MBBS 2023 BATCH - Terminal Examination: Obstetrics & Gynecology

Model Answers

QUESTION 1 (20 Marks)

Differential Diagnosis (3 Marks)

1. Carcinoma of the Cervix - Most likely. Post-menopausal woman, friable contact-bleeding mass, cachexia, and prolonged blood-stained discharge are classic features. Squamous cell carcinoma accounts for ~80% of cervical carcinomas; adenocarcinoma accounts for ~15%.
2. Cervical Polyp - Benign; usually pedunculated, softer, non-indurated; less likely to cause cachexia.
3. Cervicitis with Cervical Erosion - Inflammatory, may bleed on contact but unlikely to form a 3×2 cm mass.
4. Gestational Trophoblastic Disease - Less likely at 60 years, but must be excluded.
5. Metastatic Carcinoma to the cervix (e.g., from endometrium or ovary).

Clinical Approach (7 Marks)

• Onset, duration, and character of discharge (blood-stained, offensive, watery)
• Contact/coital bleeding (pathognomonic)
• Post-menopausal bleeding
• Pelvic or back pain (suggests parametrial spread)
• Bladder/bowel symptoms (hematuria, dysuria, rectal bleeding - suggests Stage IV)
• Weight loss, anorexia, fatigue (systemic symptoms of malignancy)
• Obstetric history: P3L3 - multiparity is a risk factor
• Sexual history, early age of marriage, multiple partners
• History of STIs (HPV is necessary cause), prior Pap smear history

• General: cachexia, pallor, lymphadenopathy (supraclavicular, inguinal)
• Abdominal: hepatomegaly, ascites, renal angle tenderness
• Speculum examination: friable bleeding mass on anterior lip - document size, site, extent
• Per vaginal (PV) examination: assess vaginal wall involvement, parametrial thickening
• Per rectal (PR) examination: assess extent of parametrial spread toward pelvic wall, rectal mucosa involvement
• Clinical staging (FIGO) is essential before treatment planning

Investigations (4 Marks)

• Punch biopsy from the mass - definitive; will show invasive squamous cell carcinoma (nests of malignant squamous cells with desmoplastic stromal response)
• Colposcopy-directed biopsy if lesion not grossly visible
• Pap smear - though biopsy is preferred when a visible lesion exists
• FNAC of lymph nodes if enlarged

• Chest X-ray - pulmonary metastases
• Ultrasound abdomen/pelvis - hydronephrosis, liver metastases
• CT scan abdomen and pelvis (or MRI) - parametrial spread, lymphadenopathy
• Cystoscopy - bladder involvement
• Proctoscopy - rectal involvement
• IVU (Intravenous Urography) - ureteric obstruction

• CBC, LFTs, KFTs, blood group and crossmatch
• Blood glucose, coagulation profile
• ECG

Principles of Treatment (6 Marks)

• Pre-operative optimization: correct anemia, nutrition support
• Concurrent chemoradiotherapy (external beam radiation + intracavitary brachytherapy + cisplatin) is likely the primary modality
• Surgery (Radical hysterectomy + bilateral pelvic lymph node dissection) if operable
• Prognosis depends on stage at diagnosis; small cell neuroendocrine variants carry very poor prognosis
• Follow-up: 3-monthly clinical examination for 2 years, then 6-monthly

QUESTION 2 (20 Marks)

a) Provisional Diagnosis (5 Marks)

• Young primipara (risk factor)
• 36 weeks (>20 weeks gestation - hallmark of the disease)
• BP 150/100 mmHg (hypertension - systolic ≥140 or diastolic ≥90)
• Bilateral pedal edema
• Proteinuria +2 on dipstick (significant proteinuria)
• History of convulsions - this is the defining feature that differentiates eclampsia from severe preeclampsia

b) How to Confirm Diagnosis (3 Marks)

1. Documented hypertension (BP ≥140/90 mmHg) - confirm with two readings 4 hours apart
2. Proteinuria ≥300 mg in 24-hour urine collection (or spot urine protein:creatinine ratio ≥0.3), OR dipstick +2
3. New-onset generalized tonic-clonic convulsions not attributable to other causes
4. Rule out other causes of seizures: exclude hypoglycemia (blood glucose), drug overdose, hypertensive encephalopathy, intracranial pathology
5. CT scan of head if - consciousness is decreased, seizures persist, lateralizing signs are present, or other concerns

c) Investigations (4 Marks)

• CBC with platelet count - thrombocytopenia (suggests HELLP syndrome)
• Liver function tests (LFTs) - elevated transaminases (hepatic involvement)
• Blood urea nitrogen and serum creatinine - renal function
• Serum uric acid - elevated in preeclampsia
• Coagulation profile (PT, aPTT, fibrinogen) - DIC screen
• 24-hour urine protein (or spot PCR) - quantify proteinuria
• Urine output monitoring (Foley catheter) - maintain >25 mL/hr

• Cardiotocography (CTG/NST) - fetal wellbeing
• Obstetric ultrasound - fetal growth, amniotic fluid index (AFI), biophysical profile
• Doppler velocimetry - umbilical artery S/D ratio, ductus venosus

d) Fetomaternal Complications (4 Marks)

1. HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)
2. Acute renal failure (ATN)
3. Intracranial hemorrhage / CVA
4. Pulmonary edema / ARDS
5. Placental abruption
6. DIC (disseminated intravascular coagulopathy)
7. Liver rupture / hepatic failure
8. Maternal death

1. Intrauterine growth restriction (IUGR/FGR)
2. Preterm birth (at 36 weeks here - late preterm)
3. Placental abruption leading to fetal distress
4. Intrauterine fetal demise (IUFD)
5. Perinatal asphyxia
6. Oligohydramnios

e) Management (4 Marks)

1. Admit to ICU/HDU; left lateral position; airway protection
2. Magnesium sulfate (MgSO4) - DRUG OF CHOICE:
   • Loading dose: 4-6 g IV over 15-20 minutes
   • Maintenance: 2 g/hr IV infusion
   • Monitor: patellar reflexes (loss at ~10 mg/dL), respiratory rate (depression at ~12 mg/dL)
   • Antidote: Calcium gluconate 1 g IV (for hypermagnesemia)
3. Antihypertensive therapy (after seizure control, if diastolic >105 mmHg):
   • Hydralazine 5-10 mg IV bolus q2-4h, OR
   • Labetalol 20 mg IV bolus, repeat q10 min up to 300 mg
   • Nifedipine 10 mg oral
4. Fluid management: Restrict IV fluids; avoid diuretics; maintain urine output >25 mL/hr
5. Delivery - definitive treatment:
   • At 36 weeks: proceed to delivery (vaginal induction preferred if no contraindication; cesarean section if obstetric indication)
   • Administer antenatal corticosteroids (betamethasone) given 36 weeks gestation
6. CT head if seizures persist or consciousness doesn't recover

QUESTION 3 - SHORT NOTES (6 Marks each)

a) Biophysical Profile (BPP)

• 8-10/10: Normal - reassuring; no intervention needed
• 6/10: Equivocal - repeat within 24 hours; deliver if at term or if fetal lung maturity confirmed
• 4/10 or less: Abnormal - strongly associated with fetal asphyxia; expedite delivery
• 0/10: Deliver immediately

b) Obstetric Uses of Magnesium Sulphate (MgSO4)

1. Eclampsia - Treatment of acute seizures:
   • Loading: 4-6 g IV over 15-20 minutes
   • Maintenance: 2 g/hr IV
2. Severe Preeclampsia - Seizure prophylaxis:
   • Same dosing regime
3. Tocolysis (Preterm Labor):
   • MgSO4 used to inhibit uterine contractions (though beta-agonists and calcium channel blockers now preferred)
4. Fetal Neuroprotection (before 32 weeks gestation):
   • Reduces risk of cerebral palsy in preterm infants
   • Recommended when delivery is anticipated <32 weeks

• Patellar reflexes - first to disappear (~10 mg/dL)
• Respiratory depression (~12 mg/dL)
• Respiratory rate: should be >16/min
• Urine output: >25 mL/hr (renally excreted)

c) MTP Act (Medical Termination of Pregnancy Act)

• Must be performed by a Registered Medical Practitioner (RMP)
• Up to 20 weeks: Single RMP opinion required
• 20-24 weeks: Opinion of two RMPs required (for special categories only)

• 24 weeks: Only with Medical Board approval for substantial fetal abnormalities

1. Therapeutic - Continuation would endanger the woman's life or cause grave injury to physical/mental health
2. Eugenic - Substantial risk of physical/mental abnormality in the child
3. Humanitarian - Pregnancy resulting from rape (presumed to cause grave mental injury)
4. Socio-economic - Failure of contraception in married women (extended to unmarried women in 2021 amendment)

• Upper limit extended from 20 to 24 weeks for specific categories: survivors of sexual assault/rape, minors, change in marital status (widowhood/divorce), women with physical disabilities, humanitarian settings
• "Married woman" replaced with "any woman" - includes unmarried women
• Medical Board to decide beyond 24 weeks for fetal anomalies

d) Physiological Changes in the Cardiovascular System in Pregnancy

• Plasma volume increases by ~45-50% (by 34 weeks)
• RBC mass increases by ~25%
• Net effect: Physiological dilutional anemia of pregnancy (Hb falls to ~10.5-11 g/dL)

• Increases by ~40-50% above non-pregnant levels
• Due to: increased stroke volume (early) + increased heart rate (~15-20 bpm above baseline)
• Peaks at 28-32 weeks

• Increases by 10-20 bpm (resting tachycardia is normal)

• Falls in the first and second trimesters (due to progesterone-mediated vasodilation)
• Returns to pre-pregnancy levels in third trimester
• Diastolic BP falls more than systolic (widened pulse pressure)

• Decreases significantly (progesterone causes smooth muscle relaxation, uteroplacental low-resistance circuit)

• Supine hypotension syndrome (aortocaval compression by gravid uterus when lying supine) - relieved by left lateral position

• Heart is displaced upward and laterally (apex beat shifts)
• Physiological murmurs common (increased flow): ejection systolic murmur at left sternal edge
• S3 may be heard normally
• ECG: left axis deviation, T-wave changes

e) Active Management of the Third Stage of Labor (AMTSL)

1. Uterotonic drug administration (within 1 minute of birth of baby):
   • Oxytocin 10 IU IM - drug of choice (safe, effective, affordable)
   • Alternatives: Ergometrine (0.2 mg IM), Syntometrine (oxytocin + ergometrine)
   • Misoprostol (600 mcg oral) - if no injectables available
2. Controlled Cord Traction (CCT) - Brandt-Andrews maneuver:
   • One hand applies suprapubic counterpressure (guards uterus)
   • Other hand applies steady, controlled traction on the cord
   • Only when uterus is contracted and signs of placental separation appear
3. Uterine massage - after delivery of placenta (to maintain uterine tone)

• Calkin's sign: uterus becomes globular and firm
• Gush of blood
• Cord lengthens at introitus
• Uterus rises in the abdomen

• Reduces risk of postpartum hemorrhage (PPH) by ~60-70%
• Reduces need for blood transfusion
• Shortens third stage duration

f) Emergency Contraception (EC)

• Levonorgestrel (Plan B): 1.5 mg single dose (or 0.75 mg × 2, 12 hrs apart)
  • Within 72 hours (most effective within 24 hours); can be used up to 120 hours
  • Prevents ~85% of expected pregnancies
  • Mechanism: Primarily delays or inhibits ovulation; may alter cervical mucus
  • Safe; does not interrupt established pregnancy
• Ulipristal Acetate (ella): 30 mg single tablet
  • Effective up to 120 hours (5 days); superior to levonorgestrel between 72-120 hours
  • Selective progesterone receptor modulator
• Combined OCPs (Yuzpe method): Two doses of combined OCP (e.g., ethinyl estradiol 100 mcg + levonorgestrel 0.5 mg) 12 hours apart - less effective, more side effects

• Inserted within 5 days of unprotected sex

• 99% effective

• Also provides ongoing contraception
• Works by preventing fertilization and implantation

g) Precocious Puberty

• Girls: before 8 years
• Boys: before 9 years

• Premature activation of hypothalamic-pituitary-gonadal (HPG) axis
• GnRH stimulates increased gonadotropin (FSH/LH) secretion
• Causes:
  • Idiopathic (most common in girls, ~80%)
  • Hypothalamic hamartoma (2-28% of cases; GnRH-secreting heterotopic neurons)
  • CNS tumors, infections, trauma, hydrocephalus, craniostenosis
  • Cranial irradiation
• Treatment: GnRH agonists (leuprolide, histrelin) - suppress HPG axis; preserve adult height

• Sex steroids from gonads/adrenals without HPG axis activation
• Causes in girls:
  • Ovarian cysts or tumors (granulosa cell tumor - estrogen producing)
  • McCune-Albright syndrome
  • Congenital adrenal hyperplasia (CAH)
  • Exogenous estrogen exposure
• Treatment: Directed at underlying cause

h) Acute Pelvic Inflammatory Disease (PID)

• Neisseria gonorrhoeae
• Chlamydia trachomatis (most common STI-related cause)
• Anaerobes, gram-negative bacteria, streptococci (polymicrobial)

• Cervical motion tenderness (CMT), AND
• Uterine tenderness, AND/OR
• Adnexal tenderness

• Oral temperature >38.3°C
• Mucopurulent cervical/vaginal discharge
• WBCs on wet prep
• Elevated ESR or CRP
• Documented cervical infection with GC or Chlamydia

• Cefotetan/Cefoxitin + Doxycycline, OR
• Clindamycin + Gentamicin

• IM Ceftriaxone + oral Doxycycline ± Metronidazole (14 days)

i) Medical Management of Ectopic Pregnancy

• Hemodynamically stable
• No evidence of rupture
• Willing and able to comply with follow-up

• Intrauterine pregnancy
• Hemodynamic instability
• Ruptured ectopic
• Breastfeeding
• Hepatic/renal/hematologic dysfunction
• Immunodeficiency

• Ectopic size >4 cm
• Embryonic cardiac activity on TVS
• β-hCG >5,000 mIU/mL

j) "Birth Spacing is Must and Very Important for Both the Mother and Society" - Comment

1. Nutritional recovery: Pregnancy and lactation deplete maternal stores of iron, folate, calcium. Adequate spacing allows replenishment and prevents maternal anemia and osteoporosis.
2. Physical recovery: The uterus and pelvic floor need time to recover, reducing risk of uterine rupture in subsequent pregnancy.
3. Reduced obstetric complications: Short intervals (<18 months) are associated with increased risk of preterm birth, low birth weight, placenta previa, placental abruption, and maternal mortality.
4. Breastfeeding: Adequate spacing supports exclusive breastfeeding (6 months) and extended breastfeeding, with its benefits for both infant and maternal health.
5. Mental health: Adequate interval reduces maternal stress, depression, and burnout.

1. Infant mortality: Short birth intervals (<24 months) significantly increase infant and under-5 mortality.
2. Nutritional competition: Closely spaced pregnancies mean the older sibling is displaced from breastfeeding prematurely, increasing the risk of malnutrition.
3. Growth: Children born after short intervals have lower birth weight and poorer growth.

1. Population control: Birth spacing is a key component of family planning programs, helping reduce total fertility rate (TFR).
2. Economic productivity: Smaller, well-spaced families have better access to education, healthcare, and economic opportunities.
3. Reduced maternal/neonatal healthcare burden: Prevention of high-risk pregnancies reduces strain on healthcare systems.
4. SDG goals: Spacing aligns with Sustainable Development Goals (SDG 3 - Good Health & Wellbeing).

• Barrier methods (condoms, diaphragm)
• Hormonal contraceptives (oral pills, injectables, implants)
• Intrauterine devices (copper IUD, hormonal IUD)
• Lactational Amenorrhea Method (LAM) - effective for up to 6 months if exclusively breastfeeding + amenorrheic
• Counseling and awareness programs (RMNCH+A strategy in India)