1. A 32-year-old G2P1 woman with a previous cesarean section presents to OPD at 30 weeks of gestation. She has a history of chronic hypertension and is on oral labetalol 100 mg twice daily. Her BP is 160/100 mmHg, and fundal height corresponds to 26 weeks. Doppler ultrasound shows reduced end-diastolic flow.
What is the next step in management?
A. Ductus Venosus Doppler
B. Umbilical and Middle Cerebral Artery Doppler
C. Middle Cerebral Artery Doppler
D. Uterine Artery Doppler
Answer: A. Ductus Venosus Doppler
Explanation: Reverse end-diastolic flow in umbilical artery Doppler is an ominous sign of fetal compromise. Ductus Venosus Doppler is the next step to assess fetal well-being, particularly cardiac compromise to time delivery before time
2. A 35-year-old P4+0 woman presents with complaints of something coming out of the vagina. On POP-Q staging, the findings are Aa +3, Ba +6, C -8, Ap +3, Bp +6, and TVL 10 cm.
What is the best management option?
A. Manchester Repair
B. Anterior Colporrhaphy & Colpoperineorrhaphy
C. Sacro hysteropexy
D. Vaginal hysterectomy & repair
Answer: B. Anterior Colporrhaphy & Colpoperineorrhaphy
Explanation: The patient has anterior compartment prolapse (Ba +6), which indicates significant cystocele. The best approach is anterior colporrhaphy and colpoperineorrhaphy to reinforce vaginal support.
3. A 63-year-old woman, para 6, presents with complaints of something coming out of the vagina. On POP-Q staging, the findings are Aa +3, Ba +3, Ap -3, Bp +4, C -4, Gh 4 cm, and TVL 10 cm.
Which anatomical support is weak, and what is the best management?
A. Uterosacral Ligament
B. Perineal Body
C. Transverse Cervical Ligament
D. Pubocervical Fascia
Answer: D. Pubocervical Fascia
Explanation: The findings suggest anterior compartment prolapse, which is due to pubocervical fascia weakness. Repair of this fascia helps restore normal pelvic support.
4. A 29-year-old woman presents with vaginal bleeding and lower abdominal pain. She missed her periods 5 days ago. Her beta-HCG is 1750 IU/ml. Ultrasound reveals an empty uterus and a sac-like structure in the left fallopian tube.
What is the most appropriate next step in management?
A. Laparotomy
B. Laparoscopy
C. Single dose of Methotrexate
D. Repeat beta-HCG after 48 hours
Answer: B. Laparoscopy
Explanation: In a hemodynamically stable patient with an ectopic pregnancy and β-HCG >1500 IU/ml with an adnexal mass, laparoscopy is the preferred surgical approach. Methotrexate is considered in cases with β-HCG <5000 IU/ml and no significant symptoms.
5. A 28-year-old woman had a miscarriage at 8 weeks. She has a history of stroke last year and developed DVT two years ago for which she was treated with anticoagulants.
What is the most likely diagnosis?
A. Cardiovascular Disease
B. Factor V Leiden Deficiency
C. Anti-Phospholipid Antibody Syndrome (APS)
D. Thrombocytopenia
Answer: C. Anti-Phospholipid Antibody Syndrome (APS)
Explanation: APS is a prothrombotic disorder associated with recurrent pregnancy loss, DVT, and stroke. Women with APS require low-dose aspirin and heparin to improve pregnancy outcomes.
6. A 40-year-old P4+0 woman presents for contraception. She complains of heavy menstrual blood flow, and her husband does not want a permanent surgical method.
What is the best contraceptive option for her?
A. Progestogen-only pill (POP)
B. Copper IUCD
C. LNG IUS
D. Combined Oral Contraceptive Pills (COCPs)
Answer: C. LNG IUS (Levonorgestrel Intrauterine System)
Explanation: LNG IUS (Mirena) is the best option for heavy menstrual bleeding as it reduces endometrial thickness, decreasing menstrual flow. Copper IUCD is contraindicated as it can increase bleeding. COCPs are effective but less suitable in older women (>35 years) with heavy bleeding.
7. A 5-year-old girl is brought by her mother with complaints of vaginal discharge and per vaginal bleeding. On local examination, she is found to have an ulcerated polypoidal growth.
What is the most likely diagnosis?
A. Clear cell carcinoma
B. Rhabdomyosarcoma
C. Poorly differentiated squamous cell carcinoma
D. Endometrial hyperplasia
Answer: B. Rhabdomyosarcoma
Explanation: Rhabdomyosarcoma (sarcoma botryoides) is the most common vaginal malignancy in children. It presents as a polypoidal or grape-like mass protruding from the vaginal introitus with ulceration. Clear cell carcinoma is associated with diethylstilbestrol (DES) exposure.
8. A patient underwent suction curettage for a molar pregnancy.
What is the most appropriate follow-up advice?
A. Urine Beta-HCG weekly until it becomes normal
B. Serum Beta-HCG weekly until it becomes normal
C. Serum Beta-HCG monthly until it becomes normal
D. No follow-up is needed if asymptomatic
Answer: B. Serum Beta-HCG weekly until it becomes normal
Explanation: Weekly serum Beta-HCG monitoring is required to detect persistent trophoblastic disease. Figo says 1to 2 weekly beta hcg
9. A patient presents for follow-up after suction evacuation for molar pregnancy. She is asymptomatic, and her examination is unremarkable.
What is the indication to start single-agent chemotherapy?
A. Biopsy showing complete hydatidiform mole
B. Positive urine pregnancy test
C. Rising Beta-HCG
D. Retained products of conception
Answer: C. Rising Beta-HCG
Explanation: Rising Beta-HCG is the most reliable indicator of persistent trophoblastic disease (PTD), warranting chemotherapy. Urine pregnancy tests are unreliable, and biopsy is not required for diagnosis.
10. A 36-year-old G2P1 woman is admitted in labor at 39 weeks of gestation. She receives epidural analgesia at 6 cm dilation. Shortly after, she develops hypotension, dizziness, nausea, and lightheadedness upon lying on her back. Her symptoms resolve when she is positioned on her left side.
What is the most likely diagnosis?
A. Amniotic fluid embolism
B. Uterine rupture
C. Supine Hypotensive Syndrome
D. Pulmonary embolism
✅ Answer: C. Supine Hypotensive Syndrome
Explanation:
- Supine Hypotensive Syndrome (SHS), also called aortocaval compression syndrome, occurs when the gravid uterus compresses the inferior vena cava and aorta, reducing venous return and cardiac output, leading to maternal hypotension and fetal distress.
- Symptoms: Hypotension, dizziness, nausea, lightheadedness, and syncope.
- Management:
- Immediate left lateral positioning to relieve pressure.
- Placing a wedge under the right hip also helps.
- Avoid prolonged supine positioning in late pregnancy.
🔹 Why not other options?
- Amniotic fluid embolism (AFE): Causes sudden cardiorespiratory collapse, respiratory distress, and coagulopathy—not relieved by repositioning.
- Uterine rupture: Presents with severe pain, fetal distress, and vaginal bleeding—not just hypotension.
- Pulmonary embolism: Causes dyspnea, chest pain, and hypoxia, not positional hypotension.
✅ Key Learning Point: SHS is a positional condition that resolves with left lateral positioning. It typically occurs in late pregnancy or postpartum and can be prevented by avoiding prolonged supine positioning.
11. A 60-year-old nulliparous woman presents with complaints of watery and blood-stained vaginal discharge for the last 6 months. She is postmenopausal for 10 years. Speculum examination reveals thin watery discharge draining from the cervical os. Ultrasound shows a 10×4 cm irregular mass in the right adnexa.
What is the most likely diagnosis?
- A. Uterine Carcinoma
- B. Chronic Pelvic Inflammatory Disease (PID)
- C. Fallopian Tube Carcinoma
- D. Ovarian Carcinoma
Answer: B
Answer: B. Chronic Pelvic Inflammatory Disease (PID)
Explanation:
Chronic Pelvic Inflammatory Disease (PID) can present with persistent vaginal discharge, postmenopausal bleeding, and an adnexal mass due to hydrosalpinx or tubo-ovarian abscess (TOA). Though bilateral involvement is more common, unilateral tubo-ovarian masses can also occur, especially if the infection is localized.
Key Features Supporting PID:
✅ Watery/blood-stained vaginal discharge – Common in chronic PID.
✅ Adnexal mass – Can represent hydrosalpinx, pyosalpinx, or TOA, which may be unilateral or bilateral.
✅ Postmenopausal status – Though PID is more common in younger women, chronic PID with adhesions or past infections can persist.
✅ Differentiation from malignancy – Fallopian tube carcinoma (hydrops tubae profluens) typically presents with profuse watery discharge and is rare; ovarian cancer usually presents with bloating, weight loss, and ascites.
12. A woman undergoes laparotomy for bilateral ovarian tumors. On exploration, omentum was found to have deposits, and the undersurface of the diaphragm was involved with extensive metastasis. The liver surface was smooth.
What is the most likely stage of disease?
- A. Stage 3A
- B. Stage 3B
- C. Stage 3C
- D. Stage 4
Answer: C. Stage 3C
Explanation: According to the FIGO staging system, Stage IIIC ovarian cancer involves macroscopic peritoneal metastasis beyond the pelvis more than 2 cm in greatest dimension, including metastasis to the omentum and diaphragm. The absence of liver parenchymal involvement excludes Stage IV disease.
13. A patient undergoes total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO). Cut section of the uterus shows irregular polypoidal growth with grayish-white necrotic areas. Biopsy reveals atypical closely packed cells with necrosis and atypia.
What is the most likely diagnosis?
- A. Poorly differentiated carcinoma
- B. Well-differentiated carcinoma
- C. Carcinosarcoma
- D. Endometrial Hyperplasia with Atypia
Answer: C. Carcinosarcoma
Explanation: Uterine carcinosarcoma, also known as malignant mixed Müllerian tumor, presents as a polypoidal mass with areas of necrosis and atypia. Histologically, it contains both malignant epithelial and mesenchymal components, distinguishing it from poorly differentiated carcinoma, which lacks mesenchymal elements.
14. A 60-year-old woman underwent radical hysterectomy for cervical carcinoma with obvious parametrial involvement.
Which stage does this correspond to?
- A. Stage 1B2
- B. Stage 2B
- C. Stage 3A
- D. Stage 3B
Answer: B. Stage 2B
Explanation: In the FIGO staging system for cervical cancer, Stage IIB is defined as tumor extension into the parametrial tissues but not reaching the pelvic sidewall. The presence of parametrial involvement without extension to the pelvic sidewall or lower third of the vagina corresponds to Stage IIB.
15. What percentage of women in Pakistan experience domestic violence by their partner?
- A. 10%
- B. 25%
- C. 50%
- D. 70%
Answer: B. 25%
Explanation: Various reports indicate that approximately 25% of Pakistani women experience domestic violence. However, due to cultural factors and underreporting, the actual prevalence may be higher.
Domestic Violence in Pakistan
Prevalence:
- 28% of women aged 15–49 have experienced physical violence.
- 6% of women aged 15–49 have experienced sexual violence.
- 34% of ever-married women have experienced spousal physical, sexual, or emotional violence.
- 90% of married women have experienced psychological abuse.
- 65% of women interviewed at a rural health center had experienced domestic violence.
16. A 32-year-old P2+0 woman presents with second-degree cervical descent. She can urinate after digital manipulation.
What is the most appropriate treatment for her?
- A. Fothergill Operation
- B. Sacro-hysteropexy
- C. Cervicopexy
- D. Total Abdominal Hysterectomy
Answer: B. Sacro-hysteropexy
Explanation: Sacro-hysteropexy is a uterine-sparing procedure suitable for young women with uterovaginal prolapse who wish to preserve their uterus. It involves attaching the uterus to the sacral promontory using a mesh, providing support while maintaining reproductive potential.
17. A 35-year-old P1+0 obese woman presents with palpitations, lethargy, and headache. Her last menstrual period was 6 months ago. Investigations show borderline raised serum prolactin, along with elevated FSH and LH.
What is the most likely diagnosis?
- A. Hypothyroidism
- B. Premature Ovarian Failure
- C. Pregnancy
- D. Hyperprolactinemia
Answer: B. Premature Ovarian Failure
Explanation: Premature Ovarian Failure (POF), also known as primary ovarian insufficiency, is characterized by elevated follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels in women under 40 years with secondary amenorrhea. The mildly elevated prolactin does not exclude POF.
Here is the updated MCQ set with the additional information on domestic violence prevalence and the updated question on fibroid management.
18. A 30-year-old P1+0 woman is keen to conceive. She complains of heavy menstrual bleeding for one year. Ultrasound reveals an intramural fibroid (6×6 cm) and submucous fibroids of similar size.
What is the most appropriate management?
- A. UAE
- B. GnRH Analogues and Hysteroscopic Myomectomy
- C. Combined Laparoscopic and Hysteroscopic Myomectomy
- D. Abdominal Myomectomy
Answer: UAE . MRCOG BOOK
19. A 20-year-old woman presents with irregular anovulatory cycles. She previously had normal menstrual cycles. Her serum prolactin levels are raised.
What is the most relevant investigation?
- A. Serum Testosterone
- B. Progesterone Challenge Test
- C. Karyotyping
- D. Measurement of Gonadotropin Levels
Answer: D. Measurement of Gonadotropin Levels
Explanation: Measurement of FSH and LH levels helps distinguish ovarian failure (high FSH/LH) from hypothalamic or pituitary dysfunction (low/normal FSH/LH). Karyotyping is only indicated if Turner’s syndrome is suspected.
20. A 38-year-old nulliparous woman complains of heavy menstrual bleeding, dysmenorrhea, and dyspareunia. Examination reveals a firm, tender, and uniformly enlarged uterus (10 weeks size).
What is the most likely diagnosis?
- A. Dysfunctional Uterine Bleeding (DUB)
- B. Fibroids
- C. Adenomyosis
- D. Pelvic Inflammatory Disease
Answer: C. Adenomyosis
Explanation: Adenomyosis is characterized by a globally enlarged, tender uterus with severe dysmenorrhea and heavy bleeding. Fibroids usually cause irregular uterine enlargement, while DUB presents without uterine tenderness or enlargement.
Q22: A 15-year-old girl presents with heavy periods, dizziness, shortness of breath, and Hb 6.0 g/dL. She is still bleeding despite initial stabilization with IV fluids.
What will you give next?
- A) High dose of estrogen
- B) Tranexamic acid (Transamine)
- C) PCV (Packed Cell Volume) transfusion and correct anemia
- D) Iron supplementation and follow-up
Answer: C) PCV transfusion and correct anemia
Explanation:
This adolescent has acute heavy menstrual bleeding (HMB) with severe symptomatic anemia (Hb 6 g/dL, dizziness, SOB). The priority is to stabilize the patient with blood transfusion before addressing the ongoing bleeding.
- THEN High-dose estrogen : Effective for controlling ongoing bleeding, but only after stabilization of anemia.
- A G3P2 woman presents to the emergency department with lower abdominal pain and vaginal spotting. She is 5 weeks pregnant. On examination, BP is 80/40 mmHg, PR 120 bpm, and pallor is present.
What is the most appropriate management?
- A) Laparoscopic Salpingostomy
- B) Laparotomy and Salpingectomy
- C) Injection Methotrexate
- D) Expectant Management
Explanation:
Hypotension (BP 80/40), tachycardia, and pallor indicate ruptured ectopic pregnancy with hemodynamic instability, requiring urgent laparotomy.
Methotrexate is only given for stable patients with unruptured ectopic pregnancy.
- A 55-year-old postmenopausal woman with a history of mastectomy due to breast cancer presents with hot flashes, insomnia, and Low mood. She is hypertensive
What is the best treatment for her?
- A) Antidepressant and symptomatic treatment
- B) Clonidine
- C) Reassure and give calcium supplements
- D) Combined estrogen and progesterone
Explanation:
CLONIDINE IF HIGH BP
SNRI IF BREAST CANCER
SSRI IF ON TAMOXIFEN
- A woman who was using COCPs for contraception has now stopped them and is keen to conceive.
Which of the following is true regarding COCPs?
- A) There is an increased risk of miscarriage
- B) After discontinuation of COCPs, most of women ovulate within one month
- C) Fertility is rarely achieved after stopping COCPs
- D) COCPs permanently reduce fertility
Explanation:key b
COCPs do not delay the return of fertility.
Ovulation resumes quickly (90% within 3 months) after stopping pills. No increased risk of miscarriage post-COCP use.
- A 38-year-old woman presents to the emergency department with physical injuries after an alleged domestic violence incident. Upon further inquiry, she reports ongoing psychological and financial abuse.
What is the most common underlying cause of domestic violence in Pakistan?
- A) Drug abuse
- B) Economic instability
- C) Cultural values ✅
- D) Poor education
Explanation:
Cultural norms and societal values play a major role in domestic violence in Pakistan. While economic instability, drug abuse, and poor education are contributing factors, deep-rooted patriarchal values often lead to the justification and perpetuation of violence against women.
- A 65-year-old multiparous woman presents with complaints of persistent vulval itching. On examination, she has white raised lesions on the vulva. A biopsy confirms the diagnosis of squamous cell hyperplasia.
What is the best initial treatment?
- A) 5-Fluorouracil
- B) 1% Hydrocortisone topical application ✅
- C) Podophyllins
- D) Cryotherapy
key b
Explanation:
Squamous cell hyperplasia (lichen simplex chronicus) is best managed with topical steroids. Low-potency topical corticosteroids such as 1% hydrocortisone help in reducing inflammation and itching. High-potency steroids may be used in more severe cases.
- A 27-year-old nulliparous woman with primary infertility and BMI of 30 kg/m² presents with irregular periods and mild hirsutism. On further evaluation, she is diagnosed with polycystic ovarian syndrome (PCOS).
What is the most appropriate first-line treatment for ovulation induction?
- A) Clomiphene citrate ✅
- B) Cortisol and mineralocorticoid therapy
- C) Intrauterine insemination (IUI)
- D) Letrozole
Explanation:
Clomiphene citrate is the first-line treatment for ovulation induction in women with PCOS. It enhances follicular development and increases the chances of conception. Letrozole is an alternative in cases of clomiphene resistance.
- A 30-year-old woman with primary infertility presents with a history of regular menstrual cycles. Her husband’s semen analysis shows a sperm count of 5 million, motility of 5%, and morphology of 3%. Ultrasound reveals a left hydrosalpinx with multiple subserosal and intramural fibroids.
What is the most appropriate initial treatment?
- A) Intrauterine insemination (IUI)
- B) Intracytoplasmic sperm injection (ICSI)
- C) GnRH analogues and IUI
- D) Salpingectomy and IVF ✅
Explanation:
Hydrosalpinx is associated with reduced success rates in assisted reproductive techniques. Salpingectomy prior to IVF improves implantation and pregnancy rates. GnRH analogues may be used in fibroid management but are not the first-line approach in this case.
- A 23-year-old primiparous woman presents with complaints of continuous watery vaginal discharge for the past two months following a difficult vaginal delivery. A speculum examination reveals a 3 cm vesicovaginal fistula at the anterior vaginal wall.
What is the most appropriate timing for surgical repair?
- A) After 3 months
- B) After 1 month
- C) After 4 months
- D) After 1 week
key after 1 month.....
31. A 12-week pregnant woman presents with vomiting and per vaginal bleeding. On examination, BP is 140/90 mmHg, and fundal height corresponds to 16 weeks.
What is the most likely diagnosis?
- A) Ectopic Pregnancy
- B) Hyperemesis Gravidarum
- C) Complete Hydatidiform Mole ✅
- D) Missed Miscarriage
Answer: C. Complete Hydatidiform Mole
32. A 48-year-old obese, diabetic woman presents with postmenopausal bleeding. Biopsy reveals poorly differentiated adenocarcinoma (high grade, Grade 3).
What is the most appropriate treatment?
- A) Chemotherapy
- B) Radiotherapy
- C) TAH + BSO
- D) TAH + BSO + PLND ✅
Answer: D. TAH + BSO + PLND
Explanation:
- Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO) is the standard treatment for endometrial cancer.
- Pelvic and para-aortic lymph node dissection (PLND) is required for high-grade (Grade 3) endometrial carcinoma to assess metastasis.
- Chemotherapy (A) and Radiotherapy (B) are used for advanced/metastatic cases, but surgical staging remains the first-line treatment in localized disease.
- TAH + BSO alone (C) is insufficient for high-grade cancer, as lymph node involvement must be assessed for proper staging.
33. A 32-year-old woman, G3P2, with previous vaginal deliveries, presents at 24 weeks of gestation. The anomaly scan reveals hydrocephalus, meningomyelocele, and agenesis of the corpus callosum.
What is the most appropriate management in this case?
A. Termination of pregnancy
B. Repeat ultrasound
C. Intrauterine feticide
D. Counseling of the couple
Key: D. Counseling of the couple
Explanation: At 24 weeks of gestation, termination is not an option due to legal and ethical constraints in many countries, including Pakistan. The best management involves counseling the couple regarding the prognosis, neonatal outcomes, and possible postnatal interventions.
34. A 38-year-old grand multipara presents with massive postpartum hemorrhage (PPH) following a normal vaginal delivery. Mechanical and pharmacological interventions have failed to control the bleeding. There are no retained products of conception (RPOCs) or genital tract trauma.
What is the most appropriate surgical management?
A. Internal Iliac Artery Ligation
B. Balloon Tamponade
C. Hysterectomy
D. B-Lynch Compression Suture
Key: B. Balloon Tamponade
Explanation: Since mechanical and pharmacological measures have failed, and the patient is a grand multipara (higher risk of uterine atony), hysterectomy is the definitive treatment. B-Lynch sutures or arterial ligation are more suitable for uterine atony cases before irreversible damage occurs.
35. A 28-year-old woman, G2P1, visits the clinic concerned about the COVID-19 vaccine. She received the first dose three weeks ago, and now her urine pregnancy test is positive.
What is the most appropriate management?
A. Termination of pregnancy
B. No further dose as teratogenic
C. Second dose as per schedule
D. Delay the second dose until after delivery
Key: C. Second dose as per schedule
Explanation: COVID-19 vaccines are safe in pregnancy as per RCOG and WHO guidelines. Pregnant women are encouraged to complete their vaccination schedule, as the benefits outweigh the risks.
36. A 30-year-old woman, P0+1, married for 5 years, presents with severe dysmenorrhea and secondary infertility. All baseline investigations, including her husband's semen analysis, are normal.
What is the next best step in her evaluation?
A. Hysterosalpingography (HSG)
B. Saline Sonography
C. Laparoscopic and Dye Test
D. Endometrial Biopsy
Key: C. Laparoscopic and Dye Test
Explanation: Since the patient has dysmenorrhea and secondary infertility, endometriosis or tubal pathology is suspected. The gold standard for diagnosing these conditions is laparoscopy with dye test, as per NICE guidelines.
37. A 55-year-old woman, post-vaginal hysterectomy, presents on postoperative day 5 with severe lower abdominal pain, high-grade fever, and diarrhea. Examination reveals a tender swelling in the pelvis just above the vault. TLC: 18,000/mm³, ESR: 60.
What is the most likely diagnosis?
A. Ureter Injury
B. Bladder Injury
C. Pelvic Abscess
D. Vault Hematoma
Key: C. Pelvic Abscess
Explanation: The high fever, elevated TLC and ESR, pelvic swelling, and post-op timing (5 days post-hysterectomy) suggest pelvic abscess, which is a serious infectious complication requiring drainage and antibiotics. The treatment schedule includes intravenous antibiotics, supportive care, and possible surgical intervention if no response to medical therapy.
38. A 31-year-old woman, P1+1, with a history of spontaneous vaginal delivery (SVD) and a prior ruptured ectopic pregnancy, presents to the ER with amenorrhea of 2 months and lower abdominal pain. She smokes five cigarettes per day and has had an IUCD inserted 2 years ago, along with the use of oral contraceptive pills. Urine pregnancy test is positive.
What is the most significant risk factor for ectopic pregnancy in this patient?
A. Cigarette smoking
B. IUCD
C. Oral contraceptive pills
D. Previous history of ectopic pregnancy
Key: D. Previous history of ectopic pregnancy
Explanation: A previous ectopic pregnancy is the strongest risk factor, increasing the risk by 5-fold (10-20%). Other risk factors, such as smoking and IUCD, contribute to risk, but the history of ectopic pregnancy remains the most significant factor as per Oxford guidelines.
39. A 32-year-old woman, G2P1, presents at 32 weeks gestation with a history of per vaginal leaking. Examination reveals a moderately soaked pad. She is otherwise fit and well.
What is the most appropriate initial step in management?
A. Umbilical Artery Doppler
B. Emergency Cesarean Section
C. Steroid cover + Emergency Cesarean Section
D. Steroid cover + Antibiotics + Expectant management
Key: D. Steroid cover + Antibiotics + Expectant management
Explanation: The recommended management for PPROM at 32 weeks is steroids for lung maturity, antibiotics to prevent infection, and expectant management to prolong pregnancy unless there is fetal distress or infection. Immediate delivery is not indicated unless complications arise (RCOG guidelines).
40. A third-year postgraduate resident (PGR) is performing an emergency cesarean section on a patient fully dilated for 3 hours. The fetal head is deeply impacted.
What is the most appropriate technique to deliver the baby safely?
A. Pull Technique
B. Push Technique
C. J-Shaped Incision
D. T-Shaped Incision on Uterus
E. Patwardhan Manoeuvre
Key: A. Pull Technique
Explanation: best is pull
41. A woman has just delivered a healthy baby through normal vaginal delivery. She is found to be positive for HBsAg and HBeAg.
What is the recommended prophylaxis for the newborn?
A. Hepatitis B vaccine only
B. Check viral load
C. Hepatitis B vaccine and Hepatitis B immunoglobulin
D. Hepatitis B immunoglobulin only
Key: C. Hepatitis B vaccine and Hepatitis B immunoglobulin
Explanation: Infants born to mothers who are HBsAg+ and HBeAg+ are at high risk of perinatal transmission. Administration of both Hepatitis B vaccine and immunoglobulin within 12 hours of birth significantly reduces the risk of chronic infection, as per RCOG guidelines.
42. A primigravida at 39 weeks gestation is admitted in labor with 3 cm cervical dilation.
After 5 hours, her cervix is 7 cm dilated, 90% effaced, with the vertex at -1 station. CTG shows variable decelerations with decreased variability, and fetal blood sampling pH is 7.04. What is the most appropriate next step in management?
A. Cesarean Section
B. Forceps Delivery
C. Vacuum Delivery
D. Expectant Management
Key: A. Cesarean Section(old guidline /old mcq)
Answer: A fetal blood pH of 7.04 indicates severe acidosis, suggesting fetal distress. CTG abnormalities with metabolic acidosis require urgent cesarean section to prevent fetal hypoxia and neurological injury.
43. A 32-year-old woman, G3P2, is admitted to the labor ward with labor pains for 2 hours.
She is 5 cm dilated, vertex at -1 station, and ruptured membranes with meconium-stained liquor. Fetal heart rate baseline is 160 bpm. What is the most appropriate management?
A. Cesarean Section
B. Fetal scalp sampling
C. IV Syntocinon
D. Prostaglandin E2
Key: A. Cesarean Section(base line 160 is red feature )
Answer: Meconium-stained amniotic fluid with fetal tachycardia (160 bpm) suggests fetal distress, potentially due to evolving chorioamnionitis. Immediate cesarean section is required to prevent fetal hypoxia and meconium aspiration syndrome.
44. A 38-week pregnant woman with type 2 diabetes is admitted for induction of labor.
During the second stage of labor, shoulder dystocia occurs. Despite downward traction and suprapubic pressure, the shoulders cannot be delivered. Additional staff is called for help. What is the most appropriate next step?
A. Delivery of posterior arm
B. all four position
C. Fundal pressure
D. Zavanelli maneuver
Key: A. Delivery of posterior arm
Answer: Shoulder dystocia is a life-threatening obstetric emergency. Delivery of the posterior arm is an effective internal maneuver that reduces shoulder width and facilitates delivery. step wise A is option
45. A 38-year-old woman, P2+0, presents for contraception.
She has heavy menstrual flow, and her husband does not want her to undergo surgery. What is the best contraceptive option for her?
A. Levonorgestrel IUS
B. Copper IUCD
C. Progesterone-only pill
D. Low-dose combined oral contraceptive pills
Key: A. Levonorgestrel IUS
Answer: The Levonorgestrel intrauterine system (IUS) is the preferred contraceptive option for women with heavy menstrual bleeding, as it reduces menstrual flow while providing long-term contraception. Copper IUCD can worsen bleeding, and oral hormonal methods have a lower efficacy in controlling heavy bleeding.
46. A 38-year-old woman, P4, presents with irregular vaginal bleeding.
A Pipelle biopsy reveals adenomatous hyperplasia with atypia. What is the most appropriate treatment?
A. Hysterectomy
B. Hysteroscopy
C. Progesterone
Key: A. Hysterectomy
Answer: Atypical endometrial hyperplasia carries a high risk of progression to endometrial carcinoma, especially in a multiparous woman (P4) who has completed her family. Hysterectomy is the definitive treatment to eliminate the risk of malignancy.
47. A 30-year-old nulliparous woman, married for 2 years, presents with heavy menstrual cycles.
She is keen to conceive. Ultrasound shows a fibroid uterus measuring 8 mm. What is the next managrment option?
A. Tranexamic Acid
B. Mirena
C. Uterine Artery Embolization
D. Myomectomy
Key: A. Tranexamic Acid
Answer: This patient has heavy menstrual bleeding with small fibroids but wants to conceive. Tranexamic acid is a first-line non-hormonal treatment that helps reduce bleeding while preserving fertility. Mirena (Levonorgestrel IUS) and Uterine Artery Embolization are not suitable due to their effects on fertility.
48. A woman presents for routine cervical screening.
She has a copper IUCD in situ. Pap smear shows actinomyces. What is the most appropriate first step in management?
A. Remove the coil
B. Ask about her symptoms
C. Antibiotics D.Remove coil and give antibiotics
Key: B. Ask about her symptoms
Answer: Actinomyces detected on a Pap smear is often an incidental finding and does not necessarily require treatment. If the patient is asymptomatic, no intervention is needed. However, if she has pelvic pain or abnormal discharge, further evaluation and removal of the IUCD with antibiotic therapy may be necessary.
49. A G4P3 woman presents to GOPD with a 7-week unwanted pregnancy.
Ultrasound shows a single alive fetus. What is the best approach?
A. Suction curettage
B. Vaginal prostaglandins
C. Misoprostol
D. Refusal of any treatment
Key: D. Refusal of any treatment
Answer: Under the Pakistan Penal Code, termination of pregnancy is not allowed unless there is a threat to the mother's life or serious health complications. In an unwanted but healthy pregnancy, refusal of any treatment is the only legal option.
50. A 34-year-old man presents with azoospermia.
His female partner has a regular menstrual cycle with normal fertility investigations. Recent reports show a sperm count of 0.01 million/ml with reduced motility and morphology. What is the most appropriate next investigation?
A. Karyotyping
B. Cystic Fibrosis Screening
C. Repeat Semen Analysis after 3 Months D. Hormonal profile
Key: D hormonal profile
Answer: In cases of azoospermia or severe oligospermia,hormonal profile is next step. ebm
51. A 24-year-old woman presents to the gynecology clinic with primary infertility and oligomenorrhea. Her last menstrual period (LMP) was 7 months ago. Clinical examination is unremarkable. Ultrasound reveals a normal uterus and ovaries, and semen analysis is normal. What is the most appropriate next investigation?
A. Serum prolactin, FSH & LH ratio
B. Serum prolactin, Serum FSH, Serum LH, Free T4 & Serum TSH
C. Serum TSH, Free T4, Free T3 & Day 21 progesterone
D. Serum estradiol, Serum FSH & Serum TSH
Key: B. Serum prolactin, Serum FSH, Serum LH, Free T4 & Serum TSH
Answer: In a woman with primary infertility and oligomenorrhea, common causes include hypothalamic-pituitary dysfunction, thyroid disorders, and hyperprolactinemia. Comprehensive hormonal testing, including TSH, prolactin, FSH, and LH, is essential to differentiate between PCOS, hypogonadotropic hypogonadism, and thyroid dysfunction.
52. A 30-year-old woman presents with lower abdominal pain and mucopurulent vaginal discharge. On examination, her cervix appears congested, edematous, erythematous, and bleeds on touch with small follicles.
What is the most appropriate treatment?
- A. Benzyl Penicillin
- B. Metronidazole
- C. Tetracycline ✅
- D. Azithromycin
Explanation:
The clinical findings suggest Chlamydia trachomatis cervicitis, which presents with a friable cervix, mucopurulent discharge, and contact bleeding. Tetracycline (or Doxycycline) is the first-line treatment for chlamydial infections. (BASHH guidelines)
53. A woman using OCPs for contraception is diagnosed with tuberculosis and starts anti-tubercular therapy (ATT).
Which drug will reduce the efficacy of OCPs?
- A. Isoniazid
- B. Rifampicin ✅
- C. Ethambutol
- D. Pyrazinamide
- E. Streptomycin
Explanation:
Rifampicin is a potent enzyme inducer that accelerates the metabolism of estrogen and progesterone, reducing the effectiveness of oral contraceptive pills (OCPs). Women on Rifampicin should use additional or alternative contraception. (FSRH guidelines)
54. A 60-year-old woman presents with severe back pain. Clinically, she has kyphosis.
What is the most appropriate investigation?
- A. X-Ray Thoracic Spine ✅
- B. DEXA Scan
- C. CT Scan
- D. Double Photon Absorptiometry
- E. Single Photon Absorptiometry
Explanation:
In an elderly woman with kyphosis and severe back pain, the first-line investigation is an X-ray of the thoracic spine to assess for vertebral fractures, osteoporosis, or malignancy. A DEXA scan diagnoses osteoporosis but does not evaluate fractures. (NHS guidelines)
55. A G2P1 woman with a twin pregnancy presents in labor. The first twin has been delivered, but the second twin is in a transverse lie. Fetal heart rate is 100 bpm, and there are no palpable uterine contractions.
What is the most appropriate next step in management?
- A. External Cephalic Version
- B. Emergency Cesarean Section
- C. Internal Podalic Version ✅
- D. IV Syntocinon
Explanation:
For a transverse lie of the second twin, the preferred approach is Internal Podalic Version (IPV) with breech extraction if the cervix is fully dilated. External Cephalic Version (ECV) is contraindicated once labor has started. Emergency Cesarean section is done if the baby is distressed. (RCOG-TOG, Oxford)
56. A pregnant woman at 32 weeks gestation presents to the ER with fresh vaginal bleeding. On examination, the pad is moderately soaked, BP 120/80 mmHg, PR 80 bpm, and CTG is reactive. Ultrasound is unremarkable.
What is the most appropriate initial step in management?
- A. Give steroid cover and then proceed for emergency LSCS
- B. Perform umbilical artery Doppler
- C. Proceed for emergency LSCS
- D. Give steroid cover and do expectant management ✅
Explanation:
In a stable patient with preterm antepartum hemorrhage (APH) at 32 weeks, expectant management with corticosteroids is recommended unless there is fetal distress or maternal instability, which would then require emergency LSCS. (NICE guidelines)
57. A G4P3 woman at 40 weeks gestation presents with labor pains. She has 3 contractions in 10 minutes, each lasting 60 seconds. On vaginal examination, the cervix is 2 cm dilated and 50% effaced.
What is the most appropriate management?
- A. Maintain partogram
- B. Perform artificial rupture of membranes (ARM)
- C. Give analgesia ✅
- D. Start Syntocinon infusion
- E. Observation only
Explanation:key C
This patient is in the latent phase of labor, where pain relief is the mainstay of management. ARM and oxytocin are not required at this stage. (NICE guidelines)
58. A pregnant woman comes for an antenatal checkup, and you notice multiple bruises on her abdomen. She has low self-confidence, making you suspect domestic violence.
What should you avoid in this case?
- A. Ask her what she wants to do
- B. Provide her helpline number
- C. Confront the patient’s partner ✅
- D. Take history about support from family
Explanation:
In suspected domestic violence, confronting the partner may increase risk for the patient. The best approach includes ensuring safety, offering support, and providing resources. (NHS guidelines)
59. A young girl presents with weight gain and increasing facial hair.
Which criteria are used to diagnose polycystic ovary syndrome (PCOS)?
- A. American Society of Reproductive Medicine Criteria
- B. Rotterdam Criteria ✅
- C. Swansea Criteria
- D. NIH Criteria
Explanation:key b
The Rotterdam Criteria require two out of three findings for a PCOS diagnosis:
- Oligo/anovulation
- Hyperandrogenism (clinical or biochemical)
- Polycystic ovaries on ultrasound (RCOG guidelines)
60. A 39-year-old multiparous woman presents with heavy and irregular vaginal bleeding for 6 months. She has completed her family, and examination shows a bulky uterus.
What is the most appropriate management?
A. Endometrial Ablation
B. Cocp
C. Total Abdominal Hysterectomy ✅
D. Levonorgestrel Intrauterine System (LNG-IUS)
Explanation: key c
In a multiparous woman with a bulky uterus and chronic abnormal uterine bleeding, a Total Abdominal Hysterectomy (TAH) is the definitive treatment. Endometrial ablation is not suitable for a bulky uterus
61. An 8-year-old girl presents to GOPD with complaints of vaginal bleeding for 2 days. On examination, she has Tanner Stage 2 sexual characteristics development.
What is the most likely diagnosis?
- A. Central Precocious Puberty ✅
- B. Delayed Puberty
- C. Peripheral Precocious Puberty
- D. McCune-Albright Syndrome
Explanation: key A
Precocious puberty is defined as the development of secondary sexual characteristics before 8 years in girls. Central Precocious Puberty (CPP) is the most common cause, resulting from early activation of the hypothalamic-pituitary-gonadal axis. Peripheral precocious puberty is due to hormone-secreting ovarian or adrenal tumors. (RCOG-TOG 2012)
62. A 75-year-old woman (Para 4+0) with diabetes and hypertension presents with a 3rd-degree uterovaginal prolapse. She recently underwent coronary artery bypass surgery.
What is the best treatment for her?
- A. Le-Fort’s operation ✅
- B. Estrogen cream local application
- C. Vaginal hysterectomy with repair
- D. Ring pessary
Key: A. Le-Fort’s operation
Explanation:
Le-Fort’s operation is the preferred surgical treatment for severe prolapse in elderly, high-risk surgical patients who are not fit for major surgery. It involves partial colpocleisis, reducing prolapse without major pelvic floor reconstruction. (RCOG guidelines)
63. A 55-year-old woman (Para 3+1) underwent laparotomy for bilateral ovarian tumors. On exploration, omental deposits were found, and the undersurface of the diaphragm was extensively involved with metastasis. The liver surface was smooth.
What is the most likely stage of the disease?
- A. Stage IIIa
- B. Stage IV
- C. Stage IIIb
- D. Stage IIIc ✅
Key: D. Stage IIIc
Explanation:
According to FIGO staging, Stage IIIc ovarian cancer involves macroscopic peritoneal metastasis beyond the pelvis, including diaphragmatic or omental involvement. The absence of liver parenchymal metastasis excludes Stage IV. (FIGO guidelines)
64. A 40-year-old woman (Para 3+1) underwent routine cervical screening. Her Pap smear report showed the presence of Actinomyces. She is asymptomatic and has an intrauterine contraceptive device (IUCD) in place.
What is the most appropriate first step in management?
- A. Inquire about her symptoms ✅
- B. Coil removal
- C. Penicillin
- D. Immediate IUCD removal and culture
Key: A. Inquire about her symptoms
Explanation:
If Actinomyces is detected on a Pap smear in an asymptomatic woman with an IUCD, immediate treatment or removal of the coil is not necessary. The first step is to assess symptoms (pelvic pain, discharge, fever). If symptomatic, further evaluation is required. (RCOG guidelines)
65. A 50-year-old woman (Para 4+1) underwent vaginal hysterectomy with anterior-posterior (AP) repair. Within two weeks, she develops complaints of urine leakage on coughing and sneezing.
What is the most likely complication?
- A. Stress urinary incontinence (SUI) ✅
- B. Dyspareunia
- C. Vaginal vault prolapse
- D. Urinary tract infection (UTI)
Key: A. Stress urinary incontinence (SUI)
Explanation:
SUI is a common early complication after vaginal hysterectomy and pelvic floor repair due to weakened urethral support. It presents within weeks post-surgery. UTI presents with dysuria and fever, and vaginal vault prolapse is a later complication. (NICE guidelines)
66. A 30-year-old woman (Para 3+1) presents with continuous leakage of urine since a home childbirth two months ago.
What is the most appropriate initial investigation for vesicovaginal fistula (VVF)?
- A. CT urogram
- B. Three-swab test with methylene blue dye ✅
- C. Intravenous urography
- D. Cystourethroscopy
Key: B. Three-swab test with methylene blue dye
Explanation:
The three-swab test is a simple bedside test to differentiate urine leakage from a vesicovaginal fistula (VVF) versus incontinence. If the swabs turn blue, it confirms urine leakage from the bladder into the vagina. Further imaging is required if surgical planning is needed. (WHO guidelines)
67. A 32-year-old woman (Para 2+0) presents with second-degree cervical descent and difficulty urinating.
What is the most appropriate treatment?
- A. Fothergill’s operation
- B. Sacrohysteropexy ✅
- C. Cervicopexy
- D. Manchester repair
Key: B. Sacrohysteropexy
Explanation:
Sacrohysteropexy is the preferred uterine-preserving surgical procedure for uterine prolapse. It involves mesh suspension to the sacrum, providing long-term support. (RCOG guidelines)
68. A 32-year-old woman (G2P1) at 32 weeks of gestation presents with per vaginal (PV) leaking.
What is the most appropriate initial step in management?
- A. Steroid cover + emergency LSCS
- B. Umbilical artery Doppler
- C. Emergency C-section
- D. Steroid cover, antibiotic, and expectant management ✅
Key: D. Steroid cover, antibiotic, and expectant management
Explanation:
This patient has preterm premature rupture of membranes (PPROM) at 32 weeks. Management includes:
✅ Antenatal corticosteroids for fetal lung maturity
✅ Prophylactic antibiotics to reduce infection risk
✅ Expectant management unless chorioamnionitis, fetal distress, or labor progression occurs. (NICE guidelines)
69. A 48-year-old obese diabetic woman (Para 3+1) presents with postmenopausal bleeding. Endometrial biopsy reveals poorly differentiated adenocarcinoma.
What is the most appropriate treatment?
- A. Radiotherapy
- B. Chemotherapy
- C. TAH+BSO+pelvic lymph node sampling ✅
- D. TAH+BSO
Key: C. TAH+BSO+pelvic lymph node sampling
Explanation:
Endometrial adenocarcinoma, particularly poorly differentiated, has a higher risk of lymphatic spread. The standard treatment includes:
✅ Total Abdominal Hysterectomy (TAH)
✅ Bilateral Salpingo-Oophorectomy (BSO)
✅ Pelvic lymph node sampling to check for metastasis
Radiotherapy is used for adjuvant therapy or in inoperable cases, while chemotherapy is considered in advanced or recurrent disease. (RCOG guidelines, NCCN guidelines for endometrial cancer)
70. A 35-year-old woman (Para 3+0) presents with multiple bruises and reports emotional and physical abuse by her husband. Upon further inquiry, she states that her family encourages her to remain silent to protect the marriage.
What is the most common underlying cause of domestic violence in Pakistan?
- A. Poor education
- B. Political instability
- C. Drug abuse
- D. Cultural values ✅
Key: D. Cultural values
Explanation:
In Pakistan, domestic violence is often normalized due to deeply rooted cultural values. Factors include:
✅ Patriarchal norms
✅ Social pressure to maintain family honor
✅ Reluctance to report abuse due to fear of societal backlash
While poor education, economic hardship, and substance abuse contribute, the main cause is cultural acceptance of gender-based violence. (WHO & UN Women reports, Pakistan Demographic and Health Survey PDHS 2018-19)
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