2 B) Tell medical treatment of fibroid?

●Antiprogesterone: Mifepristone
●Anti Gonadotropin: Danazol, Gestrinone
●GnRH agonist: Goserelin, Buserelin
●GnRH antagonist: Cetrorelix, ganirelix
●Levonorgestrel releasing intrauterine system (LNG-IUS)
combined oral contraceptive.
Prostaglandin synthetase inhibitors.
●Selective progesterone receptor modulator (SPRMS):
Asoprisnil.

3. Define menorrhagia. What are the common causes of

menorrhagia? Complications of fibroid
uterus.
Ans:
Menorrhagia is defined as cyclic bleeding at normal interval
where the bleeding is either excessive in amount (>80 mL) or
duration 7 days or both.

Common causes:
● Dysfunctional uterine bleeding
● Fibroid uterus
● Adenomyosis
● Chronic tubo-ovarian mass
Complications of Fibroid Uterus :
● Degenerations
● Necrosis
● Infections
● Sarcomatous change (rare)
● Torsion of subserous pedunculated fibroid
● Hemorrhage
● Polycythemia

4. What is endometriosis? What are the common site for

endometriosis? Write symptoms of endometriosis.
Ans:
Presence of functioning endometrium (glands and stroma) in
sites other than uterine mucosa is called endometriosis.
Common site :
● Ovaries
● Pelvic peritoneum
● Pouch of Douglas
● Uterosacral ligaments
● Rectovaginal septum
● Sigmoid colon
● Appendix
● Pelvic lymph nodes
● Fallopian tubes
Symptoms:
● Dysmenorrhea (70%)
● Infertility (40-60%)
● Dyspareunia (20-40%)
● Abnormal menstruation (20%)
● Chronic Pelvic Pain
● Abdominal Pain
● Others:
➤ Bladder Frequency,dysuria, haematuria
➤ Sigmoid colon & Rectum : Painful daefecation,
diarrhea,rectal bleeding
➤ Chronic fatigue, premenstrual symptoms
5. A) Enumerate the screening test for cervical carcinoma?
B)what is VIA?
Ans: a) •VIA
• pap's smear
• HPV - DNA testing
• colposcopy

b) VIA: VIA means Visual Inspection of cervix with Acetic

acid.
It is a means of screening apparently healthy and symptoms
-free women to discover those who need further investigations
to see any malignant change. VIA suggests that has similar
sensitivity to that of cervical cytology in detecting CIN, but has
lower specificity.

6 .A) classify hormonal contraceptives?

B) How you will diagnose a case of missing thread in IUCD &
manage such a case .
Ans : a) Hormonal contraceptives (Steroidal contraception):

a) Oral contraceptives (pills):

✓Combined pills:
•Monophasic.
•Biphasic.
•Triphasic.
•Emergency (Post-coital pill).
✓Single preparation:
•Sequential pill.
•Mini pill.
•Oestrogen only (emergency).
b) Parenteral preparations (progestogens):
✓Injectable:
•DMPA.
•NET-EN.
•Combined (once a month injection),
✓Implants:
•Implanon.
•Norplant-II.
•LNG Rod.
c) Device:
✓IUD: LNG-IUS.
✓Vaginal ring:
•LNG ring.
•Combined (Oestrogen & progesterone) ring.
d) Transdermal patches: Nesterone.

B)In case of missing coil / Cu-T:

History: Ask questions –

1. When did you feel the coil last?
2. Is the thread torn out?
3. Is there any pain?
4. Have you experienced a missed period?

Examination:
Breast examination: To see early signs of pregnancy.
Abdomen and pelvic examination:
To see early signs of pregnancy.
Any tenderness.
To search for missing thread.
Investigations:
1. USG of uterus and adnexae.
2. Hysteroscopy.
3. Sounding the uterine cavity by a probe.
4. X-Ray of pelvis after radio-opaque probe into the uterine
cavity.

Treatment:
If device inside the uterine cavity
✓Specially designed blunt hook
✓Artery forceps
✓Uterine curette
✓Hysteroscopically under direct vision

If outside the uterus but inside the abdominal cavity

✓Laparotomy
✓ Laparoscopy
 SET—2
Set-2

Q1. A) Define ovulation

B) How can you diagnose ovulation

Ans a)- The rupture of mature graffian follicle and release of

ovum in the form of secondary oocyte to make it available for
conception is called ovulation.

Ans b)- clinical features:

i)cyclical bleeding
ii) ovulation pain
iii) premenstrual mastalgia
iv) temperature change
Investigation:-
i) Evaluation of peripheral or end organ changes:-
> Basal body temperature
> Cervical mucus study- disappearance of fern pattern.
> Vaginal cytology: shift of MI to the left
> Hormone estimation:-
- serum LH: midcycle surge
- serum estradiol: midcycle rise
- urine LH
> Endometrial biopsy
> Sonography

ii) Direct - laparoscopy

iii) conclusive - pregnancy
Question number 2

a)What are the causes of vaginal discharge?

Ans- 1.Infective cause

-trichomoniasis
-vaginosis
-candidiasis
2.Non infective cause
Physiological cause - like during pregnancy, ovulation,
menstruation and sexual arousal

Chemical and allergic reactants

Post vaginal atrophy

b) Points TRICHOMONIASIS CANDIDIASIS

1.Colour of
Vaginal discharge Greenish yellow Curdy white

2.Consistency thin,frothy&adherent Thick

3.pH >4.5 <4.5

4.Pruritis marked less marked

5.Dysuria & frequency Present Usually absent

6.White plaques in vagina Absent Present
7.Diagnosis Motile trichomonas Hyphae&buds
8.Treatment Metronidazole clotrimazole

Q3a)Define Menopause? What are the Menopausal symptoms?

Ans-Permanent cessation of menstruation at the end of

reproductive life due to loss of the ovarian follicular activity is
called Menopause.

The menopausal symptoms are as follows

IMMEDIATE SYMPTOMS -
1. Hot flushes
2.Difficulty to fall asleep
3.Vaginal dryness?Dsypareunia
4.Mood swings
5.Insomnia
6.Headache,palpitation,night sweats
7. Urinary- urgency,dysuria, recurrent UTI
8. Anxiety

LONG TERM HAZARDS - 1.Osteroporosis

2.Coronary artery disease
3.Recurrent UTI, stress, Incontinence, dysuria
4.Psychological-emotional liability
5.Fear of cancer
b)What are the contradications of HRT?

Ans-1.Undiagnosed genital tract bleeding

2.Endometrial or Breast cancer
3.Venous thromboembolism
4.Active liver disease
5.Gall bladder disease
6.Uncontrolled hypertension
7.Existing cardiovascular disease
8.porphyria

Q4. a) Define ectopic pregnancy.

b)What are the risk factors of ectopic pregnancy?
c) Describe medical treatments of ectopic pregnancy.
Ans-
a) An ectopic pregnancy is one in which the fertilized ovum
becomes implanted in a site other than the
normal uterine cavity.

b) Risk factors:
1 History of pelvic inflammatory disease
a History of tubal ligation.
3 Previous ectopic pregnancy.
4 Tubal reconstructive surgery.
S. History of infertility.
6. ART particularly if the tubes are patent but
damaged.
0 Use of IUCD's (3-5% increasedisk
8. Smoking (2.5% increased risk).
9 Previous induced abortion.
1o Tubal endometriosis.
c) Medical treatment for ectopic pregnancy are:
Methotrexate
Potassium chloride
Prostaglandins
Hyperosmolar glucose

Q5. A post menopausal lady para -5, complaints something

coming down per
vagina for last S years. She has some difficulty in voiding.
a) What is your probable diagnosis
b) How can you manage the case?

Ans-
a) My probable diagnosis is genito urinary prolapse.

b) Management:
A. Clinical features:
Symptoms:
► Feeling of something coming coming down per vagina.
> Backache or dragging pain in the pelvis.
> Dyspareunia
Urinary symptoms
✔ Difficulty in passing urine
✔ Incomplete evacuation
✔ Increased urgency & frequency of micturition.
✔ Painful micturition
✔ Stress incontinence
✔ Retention of urine
> Difficulty in emptying the rectum
> Discharge : Excessive white or blood stained vaginal
discharge .
Sign :
a) General examination: No abnormality detected.
b) On per abdominal examination: No abnormality detected.
c) On per vaginal examination: It depends upon presence, type
& extent of prolapse.
First degree prolapse :
> Feeling of descent cervix on straining.
> Speculum examination: cervix will come down in the vagina
on straining but will lie
within the introitus.
2nd degree prolapse :
Inspection :
► The cervix will lay outside the introitus, it will be identified
by the presence of
external os
Cystocele may be present which show transmitted impulse on
coughing.
Urethrocele may be present.
► Decubitus ulcer may be present.
Speculum examination : Enterocele and rectocele may be seen
in posterior vaginal wall.
Palpation : Cervix will be felt in between the anterior and
posterior vaginal walls at the
level of introitus.
Bimanual examination : Uterus normal in size, mobile & the
fornices are free.
Rectal examination: Rectocele can be differentiated from
enterocele
3rd degree prolapse:
Inspection :
► A mass is protruded from the vaginal introitus.
Cystocele and rectocele may be present.
> Vagina becomes thickened, corrugated & white keratin
> Ulceration in the prolapsed uterus.
Palpation: At the level of introitus, the anterior & posterior
vaginal wall can be apposed &
the fundus of the uterus will be felt outside the introitus.

B. Investigation :
a) General:
> Blood for TC, DC,ESR &b '%,
> Blood grouping, Rh typıng & cross matching
> Blood urea, Serum creatinine.
Blood sugar
> Urine R/M/E
> Chest X-ray P/A view
> ECG if age > 40 yrs.
b) Special:
Midstream specimen of urine has to be examined to exclude
UTI
► Urodynamic assessment & uroflowmetry to exclude urinary
incontinence.
C. Treatment :
a) Preventive treatment :
Adequate antenatal and intranatal care:
✔ To avoid injury to the supporting structure during the time
of vaginal delivery either
spontaneous or instrumental.
Adequate postnatal care:
✔ To encourage early ambulance
✔ To encourage pelvic floor exercise by squeezing the pelvic
floor muscle in the puerperium
General measures:
✔ To avoid strenuous activities, chronic cough, constipation &
heavy weight lifting.
✔ To avoid future pregnancy too soon & too many by
contraceptive practice.
b) Conservative treatment:
► Improvement of general measures.
> Oestrogen replacement therapy may improve minor degree
prolapse
In postmenopausal women.
Pelvic floor exercise in an attempt to strengthen the muscle.-
Pessary treatment : used in
✔ Early pregnancy, Peurperium
✔ Patients absolutely unfit for surgery.
✔ Patient's unwillingness for operation,
✔ While waiting for operation.
c) Surgical treatment:
Age > 60 years :
V Vaginal hysterectomy with anterior colporrhaphy and
posterior colpoperineorrhaphy
Age < 40 yrs:
Family incomplete : Fothergill's operation.

Set 3
SET-3
Q1 (a) Classify germ cell tumours of ovary? Answer:
Germ cell tumours of the ovary:
a) Dysgerminoma.
b) Yolk sac tumour.
c) Embryonal cell carcinoma
d) Polyembryoma.
e) Choriocarcinoma.
f) Teratoma

(b) What are the findings of malignant ovarian tumour during

laparotomy? Answer :
Finding of malignant ovarian tumour at laparotomy:
1) At opening of the abdomen there may be presence of
haemorrhagic
2) Broken capsule.
3) Engorged blood vessels over the surface of the ovary.
4) Bilateral distribution.
5) Solidity of the tumour.
6) Multiple secondary deposits over the peritoneum &other
pelvic structures. 7) Adhesions with surrounding structures.
2. (a) What is fibroid uterus? What are the type? Answer :
Fibroid uterus; Fibroids are the most common benign tumors of
the uterus composed of whorls of smooth muscle &fibrous
connective tissue enclosed in a pseudo capsule.
Classification o f fibroid uterus:
1) Body:
a ) Interstitial
b) Subserous
C) Submucous
-Sessile. -Pedunculated.
2) Cervical
a)anterior
b) Posterior.
c) Central.
d) Lateral

b) How can you manage a case of fibroid uterus with sub

fertility? Answer :
Clinical features:
a) Symptoms:
1) Asymptomatic
2) Menstrual abnormality: Menorrhagia, metrorthagia.
3) Dysmenorrhoea
4) Dyspareunia
5) Subfertility
6) Pressure symptoms: Constipation, dysuria, retention of urine
7) Recurrent pregnancy loss: Miscarriage, preterm labour.
8) Lower abdominal or pelvic pain.
9 Abdominal enlargement.
Sign:
1) On general examination: Varying degrees of pallor
depending upon the magnitude & duration of menstrual loss
2) On abdominal examination: The tumour may not be
sufficiently enlarged to be felt per abdomen. But if enlarged to
41 wecks or more the folowing features are noted:
On palpation: Feel is firm, more
towards hard; may be cystic in degeneration.
Margins are well defined except the lower pole which cannot be
reached suggestive of pelvic in origin.
Surface is nodular, may be uniformly enlarged in single fibroid.
Mobility is restricted.
On percussion: The swelling is dull on percussion.
3) On pelvic examination: Bimanual examination reveals the
uterus irregularly enlarged by the swelling felt per abdominal.

Investigations:
To confirm the diagnosis:
1) Ultrasonography
2)Colour Doppler (TVS).
3) Saline infusion sonography (SIS).
4) MRI.
5) Laparoscopy.
6) Hysteroscopy.
7) Hysterosalpingography
8) Uterine
eurettage.
Pre-operative assessment:
1) Blood for TC, DC, Hb%, ESR.
2) Blood sugar: Fasting &2 hours post-prandial.
3) Blood urea.
4) Blood grouping, Rh typing and cross matching.
5) Screening for hepatitis Bvirus and HIV.
6) Urine for R/M/E.
7) X-ray chest,
8) ECG
Treatment:
Expectant: Small fibroids without symptoms.
Medical: When fibroids are small &for temporary treatment.
Surgical:
Hysterectomy when:
Patient is elderly, Family is completed.
Myomectomy when: Patient is nulliparous, Patient is
young,Family is not complete. Conservative non-excisional
surgery

Q3. (a) what is emergency contraception?

Answer :
Emergency contraception: It is defined as any drug or device
used after unprotected intercourse to prevent pregnancy.
(b) How can you select a case for contraceptive pill? Answer :
History &examination:
1) Age of the patient is important, fi she is more than 35 years
she should be prescribed with caution and regular check-up is
needed
2) In case of smokers, it should be prescribed with caution, as it
is associated with increased incidence of thromboembolism.
3) Menstrual history is to be taken to exclude pregnancy,
undiagnosed uterine disease
4) Obstetrical history including breast feeding.
5) Family history of cerebrovascular disease including
hypertension, breast cancer and hyperlipidaemia should also be
excluded.
6)Medical history regarding thromboembolic episodes,
jaundice, epilepsy, hypertension, diabete, allergic condition,
migraine should also be excluded.
7) Weight and blood pressure should be noted. Breast,
abdominal and pelvic examination should be done to exclude
any pathology.
8) Pelvic examination to exclude cervical pathology, is
mandatory.
Investieations:
1) Cervical smear if possible
2) Serum bilirubin
3) Lipid profile.

Q4. (a) Define infertility?

Answer:
Infertility is defined as inability to conceive within 1 or more
years of regular unprotected coitus
(b) what are the causes of female infertility? Answer :
A) Ovarian factors:
1. Anovulation or oligo-ovulation. 2. Decreased ovarian reserve.
3. Luteal phase defect.
4. Luteinized unruptured follicle 5. Tubal factors
B) Peritoneal factors:
.1 Pelvic infections.
2. Previous tubal surgery or sterilization.
 3. Salpingitis
4. Tubal endometriosis,
5. Polyp
C)Uterine factor:
1. Uterine hypoplasia
2. Inadequate secretory endometrium. 3. Fibroid uterus.
4. Endometritis.
5. Uterine synechiae.
6. Congenital malformation of uterus.

D) Cervical factor:
1. Congenital elongation of the cervix.
2. Second degree uterine prolapse.
3. Acute retroverted uterus.
4. Chronic cervicitis.

E) Vaginal factor:
1. Vaginal atresia.
2. Transverse vaginal septum.
3. Septate vagina.

Q5. Ayoung lady with history of induced abortion 03 days back

is presented with fever & lower abdominal pain.
(a) what is the diagnosis?
Answer : Diagnosis is septic abortion
(b) How will you manage this case?
Answer:
Management of septic abortion:
History:
1) The patient usually gives history of induction of abortion
unhygenically by untrained person.
2) She may complain of lower abdominal pain &foul-smelling
vaginal discharge. Clinical features:
.1 The woman looks sick &anxious.
2. Temperature > 38°C.
3. Chills &rigor
4. Persistent tachycardia > 90bpm 5.Hypothermia
6. Abdominal or chest pain.
7. Tachypnoea (RR) > 20/min,
8. Impaired mental state.
9. Diarrhoea and/or vomiting. 10. Renal angle tenderness.
11) Pelvic examination:
.i Offensive, purulent vaginal discharge. ii. Uterine tenderness.
ili. Boggy feel in. POD

Investigations:
1 Routine investigation:
a) Cervical or hieh vaginal swab is taken for C/S. b) CBC with
ESR
c) Blood grouping &RH typing.
d) Urine RME
2. Special investigations:
a) Ultrasonography of pelvis &abdomen. b) Blood for C/S
c) Serum electrolytes.
d) C-reactive protein.
e) Serum lactate.
f) Coagulation profile.
g) Plain X-ray abdomen in suspected cases of bowel injury
h) Plain X-ray chest for cases with pulmonary complications
(atelectasis). i) Urine for
culture &sensitivity.
 Treatment:
General management:
1 Hospitalization and should be kept in isolation,
2. Collection of high vaginal swab for culture, drug sensitivity
&Gram stain
3. Vaginal examination is done to note the state of the abortion
process% extension of the infection.
4. Overall assessment of the case.
5. Investigations protocols,

Supportive treatment :
1. IV fluids.
2. Blood transfusion.
3. Broad spectrum antibiotics; .i Amoxicillin
i. Gentamycin.
ili. Metronidazole,
4. Prophylactic antigas gangrene serum &antitetanus serum.
5. An I/M injection of syntometrine wil assist in controlling
bleeding.

Operative treatment:
1 Evacuation and curettage of the uterus under GA after 12-24
hours of antibiotic
therapy.
2. Posterior colpotomy in case of Grade Il septic abortion.
3. fI patient is not responding to the conservative treatment,
laparotomy is indicated. After laparotomy:
i. Pus is to be drained.
i. Whole of the gut is to be inspected thoroughly for any injury.
i. Hysterectomy is the operation of choice for smooth recovery.
4. Treatment of the complications.
 SET-4
Gynae set-4

Q1a)What are the supports of the uterus?

b)What are the causes of genito-urinary prolapse?
c)Mention the indication of pessary treatment.

Ans: a). Supports of the uterus -

Upper tier:
1) Endopelvic fascia covering the uterus.
2) Round ligaments.
3) Broad ligaments with intervening pelvic cellular tissues.

Middle tier:
1) Pericervical ring:It is connected with the pubocervical
ligaments and vesicovaginal septum anteriorly, cardinal
ligaments laterally and uterosacral ligaments and rectovaginal
septum posteriorly.
2) Pelvic cellular tissues.

Lower tier:
1) Pelvic floor muscle (leavator ani)
2) Endopelvic fascia
3) Levator plate
4) Perineal body
5) Urogenital diaphragm.

b)Predisposing factor:-
1) Congenital weakness of supports
2) Child birth trauma. 3) Sugical trauma.
4) Atrophy of supportily Hissue.
Aggrevating factor..
1) increase Intra-abdominal . pressure
→chronic cough
→Constipation
→ascites
2) Increase weight of uterus resulting from subinvolution (or)
small tumor
3) Traction on the uterus by vault prolapse or Large Cervical
polyp.

c).1) During pregnancy

2) just after delivery
3) old female not fit for surgery
4) young patient desiring for pregnancy
5) during puerperium.

Question-2
a)An ectopic pregnancy is one in which the fertilized ovum is
implanted and develops outside the normal endometrial cavity.
Classification:
A) Extra uterine:
1. Tubal: a) Ampulla b) Isthmus c) Infundibulum d) Interstitial
2. Ovarian
3. Abdominal: a) Primary b) Secondary (Intraperitoneal,
Extraperitoneal)
B) Uterine:
1. Cervical
2. Angular
3. Cornual
4. Caesarean scar
b)Criteria of expectant management:
(i) Initial serum hCG level less than 1,500 IU/L and the
subsequent levels are falling. (ii) Gestation sac size less than 4
cm. (iii) No fetal heart beat on TVS. (v) No evidence of
bleeding or rupture on TVS.

Criteria of medical management:

i)Hemodynamically stable. (ii) Serum hCG level should be less
than 3,000 IU/L. (iii) Tubal diameter should be less than 4 cm
without any fetal cardiac activity. (iv) There should be no intra-
abdominal hemorrhage.

Question-3
a ) Define hysterectomy
ANS- hysterectomy is the surgical removal of uterus

B) what are the types of hysterectomy

Ans- A ). Abdominal hysterectomy
1). Total hysterectomy
2). Subtotal hysterectomy
3). Pan hysterectomy
4). Extended hysterectomy
5). Radical. Hysterectomy

B). Vaginal hysterectomy

C). laparoscopic hysterectomy
C ) What are the common indications of abdominal
hysterectomy ?

Ans - DUB
Fibroid uterus
Endometriosis
Adenomyosis
Ca. Cervix
Ca. Ovary
Ca . Endometrium
Uterine perforation

Question-4
a)define PAC, safe abortion, unsafe abortion, recurrent abortion.
b)tell causes of recurrent abortion

Ans-Post abortion care includes -

1) emergency treatment of complications of any abortion
spontaneous or induced
2)family planning counseling and referral
3) linkages to other reproductive health services. Male partner
should be involved
Safe abortion is a procedure for terminating unwanted
pregnancy performed by trained healthcare providers with
proper equipment, correct technique and sanitation.

Unsafe abortion is defined as the procedure of termination of

unwanted pregnancy either by persons lacking the necessary
skills or in an environment lacking the minimal standards or
both.
Recurrent abortion is defined as a sequence of two or more
spontaneous abortions as documented by either sonography or
histopathology before 20 weeks.

b)Causes of recurrent abortion -

1st trimester-
Genetic factors
Endocrine disorders eg.poorly controlled diabetes
Infection
Immunological disorders
Unexplained

2nd trimester-
1)Anatomic abnormalities -
mullerian fusion defects eg.unicornuate uterus,bicornuate uterus
Congenital cervical incompetence
2)chronic maternal medical illness- eg.SLE
3) Infection eg.syphilis
4)unexplained

Question-5
A ) Define LARC
Ans - It is a method of birth control that provide effective
contraception for an extended period without requiring user
action
B ). Tell the classification of hormonal contraceptive
Ans. - A ) oral contraceptive
Combined PILL -monophasic ,biphasic , triphasic.
Single- sequential pill , mini pill
B ) parenteral preparation
Injectable - DMPA ,NET- EN
Implants - norplant , Lng rod
C ). Device
IUD , vaginal rings
D ). Transdermal patches

C ). Tell the non contraceptive benefit ocp

Ans - 1.Improvement of menstrual abnormalities:

regulation of menstrual cycle , reduction of dysmenorrhea,
reduction of menorrhagia , reduction of premenstrual tension
syndrome
2.Protection against health disorders : Protection against
iron deficiency anemia , pelvic inflammatory disease, ectopic
pregnancy, endometriosis, fibroid uterus
3.Prevention of malignancies : endometrial cancer,
epithelial ovarian cancer, colorectal.
 SET-5
Gynae-5
Q1. a) Classify epithelial ovarian tumours.
b) Name some hormone producing tumour of ovary.

Ans: a) Classification of epithelial ovarian tumor:

1. Serous tumor
2. mucinous cyst adenoma
3. Endometrioid tumor
4. Mesonephroid or clear cell tumor
5. Brenner tumor
6. Mixed epithelial tumor
7. Undifferentiated carcinoma
8. Unclassified epithelial tumor

b) Hormone producing tumor of ovary :

1. Feminizing thmor : Granulosa and theca cell
tumor
2. Masculinizing tumor : Sertoli leydig cell tumor,
choriocarcinoma, Hilus cell
3. Others : carcinoid (thyroid hormones) , struma
ovarii

Q2. a) Name the permanent method for male & female

sterilization
b) Tell the non contraceptive benefits of contraceptive pill.
Ans:
a) Permanent method for
1. male sterilization : non scalpel vasectomy
2. female sterilization : tubal ligation or tubectomy
b) Non contraceptive benefits of contraceptive pill are:
1.Improvement of menstrual abnormalities: regulation of
menstrual cycle , reduction of dysmenorrhea, reduction of
menorrhagia , reduction of premenstrual tension syndrome
2.Protection against health disorders : Protection against
iron deficiency anemia , pelvic inflammatory disease, ectopic
pregnancy, endometriosis, fibroid uterus
3.Prevention of malignancies : endometrial cancer,
epithelial ovarian cancer, colorectal.

Q3 a)How decubitus ulcer is formed?

b)What is the treatment?
Ans:
a) Pelvic organ Prolapse → Narrowing of uterine vessels →
venous duct stretching effect →> venous return is impaired →
impaired arterial supply → ischemia → necrosis → sloughing
of necrosed part - ulcer formation.

b) Treatment of decubitus ulcer:

* Vaginal pack with roller bandage soaked with antiseptic
glycerine lotion & acriflavin or using oestrogen cream.
* Cervical cytology to exclude malignancy.
* Colposcopy & directed biopsy it needed.
* Manual reduction of prolapse.

Q4 a) Define menorrhagia .
b)Mention important causes of menorrhagia?
c)How fibroid causes menorrhagia.
Answer:
a) Menorrhagia is defined as cyclic bleeding at normal intervals;
the bleeding is either excessive in amount (> 80 mL) or duration
(>7 days) or both.

b)Important causes of menorrhagia are :

a) Pelvie pathology:
1)Fibroid uterus
2)Adenomyosis
3)Pelvic endometriosis
4)IUCD in utero
5)Chronic tubo ovarian mass
6)Tuberculo endometritis
7)Retroverted uterus

Ans:c) Fibroid cause menorrhagia in following way:

a. Increased surface area of the endometrium (Normal: 15
sq.cm).
b. Interference with normal uterine contractility due to inter
deposition of fibroid.
c. Congestion & dilatation of the subjacent endometrial venous
plexuses caused by the obstruction of the tumor.
d. Endometrial hyperplasia due to hyperoestrinism(anovulation).
e. Pelvic congestion.
f. Role of prostanoids-imbalance of thromboxane &
prostacyclin with relative deficiency of TXA2.
Q5. A 60 Years old lady came with H/O 2 episodes of P/V
bleeding for last 6 months.
a) How will you manage her?
Ans:
Management of Ca cervix:
Diagnosis:
► Patient profile:
1. The patients are usually multiparous, in premenopausal age
group.
2. Previous history of post-coital or intermenstrual bleeding
which they ignored.
► Clinical features:
a) Symptoms:
1. Irregular or continued uterine bleeding.
2. Offensive vaginal discharge.
3. Pelvic pain of varying degree.
4. Leg oedema.
5. Bladder symptoms: Frequency of micturition, dysuria,
haematuria, true urinary incontinence.
6. Rectal involvement: Diarrhoea, rectal pain, bleeding per
rectum, rectovaginal fistula.
7. Urethral obstruction.
8. General symptoms: Cachectic, pallor, uraemia, weight loss.

b) Signs:
1. On general examination:
Anaemia.
Cachexia.
2. On speculum examination:
Cervix may be enlarged, ulcerated, excavated or completely
destroyed or replaced by hypertrophic mass.
Cardinal signs:
Cervix is fixed.
Hard in consistency.
friable
and bleeds on touch

3. On rectal examination:
Rectum may be involved and found nodular induration.

Investigations:
1. Pap test.
2. Colposcopy

► Treatment:
► Preventive:
Cancer cervix, a preventable disease, still remains an important
health problem among women due to high morbidity &
mortality of advanced lesions. This can be prevented by:

Primary prevention:
1. Identifying “high risk” female:
Women with high-risk HPV infection.
Early age of first pregnancy.
High parity.
Too much births / too frequent birth.
Long-term use of contraceptive oral pills (COCs).
Low socioeconomic status.
Poor maintenance of local hygiene.
2. Sexual behaviour: Early sexual intercourse.
Multiple sexual partners.
Previous wife died of cervical carcinoma.
3. Prophylactic recombinant HPV vaccine is approved to all
school girls (12–18 years) & women (16–25 years). Two or
three doses are usually to be given.
4. Use of condom during early intercourse.
5. Raising the age of marriage & of first birth.
6. Limitation of family.
7. Maintenance of local hygiene.
8. Effective therapy of STIs is a positive step in prevention.
9. Removal of cervix during hysterectomy as a routine benign
lesion.

Secondary prevention:
Screening procedure.

Curative:Curative management depends on:

1. General condition of the patient.
2. Stage of the disease.
3. Facilities available: Surgical and radiotherapy.
4. Involvement of a gynaecological oncologist.
5. Radiation oncologist.
6. Wish of the patient to be judiciously complied with.
Pretreatment evaluation: Serum tumour marker:
1. Squamous cell carcinoma antigen (SCCA).
2. CA-125.
3. CEA.
Pretreatment preparations:
1. Nutritional support.
2. Correction of anaemia by blood transfusion.
3. Relief of pain by analgesics.
4. Perioperative use of leg stockings, prophylactic doses of
heparin or LMWH are used to reduce thromboembolism.
5. Prophylactic antibiotics are to be used.
Treatment modalities:

1) Surgery:
Cervical conization.
Ca cervix stage I, II may get primary surgery & pelvic
exenteration.

Surgical Options
b) Trachelectomy
c) Simple hysterectomy
d) Radical hysterectomy
e) Pelvic exenteration:
Anterior exenteration. (Bladder dissected out under cervix —
anterior part)
Posterior exenteration. (Rectum — posterior part)
Complete exenteration.
Laparoscopic radical hysterectomy with pelvic & aortic
lymphadenectomy.
2) Radiation therapy (e.g., intracavitary & extra-beam)
3) Chemotherapy
4) Combination therapy
Up to Stage I B1 & Stage II — Surgery can be done in Ca
cervix.
In Ca cervix Radical hysterectomy & Wertheim’s hysterectomy
is done.

Follow up:
1. 3 months interval for the first 2 years.
2. 6 months interval until 5 years.
3. Then yearly afterwards.

SET-6
Gynae set 6

Q1 a)Define menopause b) What are the problems may arise

during this period?

Ans- Menopause is the permanent cessation of menstruation at

the end of reproductive life due to loss of ovarian follicular
activity.
Problems that may arise during this period are
1) menstrual changes - shorter cycle , irregular bleeding
2) vasomotor symptoms - hot flashes, upper body
sweating,anxiety ,lack of sleep
3) psychological - irritability,mood swing , depression.
4)sexual dysfunction - vaginal dryness,dysparunia
5)urinary - incontinence,urgency,dysuria.
6) others - back aches , weight gain, joint aches.
Q2 .a) Define pelvic infection and PID .b)Tell the routes of
infection in pelvic organ.
Ans pelvic inflammatory diseases is a spectrum of infection and
inflammation of the upper genital tract organs typically
involving the uterus , fallopian tube, ovaries,pelvic peritoneum,
and surrounding structures.

Routes of infection in pelvic organ are

1 Through continuity and contiguity - Gonococcal infection
2) Through lymphatics and pelvic veins - post abortal and
peurperal infection by pyogenic organisms and gonococcus
3) Through blood stream - Tubercular
4) From adjacent infected extragenital organs like intestine .

Q3 a) Tell surgical methods of evacuation?

b)Enumerate the indications and complications of D&C .
Ans:
a)Surgical methods of evacuation are:
1)Dilatation and currettage
2)Manual vacuum aspiration

b)Indication of D&C are:

A)Diagnostic-
1)Infertility
2)Abnormal uterine bleeding (AUB)
3)Pathologic amenorrhea
4)Endometrial tuberculosis
5)Endometrial carcinoma
6)Postmenopausal bleeding
•7Chorionepithelioma
B)Therapeutic-
1)Dysfunctional uterine bleeding (DUB)
2)Endometrial polyp
3)Removal of IUD
4)Incomplete abortion

C)Combined-
1)DUB
2)Endometrial polyp.

Complications of D&C are:

A) Immediate Complications
1)Injury to the cervix
2)Uterine perforation
3)Hemorrhage
4)Injury to the gut
5)Infection
B) Remote complications:
1) Cervical incompetence due to injury to internal os.
2) Uterine synechiae due to injury to uterine muscle resulting
in secondary amenorrhoea.

Q4 a)Tell the risk factor and complications of Ca cervix?

b)How to prevent Ca cervix ?
Ans :Risk factors of Ca Cervix are:
1.HPV
2. Early marriage, early sexual exposure, long sexual life,
multiparity
3. Low socio-economic condition
4. Lack of personal hygiene/cleanliness
5. Unsafe sex
6. HSV-2 & STD

⬧ who's previous partner died of Ca cervix

7. Male partner –

⬧ having HPV infection

⬧ having penile cancer
⬧ Promiscuous
8. Immunodeficiency & HIV
9. Passive Smoking
10.Long term OCP

Complications of Ca cervix are:

1)Hemorrhage.
2)Frequent attacks of ureteric pain, due to
pyelitis,pyelonephritis and hydronephrosis.
3)Pyometra especially with endocervical variety.
4)Vesicovaginal fistula.
5)Rectovaginal fistula
6)Uraemia
7)Sepsis
8)Metastasis to other organs

b) Prevention of Ca cervix
A)Primary prevention : by social awareness and prevention of
risk factors.
1. Elimination of risk factor by health education & social
awareness.
2. Avoidance of early marriage & repeated child birth.
3. Maintain personal hygiene
4. Avoidance of smoking.
5. Maintain ideal body weight.
6. Use of condom
7. Vaccination (papillovax / HPVax)
Vaccination of unmarried girl against HPV -
If 9-14 years → 2 doses - 0 & 6 months
If 14-19 years → 3 doses - 0,1 & 6 months

B)Secondary prevention -By Screening

- start at 21 year or 3 year after marriage
- Then done yearly (PAP's smear) or 2 yearly LBC until 30
years if 3 previous
negative result
- 3 reports normal consecutively, then 3 yearly after 30 years of
age.
- Screening stop at 70 years if 3 previous negative result
- VIA schedule : start at 25 years old, then By 3 years intervally
upto the age of 55
years.

Q5 A 55 years old lady presenting with foul smelling p/v

discharge with H/O contact bleeding.
a) What are possible diagnosis b)How will you manage her.
Ans: Possible diagnosis -
i)carcinoma of cervix
ii) Endometrial carcinoma

b) Clinical features-
1. Offensive vaginal discharge
2. Pelvic pain of varying degree
3. Backache
4. Leg edema
5. bladder symptoms-frequency of
micturation,dysuria,hematuria,incontinence
6. Rectal involvement- diarrhoea,rectal pain, bleeding per
rectum, rectivaginal fistula
7. Anemia.

INVESTIGATION-
1. for diagnosis-Cervical biopsy
2. for staging - 1. Clinical examination - Pelvic examination
2. Chest X-ray
3. IVU - Intravenous urogram/pyelogram
Other – Proctoscopy

TREATMENT- General management :

• Correction of anemia
• Correction of malnutrition
Staging is done (other test to assess full extension) for specific
management
Special management :
Treatment options:
✓ Primary surgery.
✓ Primary radiotherapy ē concomitant chemotherapy
✓ Chemotherapy
✓ Combined therapy
Treatment according to stage:
1) up to II-A: Primary surgery followed by radiotherapy ē
concomitant
chemotherapy
2) IIA & above: Primary radiotherapy ē concomitant
chemotherapy
3) Very advanced stage : Palliative therapy
Then Follow up for 5 years
1)Routinely every 3 monthly for the first 3 years
2)Then 6 monthly tor the next 2 years.
If positive within 5 years, recurrence of carcinoma cervix.
If negetive no recurrence .

SET-7
Gynae Set- 7

*Q1.* a) Define AUB

b) Tell the classification of AUB.

*Answer:*
a) Any uterine bleeding outside the normal volume duration
regularity or frequency is considered abnormal uterine bleeding.
b)
Classification of AUB:
# Palm(structural causes ).
Polyp, Adenomyosis,
Leiomyoma , Malignancy & hyperplasia.

# COIEN (non structural causes) classification.

Coagulopathy,
Ovulatory dysfunction,
Endometrial,
Iatrogenic,
Not yet identified.
 Q2.* a) Tell the F/up schedule of hydatidiform mole after
evacuation.
b)Tell the 5 important complications of hydatidiform mole.

*Answer:*
a) Weekly Beta-hCG upto 3 consecutive negative, then monthly
for 3 months.

b) Complications of hydatidiform mole:

# Immediate.
Haemorrhage & shock,
Sepsis,
Perforation of uterus,
Pre eclampsia,
Acute pulmonary insufficiency,
Coagulation failure.

# Late.
Choriocarcinoma

*Q3.* a) What is IUCD?

b) How you can select a case for IUCD insertion.
c) Tell the mode of action of IUCD.

*Answer:*
a) Intrauterine contraceptive device is a small plastic carrier,
usually in the shape of a 'T' or similar design on the vertical
stem of which is wound some copper wire & may have copper
bands on the transverse arms.
b) Selection of the client:
Patient profile:
# Age of the patient.
# She should have at least one child.

History:
# History should be taken to exclude menstrual abnormality,
PID, Previous history of ectopic pregnancy and suspected
pregnancy.
# Personal history.

Pelvic examination:
# To determine the size, shape position and mobility of the
uterus.
# To exclude adnexal and cervical pathology.

Investigation:
# Pregnancy test to exclude pregnancy.
# Cervical smear may be taken if possible.

Counseling:
It is essential to discuss the possible side effects of these
preparations with each woman before administration & should
be advised for follow up visits

c) Mechanism of action of 1" & 2nd generation IUCDs:

IUCD causes a foreign body reaction in the uterus causing
cellular and biochemical changes in the endometrium and
uterine fluid. These changes impair the viability of the gamete
and thus reduce its changes of fertilization rather than its
implantation.
In addition, medicated IUCD (2nd generation) affects the
enzyme in the uterus by altering the biochemical composition of
cervical mucus. Copper ion may affect sperm motility,
capacitation and survival.

Mechanism of action of 3rd generation IUCDs:

Progesterone of 3rd generation IUCDs increases the thickness
of cervical mucus and thereby prevents sperm from entering the
cervix.

It decreases the thickness of endometrial mucosa and thereby

prevents implantation.

*Q4.* a) Define CIN. How can you diagnose of CIN?

b) Tell the screening test for ca cervix.
*Answer:*
a) CIN (Cervical Intra-epithelial Neoplasia) is histologically
diagnosed pre-cancerous
lesion of the cervix characterized by disordered growth &
development of the
lining epithelium of cervix.

# How to diagnose?
A) Routine cervical screening
1. Visual inspection by VIA & VILI
2. Cervical cytology (Gold Standard)
o Pap smear
o Liquid based cytology
3. Colposcopy
4. Cervical biopsy 5. Cervico-graph
B) Incidental diagnosis during histopathological examination of
uterus. (TAH done)

b) A. Routine
1. Complete blood count
2. Blood grouping & Rh typing
3. PPBS
4. Serum creatinine
5. HBsAg, Anti-HCV
6. Urine RME

B. Special
1. CT scan
2. PET
3. Lymphangiogram
4. Venogram

C. For diagnosis - Cervical biopsy

D. For staging
1. Clinical examination - Pelvic examination
2. Chest X-ray
3. IVU - Intravenous urogram/pyelogram.

*Q5.* A 26 years primi gravida patient come to you with

history of amenorrhoea for 6 weeks with severe pain in lower
abdomen & features of shock.
a) What is your probable diagnosis?
b)How can you manage the case.
*Answer:*
a) Primigravida, 8 weeks of amenorrhea with ectopic pregnancy
with shock.
b) Management of ruptured ectopic pregnancy:

Patient profile:
1) The incidence is maximum between the age of 20 & 30 years,
being the maximum period of fertility.
2) The prevalence is mostly limited to nulliparity or following
long period of infertility.

Clinical features:
a) Symptoms:
1) The classical triad of symptoms:
# Amenorrhoea: A short period of amenorrhoea of 6-8 weeks.
# Abdominal pain: It is acute, agonizing & colicky lower
abdominal pain which may be unilateral or bilateral.
# Vaginal bleeding: May be slight & continuous.
2) Vomiting, syncopal attack: Syncopal attack (10%) is due to
vasomotor disturbance following peritoneal irritation from
haemoperitoneum.

b) Signs:
1) On general examinations:
# General look (diagnostic):
Lies quiet & concise.
Perspires & looks blanched.
# Pallor: Severe & proportionate to the amount of internal
haemorrhage.
# Features of shock:
Rapid & feeble pulse.
Hypotension.
Cold clammy extremities.

2) On per abdominal examination:

Abdomen is tense tumid, tender.
No mass is usually felt.
Shifting dullness present.
Gut may be distended.
Muscle guard: usually absent.

3) On per vaginal examination: Usually not done due to fear of

precipitating more bleeding and extreme tenderness.
The findings are-
Vaginal mucosa: Blanched white.
Uterus seems normal in size or slightly bulky.
Extreme tenderness on palpation of the fornix.
No mass usually felt through the cervix.
The uterus floats as if in water.

Investigations;
a) General investigations.
1) Blood: Hb%, TC, DC. ESR
2) Blood grouping and Rh typing.
b) Special investigations:
1) USG of the uterus and adnexae: Empty uterine cavity with
gestational sac in the adnexae.
2) Pregnancy test: Positive in 50% cases.
3) B-HCG.
4) Serum progesterone.
5) Culdocentesis.
6) Laparoscopy.
7) Dilatation & curettage.
8) Laparotomy

Treatment:
# General treatment:
1) Immediate hospitalization.
2) Haemodynamic stabilization (if unstable): by
-Secured I/V channel and IV infusions.
-Satisfactory analgesics: Inj. Pethidine 10mg I/M.
-Catheterization of the patient.
-Blood transfusion when indicated.
-Appropriate antibiotic.

# Specific treatment:
1) If family complete: Salpingectomy Other sided tubectomy.
2) If family incomplete & other sided tube healthy:
Salpingectomy.
3) If family incomplete & other sided tube absent: Partial
salpingectomy (if the tube is ruptured) & anastomosis done in
later sitting.
4) If tube is intact:
-Salpingotomy.
-Salpingostomy.
-Milking.
 SET-8
Gynae set-8( answers).

Qn-1.Amenorrhoea:-Amenorrhoea literally means absence of

menstruation. It is a symptom and not a disease.
-Clinical types of amenorrhoea:
Physiological:-
1.Primary amenorrhoea:
-Before puberty
2.Secondary amenorrhoea:
-During pregnancy, lactation, following menopause.
Pathological:-
1.Concealed(cryptomenorrhoea):
-Congenital.
-Acquired.
2.Real(true):-Primary,
Secondary.
-Cryptomenorrhoea:

Cryptomenorrhoea is a condition where the menstrual blood

fails to come out from the genital tract due
to obstruction in the passage.

##Causes of cryptomenorrhoea:
Congenital (primary):
-Imperforate hymen.
-Transverse vaginal septum.
-Atresia of the vagina.

Acquired (secondary):
A. Cervical stenosis following-
-Amputation of cervix.
-Deep cauterisation of cervix.
-post MR.

B. Secondary vaginal atresia following -

-Neglected& difficult vaginal delivery.
-Vaginal injury.

C. Vulvovaginitis of infancy leading to labial adhesion.

Answer (C):-
A. Clinical features:
-Symptoms:1.Amenorrhoea dated back from the events.2.
Periodic pain lower abdomen.
3. Heamatocolpos, retention of urine.

-Signs: 1. Abdomen examination reveals an uniform globular

mass in the hypogastrium.2. Vulvar inspection reveals the
bulging hymen. 3. Pelvic examination reveals the offending
lesion either in vagina or cervix. 4. Rectal examination confirms
the fullness of the vagina & uterine mass.

-Investigations: To know the exact anatomical defect-

1) USG.
2) MRI.

Treatment:
1) Simple dilataion of the cervix so as to drain the collected
blood is enough,
2) Imperforate hymen: Cruciate incision is made in hymen &
spontaneous drainage of dark tarry
coloured blood.
3.In case of secondary atresia of the vagina, reconstructive
surgery (Vaginoplasty) is to be performed, to maintain patency.

2. a. what is infertility?
Infertility is defined as the inability to conceive within one or
more years of regular unprotected coitus.

b. how will you investigate a infertility of male?

#. Routine:
CBC with Hb %, ESR
RBS
Urine R/M/E.

#. Special:
Semen Analysis
Prostatic smear and culture to exclude gonorrhoea
Hormone Analysis → FSH, LH, Testosterone
Karyotyping
Testicular biopsy
Immunological test

c.Tell the parameters of semen?

Semen analysis
1.Volume 2.0 mL or more (1.5 mL)
2.pH 7.2–7.8
3.Viscosity <3 (scale 0–4)
4.Sperm concentration 20 million/mL (15 million/mL)
5.Total sperm count >40 million/ejaculate (39 million/ejaculate)
6.Motility >50% progressive forward motility (Progressive
motility = 32%)
7.Morphology >14% normal form (4%)
8.Viability 75% or more living (58%)
9.Leukocytes Less than 1 million/mL
10.Round cells <5 million/mL
11.Sperm agglutination <10% spermatozoa with adherent
particles

3.a . what IUCD ?

IUCD- Intrauterine contraceptive device is a small plastic

carrier, usually in the shape of a "T or similar design on the
vertical stem of which is wound some copper wire & may have
copper bands on the transverse arms.

b. Indication of IUCD?
As a comaraceptive-
1) Parous women where steroidal contraceptives are not
suitable
2) ill literate.
3) Breast feeding
4) Un-privileged woman

Now contraceptive
1)Asherman's syndrome
2) Following excision of the uterine septum
3) Hormonal IUCD in merorhagia
c. Describe the mode of action of IUCD?

Mechanism of action of 1" & 2 generation IUCDs

IUCD causes a foreign body reaction in the uterus
causing cellular and biochemical changes in the endometrium
and uterine fluid. These changes impair the viability of the
gamete and thus reduce its changes of fertilization rather than its
implantation.
In addition, medicated IUCD (2 generation) affects the
enzyme in the uterus by altering the biochemical composition of
cervical mucus. Copper ion may affect sperm motility,
capacitation and survival

#. Mechanism of action of 3 generation TUCDs:

Progesterone of 1 generation IUCDs increases the thickness of

cervical mucus and thereby prevents sperms frons entering the
cervis.
It decreases the thickness of endometrial mucosa and
thereby prevents implantation

4. a What is CIN?
CIN (Cervical Intra-epithelial Neoplasia) is histologically
diagnosed pre-cancerous lesion of the cervix characterized by
disordered growth & development of the lining epithelium of
cervix.

b. What are the treatment modality of CIN?

Low grade (CIN-I); a. under observation b. Infection control
& follow up by PAP smear until 3 negative smears are obtained.
High grade lesion (CIN I, II): required treatment.
treatment depends on -
▪ Age of the patient
▪ Nature of CIN

Treatment modalities are

a) Local excisional method:
1) Loop electrosurgical excision procedure (LEEP) or
Large Loop excision of the transformation zone (LLTZ)
2) Cold Knife or
3) Laser
b) Local destruction method:
Cryotherapy -cold
Electro coagulation -thermal
Laser

Answer (5):1. Possible causes:-1. Endometriosis, adenomyosis,

fibroid uterus.

#Treatment:
A.Preventive:
1.To avoid tubal patency test immediately after curettage or
around the time of
menstruation.
2.Forcible pelvic examination should not be done during or
shortly after menstruation.
B Curative:
A Expectant (conservative) treatment:
1. Administration ofNSAIDS or prostaglandin synthetase
inhibiting (PSI) drugs are used to relieve pain.
2.COX-2 inhibitors are effective.
3) The married women are encouraged to have conception.
C.Hormonal treatment:
1) Combined estrogen and progesterone: OCP
2) Progesterone.
3) Danazol.
4) Gestrinone
5) GnRH agonist.
D.Surgical treatment:
1.Conservative surgery:
Laparoscopic method
-Excision / cauterization.
-Laser vaporization.
-Laparoscopic uterosacral nerve ablation.
-Adhesiolysis. - Endometrioma -
-Aspiration and irrigation. -Cyst wall excision.
-Cystectomy.

2) Definitive surgery:
Laparoscopy / laparotomy.
Hysterectomy with bilateral salpingo-oophorectomy,
Resection of bowel or ureter may be needed for complete
removal of endometriosis.
Combined medical & surgical:
3-6 months hormone therapy preoperative or
postoperatively.
 SET-9
Set 9
1.(a)The term contraception includes all measures temporary or
permanent designed to prevent pregnancy due to the coital act
other then abstinence of coitus.

(B)Method::
●Temporary or spacing method
》Barrier method
▪Mechanical:Male-condom
Female-female condom, vaginal diaphragm
▪chemical:cream ,jelly, foam, sponge
▪combination
》Natural contraception:
▪Rythm method
▪coitus interruptus
▪lactational amenorrhoea
▪Basal body temperature
》Intrauterine contraceptive device:
▪Non medicated-lippies loop
▪Medicated-CuT,progestasert
》Steroidal contraception:
▪Oral pill-combined, sequential,mini,post coital
▪Parenteral preparation-injection (DMPA,NETEN)and
subdermal implant (norplant)
●Permanent method:
》Female:tubal ligation,tubal occlusion
》Male:Non scalpel vasectomy
(C)Source of Estrogen:
●Ovarian follicle-theca interna cell, granulosa cells
 ●Corpus luteum
●Placenta
●Adrenal cortex
Source of Progesterone:
•Corpus luteum
•Adrenal cortex
•Placenta

2.a)Hysterectomy: It is the operation of removal of uterus.

(b)Upto stage (ll-A) surgery can be done in carcinoma of cervix.

Type:Redical hysterectomy or wertheim hysterectomy.

3.a)Define missed abortion?

ANSWER:(a)Missed Abortion:
when fetus dies within uterine cavity before 28th week of
gestation and uterus fails to expel it, and dead Product of
conception is Tretained within uterine Cavity, is caused missed
abortion.
b) Enumerate the clinical features & treatment of missed
abortion?
ANSWER
●Symptoms:
1. subsidence of pregnancy symptoms and
●signs.
▪cessation of uterine growth.
▪persistance of brownieh vaginal discharge.
▪Slight pain and brocon bleeding
▪Retrogression of breast change.
●Abdominal examination
▪Fetal movements ara not felt or if previously present
Fetal heart sound are not record, if it had been audible before
20 week).
•Size of uterus (if palpable) less than period of
amenorrhoea.
●On pelvic examination
•Os closed
• uterus decreased (size) than period of gestation.
•Collapsed gestational sac.
• Absence oF fetal motion.
•Fetal pole -Absent

●Treatment
▪Evacuation of uterus
a pregnanay Less 12 weeks:
Many women expel the conceptus spontaneously. Misoprostol
800 mg in posterion fornix and repeated after 24 hours if
needed.
-Surgical treatment:
suction and evacuation or dilation and evacuation If medical
treatment fails to expel.

▪Pregnancy 12 weeks induction by misoppostol 200 gm 3+3+3

3 hourly 1 day Or oxytocin (10-20 units in 500 ml of Ns) at 3
drops per min, or combination

•If placenta retained

Dilatation and evaauation (if cervix not dilated)
D and C If cervix dilated.
•AntiD in Rh negative mother having Rh positive fetus
 4.a)How you can asses Malignant ovarian tumor clinically and
preoperative?
b)What are the presentations of malignant ovarian tumour?
Answer:of malignant ovarian tumour:
➤ History:
1)Postmenopausal women (60%) & premenopausal (20%).
2) Nulliparous.
3) Family history may be present.
➤ Clinical features:
a) Symptoms:
1) Rapid enlargement of lower abdominal lump.
2) Dull abdominal pain.
3) Gradual weight loss and cachexia.
4) Respiratory distress.
5) Loss of appetite.
6) Features of dyspepsia such as flatulence & eructation.
b) Signs:
●On general examination:
Cachexia & pallor of varying degree.
Jaundice may be present in late case.
Left supraclavicular lymph gland (Virchow's) may be enlarged.
Leg oedema or vulval oedema.
●On per abdominal examination:
A mass present is felt in the hypogastrium; too often it may be
bilateral. It has got the following features:
-Feel: Solid or heterogenous.
-Mobility: Mobile or restricted.
-Tenderness: Usually present.
-Surface: Irregular.Margins: Well-defined but the lower pole is
usually not reached.
Percussion:Usually dull over the tumour.
Liver may be enlarged, firm & nodular.
●On per vaginal examination:
The uterus is separated from the mass felt per abdomen.
Nodules may be present through the posterior fornix.

5.A 25 years old patient is admitted with 8 weeks of

amenorrhoea, lower abdominal pain and vaginal bleeding with
passage of grape like structures. On abdominal examination
reveals uterus about 16 weeks pregnancy.

a.What is your diagnosis & management?

b.Tell about the follow up schedule of this patient?

Answer:
(A)Diagnosis:Molar pregnancy
●C/F:
-Vaginal bleeding
-Varying degree of lower abdominal pain
-Vomiting
-Breathlessness
-Expulsion of grape like vesicles per vaginum
-History of quickening is absent.
●Investigation:
•Full blood count, ABO and rh typing
•USG of uterus and adnexae
•Serum HCG assay
•Plain xray abdomen
•X Ray chest
•CT scan and MRI
●Treatment:
1)Suction evacuation is the method of treatment followed by
gentle sharp curettage
2) Hysterectomy is the choice of treatment with the mole in situ
or after evacuation in women age > 40 years and/or has 3 or
more children.
3)Routine follow up is mandatory.

(B)Follow up schedule:
At least 6 month
1)B-HCG:48 hr after suction evacuation.
2)Estimation of serum beta HCG weekly until 3 consecutive
negative.
3)If 3 consecutive negative then monthly for 1 year.
4)Pelvic examination:after 1 week then monthly
5)Patient can not be pregnant during this period.
6)contraceptive measures:ocp,inj,Barrier except Progesterone
and IUCD.
Set 10(Gynae)
SET-10
1. a) Define abortion
Ans: Any interruption of pregnancy or extraction or expulsion
from its mother of an embryo or fetus weighing 500gm or less
when it is not capable of independent survival

b) Clinical features and treatment of incomplete abortion

Ans: *C/F*
1. Expulsion of fleshy mass per vagina
2. Lower abdominal pain
3. Persistence of vaginal bleeding
*Sign*
1. product maybe found hanging
2. Varying amount of bleeding
3. Uterus smaller than gestational age

Treatment
Medical: Misoprostol
Surgical: D,E&C or EC

2. a) Non contraceptive benefits of OCP

Ans: 1.Improvement of menstrual abnormalities: regulation of
menstrual cycle , reduction of dysmenorrhea, reduction of
menorrhagia , reduction of premenstrual tension syndrome
2.Protection against health disorders : Protection against
iron deficiency anemia , pelvic inflammatory disease, ectopic
pregnancy, endometriosis, fibroid uterus
3.Prevention of malignancies : endometrial cancer,
epithelial ovarian cancer, colorectal.
b) Permanent method of sterilization
Male: Bilateral Non scalpel vasectomy
Female: Bilateral tubectomy

c) Progesterone containing pills

Oral: levonorgestrel ,Norethisterone, Desogestrel, Norgestrel
Parenteral:(Injectable)DMPT, NET-EN
(Implant), Implanon
Device: LNG- IUS

3. a) Define Menorrhagia
-Cyclical bleeding occuring at regular interval, bleeding is
either excessive in amount (>80ml) or duration (>7 days)

b) Enumerate causes of menorrhagia

-Pelvic Pathology
-Fibroid uterus
-Adenomyosis
-Pelvic endometriosis
_IUCD in utero
_chronic tubo ovarian mass

c) What are the 5 important complications of Fibroid uterus

-Degenerations ( Hyaline, cystic, fatty, calcific, red )
- Necrosis
- Torsion of subseropus pedunculated fibroid
- Hemorrhage ( intracapsular, ruptured surface vein of subserous
fibroid)
- polycythemia ( due to erythropoietic function of tumor, altered
erythropoietic function of kidney through ureteric pressure)
-Sarcomatous change ( rare)

4. a) Define dysmenorrhagia
- Painful menstruation of sufficient magnitude so as to
incapacitate day to day activities.
types - primary & secondary

b) What are the causes of secondary dysmenorrhagia

- Endometriosis
-Adenomyosis
-IUCD in utero
- Obstruction due to mullerian malformation( bicornuate /
septate uterus)
-Cervical stenosis
- Pelvic adhesion
- Endometrial polyp
-Uterine Fibroid
-Chronic pelvic infection

c) What are the complications of MR?

* Immediate complications
- incomplete MR
- Continuation of pregnancy
- Missed abortion
- uterine perforation
- cervical injury
-haematometra and pyometra