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What are the major clinical scenarios in various obstetric and gynaecology conditions that may be asked in final year mbbs exams as a cade scenario

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final year MBBS OSPE OSCE obstetrics gynaecology clinical case scenarios examination topics 2024

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Major Clinical Case Scenarios in Obstetrics & Gynaecology - Final Year MBBS

Below is a structured overview of the highest-yield case scenarios, organised by clinical domain, with the key discriminating features, classic exam "triggers," and what examiners typically ask.

OBSTETRICS

1. Hypertensive Disorders of Pregnancy

Classic case: A 28-year-old primigravida at 34 weeks presents with headache, blurred vision, upper abdominal pain, and blood pressure of 160/110 mmHg. Urine dipstick shows 3+ protein.
What the examiner is testing:
  • Distinguish gestational hypertension / preeclampsia / eclampsia / chronic hypertension with superimposed preeclampsia
  • Diagnostic criteria for severe features (BP ≥160/110 persistent ≥15 min, thrombocytopenia <100,000, renal/liver dysfunction, pulmonary oedema, new-onset headache unresponsive to medication)
  • HELLP syndrome - Haemolysis, Elevated Liver enzymes, Low Platelets - recognition and emergency management
  • Immediate management: IV labetalol / IV hydralazine / oral nifedipine for acute hypertensive urgency; magnesium sulphate for seizure prophylaxis and treatment; timing of delivery
Key investigations: CBC with platelets, LFT, RFT, serum uric acid, 24-hour urine protein, CTG
Pearls for long case: Mention end-organ protection, monitoring for eclampsia postpartum, and low-dose aspirin for prevention in high-risk patients.
(Creasy & Resnik's Maternal-Fetal Medicine)

2. Antepartum Haemorrhage (APH)

Classic case 1 - Placenta Praevia: A 32-year-old multigravida at 32 weeks presents with sudden, painless, bright-red vaginal bleeding. No uterine tenderness.
Classic case 2 - Placental Abruption: A 30-year-old woman at 36 weeks with hypertension presents with sudden onset severe abdominal pain and a "woody-hard" uterus. Dark vaginal bleeding. Fetal heart rate is bradycardic.
Key differentiators:
FeaturePlacenta PraeviaAbruption
BleedingPainless, bright redPainful, dark
Uterine tendernessAbsentPresent (board-hard)
Fetal lieOften malpresentationNormal
ManagementNo PV exam; USSIV access, delivery decision
Do NOT do a vaginal examination if praevia is suspected until USS confirms position.

3. Postpartum Haemorrhage (PPH)

Classic case: A woman delivers normally and 30 minutes later you find 600 mL blood in the drapes, the uterus is soft and not well contracted.
The "4 T's" framework (must know):
  • Tone - uterine atony (80% of cases) - bimanual compression, oxytocin 10 IU IM/IV, ergometrine, misoprostol, carboprost
  • Trauma - cervical/vaginal lacerations - inspect and suture
  • Tissue - retained placenta/membranes - manual removal
  • Thrombin - coagulopathy (DIC) - FFP, cryoprecipitate, platelets
Management ladder: Medical (uterotonics) → Balloon tamponade → Surgical (B-Lynch suture, uterine artery ligation) → Hysterectomy

4. Ectopic Pregnancy

Classic case: A 24-year-old woman with 6 weeks amenorrhoea presents with lower abdominal pain (right side), shoulder tip pain, and vaginal spotting. BP 90/60 mmHg, pulse 110/min. urine hCG positive.
Exam asks:
  • Risk factors (previous PID, IUD, tubal surgery, previous ectopic)
  • Investigation: Transvaginal USS (absent intrauterine sac + adnexal mass), serum beta-hCG (>1500 IU/L discriminatory zone)
  • Management: Haemodynamically unstable → emergency laparoscopy/laparotomy; Stable + criteria met → methotrexate; Stable + not meeting criteria → surgical
Ruptured ectopic is a surgical emergency - do not delay for USS if clinically shocked.

5. Gestational Diabetes Mellitus (GDM)

Classic case: A 35-year-old obese woman at 26 weeks with a previous macrosomic baby has a 75g OGTT. Fasting glucose 5.4 mmol/L, 2-hour glucose 8.9 mmol/L.
WHO 2013 criteria for GDM (used by most Indian universities):
  • Fasting plasma glucose ≥5.1 mmol/L (92 mg/dL)
  • 1-hour ≥10.0 mmol/L (180 mg/dL)
  • 2-hour ≥8.5 mmol/L (153 mg/dL) - any one value
Complications asked: Macrosomia, shoulder dystocia, neonatal hypoglycaemia, birth trauma, polyhydramnios, increased CS rate, risk of T2DM in mother later
Management: Diet + exercise first; insulin if targets not met; oral hypoglycaemics (metformin) are debated

6. Preterm Labour

Classic case: A 28-year-old woman at 30 weeks presents with regular uterine contractions every 5 minutes, cervix 3 cm dilated.
Management triad:
  1. Tocolysis - to allow steroid window (nifedipine preferred, salbutamol, atosiban)
  2. Corticosteroids - betamethasone/dexamethasone 2 doses 24 hours apart for fetal lung maturity (24-34 weeks)
  3. Magnesium sulphate - neuroprotection for fetus <32 weeks (reduces cerebral palsy)
  4. GBS prophylaxis - penicillin if status unknown or positive
Cervical cerclage - elective (history-based) vs emergency (rescue) - know the indications.

7. Prolonged/Obstructed Labour

Classic case: A primigravida at term has been in active labour for 18 hours. The partograph shows the cervical dilation curve crossing the action line. The fetus is cephalic, fully engaged. Liquor is meconium-stained.
Assessment: Partograph interpretation is a classic OSPE station - know the alert line vs action line.
Moulding grades and their significance (Grade 3 = bones overlapping, fixed = serious obstruction)
Complications of obstructed labour: Uterine rupture, vesico-vaginal fistula (VVF), fetal distress, birth asphyxia, maternal sepsis
Assisted delivery options: Vacuum extraction, forceps delivery, CS - indications and contraindications for each

8. Intrauterine Growth Restriction (IUGR) / Small for Gestational Age

Classic case: A 26-year-old with chronic hypertension has an ultrasound at 32 weeks showing fetal weight on the 3rd centile, oligohydramnios, and absent end-diastolic flow on umbilical artery Doppler.
Symmetrical vs asymmetrical IUGR - caused early vs late; "brain-sparing" redistribution
Surveillance: Serial biophysical profile (BPP), NST, Doppler studies - reversed end-diastolic flow = emergency delivery

9. Rupture of Membranes

Two key scenarios:
  • PROM (Prelabour Rupture of Membranes) at term - delivery within 12-24 hours
  • PPROM (Preterm PROM) - expectant management with steroids + antibiotics (erythromycin), monitoring for chorioamnionitis (fever, uterine tenderness, elevated WBC, offensive liquor)
Confirmation: Speculum exam (pooling of fluid), nitrazine test, fern test, IGFBP-1 / AmniSure test

10. Malpresentations & Malpositions

Classic case: A multigravida at 38 weeks. On abdominal palpation, the head is felt in the right iliac fossa, broad irregular mass at the fundus, fetal heart heard at the umbilicus level.
Transverse lie - absolute indication for CS; exclude placenta praevia, contracted pelvis
Breech presentation at term - types (frank, complete, footling), management (ECV at 36-37 weeks vs elective CS vs vaginal breech delivery with criteria)
Persistent occipito-posterior (OP) position - prolonged labour, deep transverse arrest, increased need for instrumental delivery

GYNAECOLOGY

11. Abnormal Uterine Bleeding (AUB)

Classic case 1 - Fibroids (Leiomyomata): A 38-year-old P3 presents with heavy menstrual bleeding for 6 months, pelvic pressure, and a firm irregular pelvic mass on bimanual examination. Hb 8.5 g/dL.
Classic case 2 - DUB/Dysfunctional Uterine Bleeding: A 16-year-old with irregular, heavy periods for 1 year, no structural cause found on USS.
PALM-COEIN classification (must know for AUB):
  • PALM - Structural: Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia
  • COEIN - Non-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified
Investigations: Pelvic USS, endometrial biopsy (>40 yrs or risk factors), hysteroscopy, coagulation screen

12. Cervical Cancer

Classic case (OSPE station from UHS syllabus): A 45-year-old woman presents with post-coital bleeding for 3 months, offensive vaginal discharge, and lower back pain. Speculum exam shows a friable cervical mass.
Staging (FIGO 2018):
  • Stage I - confined to cervix
  • Stage II - beyond cervix but not pelvic wall
  • Stage III - pelvic wall / lower 1/3 vagina / hydronephrosis
  • Stage IV - bladder/rectum or distant mets
Management by stage: Stage IA1 → cone biopsy/simple hysterectomy; IB-IIA → Wertheim's radical hysterectomy OR chemoradiotherapy (cisplatin-based); IIB+ → chemoradiotherapy
Cervical screening: Pap smear - when, how, what results mean (ASCUS, LSIL, HSIL)
HPV - vaccine types 16 and 18 (70% of cervical cancers)

13. Endometrial Cancer

Classic case: A 62-year-old postmenopausal woman presents with painless vaginal bleeding for 2 weeks. BMI 36. History of hypertension, nulliparity, late menopause.
Endometrial cancer = the classic "postmenopausal bleeding must be investigated" scenario.
Risk factors (ENDO mnemonic): Oestrogen excess (unopposed), Nulliparity, Diabetes, Obesity; Late menopause, Tamoxifen use
Investigation: TVUSS (endometrial thickness >4 mm in postmenopausal = abnormal) → hysteroscopy + endometrial biopsy → histology (Type I endometrioid vs Type II serous/clear cell)
Management: Total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH-BSO) ± lymph node dissection

14. Ovarian Cysts / Ovarian Cancer

Classic case - Benign cyst: A 25-year-old presents with sudden onset severe right iliac fossa pain and vomiting. USS shows a 6 cm right ovarian cyst with no flow on Doppler.
Ovarian torsion - gynaecological emergency - laparoscopy within 6 hours; detorsion rather than oophorectomy if ovary viable
Classic case - Malignant: A 55-year-old with abdominal distension for 3 months, weight loss, and ascites. CA-125 elevated.
FIGO staging for ovarian cancer - Stage I (ovary only) - surgery alone; Stage III-IV (peritoneal spread, most common at presentation) - debulking surgery + platinum/paclitaxel
Germ cell tumours (important for young patients): AFP elevated in yolk sac tumour, hCG elevated in dysgerminoma/choriocarcinoma; these are chemosensitive - fertility-sparing surgery possible

15. Ectopic Pregnancy (Gynaecology context - same as above, revisit for OSPE)

OSPE scenario from UHS: "A 24-year-old woman with 6 weeks amenorrhoea and lower abdominal pain - the following procedure is being performed" (showing salpingectomy/laparoscopy image) - describe findings and management.

16. Endometriosis

Classic case: A 28-year-old nulliparous woman presents with 3-year history of dysmenorrhoea (progressive, not relieved by NSAIDs), dyspareunia, and subfertility. Bimanual exam shows a fixed, retroverted uterus and tender nodularity in the pouch of Douglas.
"3 Ds" of endometriosis: Dysmenorrhoea, Dyspareunia, Dyschezia (painful defaecation)
Investigation: Laparoscopy is gold standard; USS for endometrioma ("chocolate cyst" - ground-glass appearance)
Management: Medical (COC, progestogens, GnRH analogues) vs surgical (laparoscopic excision); IVF for infertility

17. Pelvic Inflammatory Disease (PID)

Classic case: A 22-year-old sexually active woman presents with bilateral lower abdominal pain, fever (38.2°C), mucopurulent cervical discharge, and cervical excitation on bimanual examination (positive "chandelier sign").
Diagnosis: Clinical (Amsel's criteria-like approach); cervical swab for gonorrhoea/chlamydia
Complications: Tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome (perihepatitis), infertility, chronic pelvic pain, ectopic pregnancy risk
Treatment: Doxycycline + metronidazole ± ceftriaxone; treat partner

18. Prolapse of Uterus / Pelvic Organ Prolapse

Classic case: A 60-year-old P5 woman presents with a "something coming out" of her vagina, worse on standing/straining. She also has stress urinary incontinence. On examination, there is a pink mass at the introitus when she coughs.
Classification (POP-Q or older Baden-Walker): Degree of prolapse
  • Cystocele - anterior wall
  • Rectocele - posterior wall
  • Uterine prolapse / vault prolapse
  • Enterocele
Management: Conservative (pelvic floor exercises, ring pessary) vs surgical (vaginal hysterectomy + pelvic floor repair / Manchester repair / sacrospinous fixation)

19. Gestational Trophoblastic Disease (GTD)

Classic case: A 20-year-old woman presents at 14 weeks with excessive vomiting, uterus larger than dates, no fetal heart sounds, and a "snowstorm" appearance on USS. Serum beta-hCG is very high (>100,000 IU/L). Bilateral ovarian cysts noted.
Hydatidiform mole:
  • Complete mole - 46XX (androgenic), no fetal tissue, higher risk of malignant change
  • Partial mole - triploid (69XXX/XXY), fetal tissue present
Complications to know: Molar pregnancy → Invasive mole → Choriocarcinoma (highly chemosensitive - curable even with metastases)
Management: Suction curettage + serial serum beta-hCG monitoring; chemotherapy (methotrexate) if hCG plateaus/rises

20. Contraception Counselling (Interactive OSPE Station)

Classic scenarios:
  • An 18-year-old wants to start oral contraceptive pills - counsel her (absolute contraindications: VTE, migraine with aura, liver disease, smoker >35 years)
  • Emergency contraception (levonorgestrel within 72 hours; copper IUD within 5 days)
  • A 35-year-old who has completed her family - permanent methods (tubal ligation, vasectomy)
  • A postpartum woman being discharged - LAM (Lactational Amenorrhoea Method) criteria; POP vs COCP (avoid COCP if breastfeeding in first 6 weeks)

21. Subfertility / Infertility

Classic case: A couple has been unable to conceive for 18 months despite regular unprotected intercourse. Wife is 28, husband is 32. Both previously healthy.
Systematic approach:
  1. Ovulatory factor - day 21 progesterone, BBT chart, LH surge
  2. Tubal factor - hysterosalpingography (HSG)
  3. Uterine factor - hysteroscopy, USS
  4. Male factor - semen analysis (WHO 2021 criteria: volume ≥1.4 mL, concentration ≥16 million/mL, motility ≥42%, morphology ≥4% normal forms)
Causes of anovulatory infertility: PCOS, hyperprolactinaemia, thyroid disease, premature ovarian insufficiency

22. Polycystic Ovarian Syndrome (PCOS)

Classic case: A 22-year-old obese woman presents with irregular periods (oligomenorrhoea), acne, and excessive facial hair. USS shows bilateral enlarged ovaries with >20 follicles in each ovary.
Rotterdam criteria (2 of 3):
  1. Oligo/anovulation
  2. Clinical or biochemical hyperandrogenism
  3. Polycystic ovarian morphology on USS
Complications: Infertility, endometrial hyperplasia/cancer (from unopposed oestrogen), metabolic syndrome, T2DM
Management: Lifestyle modification (first line), COCP for cycle regulation + anti-androgen effect, metformin (insulin-sensitiser), clomiphene/letrozole for ovulation induction

23. Third Stage Complications / Retained Placenta

Classic case: A woman delivers and 30 minutes pass without placental delivery. She is not bleeding significantly.
Management: Active management of third stage (oxytocin 10 IU IM + controlled cord traction); after 30 minutes → catheterise + oxytocin infusion + attempt CCT; if still retained → manual removal of placenta under anaesthesia with IV antibiotics

24. Postnatal Care Counselling (Interactive Station)

Classic OSPE station (from UHS): "A patient delivered 6 hours ago. Counsel her about postnatal care."
Key points: Breastfeeding initiation within 1 hour; uterine involution monitoring; lochia; perineal wound care; contraception; postnatal depression screening (Edinburgh Postnatal Depression Scale); danger signs to return to hospital; iron/folate supplementation; immunisation for the baby; when to resume intercourse.

EXAM STRATEGY TIPS

  1. Long Cases - Always present as: History (obstetric index: G_P_A_L_, LMP, EDD, ANC details) → Examination (general + systemic + obstetric/gynaecological) → Investigations → Diagnosis → Management → Complications
  2. OSPE Interactive Stations - Structure your counselling: Introduction → Explain diagnosis → Explain treatment options → Address concerns → Safety netting → Summarise
  3. High-yield investigations to know: Serum beta-hCG levels and interpretation, Pap smear reporting (Bethesda system), Partograph interpretation, CTG interpretation (baseline, variability, accelerations, decelerations)
  4. "Never miss" emergency scenarios: Ruptured ectopic (haemodynamic instability), PPH, Eclamptic fit, Cord prolapse, Uterine rupture, Ovarian torsion
  5. Dosages examiners often ask: Magnesium sulphate loading dose (4g IV over 20 min) + maintenance (1-2g/hour); Oxytocin 10 IU IM for active management of third stage; Methotrexate 50 mg/m² IM for ectopic pregnancy
This covers the full breadth of what UHS, MUHS, MCI/NMC-aligned, and most South Asian MBBS final year OBG examiners test in both clinical long cases and OSPE/OSCE stations. The scenarios above are drawn from Berek & Novak's Gynecology, Creasy & Resnik's Maternal-Fetal Medicine, and validated OSPE blueprints from University of Health Sciences Lahore.
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