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WBUHS Final MBBS Solved Papers (2008-2014) with
Some Special Topics
Edited by:
Prithwiraj Maiti, MBBS
House physician
Department of Internal Medicine, R.G.Kar Medical College
Author: “An Ultimate Guide to Community Medicine”
Author: “A Practical Handbook of Pathology Specimens and Slides”
[Both published by Jaypee Brothers Medical Publishers, India]
Table of contents
Topics Page no.
1 st^ Papers
2 nd^ Papers
Supple Questions (Explain Why) 211 - 217
Some special Topics
Ovarian cancer 218 - 223
Intrauterine fetal death (IUFD) 224 - 233
Reproductive tract infection (RTI) 234 - 243
References:
DC Dutta's Textbook of Obstetrics 8th^ Edition
DC Dutta's Textbook of Gynaecology 7th^ Edition
Williams Obstetrics 24th^ Edition
Williams Gynaecology 3rd^ Edition
Radiopaedia.org and
Other internet resources.
Disclaimers:
This document is created for helping the undergraduate MBBS students for
examination purpose. The pictures used in this document are property of the
authors/ publishers and used here solely for educational, non-commercial use.
Complications of pre-eclampsia:
Immediate
Maternal: During pregnancy 1. Eclampsia
- Accidental hemorrhage
- Oliguria and anuria
- Dimness of vision and even blindness
- Preterm labor
- HELLP syndrome
- Cerebral hemorrhage
- Acute respiratory distress syndrome (ARDS) During labor 1. Eclampsia
- Postpartum hemorrhage Puerperium 1. Eclampsia
- Shock
- Sepsis
Fetal:
- Intrauterine fetal death
- Intrauterine growth restriction
- Asphyxia
- Prematurity. Remote
- Residual hypertension
- Recurrent pre-eclampsia
- Chronic renal disease
- Placental abruption.
Management of eclampsia with Magnesium sulphate:
Pritchard protocol:
Loading dose : 4 gm (20 ml of 20%) IV over 4 minutes immediately followed by 10 gm (20 ml of 50%) IM: 5 gm in each buttock. If convulsions persist after 15 minutes: 2 gm (10 ml of 20%) IV.
Maintenance dose : 5 gm (10 ml of 50%) IM every 4 hours: alternate sides.
Monitoring of MgSO4 therapy:
Repeat injections are given only if:
Knee jerks are present
Respiratory rate exceeds >12/min
Urine output exceeds 30 ml/hr. Group B
- Define habitual abortion. How will you investigate a patient with history of habitual abortion? Briefly outline the treatment of cervical incompetence in pregnancy. (2+5+3)
Definition of habitual abortion (also called recurrent miscarriage):
It is defined as a sequence of ≥3 consecutive spontaneous abortion before 20 weeks.
Investigation of a patient with H/O habitual abortion:
Before going into details of investigation, we should discuss the common causes of habitual abortion:
Trimester Common causes 1 st^ 1. Genetic factors (Balanced translocation)
- Endocrine and metabolic : a. Poorly controlled diabetic b. Luteal phase defect (Less progesterone production) c. Hypersecretion of LH
- Infection
- Inherited thrombophilia (Most common: Factor V mutation)
- Autoimmunity: a. Anti-DNA antibody (SLE) b. Anti-phospholipid antibody: Lupus anticoagulant Anti-cardiolipin antibody c. Anti-thyroid antibody 2 nd^ 1. Anatomic abnormality: a. Congenital (Defects in Mullerian duct fusion/ resorption): Unicornuate uterus Bicornuate uterus
To rule out endocrine problems Serum LH on Day 2/3 of cycle Radiological investigations
- USG to detect: a. Congenital malformations of uterus b. Uterine fibroid c. Polycystic ovaries
- Hysterosalpingography (HSG) to detect: a. Uterine malformations b. Intrauterine adhesions c. Cervical incompetence Special investigation Karyotyping (husband and wife)
Treatment of cervical incompetence in pregnancy:
Introduction:
Cervical incompetence is a clinical condition characterized by dilatation and shortening of the cervix before the 37th^ week of gestation in the absence of preterm labour.
It is most classically associated with painless, progressive dilatation of the uterine cervix in the 2nd^ / early 3rd^ trimester resulting in membrane prolapse, premature rupture of the membranes, midtrimester pregnancy loss or preterm birth.
Management of choice : Cervical circlage operation
Indication/ pre-requisite :
This operation is done mainly in cases where careful history and physical examination suggest cervical incompetence (which is mainly a diagnosis of exclusion). Clinical observation is supported by relevant USG findings:
Cervical length is short Funneling of internal os: May be present.
Principle of operation :
To reinforce the weak cervix by a non-absorbable tape; placed around the cervix at the level of internal os.
Time of operation :
I. In a proven case of cervical incompetence, circlage operation should be done around 14 weeks of pregnancy / at least 2 weeks earlier than lowest period of previous pregnancy wastage. II. Emergency circlage operation can be done when the cervix is dilated and there is bulging of membranes.
Type of operations:
Two types of circlage operations are now commonly done, both of which has a similar success rate of 80-90%. We are discussing the principles of these 2 operations in short:
Operation Principle in short McDonald A purse-string stitch (a continuous, circular inverting suture) is used to cinch the cervix shut; the cervix stitching involves a band of suture at the upper part of the cervix while the lower part has already started to efface. Shirodkar The sutures pass through the walls of the cervix so they're not exposed. This type of circlage is less common and technically more difficult than a McDonald, and is thought to reduce the risk of infection.
Group C
3.a. Lower uterine segment (LUS):
Repeat question, please see 2014 G&O 1st^ paper, Group C, Question no. 3.b.
3.b. Vulval hematoma:
Repeat question, please see 2014 G&O 1st^ paper, Group C, Question no. 3.d.
Group D
4.a. Prenatal counselling is a must: Justify.
This statement is entirely wrong in the aspect of India, where the PNDT act (Prenatal diagnostic techniques act: 1994) has strictly forbidden the use of prenatal counselling except for some of the restricted purposes as mentioned below:
Detection of abnormalities : I. Chromosomal abnormalities II. Genetic metabolic diseases III. Haemoglobinopathies IV. Sex linked genetic diseases V. Congenital anomalies VI. Any other abnormalities or diseases as may be specified by the Central Supervisory Board.
Criteria to be fulfilled:
No pre-natal diagnostic techniques shall be used or conducted unless the person qualified to do so is satisfied that any of the following conditions are fulfilled, namely:
I. Age of the pregnant woman is >35 years II. The pregnant woman has undergone of ≥2 spontaneous abortions/ fetal loss III. The pregnant woman had been exposed to potentially teratogenic agents such as drugs/ radiation/ infection/ chemicals IV. The pregnant woman has a family history of mental retardation/ physical deformities such as spasticity or any other genetic disease V. Any other condition as may be specified by the Central Supervisory Board.
4.b. External cephalic version has got a place in the management of breech presentation: Critically evaluate.
Repeat question, please see 2014 G&O 1st^ paper, Group D, Question no. 4.d.
4.c. Misoprostol has almost replaced other drugs for pregnancy termination (MTP): Comment.
Introduction:
Misoprostol is a synthetic PGE1 analogue.
It binds to myometrial cells, resulting in strong myometrial contraction and cervical softening and dilation; which ultimately leads to expulsion of product of conception.
In first trimester MTP:
For first trimester MTP, the most widely used 2 regimens consist of misoprostol and mifepristone. The regimens are as follows:
200 mg of Mifepristone orally (day 1) followed by misoprostol 400 μg orally/ 800 μg vaginally (day 3) 200 mg of Mifepristone orally, followed by 800 μg vaginal misoprostol (4 tablets, 200 μg each) after 6-48 hours
In mid-trimester MTP:
For mid-trimester MTP, misoprostol has currently become the most popular agent for midtrimester termination of pregnancy. The causes are:
I. The success rate is 90-100% II. The mean induction-abortion interval is 11-12 hours only III. Misoprostol has got a very high bioavailability IV. It has more selective action on the myometrium V. Accidental intravenous injection has minimal side-effects VI. Misoprostol is not contraindicated in bronchial asthma.
The regimens of midtrimester MTP are as follows:
400 - 800 μg vaginal misoprostol at an interval of 3-4 hours 600 μg vaginal misoprostol, followed every 3 hours by 200 μg oral misoprostol 400 μg sublingual misoprostol at an interval of 3 hours (to a maximum of 5 doses)
- For these reasons, misoprostol has become one of the most widely used, popular and safe drug of choice in medical termination of pregnancy, especially in mid-trimester abortion.
4.d. Twin pregnancy is a high-risk pregnancy: Justify.
Twin pregnancy is a high-risk pregnancy because there are increased maternal and perinatal hazards as described below:
WBUHS 2009
1 st^ Paper
G&O Group A
- A primigravida had assisted delivery with outlet forceps. She started severe vaginal bleeding 4 hours after childbirth. Enumerate the causes of this bleeding. How will you manage such a patient? (2+8)
Note:
Postpartum hemorrhage (PPH) is clinically defined as any amount of bleeding from/into the genital tract following birth of the baby upto the end of the puerperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure.
Primary: Hemorrhage occurs within 24 hours following birth of the baby
Third stage hemorrhage: Bleeding occurs before expulsion of placenta True PPH: Bleeding occurs after expulsion of placenta.
Secondary: Hemorrhage occurs after 24 hours of birth of the baby and within puerperium.
The case as described in the question above is a case of postpartum hemorrhage (PPH).
As the bleeding started after 4 hours of childbirth (that is, within 24 hours of childbirth), the PPH is said to be primary PPH.
Causes of primary PPH:
- Atonic uterus: It is the commonest cause of primary PPH (80%). With the separation of placenta, the torn uterine sinuses cannot be compressed effectively due to imperfect
Types of PPH
Primary
Third stage hemorrhage
True PPH Secondary
Management of a case of true PPH
Immediate measures
- Communication with obstetrics senior stuff on call
- Commence IV line with 2 wide bore cannulas
- Send blood for cross-matching and ask for at least 2 units of blood
- Rapidly infuse normal saline 2 lt till blood is available.
Feel the uterus by abdominal palpation
Uterus atonic (^) Uterus hard and contracted (traumatic)
Exploration
Hemostatic sutures on the tear site(s)
Massage the uterus to make it hard Oxytocin 10-20 units in 500 ml normal saline at the rate of 40 drops per minute Injection Methergin 0.2 mg slow IV Examine the expelled placenta Catheterize the bladder
Uterus still atonic
Exploration of the uterus Blood transfusion Continue oxytocin drip
Uterus still atonic
15-Methyl-PGF2 (250 μg IM/ Intramyometrial) OR Misoprostol 1000 μg per rectal
Group B
- A primigravida aged 30 years attends your clinic at 32 weeks of gestation with breech presentation. How will you manage the case till birth of the baby? What injuries may occur to the mother and the baby during vaginal breech delivery? (5+5)
Management of the case:
As the age of the patient is 30 years, she is not an elderly primi (>34 years).
Uterus still atonic
Uterine tamponade (any of the following)
- Bimanual compression
- Tight intrauterine packing under anesthesia
3. Balloon tamponade.
Uterus still atonic
Surgical methods (any 1): Stepwise uterine devascularization procedure
- Ligation of uterine artery and utero-ovarian anastomotic vessels
- Ligation of anterior division of internal iliac artery
- B-lynch compression suture and multiple square sutures
4. Angiographic arterial embolization with gelatin sponge.
Bleeding not controlled (^) Bleeding controlled
Continuous observation in high dependency unit/ ICU
Hysterectomy (rarely done)
Methods of vaginal breech delivery:
There are 3 general methods of breech delivery through the vagina:
- Spontaneous breech delivery : The fetus is expelled entirely spontaneously without any traction or manipulation other than support of the newborn.
- Partial breech extraction/ assisted breech delivery : The fetus is delivered spontaneously as far as the umbilicus, but the remainder of the body is extracted or delivered with operator traction and assisted maneuvers, with or without maternal expulsive efforts.
- Total breech extraction : The entire body of the fetus is extracted by the obstetrician.
*Indications for cesarean section in breech presentation:
1. Primi with breech
- Footling presentation
- Twins with first baby in breech
- Previous LSCS with breech
- Preterm breech
- Flying fetus.
Injuries that may occur to the mother and the baby during vaginal breech delivery Maternal dangers
In the persistent breech presentation, an increased frequency of the following complications can be anticipated:
- Prolapsed cord
- Placenta previa
- Uterine anomalies and tumors
- Difficult delivery
- Increased maternal and perinatal morbidity. Fetal dangers
- Intrapartum fetal death
- Intracranial hemorrhage (compression followed by decompression during delivery of the unmoulded after-coming head results in tear of tentorium cerebelli and hemorrhage in subarachnoid space)
- Birth asphyxia due to: a. Cord compression soon after buttocks are delivered/ after head enters pelvis b. Retraction of placental site c. Premature attempt at respiration when head is still inside d. Delayed delivery of the head e. Cord prolapse.
- Birth injuries : a. Hematoma b. Fracture (common sites: femur/ humerus/ clavicle/ odontoid process) c. Visceral injuries (rupture of liver/ kidneys/ suprarenal glands/ lungs/ testicles) d. Nerve injuries (medullary coning/ spinal cord injury/ Erb’s/ Klumpke’s palsy) e. Long term neurological damage. Group C
3.a. Face presentation:
Introduction:
With this presentation, the head is hyperextended so that the occiput is in contact with the fetal back, and the chin (mentum) is presenting part. The fetal face may present with the mentum anteriorly or posteriorly, relative to the maternal symphysis pubis. The commonest position is left mento-anterior (LMA).
Etiology/ associations:
Maternal
- Multiparity with pendulous abdomen
- Lateral obliquity of uterus (especially if it lies at the side where occiput lies)
- Contracted pelvis
- Pelvic tumors. Fetal
- Congenital malformations: Anencephaly (commonest) Congenital goitre Dolichocephalic head Congenital branchocele.
- Twist of the cord
