17

20
OBSTETRICS AND
ov
tN
GYNECOLOGY
en

Questions
em
pl

Answers
up

Explanations
IS
PG
PGI Supplement November 2017

1. Most common cause of secondary postpartum hemorrhage: 2. Management of postmenopausal women with stress urinary
a. Trauma incontinence include (s):
b. Atonic uterus a. Kegel pelvic floor exercise
c. Bleeding disorders b. Retropubic cystourethropexy
d. Retained products of conception c. Intermittent self catheterization
e. Coagulopathy d. Anticholinergic drugs
e. Retopubic midurethral sling procedures
Secondary Postpartum Hemorrhage
Dutta Obs 8th/483; Obs by JB Sharma 1st/341-42 Management of Stress Incontinence Dutta Gynae 7th/331-32
•• The bleeding usually occurs b/w 8th and 14th day of delivery •• Sympathomimetic drugs (α-adrenergic drugs)-Imipramine
•• Retained bits of cotyledon or membranes (most common) •• Retropubic cystourethropexy (colposuspension)
•• Endometritis and subinvolution of placental site •• Retopubic midurethral sling procedures
•• Secondary hemorrhage from CS wound Genuine Stress Incontinence (GSI) Shaw’s Gynae 16th/225
•• Withdrawl bleeding following estrogen therapy for suppression of •• Age: Old postmenopausal women with loss of pelvic muscle tone

17
lactation are liable to develop (estrogen deficiency)
•• Infection and separation of slough over a deep cervicovaginal •• GSI is the only kind which can be cured by surgical procedures,
laceration hence the importance of making a correct diagnosis prior to

20
•• Other rare cause- chorionepithelioma, carcinoma cervix, placental planning any surgical repair
polyp, infected fibroid polyp, puerperal inversion of uterus •• GSI require to be differentiated from urge incontinence, DI and a
•• Coagulopathy- Gabbe 6th/426 (Table) neurological bladder
Late Postpartum Hemorrhage William’s Obs 24th/1395-96 •• Lifestyle interventions can decrease stress urinary incontinence

ov
•• The American College of Obstetricians and Gynecologists in many women
(2013) defines secondary postpartum hemorrhage as bleeding 24 •• Vaginal devices (pessaries) and urethral inserts are available for

••
hours to 12 weeks after delivery.
Clinically worrisome uterine hemorrhage develops within 1 to
tN ••
treating stress urinary incontinence. Novak’s 15th/885
Urethral inserts are sterile inserts placed into the urethra by the
2 weeks in perhaps 1 percent of women. Such bleeding most patient and removed before a void, after which a new sterile
often is the result of abnormal involution of the placental site. insert is placed. Such inserts are appropriate for women with
en
It occasionally is caused by retention of a placental fragment or relatively pure stress incontinence, no history of recurrent
by a uterine artery pseudoaneurysm. urinary tract infections, and no serious contraindications to
bacteriuria (e.g., artificial heart valves)- Novak’s 15th/885-86
em

•• Usually, retained products undergo necrosis with fibrin

deposition and may eventually form a so-called placental polyp. “Anticholinergic Agents: These agents represent first-line
As the eschar of the polyp detaches from the myometrium, medicinal therapy in women with urge incontinence. These agents
hemorrhage may be brisk. are useful in treating urinary incontinence associated with urinary
pl

•• Delayed postpartum hemorrhage may also be caused by von frequency, urgency, and nocturnal enuresis”- emedicine.medscape.
Willebrand disease or other inherited coagulopathies com; Novak’s 15th/887
up

“Retained products of conception (namely placental tissue Anticholinergic Agents are useful in Detrusor Instability-
and amniotic membrane) complicate 1 in 100-200 deliveries”- Gabbe Shaw’s Gynae 16th/233; Novak’s 15th/887
6th/435 “The mainstay in the treatment of voiding difficulty is clean,
IS

“Uterine inversion is a rare event, complicating about 1 2000 to intermittent self catheterization. The most important protection
1in 23000 deliveries”- Gabbe 6th/437 against urinary tract infection is frequent and complete bladder
Primary postpartum hemorrhage: Atonic uterus (80%) is the emptying rather than avoiding the introduction of a foreign body into
PG

commonest cause- Dutta Obs 8th/475 the bladder. Voiding difficulty may be caused by neurologic diseases,
such as multiple sclerosis, medications (such as antihistamines and
anticholinergic agents), infections (in particular, herpes simplex
virus, and urinary tract infections), obstruction (following bladder
neck surgery, or in women with advanced pelvic organ prolapse),
overdistension, severe constipation (particularly in the elderly), and,
rarely, psychogenic factors”- Novak’s 15th/900

Answer
1.  . Retained products of conception
d [Ref: Dutta Obs 8th/483; William’s Obs 24th/1395-96; Obs by JB Sharma 1st/341-42; Normal and Problem
 Pregnancy by Gabbe 6th/426]
2. a. Kegel pelvic floor exercise; b. Retropubic cystourethropexy; e. Retopubic midurethral sling procedures [Ref: Shaw’s Gynae 16th/229-32; Dutta
 Gynae 7th/331-32; Novak’s 15th/882-900]

126
 Obstetrics and Gynecology

Table 1. (Shaw’s Gynae 16th/230): Management of stress (remove IUD first); chronic adrenal failure; concurrent long-
incontinence term corticosteroid therapy; history of allergy to mifepristone,
misoprostol, or other prostaglandin; and the inherited
Conservative Drugs Surgery porphyrias.
1 line of treatment
st
• Oestrogen cream 1. If others fail •• The mifepristone–misoprostol combination was studied for
• Young woman in menopausal  • Vaginal (Kelly) gestations at 9 to 13 weeks; although it is almost as effective
• Frail, old woman woman  • Abdominal as earlier in pregnancy, a larger proportion of patients will
• Postpartum, • Venlafaxine 75 mg 2. Marshall– experience heavy bleeding and require vacuum curettage
previous failed daily Marchetti–Krantz
Contraindications to Medical Abortion William’s Obs 23rd/232
surgery • Imipramine 10–20 and Pereyra
mg BD Burch
•• In addition to specific allergies to the medicines, they have
ƒƒ Combined
included an in situ intrauterine device, severe anemia,
1.  K
 egel pelvic floor coagulopathy or anticoagulant use, and significant medical
vaginal and
exercises × 4–6
abdominal conditions, such as active liver disease, cardiovascular disease,
months
suspension and uncontrolled seizure disorders.

17
2.  E lectric/magnetic ƒƒ Slings •• Additionally, because misoprostol can lower glucocorticoid
stimulation for ƒƒ Tension –free activity, women with adrenal disease or with disorders requiring
nerve damage, sling glucocorticoid therapy should be excluded.
magnetic

20
ƒƒ Transobturator
stimulation type 4. Which of the following contraceptive will be effective when
3. Laparoscopic used alone after 15 day of menstrual cycle:
3.  A
 rtificial urinary
sphincter in suspension of a. Levonorgestrel IUCD

ov
neurological bladder neck b. Progesterone only pill
condition c. Combined oral contraceptives (COC)
d. CuT IUCD
4.  Vaginal cones tN e. LNG emergency pill
3. Absolute contraindication of medical abortion:
Answer should be those method which prevent present risk of pregnancy
a. Previous LSCS
and provide medium and long term method of contraception. From
en
b. Previous myomectomy
above options, CuT (>LNG-IUCD) is single best answer. CuT prevent
c. Suspected ectopic pregnancy
implantation of even fertilized egg. LNG-IUCD act through prevents
d. Prostaglandin hypersensitivity
penetration of sperm, endometrial atrophy and prevention of ovulation
em

e. Severe rheumatic heart disease

“Intercourse b/w 11th and 17th day may result in a pregnancy”-
Absolute C/I of medical abortion: Suspected ectopic pregnancy or Shaw’s Gynae 16th/265
undiagnosed adnexal mass; Allergy to any drug”-J B Sharma 1st/126 Emergency contraception (EC) Dutta Obs 8th/629-30
pl

Table 2.(Robert Shaw Gynae 4th/435): Contraindication of medical •• LNG (0.75 stat and after 12 hour)
•• Cu IUCD (gold standard): Introduction within maximum
abortion
up

period of 5 days can prevent conception following accidental

Absolute contraindications unprotected exposure. This prevent implantation. It is gold
• Adrenal insufficiency standard method to be offered to all women for EC
IS

• Ectopic pregnancy IUD- CuT and LNG-IUS. It can be used as postcoital

• Asthma contraceptive- Dutta Obs 8th/615-16
• Cardiac disease COC: Simple regime of 3 week on and 1 week off is to be
PG

• Heavy smoker followed. New users should normally start their pills packet on day
• Older than 35 years 1 of their cycle”- Dutta Obs 8th/623
• On anticoagulants or bleeding disorder POP: It has to be taken daily from the 1st day of the cycle- Dutta
Relative contraindications Obs 8th/627
• Heavy smoker Minipill/Progestogen-only pill: The tablet is taken daily
• >35 years without break. The bill should be started within 5-7 days of the
• Obesity menstruation and taken at same time with a leeway of 3 hr on either
• Hypertension (diastolic > 100 mmHg) side of fixed time each day. If this regime is nt observed any day, the
women continues with POP but observes extra precaution for 48 h”-
Shaw’s Gynae 16th/275
Contraindications to Medical Abortion Novak’s Gyae 15th/256-57 IUD (Interval): It is preferable to insert 2-3 days after the
•• Contraindications to medical abortion with mifepristone/ period is over. But can be inserted any time during the cycle even
misoprostol include ectopic pregnancy; an IUD in place during menstrual phase which has certain advantage- Dutta Obs
Answer 8th/616
3. c . Suspected ectopic pregnancy; d. Prostaglandin hypersensitivity; e. Severe rheumatic heart disease [Ref: Dutta Obs 8th/204,206; J B Sharma
 1st/126; William’s Obs 23rd/232; Novak’s Gyae 15th/256-57; Robert Shaw Gynae 4th/435]
4. d. CuT IUCD [Ref: Shaw’s Gynae 16th/275; Dutta Gynae 7th/270; Dutta Obs 8th/629-30]

127
PGI Supplement November 2017
“It is advisable to insert IUCD during or soon after menstruation
and after abortion or MTP. Lately, immediate postpartum insertion
within 10 min of placental expulsion or within 24 hr of delivery is
practical and is found effective”- Shaw’s Gynae 16th/270
5. A women forget to take 3 Combined oral contraceptive
(COC) active pills. What should she do now:
a. Take all missing piles at a time and continue rest pills as
usual
b. For 2–3 day use barrier method and continue rest pills as
usual
c. Immediately switch to non hormonal contraceptives ( e.g.
CuT-IUD) and discontinue COC
d. If she exposed to recent intercourse, use emergency
contraceptive
e. Use another method of contraception like barrier method
for remaining period and start next COC pack without
break
Missed Combined oral contraceptive (COCs): Management
Dutta Gynae 7th/400
•• When a woman forgets to take one pill (late up to 24 hours),
she should take the missed pill at once and continue the rest as
schedule. There is nothing to worry.
•• When she misses two pills in the first week (days 1-7), she
should take 2 pills on each of the next 2 days and then continue
the rest as schedule. Extra precaution has to be taken for next 7
en
days either by using a condom or by avoiding sex.
•• If 2 pills are missed in the third week (days 15-21) or if more
than two active pills are missed at any time, another form
em
of contraception should be used as back up for next 7 days as
mentioned above. She should start the next pack without a
break. If she misses any of the 7 inactive pills (in a 28-day pack
pl
only) she should throw away the missed pills. She should take
the remaining pills one a day and start the new pack as usual.
up
“If she forgets to take a tablet, she should take two tablets the
following day.If she forgets to take tablet more than once in a cycle,
she is no longer adequately protected and must use a barrier method
IS
during that cycle”- Shaw’s Gynae 16th/273
Emergency contraceptive: It should be used mainly as back-
up methods. It is used in misplaced IUCD and missed pills”- Shaw’s
PG
Gynae 16th/279
6. Which of the following is/are true regarding haemodynamic
changes in pregnancy:
a. Maximum cardiac changes occurs at 8 weeks of gestation
b. Venocaval compression begins at about 16 weeks of
gestation
c. There is midtrimester fall in blood pressure
d. Systolic murmur may occur normally
e. Cardiac output return to pregnant level by 20 days after
delivery
Answer
5.  . If she exposed to recent intercourse, use emergency contraceptive; e. Use another method of contraception like barrier method for remaining
d
period and start next COC pack without break
6. b. Venocaval compression begins at about 16 weeks of gestation; c. There is midtrimester fall in blood pressure; d. Systolic murmur may occur
normally; e. Cardiac output return to pregnant level by 20 days after delivery
 [Ref: Dutta Obs 8th/60-61; Obs by JB Sharma 1st/49-52; Normal and Problem Pregnancy by Gabbe 6th/46-50]
128
Cardiovascular system in pregnancy Dutta Obs 8th/60-61
•• Cardiac output starts to increase from 5th week of pregnancy and
reaches its peak 40-50% at about 30-34 weeks. CO increases
further during labor (+50%) and immediately following delivery
(+70%) over the pre-labor values
•• CO return to pre-labor values by 1 hr following delivery and to the
pre-pregnant level by another 4 weeks, time
•• Blood pressure unaffected or mid-pregnancy drop of diastolic
pressure by 5-10 mm Hg
•• A systolic murmur may be audible in the apical or pulmonary
area
•• A continuous hissing murmur may be audible over the tricuspid
area in the left second and third intercostal spaces called the
mammary murmur
17
Cardiovascular System in Pregnancy Obs by JB Sharma 1st/49-51
•• An increase in cardiac output begins early in pregnancy (6
weeks) and reach peak at 32-34 week
20
•• Changes in cardiac function become apparent during the first 8
weeks of pregnancy. Cardiac output is increased as early as the
fifth week and reflects a reduced systemic vascular resistance
and an increased heart rate- William’s Obs 23rd
ov
•• Cardiac output returns to normal by about 2 weeks following
delivery
tN•• Maternal BP decreases during pregnancy to reach the lowest peak
at 24-26 weeks and increases thereafter to reach pre-pregnancy
level at term. There is more fall in diastolic and mean arterial
pressure (5-10 mm Hg) as compared with systolic BP. The mid
trimester fall in BP may be absent in women with pre-eclamsia
•• Systolic ejection murmur (d/t increased flow across pulmonary
and aortic valve) can be heard in 90% cases of normal pregnancy.
These physiological murmurs are mostly midsystolic and less than
grade 3
•• A soft,diastolic murmur may be hard transiently in 20% women
•• A continuing mammary murmur may be heard in 10% women
Cardiac changes in pregnancy Normal and Problem Pregnancy by
Gabbe 6th/49
•• CO- return to normal in 2-4 postpartum week
•• By 5th week, CO has already risen by more than 10%
Supine hypotensive syndrome is caused when the inferior
vena cava is compressed by the weight of a pregnant female’s uterus,
fetus, placenta and amniotic fluids while lying in the supine position
This condition can develop as early as the second trimester but is
maximal during the third trimester, 36 to 38 weeks- jacobburton.
wordpress.com
“Vena cava compression begins as early as 13 to 16 week’s
gestation and nearly complete at term”- Bonica’s Management of Pain
by Scott M. Fishman 4th/795
[Ref: Dutta Obs 8th/624; Dutta Gynae 7th/400]
 Obstetrics and Gynecology

•• It can detects 62% Down’s syndrome pregnancies with a 5%

7. Screening test (s) for aneuploidy in 1st trimester:
false-positive rate
a. PAPP-A and β-hCG estimation
b. Quadruple test Second Trimester Screening J B Sharma 1st/155
c. Chorionic villus Sampling •• Double test (MSAFP is lower while total hCG or free β-hCG is
d. Amniocentesis raised in Down’s syndrome
e. Triple test •• Triple test- MSAFP, hCG and uE3 (unconjugated estriol)
•• Quadruple test- MSAFP, hCG, uE3 and inhibin-A
CVS is done for first trimester prenatal diagnosis b/w 10-14 •• Penta screen: AFP, hCG, uE3, diameric inhibin-A and hyper-
week- J B Sharma 1st/160 glycosylated hCG
First Trimester Screening J B Sharma 1st/155; Dutta Obs 8th/128
•• It uses PAPP-A (lower in Down syndrome) and free β-hCG
(higher in Down’s syndrome) b/w 11 and 14 weeks
Table 3. (Dutta Obs 8th/130): Prentatal Diagnosis- CVS, Amniocentesis and Cordocentesis

Chorionic villus Sampling Amniocentesis Cordocentesis

17
Time Transcervical 10–13 weeks After 15 weeks (early 12-14 weeks) 18–20 weeks
Transabdominal 10 weeks

to term
Materials for study Trophoblast cells
Karyotype result Direct preparation: 24–48
20
• Fetal fibroblasts • Fetal white blood cells (others–
• Fluid for biochemical study (see p. 741) infection and biochemical study)
Culture: Culture:

ov
• • •
hours 3–4 weeks 24–48 hours
• Culture: 10–14 days

Fetal loss
Accuracy
0.5–1%
Accurate; may need
0.5%
Highly accurate
tN 1–2%
Highly accurate
amniocentesis for
en
confirmation
Termination of 1st trimester–safe 2nd trimester–risky 2nd trimester–risky
pregnancy when
em

indicated

Screening Methods: Second Trimester Dutta Obs 8th/129

8. Double test in 2nd trimester for screening of Down syndrome
•• It is done b/w 15 weeks and 22 weeks
pl

includes:
•• MSAFP: Low level are found in down syndrome
a. PAPP and AFP b. MSAFP and hCG
•• Triple test: It is a combine test which includes MSAFP, hCG and
up

c. MSAFP and uE3 d. MSAFP and inhibin-A

uE3 (unconjugated estriol). It is used for
See explanation of above question detection of down syndrome. In an affected pregnancy, levels of
MSAFP and uE3 tend to low while that of hCG is high
IS

Screening Methods: First Trimester Dutta Obs 8th/128-29

•• Screening Parameters are •• Quadruple (Quad) screening include four biochemical
•• Biophysical: (i) ultrasound measurement of nuchal transluceny analytes: MSAFP, hCG, uE3 and dimeric inhibin-A. It can detect
(NT), (ii) nasal bone trisomy 21 in 85% cases. Level of serum analytes in cases with
PG

•• Biochemical: (i) free β –hCG, (ii) PAPP-A (Pregnancy associated trisomy 21: MSAFP-reduced, hCG-increased, uE3- reduced and
plasma protein-A) dimeric inhibin-A- elevated
•• Time of test: b/w 11 weeks and 14 weeks •• Note: Best screening procedure is combined first and second
•• Values: PAPP-A- reduced; β –hCG- increased; NT- measurement trimester procedures
increased in trisomy 21 9. True about adenomyosis:
Note: a. Capsulated lesion
•• NT is the fluid-filled space (detected by USG) b/w the fetal skin b. Associated with dysmenorrhea and menorrhagia
and the underlying soft tissue at the region of fetal neck. NT ≥ mm c. Total hysterectomy is the treatment of choice
is abnormal. Combined tests can detect trisomy 21 in 92% cases
d. Asymmetrically enlarged and tender uterus
with a false-positive rate of 5%
e. Tenderness of uterus may be seen before and during
•• First trimester screening is either equal or even superior to
menses
second trimester screening
Answer
7. a. PAPP-A and β-hCG estimation; c. Chorionic villus Sampling [Ref: Dutta Obs 8th/128-130; William’s Obs 23rd/292-93; Fernando Arias 3rd/44-45]
8. b. MSAFP and hCG [Ref: Dutta Obs 8th/128,132; J B Sharma 1st/155]
9. b. Associated with dysmenorrhea and menorrhagia; c. Total hysterectomy is the treatment of choice; e. Tenderness of uterus may be seen before
and during menses [Ref: Shaw’s Gynae 16th/420-22; Dutta Gynae 7th/256-58; Novak’s Gynae 15th/484-85; Robbins 9th/1012]

129
PGI Supplement November 2017
Adenomyosis Shaw’s Gynae 16th/420-22
•• Grossly, the uterus appears symmetrically enlarged to not more
than 14 weeks size
•• Unlike fibroid- there is no capsule surrounding the lesion-
Dutta Gynae 7th/257
•• Some are aymptomatic, others present with menorrhagia and
progressively increasing dysmenorrhea, pelvic discomfort,
backache and dyspareunia
•• If a patient gives a history of menorrhagia with accompanying
dysmenorrhea, one should always consider the possibility of
adenomyosis
•• Uterus is tender
•• NSAIDS are commonly used to control pain and bleeding.
Treatment with progestins or cyclic estrogen and progestins
have got little benefit. LNG-IUD is found to improve the
menorrhagia and dysmenorrhea- Dutta Gynae 7th/257
•• Since most women are elderly and past the age of age of
childbearing, total hysterectomy is the treatment
Adenomyosis Novak’s Gynae 15th/484-85
•• Adenomyosis is defined as presence of endometrial stroma
and glands within the myometrium, at least one low-
power field from the basis of the endometrium, whereas
endometriosis is characterized by ectopic endometrium
appearing within the peritoneal cavity.
•• Although occasionally noted in women in their younger
reproductive years, the average age of symptomatic women is
usually older than 40 years. Increasing parity, early menarche,
and shorter menstrual cycles may all be risk factors according
tN
to one study
en
em
pl
up
IS
PG
Fig. 1 (Shaw’s Gynae 16th/332): Secondary amenorrhea
Answer
10. a. Hypothalamic and pituitary cause; b. Ovarian failure
130
•• Symptoms typically associated with adenomyosis include ex-
cessively heavy or prolonged menstrual bleeding, dyspareunia,
and dysmenorrhea. Symptoms often begin up to 2 weeks before
the onset of a menstrual flow and may not resolve until after
the cessation of menses.
•• The uterus is typically diffusely enlarged, although usually less
than 14 cm in size, and is often soft and tender, particularly at
the time of menses.
•• The uterus is usually tender and slightly softened under
bimanual examination performed premenstrually (Halban’s
sign)- COGDT 2006/Chap 39
•• Adenomyosis is a clinical diagnosis.
•• Imaging studies including pelvic ultrasound or MRI, although
helpful, are not definitive
•• The management of adenomyosis depends on the patient’s age
and desire for future fertility. Relief of secondary dysmenorrhea
caused by adenomyosis can be ensured after hysterectomy, but
17
less invasive approaches can be tried initially.
•• NSAIDs, hormonal contraceptives, and menstrual suppression
using oral, intrauterine, or injected progestins or gonadotropin-
20
releasing hormone agonists are all useful. Treatment follows the
same protocol as treatment for endometriosis. Uterine artery
embolization can be effective
10. A lady with secondary amenorrhea is negative for
ov
progesterone challenge test but positive for combined
estrogen and progesterone challenge test. What is the
probable cause (s):
a. Hypothalamic and pituitary cause
b. Ovarian failure c. PCOD
d. Asherman syndrome e. Pregnancy
[Ref: Shaw’s Gynae 16th/330-32; Dutta Gynae 7th/387,441-43]
 Obstetrics and Gynecology

17
20
ov
tN
en
em
pl
up
IS
PG

Fig. 2 (Dutta Gynae 7th/387): Secondary amenorrhea

131
PGI Supplement November 2017

11. True about chronic hypertension in pregnancy:
a. Hypertension before pregnancy, elevation of blood
pressure during the first half of pregnancy, or high blood
pressure that lasts for longer than 12 weeks after delivery
b. Fetal complication may occur
c. Incidence is about 50%
d. High blood pressure may require antihypertensive medica-
tions
Chronic Hypertension in Pregnancy Dutta Obs 8th/277
•• Chronic hypertensive disease (CHD) is defined as the
presence of hypertension of any cause antedating or before
the 20th week of pregnancy and its presence beyond the 12
weeks after delivery.
initial ultrasound examination should be performed as early as
possible to confirm the due date and to ensure that no obvious
fetal anomalies are present. Thereafter, fetal growth may be
assessed by ultrasound as needed, usually no more frequently
than every 2–4 weeks. Antepartum fetal monitoring usually is
started by 32–34 weeks.
•• Pregnancy outcome usually is good in patients with mild
chronic hypertension and no other serious medical conditions.
Fetal growth restriction, superimposed preeclampsia, placental
abruption, and preterm delivery are the most common
complications.
•• In pregnant women with mild hypertension and no evidence of
renal disease, serious medical complications are rare.
•• Women with sustained blood pressure ≥180/110 mm Hg or those

17
•• The condition poses a difficult problem as regards the diagnosis with evidence of renal disease may be at higher risk for serious
and management when seen for the first time, beyond the 20th complications, such as heart attack, stroke, or progression
week of pregnancy. of renal disease, and are candidates for antihypertensive

20
•• Overall incidence is 2-4% of which 90% are due to essential medication.
hypertension. 12. Which of the following are true about Breech presentation:
•• The high risk factors for CHD are: (i) Age (> 40 years), a. Frank breech is most common breech presentation
(ii) Duration of hypertension (>15 years), (iii) Level of BP

ov
b. Complete breech is more common in multiparae
(>160/110 mm of Hg), (iv) Presence of any medical disorder c. Frank breach is more common in primigravida
(renovascular), and (v) Presence of thrombophilias. d. Chance of cord prolapse in footling presentation is 5–6%
•• Majority of women with CHD are low risk and have satisfactory
maternal and fetal outcome without any antihypertensive
tN e. Chance of cord prolapse in complete breech is 5%

therapy Breech Presentation Obs by JB Sharma 1st/302-03; Dutta Obs 8th/435-36

Fetal complication of chronic hypertension of pregnancy •• Complete (Flexed breech): It is commonly present in multiparae
en
Obs by JB Sharma 1st/441 (10%)
•• Abortions •• Incomplete breech: 3 types (Frank, footling and Knee)
Fetal growth restriction (FGR) Breech with extended leg (Frank breech): It is commonly
em

•• ••
•• Intrauterine death present in primigravidae, about 70%
•• Increased neonatal complications •• Footling presentation: 25% (10-30%)
•• Prematurity •• Knee presentation-rare
pl

Chronic Hypertension COGDT 2006/Chap 19 •• Cord prolapse chance in Complete (Flexed breech): 4-6%
•• Chronic hypertension complicates as many as 5% of •• Cord prolapse chance in footling presentation: 12%
up

pregnancies. •• Cord prolapse chance in extended leg (Frank breech): 0.5%

•• It is characterized by a history of high blood pressure before Table 4. (Gabbe 6th/396): Breech categories
pregnancy, elevation of blood pressure during the first half of
IS

pregnancy, or high blood pressure that lasts for longer than 12 Type Overall % of Risk (%) of Premature
weeks after delivery. breech prolapse
•• After evaluating the possible causes of chronic hypertension,
PG

Frank 48-73 0.5 38

further assessment is directed at end-organs and systems most
likely to be affected by hypertension, including the eyes, heart, Complete 4.6-11.5 4-6 12
kidneys, uteroplacental circulation, and the fetus. Footling 12-38 15-18 50
•• Pregnancies complicated by chronic hypertension, regardless
of the cause, are at increased risk for poor fetal growth. An

Answer
11. a . Hypertension before pregnancy, elevation of blood pressure during the first half of pregnancy, or high blood pressure that lasts for longer than
12 weeks after delivery; b. Fetal complication may occur; d. High blood pressure may require antihypertensive medications
 [Ref: Dutta Obs 8th/277; William’s Obs 23rd/709; Obs by JB Sharma 1st/441-43; Normal and Problem Pregnancy by Gabbe 6th/781]
12.  a. Frank breech is most common breech presentation; b. Complete breech is more common in multiparae; c. Frank breach is more com-
mon in primigravida; e. Chance of cord prolapse in complete breech is 5% [Ref: Dutta Obs 8th/435-36; William’s Obs 23rd/527-35; Obs by JB
 Sharma 1st/302-03; Normal and Problem Pregnancy by Gabbe 6th/396]

132
 Obstetrics and Gynecology

13. True about benign gestational trophoblastic disease: pregnancy values are below 60, 0000 mIU/ml. (there is no
a. Occur due to proliferation of placenta mention of doubling time)
b. No risk of carcinoma •• Sonography: Characteristic snowstorm appearance
c. Fetus may be absent
Table 5. (COGDT): Comparison of Complete and Partial
d. Karyotype 69XXY may result from fertilization of 1 ovum
Hydatidiform Moles
and 2 sperm
e. Snowstorm appearance on USG Complete Partial
Karyotype Diploid (46,XX or Triploid (69,XXX or
“The development of choriocarcinoma following hydatidiform mole
46,XY) 69,XXY)
ranges b/w 2-10%”- Dutta Obs 8th/226
Embryo/fetus Absent Often present
Gestational Trophoblastic Disease Dutta Gynae 7th/298-300
•• It is a spectrum of abnormal growth and proliferation of the Villi Hydropic Few hydropic
trophoblasts of the placenta that continue even beyond the end Trophoblasts Diffuse hyperplasia Mild focal
of pregnancy of the placenta hyperplasia
•• Benign GTD includes: Hydatidiform mole-complete and
Implantation-site Diffuse atypia Focal atypia
partial

17
trophoblast
•• GTN encompasses: persistent hydatiform mole, invasive mole,
choriocarcinoma and a rare entity of placental site trophoblastic Fetal RBCs Absent Present
tumour

20
β-hCG High (> 50,000) Slight elevation (<
H. mole: (Short Review) Dutta Obs 8th/221-31 50,000)
•• It is prevalent among teenaged and elderly patients with high Frequency of classic Common Rare
parity clinical symptoms1

ov
•• It is best regarded as a benign neoplasia of chorion with Risk for persistent 20–30% < 5%
malignant potential GTT
•• In general completes moles have a 45XX karyotype (85%), the tN
molar chromosomes are derived entirely from the father. The
1
Hyperemesis, hyperthyroidism, excessive uterine enlargement,
ovum nucleus may be either absent (empty ova) or inactivated anemia, and preeclampsia
which have been fertilized by a haploid sperm. It then
en
duplicates its own chromosomes after meosis. Infrequently, the
chromosome pattern may be 46Xy or 45X
•• The higher the ratio of paternal: maternal chromosomes, the
em

greater is the molar change. Complete moles show 2: 0 paternal/

maternal ratio whereas partial mole shows 2: 1 ratio
•• Symptoms
 Vaginal bleeding (Commonest, in 90%, “white currant in
pl

red currant juice”)

 Varying degrees of lower abdominal pain
up

 Constitutional symptoms like excessive vomiting, breath­

lessness, thyrotoxicosis, features of tremors or tachycardia
 Expulsion of grape like vesicles per vaginum is diagnostic
IS

of vesicular mole
 History of quickenig is absent.
•• Signs
PG

 Ill looking patient, prominent pallor

 Features of pre-eclampsia (hypertension, oedema and or
proteinuria).
 The size of the uterus is more than that expected for the
period of amenorrhea
 Doughy, firm elastic feel of the uterus
 Fetal parts are neither felt nor fetal movements
Fig. 3: (William’s Obs): Typical pathogenesis of complete and partial
moles. A. A 46,XX complete mole may be formed if a 23,X-bearing
 Absence of Fetal Heart Sound
haploid sperm penetrates a 23,X-containing haploid egg whose genes
 High HCG in urine (positive pregnancy test) diluted up to have been “inactivated.” Paternal chromosomes then duplicate
1: 200 to 1: 500 beyond 100 days of gestation is very much to create a 46,XX diploid complement solely of paternal origin.
suggestive. Rapidly increasing value of serum HCG > 100, B. A partial mole may be formed if two sperm—either 23,X- or
000 mIU/ml, are usual with molar pregnancy. Normal 23,Ybearing— both fertilize (dispermy) a 23,X-containing haploid egg
whose genes have not been inactivated. The resulting fertilized egg
is triploid with two chromosome sets being donated by the father
Answer (diandry).
13. a . Occur due to proliferation of placenta; c. Fetus may be absent; d. Karyotype 69XXY may result from fertilization of 1 ovum and 2 sperm; e. Snow-
storm appearance on USG [Ref: Dutta Obs 8th/221-31; Dutta Gynae 7th/298-300; William’s Obs 23rd/257-61; Obs by JB Sharma 1st/143-49]

133
PGI Supplement November 2017

14. Pap smear of a patient with condyloma accuminita shows
what kind of smear:
a. Inflammatory
b. High-Grade Squamous Intraepithelial Lesion (HSIL)
c. Squamous cell carcinoma
d. Low-Grade Squamous Intraepithelial Lesion (LSIL)
e. Normal
“Condyloma acuminatum-Subcategory of LSIL” pathologyoutlines.com
What is Condyloma Acuminatum of Uterine Cervix
www.dovemed.com
•• Condyloma Acuminatum of Uterine Cervix is strongly
associated with HPV type 6 and HPV type 11. The infection
typically manifests as a benign wart on the mucous membrane
of the cervix
Treatment of the condition is necessary, since Condyloma
15. High-grade squamous intraepithelial lesions (HSIL) are
found in pap smear. Next step (s) of management:
a. HPV DNA Testing
b. Liquid based cytology
c. Colposcopy study and biopsy of suspicious lesion
d. Hysterectomy
e. Radiotherapy
HSIL includes CINII, CINIII and CIS- Shaw’s 16th/88
High-Grade Squamous Intraepithelial Lesions
Novak’s Gyae 15th/588
•• Any woman with a cytologic specimen suggesting the presence
of HSIL should undergo colposcopy and directed biopsy. This
is because two-thirds of patients with this cytologic finding will

17
•• have CIN 2 or greater.
Acuminatum of Uterine Cervix is termed as a variant of low- •• After colposcopically directed biopsy and determination of the
grade squamous intraepithelial lesion (SIL). Low-grade SIL is distribution of the lesion, excisional or ablative therapy that

an early indicator for future ‘invasive carcinoma’ development
•• The prognosis of Condyloma Acuminatum of Cervix depends
upon 2 key factors, namely the type of HPV involved and the
grade of the premalignant lesion present (whether low-grade
20
addresses the entire transformation zone should be performed
“Since cytology alone does not give a clue to which abnormal
cells progress to invasive cancer and aneuploidy which suggest the
risk of progression is not routinely performed, it is necessary to submit

or high-grade SIL)
•• Informing and educating the infected individuals on the
importance of safe sex is essential to prevent the spread of HPV
infection, and thus of Cervical Condyloma Acuminatum
How is Condyloma Acuminatum of Uterine Cervix Diagnosed
www.dovemed.com
en
•• Pap smear: Cells are collected from the tip of the cervix and
examined under the microscope for any associated precancerous
or cancerous lesions. Pap smear results may indicate
em
ov
all women with HSIL cytology for colposcopic study and biopsy of
suspicious lesions”- Shaw’s 16th/489
tN “A combined HPV testing and pap smear yields 96% sensitivity
as compared to only 60-70% with pap smear alone. PCR, southern blot
or hybrid capture detects HPV DNA”-Shaw’s 16th/491
“A single pap smear has a diagnostic sensitivity of about
60%. False negative results may be upto 25%. False negative rate
of Pap smear after 3 consecutive negative tests is less than 1%.
Error in cytology could be reduced further by liquid-based thin layer

abnormalities such as low-grade squamous intraepithelial lesion slide preparation and automated (computer) screening methods.
•• Cervical Condyloma Acuminata is a variant of low-grade Abnormal cytology is an indication of colposcopic evaluation and
squamous intraepithelial lesion (SIL), which are asymptomatic directed biopsy”-Dutta Gynae 6th/113
pl

lesions, but present a low risk for future cancer “In 2003, the FDA approved HPV DNA testing combined with
cervical cytology as a screening technique for women older than age
Table 6. (Shaw’s Gynae 16th/88): Comparison of different
up

30. When the results of both tests are negative, the woman does not
classification
have to be retested for 3 years. The negative predictive value of a
double negative test exceeds 99% . Because most HPV infections
IS

Pap Smear (1943) CIN (WHO 1975) SIL Bethesda (1988)

are transient, clear spontaneously, and do not lead to real cancer
I Normal Normal precursors (especially in young women), it should not be used for
II Inflammatory Inflammatory screening in women younger than 30. Women who have negative test
PG

– HPV results for both cytology and HPV have a 1 in 1,000 chance of having
– ASCUS CIN 2 or worse detected in the following 6 months. Prospective
III CIN I Low SIL studies report less than 2 per 1,000 women will develop CIN 2 or
greater in the following 3 years”-Novak’s Gyae 15th/5887
IV CIN II, CIN III, CIS High SIL
V SCC SCC
ASCUS: atypical squamous cell of undetermined significance:
CIN: Cervical intraepithelial neoplasia; CIS: carcinoma in situ; SIL:
squamous intraepithelial lesion and SCC: squamous cell carcinoma

Answer
 . Low-Grade Squamous Intraepithelial Lesion (LSIL) [Ref: Shaw’s Gynae 16th/157,88-89; Dutta Gynae 7th/90,128; Neena Khanna 5th/339-40; Gynae
14. d
 by Robert Shaw 4th/969]
15. a. HPV DNA Testing; b. Liquid based cytology; c. Colposcopy study and biopsy of suspicious lesion
 [Ref: Shaw’s 16th/88-90; Dutta Gynae 6th/111-15, 323-28; Novak’s Gyae 15th/588]

134

16. Indication (s) of postoperative radiotherapy in vulval
carcinoma is/are all except:
a. Lymphovascular space permeation
b. Positive margins
c. Margin < 8-10 mm
d. Single metastatic nodule with capsular involvement
e. Only one microscopically positive lymph node
Post-op Radiation indicated for: >1 LN+, LN with ECE, margin
< 8-10 mm, lymphadenectomy not performed due to comorbid
disease, LVSI”-en.wikibooks.org
Post-op indications for radiotherapy: www.astro.org
•• Vulva (Heaps criteria): (+) margins, margin <8 mm
pathologically or < 1 cm clinically, LVSI (lymphovascular space
involvement), lesions > 5 mm deep
•• Inguinal/pelvic nodes (Homesley GOG371986): clinically +
groin LN, >1 groin LN+, nodal ECE
Postoperative Adjuvant Radiotherapy
Gynaecology by Robert Shaw 4th/41
•• Patient with risk factors for local recurrence such as a close
surgical margin, lymphovascular space permeation, poorly
differentiated tumor grade or diffuse infiltrative growth pattern,
should be considered for adjuvant external beam radiation
therapy to reduce the risk of recurrence
•• With regard to the nodal status, no additional treatment is
recommended if there is only one microscopically positive
lymph node. However, if two or more metastatic nodes are
present or there is capsular involvement in a single metastatic
en
node, postoperative adjuvant radiotherapy is usually
recommended
em
Role of Radiation Therapy in Vulvar carcinoma
Novak 15th/1142-43
•• It is important to remember that, with a rare exception, radiation
therapy alone has little place in the primary management of
pl
vulvar cancer. It is indicated in conjunction with surgery.
•• Radiation seems to be indicated in the following situations:
up
 Preoperatively, in patients with advanced disease who would
otherwise require pelvic exenteration or suffer loss of anal or
urethral sphincteric function
IS
 Preoperatively, in patients with fixed, unresectable groin
nodes
 Postoperatively, to treat the pelvic lymph nodes and groins of
PG
patients with multiple microscopically positive groin nodes,
one or more macrometastasis (10 mm or larger), or any
evidence of extracapsular spread.
•• No additional treatment is recommended if one microscopically
positive groin node (5 mm or less tumor deposit) is found in a
fully dissected groin. The prognosis for this group of patients is
excellent, and only careful observation is required.
•• If clinically evident groin metastases (any extracapsular spread
or two or more microscopically positive groin nodes) are found,
the patient is at increased risk of groin and pelvic recurrence
and should receive postoperative groin and pelvic irradiation.
Answer
16. e. Only one microscopically positive lymph node
 Gynaecology by Robert Shaw 4th/41]
17. a. Keep the IUCD, give antibiotic, follow up for antibiotic response and then take decision regarding IUCD removal
 [Ref: Shaw’s Gynae 16th/271; Novak’s Gynae 15th/223-24]
18. a. KRAS; c. TP53; d. PTEN
135
Obstetrics and Gynecology
17. A female with IUCD develops pelvic inflammatory disease.
Which of the following should be done?
a. Keep the IUCD, give antibiotic, follow up for antibiotic
response and then take decision regarding IUCD removal
b. Start antibiotics and then remove IUCD
c. Remove IUCD and then start antibiotics
d. Wait till next menstrual cycle for any intervention
e. Do nothing
“When PID is suspected in a woman wearing an IUD, appropriate
cultures should be obtained, and antibiotic therapy should be
administered. Removal of the IUD is not necessary unless symptoms
do not improve after 72 hours of treatment. Pelvic abscess, if
suspected, should be ruled out by ultrasound examination. Novak’s
Gynae 15th/223-24
“Leaving an IUD in place is not thought to increase the chance
17
of long-term complications from PID, although this cannot be
guaranteed. In general the IUD can be left in place if the symptoms
respond to antibiotic treatment within 48-72 hours”- www.fpnsw.
20
org.au
18. Mutation involved in serous ovarian carcinoma:
a. KRAS
ov
b. WT1
c. TP53
tN d. PTEN
e. ARID1A
Two Important Carcinogenic Pathway Dutta Gynae 7th/305
•• Type I: Incorporation of Mullerian epithelial cells on the
ovary with formation of endometriosis or cortical inclusion
cyst. Type I ovarian tumors, are borderline tumors, low grade
serous ovarian cancers (LGSOC) or clear cell carcinoma. These
patients harbor somatic gene mutations (KRAS, BRAF, or
PTEN) but no association with p53 mutations.
Type II: Incorporation of serous tubal intraepithelial
••
carcinoma (STIC), with exfoliation of cells, on to the surface
of the ovary or both. This pathogenesis leads to development
of high grade serous ovarian carcinoma (HGSOC). HGSOC
are aggressive from the outset as opposed to LGSOC that
are indolent in nature. Individuals with HGSOC harbor p53
mutations in about 100% of situation. Currently the concept of
distal fallopian tube origin of many pelvic serous carcinomas is
considered indisputable.
•• Majority of epithelial ovarian cancers are not familial or
hereditary. Familial cancer account for 10-15% of all ovarian
cancers
“Low-grade serous carcinomas exhibit low-grade nuclei with
infrequent mitotic figures. They evolve from adeno fibromas or
borderline tumors, have frequent mutations of the KRAS, BRAF,
or ERBB2 genes, and lack TP53 mutations (Type I pathway). Low-
grade tumors are indolent and have better outcome than high-grade
tumors. In contrast, high-grade serous carcinomas have high-grade
nuclei and numerous mitotic figures. More recently, studies have
[Ref: Shaw’s Gynae 16th/480; Dutta Gynae 7th/277; Novak 15th/1142-43;
[Ref: Shaw’s Gynae 16th/436; Dutta Gynae 7th/304-05]
PGI Supplement November 2017

suggested that a proportion appear to originate from intraepithelial carcinoma in the fallopian tube. The development of these tumors is rapid
(Type II pathway). The vast majority are characterized by TP53 mutations and lack mutations of KRAS, BRAF, or ERBB2”-www.ncbi.nlm.
nih.gov
“Mutations in the ARID1A gene have been found in many types of cancer, including cancers of the ovaries and lining of the uterus
(endometrium) in women and cancers of the kidney, stomach, bladder, lung, breast, and brain. These mutations are somatic, which means
they are acquired during a person’s lifetime and are present only in tumor cells”-ghr.nlm.nih.gov
“ARID1A is mutated in ~50% of ovarian clear cell carcinoma (OCCC)”-www.ncbi.nlm.nih.gov
“WT1: Wilms tumor, certain leukemias - Robbins 9th/291
Common Epithelial Tumour Shaw’s Gynae 16th/436
•• Serous
•• Mucinous
•• Endometrioid
•• Clear cell
•• Brenner tumour

17
•• Mixed epithelial tumor

20
ov
tN
en
em
pl
up

Fig. 4 (Dutta Gynae 7th/305): The schematic presentation of distal fallopian tube origin of ovarian carcinoma
IS
PG

136