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SECTION A - MCQs (Answers with Reasoning)

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SECTION B

Q1. Eclampsia (10 marks)

(a) Definition of Eclampsia (2 marks)

• Occurs in the context of hypertension (BP ≥140/90) + proteinuria (≥2+ or ≥300 mg/24 hrs) in pregnancy
• Can occur antepartum (most common, 50%), intrapartum (25%), or postpartum (25%, up to 48 hrs)
• Convulsions occur in 4 stages: Premonitory → Tonic → Clonic → Comatose

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(b) Immediate Management and Pritchard Regimen (5 marks)

• Lateral position to prevent aspiration
• Maintain airway - padded tongue blade (bite block)
• O2 inhalation
• IV access, Foley catheter (monitor urine output)
• Assess fetal condition

1. Knee jerk present
2. Urine output >25 mL/hour (>100 mL/4 hrs)
3. Respiratory rate >12/min

• IV Labetalol 20 mg bolus (drug of choice) or
• Hydralazine 5-10 mg IV or
• Nifedipine 10 mg oral (if no IV access)
• Target: Keep BP 140-150/90-100 mmHg (avoid sudden drop)

• Eclampsia is NOT an indication for immediate CS
• Stabilize for at least 4-6 hours, then decide mode of delivery
• If cervix favorable - induce; if not - LSCS after stabilization
• Postpartum MgSO4 continued for 24-48 hours after last fit

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(c) Complications of Eclampsia (3 marks)

• Cerebral hemorrhage (leading cause of death)
• Pulmonary edema / ARDS
• Acute renal failure (oliguria/anuria)
• Liver rupture / HELLP syndrome
• Placental abruption
• DIC
• Cortical blindness
• Maternal death

• Intrauterine fetal death (IUFD)
• Prematurity and its complications
• Intrauterine growth restriction (IUGR)
• Perinatal asphyxia

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Q2. Short Notes (4 x 5 = 20 marks)

(a) Minimum Antenatal Visits (GOI Guidelines) + Services at Each Visit

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(b) Classification of Placenta Previa + Stallworthy's Sign

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(c) Management of Rh-Negative, Unsensitized (ICT Negative) Pregnant Woman

• Blood group and Rh typing, ICT (Indirect Coombs Test) - if negative, unsensitized confirmed

• Repeat ICT at 28, 32, 36 weeks
• Anti-D 300 mcg IM at 28 weeks (prophylactic) - as per current guidelines
• Anti-D after any sensitizing event: amniocentesis, CVS, antepartum hemorrhage, external cephalic version, abdominal trauma

• Cord blood: blood group, Rh, DCT (Direct Coombs Test)
• If baby is Rh-positive:
  • Kleihauer-Betke test to quantify FMH
  • Anti-D 300 mcg IM within 72 hours of delivery (covers up to 30 mL FMH)
  • If FMH >30 mL, additional Anti-D needed

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(d) Modified WHO Partogram: Components + Clinical Significance

1. Patient Information: Name, gravida/para, date, time of admission, time of ROM
2. Fetal Condition:
   • Fetal heart rate (recorded every 30 min)
   • Amniotic fluid (C=clear, M=meconium, B=blood, A=absent)
   • Moulding (0, +1, +2, +3)
3. Progress of Labor:
   • Cervical dilatation (plotted on graph - Alert and Action lines)
   • Descent of head (fifths palpable above brim)
   • Uterine contractions (frequency + duration every 30 min)
4. Maternal Condition:
   • Pulse, BP, temperature (every 4 hours)
   • Urine output, protein, acetone
5. Drugs/IV fluids/Oxytocin

• Identifies abnormal labor early (when cervical progress crosses the alert line)
• Guides decision to transfer, augment, or perform CS
• Reduces unnecessary CS and obstructed labor
• Monitoring tool in resource-limited settings

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Q3. Very Short Notes (5 x 2 = 10 marks)

(a) LSCS - Any Two Indications

1. Cephalopelvic disproportion (CPD) - contracted pelvis/obstructed labor
2. Placenta previa (Type III & IV) - major degree, antepartum hemorrhage

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(b) Couvelaire Uterus

• Also called Uteroplacental apoplexy
• Occurs in severe Abruptio Placentae
• Blood extravasates into the myometrium between muscle fibers (under pressure) reaching the serosa
• Uterus appears "bruised" - purple/copper-colored, wooden hard, ecchymotic patches under serosa
• Myometrium loses contractility - risk of PPH
• In severe cases, hysterectomy may be needed
• Uterus may still contract after delivery (does not automatically require hysterectomy)

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(c) Two Drugs Used for Induction of Labor

1. Dinoprostone (PGE2) - cervical gel or vaginal insert (Cerviprime, Propess) - for cervical ripening and induction
2. Misoprostol (PGE1) - 25 mcg intravaginally or 50 mcg oral - inexpensive, effective, stable at room temperature
3. (Also: Oxytocin IV infusion - after cervical ripening; artificial rupture of membranes is a mechanical method)

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(d) Puerperal Pyrexia

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(e) "Golden Hour" in Neonatal Resuscitation

• The first 60 minutes of a newborn's life are called the "Golden Hour"
• Optimal care during this period significantly reduces neonatal morbidity and mortality
• Key interventions: Immediate newborn resuscitation (NRP), skin-to-skin contact, early breastfeeding initiation within 1 hour, prevention of hypothermia (dry and warm), delayed cord clamping (1-3 min), Vitamin K injection, eye care
• Forms part of Essential Newborn Care (ENC) protocol

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SECTION C

Q1. Normal Labor - Definition, Stages, and Mechanism (LOA) (10 marks)

Definition of Normal Labor (DC Dutta)

• Spontaneous onset
• Viable gestational age
• Duration within normal limits
• Occipitopresentation (vertex), with no complications

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Stages of Labor

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Mechanism of Labor in LOA Position

• Biparietal diameter passes through the pelvic inlet
• Head enters in the transverse or oblique diameter
• In LOA: occiput points to left iliac fossa

• Progressive downward movement throughout labor
• Due to: uterine contractions, bearing-down efforts, straightening of fetal body

• As head meets resistance of pelvic floor, neck flexes
• Sub-occipito-bregmatic diameter (9.5 cm) replaces sub-occipito-frontal (10 cm)
• Smallest diameter presents

• Occiput rotates anteriorly from LOA to OA (45° rotation)
• Occiput comes under the symphysis pubis (anterior fontanelle goes to the sacrum)
• Facilitated by gutter shape of levator ani

• Occiput under the pubic arch, head extends
• Delivery of head by extension: occiput, bregma, forehead, nose, mouth, chin delivered in sequence
• Head is born by extension

• After head is born, it rotates 45° back to LOA position (undoes internal rotation)
• Head aligns with the shoulders

• Head further rotates to LOT (transverse) as shoulders undergo internal rotation
• Anterior shoulder under symphysis pubis

• Anterior shoulder delivered first (under pubic arch)
• Posterior shoulder over the perineum
• Body delivered by lateral flexion

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Q2. Short Notes - Section C

(a) Legal Indications for MTP + Drugs for Medical Abortion up to 7 weeks

1. Risk to life of the pregnant woman
2. Grave injury to physical or mental health (including rape, failure of contraception)
3. Fetal abnormalities - substantial risk that child would be seriously handicapped
4. Humanitarian grounds - pregnancy due to rape (mental health risk presumed)
5. Contraceptive failure - for married women AND now unmarried women (2021 amendment)

• Up to 20 weeks - single doctor's opinion
• 20-24 weeks - two doctors' opinion (for special categories: rape survivors, minors, differently-abled, FMR)
• Beyond 24 weeks - State Medical Board for fetal abnormalities only

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(b) HELPERR Mnemonic for Shoulder Dystocia

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(c) Physiology of Lactation + Benefits of Exclusive Breastfeeding

1. Lactogenesis I (Mammogenesis): During pregnancy - estrogen + progesterone + hPL develop ductal and alveolar system; colostrum secreted from 16 weeks
2. Lactogenesis II (Initiation): After delivery - fall in progesterone + estrogen → Prolactin (from anterior pituitary) drives milk synthesis
3. Milk Ejection/Let-down reflex: Infant suckling → afferent signals → hypothalamus → posterior pituitary → Oxytocin → myoepithelial cell contraction → milk ejection
4. Galactopoiesis (Maintenance): Continued suckling maintains prolactin levels; demand = supply
5. Inhibitor of Feedback of Lactation (FIL): Whey protein in breast milk - if milk is not removed, FIL accumulates and inhibits further production

• Passive immunity (SIgA, lactoferrin, lysozyme)
• Protection against GI infections, respiratory infections, otitis media, meningitis
• Reduces risk of SIDS, obesity, diabetes, allergies
• Optimal nutrition - easily digestible

• Uterine involution (oxytocin release)
• Reduces postpartum bleeding
• Lactational amenorrhea (LAM) - contraceptive benefit
• Reduces risk of breast and ovarian cancer
• Promotes mother-infant bonding
• Economical

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(d) Janani Suraksha Yojana (JSY) + Role in Institutional Deliveries

• Centrally Sponsored Scheme under National Rural Health Mission (NRHM), launched 2005
• Promotes institutional delivery to reduce maternal and neonatal mortality
• Cash incentive scheme for pregnant women

• All pregnant women for institutional delivery in government health facilities
• BPL women for delivery in accredited private institutions

• Financial incentive removes economic barrier
• ASHA acts as link worker - antenatal follow-up, transport facilitation
• Significantly increased institutional delivery rates from ~40% (2005) to >80% (2020)
• Associated with decline in MMR and neonatal mortality in India
• Beneficiary is provided for transport, meals, and medicines during hospital stay

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Q3. Very Short Notes - Section C

(a) Two Ultrasound Markers for Down Syndrome (First Trimester)

1. Increased Nuchal Translucency (NT): NT ≥ 3.0 mm at 11-13+6 weeks (CRL 45-84 mm) is the single most important marker. Normal <2.5 mm.
2. Absent Nasal Bone: Nasal bone absent or hypoplastic at 11-14 weeks on USG - present in ~60-70% of Down syndrome fetuses.

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(b) Polyhydramnios - Definition

• Mild: AFI 25-29.9 cm
• Moderate: AFI 30-34.9 cm
• Severe: AFI ≥ 35 cm

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(c) Dose of Folic Acid for Preconception Care

• Standard dose: 0.4 mg (400 mcg) per day starting at least 1 month before conception and continued through first trimester (up to 12 weeks)
• High-dose: 5 mg per day for women with:
  • Previous NTD-affected pregnancy
  • On anti-epileptic drugs (valproate, carbamazepine)
  • Diabetes mellitus
  • Obesity (BMI >30)
  • Malabsorption syndromes

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(d) Two Absolute Contraindications for Oral Contraceptive Pills (OCPs)

1. Thromboembolic disease / history of DVT or pulmonary embolism - estrogen increases clotting factors; risk of fatal PE
2. Breast cancer (current or recent) - estrogen/progesterone receptor-positive tumors
3. Others: Active liver disease, undiagnosed vaginal bleeding, migraine with aura, smokers >35 years, hypertension (SBP >160), lactating mothers <6 weeks postpartum, ischemic heart disease

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(e) Spalding's Sign

• Definition: Overlapping of fetal skull bones due to liquefaction and shrinkage of the brain after intrauterine fetal death (IUFD)
• Seen on X-ray (skull radiograph) - collapse and overlapping of cranial bones
• Occurs 7+ days after fetal death
• Pathognomonic of IUFD
• Other X-ray signs of IUFD: Robert's sign (gas in fetal heart/great vessels), Hyperflexion of spine, Crowding of ribs

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All answers are based on DC Dutta's Textbook of Obstetrics (10th edition) and standard teaching for MBBS 3rd Professional examinations. Diagrams (e.g., Mechanism of labor, Partogram, Pritchard Regimen table) should be drawn to supplement written answers as instructed.Quick clarification on Q9: Per DC Dutta, the maternal hypercoagulable state in pregnancy is primarily due to Estrogen - which increases clotting factors (VII, VIII, X, fibrinogen, vWF) and decreases anticoagulants (protein S). Answer: (b) Estrogen.

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