumour-walthard cell nest

5)Krukkenberg tumour - signet ring cell

6)Clear cell tumour-hobnail cells

7)Hilus cell tumour-reinke's crystal

Q8.A primigravida came with 6 cm cervical dilatation with contraction rate of 3/10
min.which stage of labour is she in

A.first stage

b.second stge
C.third stage

D.fourth stage

Ans.first stage

Ref- Arul kumaran labour management 6th edition p.127

WILLIAMS obstretics p.321

1st stage (onset of true labour pains to full cervical dilatation):

<4cm (latent phase) 4 or more cm -active phase

maximum A)cervical dilation:

primi- 20hrs primi-1.2 cm/hr.

multi-14hrs multi-1.5 cm/hr.

Average B)Descent:

Primi-12 hours primi-1cm/hr.

Multi- 6 hours
multi-2cm/hr.
2nd stage(delivery of baby):

primi: max 2hr avg-1hr

multi: max 1hr avg-30min

IN EPIDURAL ANALGESIA(PAINLESS LABOR)

PRIMI 3 HOURS

MULTI 2 HOURS

3rd stage(delivery of placenta):

maximum time-30min(both primi and multi)

avg-15min (primi),

5min(multi)

4th stage(1hr observation):

m/c complication PPH.

Q9.Postmenopausal female with biopsy report as endometrial hyperplasia with

atypia-next line of management is

A)type 1 hysterectomy
B)oral progestins

C)mirena

D)dilatation and curretage

ANS: A)type 1 hysterectomy(simple hysterectomy-intrafascial variety)

Ref -Shaws gynaecology 16th edition p.826

NOVAK's gynecology 15th edition p.1121

Williams gynecology

CHANCES OF MALIGNANCY;

1)simple hyperplasia without atypia-1%.

2)complex hyperplasia without atypia-3%.

3)simple hyperplasia with atypia-8%.

4)complex hyperplasia with atypia-29%.

HYPERPLASIA WITHOUT ATYPIA HYPERPLASIA WITH ATYPIA:

(all ages);

-LNG-IUS(MIRENA)=1st line 1)postmenopausal women/women

-POP/DMPA/IMPLANON
if fails endometrial ablation
completed family -
-simple (type1 ) hysterectomy i.e intrafascial
variety(always extrafascial variety only for
malignancy).

2)young women/not completed family -

-LNG-IUS/POP/DMPA(duration 9 to 12
 months)

biopsy 3 monthly.

Q10.for effective protection after unprotected intercourse one single tab of

levonorgestrel 0.75mg already been taken, when to take next dose?

A)1 tab after 24hrs.

B)1 tab after 12hrs.

C)2 tab after 12hrs.

D)2 tab after 24hrs.

ANS- B)1 tab after 12hrs.

Ref-Shaws gynaecology 16th edition p.609

EMERGENCY/POSTCOITAL CONTRACEPTION(morning after pill):

-hormonal cutoff 3 days.

-copper T cut off 5 days.

OLD:Yuzpe method(within 72hrs) NEW

not followed

high dose OCPs 2+2 (12 hrs apart) 750 micrograms (0.75mg) 1+1 (12 hrs
apart)

OR OR

low dose OCPs 4+4 (12 hrs apart) 1500 micrograms 1 tab (followed now)

OTHERS:

1)mifepristone(RU486).

2)ulipristal 30mg tab.

3)centchroman 60mg.

4)GnRH agonists (buserelin).

5)copper T IUCD.

6)prostaglandins.

7)Danazol
Q11.which of the following drug must always be available for emergency use in
labour ward if a patient on opoid analgesia?

A)fentanyl

B)naloxone

C)morphine

D)bupivacaine

ANS: Naloxone

Ref- Arul Kumaran labor management 6th edition p.221

SIGNS AND SYMPTOMS OF OPIOID TOXICITY:

-nausea and vomiting

-drowsiness

-resiratory deprression

-delayed gastric emptying

-decreased variability on fetal heart tracing

-neonatal respiratory depression

Naloxone may be given to the mother if delivery become imminent soon after
giving to these group of opioid analgesics

however it is perhaps better to give it to the neonate at birth if it exhibits low apgar
in absence of other causes of resiratory depression

To the mother -400mcg iv

To the depressed neonate -10 mcg/kg of birth wieght in to the umbilical vein
Q12.father of 2 children now they are not able to conceive diagnosed to be having
hypogonadotrophic hypogonadism which of the following is not true.

A)low LH AND FSH

B)low testosterone

C)oligospermia

D)high prolactin levels

Ans:High prolactin levels

Ref- Shaws gynecology 16th edition p.431

Novocks gynecology 15th edition p.782

Williams gynecology p.921

HYPOGONADOTROPHIC HYPOGONADISM:

-low LH &FSH

-low testosterone

-low testicular volume(oligospermia)

-low prolactin levels

 HYPERGONADOTROPHIC HYPOGONADISM:

-high LH and FSH

-low testosterone

-low testicular volume(oligospermia)

-high prolactin level

NORMOGONADOTROPHIC HYPOGONSDISM:

-ormal LH and FSH

-normal testosterone

-normal testicular volume

-normal prolactin levels

Q13.Deepest part of perineal body injury to which causes cystocoele,entercoele &

urethral descent

A)pubococcygeous

B)ishchiocavernosus

C)bulbospongiosus
D)sphincter of urethra and anus

ANS:pubococcygeous(pelvic diaphragm)

Ref- Shaws gynecology 16th edition p.493

Novacks gynecology 15th edition p.861

Williams gynecology p.1012

Telindes gynecology p.983

pelvic diaphragm consists of two levator ani muscles

EACH LEVATOR ANI MUSCLES HAS 3 PARTS:

-Pubococcygeous

-Iliococcygeous

-Ischiococcygeous

PUBOCOCCYGEUS: Arising from pubic bone, passing lateral to vagina and rectum
and inserted in to coccyx.

A. Fibers passing close to rectum -Puborectalis

B. Some fibers decussate between vagina and rectum, these fibers divide space
between two levator ani muscles.

1)anterior portion-hiatus urogenitalis

2)posterior portion-hiatus rectalis

Perineal tears occuring during parturition divide these decussating fibers causing
hiatus urogenitalis and hiatus rectalis to become patulous and lead to prolapse.
 Q14.18 year old girl with primary amenorrhea having a karyotype of
45X0/presents with infantile uterus. What should be done next?
a. HRT to induce puberty
b. Vaginoplasty
c. Clitoroplasty
d. B/L gonadectomy

Ans. D
Ref: Leon speroff endocrinology, 8th ed, pg.461,
Novaks gynecology, 15th ed, pg. 1040
Williams gynecology, pg. 841
Explanation:
Turners syndrome is usually associated with a karyotype of 45X. Patients
with turner usually present at or near the time of expected puberty with
primary amenorrhea and absent secondary sexual development.
Approximately 5% of women with turner have a karyotype with Y
chromosome ( 45X/46XY ). It is important to identify a Y chromosome
because affected individuals are at significant risk of gonadablastoma ( 20 to
30% ).
The other condition with 45XO/46XY is mixed gonadal dysgenesis where the
gonad is testis on one side and streak on the other side. In this condition
there is variable androgen secretion and features of partial masculinisation
of external genitalia.
So friends,from the above discussion it is clear that gonadectomy followed
by HRT should be done for the above condition and in addition clitoroplasty
will also be required if it is mixed gonadal dysgenesis out of which the most
important and the first step is gonadectomy.
Q15. A primigravida was given dietary advice in the first trimester. What should
be the extra calorie intake in pregnancy?
a. 200 kilocal
b. 300 kilocal
 c. 500 kilocal
d. No extra calories

Ans: d
Ref: William obstetrics 24th ed pg.178
Explanation:
Pregnancy requires an additional 80,000 kilocal mostly during the last 20
weeks. Recommended calorie increase during pregnancy is 100 to 300
kcal/day. Institute of medicine recommends adding 0,340,452 kcal/day in
the 1st ,2nd, 3rd trimesters respectively.

Q16.You treat a 27 year old infertile patient with bromocriptine. What should
be the diagnosis?
a. Hyperpituitarism
b. Hypopituitarism
c. PCOS
d. Hyperprolactinemia

Ans: d
Ref: Novaks gynec ,15th ed,pg 1107
Explanation:
Bromocriptine is an ergot alkaloid, a strong dopamine agonist, decreases
prolactin levels within hours.
Dose : 1.25 to 2.5 mg BD

Q17. 35 year old woman comes with postcoital bleeding. What is the next step?
a. PAP smear
b. Conisation
c. Cryotherapy
d. Targeted Biopsy
 Ans: d
Ref: Novaks gynecology 15th ed, pg 1305, 597-605
o Explanation:
Option A: The false negative rate of pap smear in the presence of invasive
cancer is 50% and a negative pap test should never be relied on in a
symptomatic patient.

Option B: Conisation is an invasive procedure where the cervix is cut in a

cone shaped manner. It is both diagnostic and therapeutic. Conisation is
indicated for diagnosis in women with HSIL or AGC- adencarcinoma in situ
and may be considered under the following conditions
Limits of the lesion cannot be visualized
SCJ is not seen at colposcopy
Endocervical curettage is positive for CIN 2/CIN 3
Lack of correlation between cytology, biopsy and colposcopy
Suspected microinvasion in cytology,colposcopy or biopsy
Colposcopist is unable to rule out invasive cancer

Hence it is very clear that conisation is not indicated for all symptomatic
women and it should be done following either a PAP, colposcopy or a biopsy
with abnormal or inconclusive result

Option C: Cryotherapy destroys the surface epithelium of the cervix by

crystallizing the intracellular water using nitrous oxide or carbondioxide.
Cryotherpy is ideal only for small superficial lesions. Cryotherapy is
appropriate for
CIN 1 that has persisted for more than 24 months
Confined to the ectocervix
 No endocervical involvement. Cytology or biopsy from the endocervix is
normal.

o Hence cryotherapy is indicated only for biopsy proven cases of

abnormal epithelium.

-Dr. Anil Thimmanayaka

-Dr. Vidya