KAMPALA INTERNATIONAL UNIVERSITY

FACULTY OF CLINICAL MEDICINE AND DENTISTRY

DEPARTMENT OF OBSTETRICS & GYNAECOLOGY

COURSE : Obstetrics& Gynaecology /Reproductive health

Continuous Assessment Test for Series 133

May10th 2018

REGISTRATION NUMBER No……………………………………………………

Instructions :

Write your registration number on all pages

The examination consists of three sections :

1. SECTION A 50 MCQS: choose the one best answer for each question .
2. SECTION B: 3 SHORT ESSAY QUESTIONS 30 Marks
3. SECTION C: 1 LONG ESSAY QUESTION 20Marks
4. Duration : 3 hours

1. The plane from the sacral promontory to the inner posterior surface of the pubis
symphysis is an important dimension of the pelvis for normal delivery. What is
the name of this plane ?
a) True conjugate
b) Obstetric conjugate
c) Diagonal conjugate
d) Oblique diameter
e) Bi- Ischial diameter
2. During the performance of pelvic examination the area of Bartholin’s duct should
be inspected. Where do Bartholin’s glands ducts open ?
a) into the midline of the posterior fourchette
b) bilaterally beneath the urethra
c) bilaterally on the inner surface of labia majora
d) bilaterally into the posterior vaginal vestibule
e) bilaterally , approximately 1cm lateral to the clitoris
3. A 65year old patient presents with vulvar lesion. The pathology report of the
vulvar biopsy is returned with the following prescription: There is hyperplasia of
keratinocytes in the prickle cell layer thickening the epidermis . This is descriptive
of which of the following?
a) Atrophic vaginitits
b) Syphilitic ulceration
c) Acanthosis
d) Lichen scelosus
e) Parakeratosis
4. During routine examination an asymptomatic multparous patient is found to have
raised 1cm cyst on her cervix. The area is biopsied and clearly mucus extruded.
Histological examination of the spacemen shows a lining of columnar epithelium
or cuboid type cells. With what would this clinical picture be most compatible ?
a) Herpes cervitis
b) Varicella infection
c) Cervical intraepithelial neoplasia
d) Nabothian cyst
e) Cervical adenosis

5. A 35 year old G5P4+0 is found to have ASCUS on her Pap smear done at her
new obstetrics visit. In your counseling of the patient as to what this result means
you note that hormonal changes of pregnancy will cause changes in the cervix .
which of the following cervical changes may be found more frequentlty in
pregnant state than in non pregnant state ?
a) Atypical glandular hyperplasia
b) Dysplasia
c) metaplasia
d) neoplasia
e) vaginal adenosis
6. The physiological changes during pregnancy can alter many laboratory tests.
During the evaluation of a patient with tachycardia, hypertension and headache.
You are considering both hyperthyroidism and atypical preeclampsia and draw
the following tests to correctly interpret the results, it is necessary to distinguish
normal versus abnormal changes during pregnancy. Which of the following would
be expected to increase during pregnancy?
a) Alanine aminotransferase
b) Aspartate aminotransferase
c) Hemotocrit
d) Plasma creatinine
e) Thyroxine binding globulin
7. The management of vaginal bleeding of first trimester pregnancy requires
trending of human chorionic gonadotropin levels. Because urine test can be
typically less expensive and results are more readily available. It is important to
know their sensitivity. Immunologic test for pregnancy can detect HCG in the
urine in which of the following concentrations ?
a) 2IU/L
b) 20IU/L
c) 100IU/L
d) 200IU/L
e) 1000IU/L
8. How many weeks is ultrasound scan useful in evaluating fetal anatomy ?
a) Between 2 and 4 weeks after LMP
b) Between 7 and 9 weeks after LMP
c) Between 12 and 14 weeks after LMP
d) Between 19 and 21 weeks after LMP
e) Between 30 and 32 weeks after LMP

9. The patient has microcytic anemia with a hemoglobin of 9g/dl and normal iron
stores. What is the most likely diagnosis?
a) Folate deficiency
b) Vitamin 12 deficiency
c) Vitamin B12 deficincy
d) Thalassaemia
e) Acute blood loss
10. When educating about signs of labour, you mention blood show. This is which
of the following ?
a) A result of small abruptions
b) Not seen in breech presentations
c) A consequent of cervical effacement and dilatation
d) Associated with passage of mecomium
e) Problematic in rhesus positive mothers if not given RhoGAm in 72 hours

11. Preterm rupture of the membranes is mostly strictly defined as spontaneous

rupture at any time prior to:
a) A stage of fetal viability
b) The second stage of labour
c) The 32nd week of gestation
d) The onset of labor
e) The 37 week of gestation
12. 41 years old PG with BMI 31 attends the antenatal clinic at 10 weeks of gestation.
Her father has type 2 diabetes.In this pregnancy she will require aspirin 75mg
daily. At what gestation should she commence aspirin?
a) Aspirin from 12 weeks
b) From 14 weeks
c) From 16 weeks
d) From 18 weeks
e) From 20 weeks
13. 25 years old woman has presistently high blood pressure of >150/100 mm of Hg
for three days following delivery with no biochemical and haematological
abnormalities.She was not on any anti hypertensive drugs during pregnancy.She
is breast feeding .Which is the most appropriate anti hypertensive agent that can
be prescribed for her
a) Amlodipine
b) Bendroflumethiazide
c) Candesartan
d) Methyldopa
e) Enalapril
14. 41 years old woman presents at 36 weeks of gestation in active labour.An
ultrasound at 20 weeks showed bilobed low lying placenta.Immediately after
rupture of memberanes,she started bleeding vaginally with associated
cardiotocography abnormalities.What is the most likely diagnosis?

a) Abruptio placentae
b) Placenta Previa
c) Placenta percreta
d) Placenta Accreta
e) Vasa Previa
15. 27 years old woman attends antenatal clinic at 29 weeks of gestation found to
have a blood pressure of 148/90 mm of Hg.Her urine shows ++ of
proteinuria.Otherwise she is asymptomatic.What is the most appropriate initial
management.?
a) Admit to hospital for observation
b) Community midwife should visit her at home in 24 hours
c) Start methyldopa 250 mg three times a day
d) Start Labetalol 200 mg three times a day
e) Refer for further investigations and assesment
16. 23 years old woman undergoes a surgical evacuation for a suspected molar
pregnancy.Histology shows a partial mole.What is the most common
chromosomal composition of a partial mole?
a) 1 paternal 1 maternal gametes
b) 1 paternal 2 maternal gametes
c) 2 paternal and 1 maternal gamates
d) 2 paternal and no maternal gamates
e) 3 paternal and 1 maternal gamates

17. 40 years old prim gravida known diabetic is 33 weeks pregnant. She presented
with second episode of reduced fetal movements. Initial examination and
cardiotocography are normal. What is the most appropriate next step?

a) Deliver the baby after a course of steroids

b) Reassure her n give her kick count chart
c) Repeat CTG after 2 days
d) Ultrasound scan
e) Umbilical artery Doppler study

18. HIV in pregnancy.Which of the following is TRUE?

a) Low CD4 count is associated with increased risk of transmission.
b) Risk of transmission through breast feeding is 50 %
c) Clinical course of HIV not altered in pregnancy
d) Lactational amenorrhea is effective method of contraception
e) Is associated with macrosomic baby
19. Regarding Rubella immunization :
a) Rubella negative patients should be vaccinated during pregnancy
b) Rubella vaccine is a Toxoid
c) The majority of pregnant patients are rubella non immune
d) Breast feeding should be inhibited if vaccine is given postnatally
e) Pregnancy should be avoided for 3 months after vaccination
20. A woman presenting in active labour has preclampsia and polyhydromnios.She is
Para 5 with all vaginal deliveries.Her progress of labour was good and active
phase of labour lasting 6 hours.Delivery is now imminent.What is the most
immediate postpartum management?
a) Misoprostol 1000 mg P/R
b) 10 IU Oxytocin I/M post delivery
c) Syntometrine I/M post delivery
d) Oxytocin infusion 40 units at 125ml/hr
e) Oxytocin infusion 40 units at 125ml/hr + Misoprostol 1000mg P/R
21. 24 years old primigravida known diabetic presented in antenatal clinic with
dichorionic diamniotic twin pregnancy at 34 weeks and requesting a plan
regarding the timing of her delivery .Both babies on ultrasound scan are cephalic
presentation.What is the most appropriate advice ?
a) Awaits spontaneous onset of labour
b) Elective C/S at 36 weeks following steroid cover
c) Elective C/S at 39 weeks
d) Induction of labour at 36 weeks following steroid cover
e) Induction of labour at 38 weeks

22. Regarding induction of labor all statements are false, EXCEPT:

a) Chance of success is not dependent on the cervical bishop score.
b) Is indicated in patient with mitral stenosis.
c) Vaginal prostaglandin pessaries reduce the induction of delivery interval.
d) In indicated at 40 weeks gestation.
e) All diabetic women should be induced at 38 weeks of gestation

23. Regarding Puerperium: which is TRUE?

a) Refer to the first 6 months after delivery

b) The lochia usually persist for 7 weeks
c) The uterine fundus should not be palpable abdominally by 14 days after
delivery
d) The incidence of post partum depression is 50%
e) Fever due to engorged breast occurs on the second day after delivery

24. Obstructed labor: Which is true?

a) Diagnosis only when the cervix is fully dilated
b) Usually predicted before onset of labor
c) More common in developed countries
d) Mento-posterior position could be a cause
e) X-ray pelvimetry is essential to predict cephalo-pelvic disproportion in
Primigravida

25. The most serious maternal complication of IUFD:

a) Acute amnionitis.
b) Acute psychosis.
c) Pelvic thrombophlebitis.
d) Hypofibrinogenemia.
e) Infertility.
26. Each of the following typical feature of placenta previa, EXCEPT:
a) Painless bleeding
b) First episode of bleeding is usually self limited
c) May be associated with post coital bleeding
d) Commonly associated with coagulopathy
e) The uterus tends to be soft and non-tender

27. Multiple pregnancy increases

a) In white people more than black
b) With advancing maternal age
c) With Bromocriptine use for infertility treatment
d) If first pregnancy
e) After ovarian diathermy for polycystic ovary syndrome
28. Atonic Post partum hemorrhage is best managed with :
a) Intra-venous progesterone
b) 0.5 mg oral ergometrine and uterine massage
c) 5 units oral syntocinon and uterine massage
d) Uterine massage
e) Uterine massage with 40 units syntocinon in 500 ml D5 % NS to be given
Intravenously
29. Regarding Secondary postpartum haemorrhage:
a) Is diagnosed when bleeding occurs 72 hours after delivery
b) Contra indicate breast feeding
c) The commonest cause is the cervical tears
d) Very common when the patient delivers a congenitally abnormal baby
e) Choriocarcinoma could be a cause.

30. Postulated mechanism of the IUCD include all of the following action
EXCEPT:
a) Altered tubal motility
b) Altered endometrium
c) Altered cervical mucus
d) Copper has spermicidal effect
e) inhibition of implantation

31. Causes of first trimester abortion

a) Chromosomal abnormalities
b) Cervical incompetence
c) Bicornuate uterus
d) Gestational hypertension
e) Pre-eclampsia

32. The treatment of endometriosis include all the following EXCEPT:

a) Birth control pills (BCP).
b) Oral progesterone.
c) Estrogen.
d) Depoprovera.
e) GnRH analogue

33. 28 year old lady P3+2 presented to the clinic with history of irregular
menstrual cycle for 2 months, no history of post-coital bleeding. She had
pap smear which showed high grade squamous cell intraepithelial lesion
(CIN II). The proper management is:
a) Follow up & repeat pap smear after 6 months.
b) Laser cone biopsy.
c) Examination under anesthesia & (D&C)
d) Colposcopic assessment & pelvic biopsy.
e) Cryotherapy & antibiotic.

34. Intrapartum CTG , a finding of late decelerations is:

a) Relived by maternal position of left side
b) Compression of fetal head mediated by vagus nerve
c) Caused by umbilical cord compression
d) Is not worrisome if non recurrent
e) Is mostly due to placental insufficiency

35. Repetitive late decelerations most commonly indicate:

a) Fetal academia.
b) Fetal hypoxia.
c) Fetal sleep state.
d) Fetal efforts of maternal sedation.
e) Rapid cervical dilation

36. During pregnancy the treatment of uterine prolapse if the cervix is outside
the introitus is with ring pessary. About this, select the correct answer.

a) The pessary is to be kept until 18–20th week of pregnancy.

b) The pessary is to be kept until 22-24th week of pregnancy.
c) The pessary is to be kept until 26-28th week of pregnancy.
d) The pessary is to be kept until 28-30th week of pregnancy.
e) The pessary is to be kept until 30-36th week of pregnancy.

37. N-T 26 years old G3P1+1 at 37 WOA, was Nocked by a speeding bicycle while
walking to her home she presents to the hospital when fully conscious, No any
fractures, noted how ever had inoderate pallor, left sides abdominal pain, the fetal
heart rate was not heard. Also had minimal PV bleeding. What is the best
management option for this patient.
A. Delivery by ceseream section
B. Transfuse with whole blood
 C. Induce labour
D. Analgesiscs, bedrest and interveneus fluids.
E. Conservative management

38. In the presence of abnormal CTG, fetal hypoxia and acidosis may develop faster
or may affect the normal outcome in the following situation accept,
A. When there is intrautesine infection
B. When the fetus is preterm <32 weeks
C. When the fetus has intrauterine growth restriction.
D. In the presence of thicks meconium with scantly fluid.
E. Aprecipitated labour.

39. The patient is experiencing an arrest. During the the evaluation one can feel that it
is avertex presentation with sagittal suture transverse or oblique but closer to the
symptysis than the promontory. What is this specific condition called.
A. Posterior asynclitism
B. Internal rotation
C. Anterior asynclitism
D. Extention
E. Restitution

40. A 28 years old nulliparous woman presents to your gynaecological clinic with the
history of infrequent periods of pervaginal bleeding occurying every two to four
months since menarche at 13.Her body mass index is 32.She suffers from mild
asthma and has no other medical or surgical history of note.What is the most
likely cause for her presentation?
a) Excessive physical exercise
b) hyperthyroidism
c) ovarian cysts
d) polycystic ovarian syndrome
e) prolactinoma
41. A medical student is atttending colposcopy clinic with you,and asks you why the
area you are looking at is called the transformation zone of the cervix.Which of the
following best describes the transformation zone of the cervix?
a) Glandular transformation of squamous epithelium
b) Metaplastic transformation of columnar to squamous epithelium
c) Pre cancerous transformation of squamous epithelium
d) Transformation from columnar to transitional epithelium
e) Transformation from squamous to transitional epithelium
42. A 24 year old woman is taken to theatre following presentation with severe l
ower abdominal pain and a positive pregnancy test. Laparoscopy show
healthy appearance of the left fallopian tube but on the right side there is a t
ubal mass consistent with an ectopic pregnancy. What is the most appropri
ate management ?

a) Methotrexate
b) Right salpingectomy
c) Right Salpingotomy
d) Expectant management
e) Bilateral salpingectomy
43. A 38 year old woman undergoes an ultrasound scan which shows a left sided

complex ovarian mass. In addition to Ca125 what blood tests, if any, are indicated?

a) No further blood tests required

b) αFP, HCG and LDH
c) Ca15.3, CEA and Ca19.9
d) αFP, CEA and HCG
e) LDH, CEA and αFP
44. A couple have been trying to conceive for 2 years. The male partner (36) semen a
nalysis shows: Volume 1.0ml, 0.5 million sperm/ml, 40% motility and 3.5% normal
forms. Female partner has regular periods.
Physical examination of both partners is unremarkable. Which of the following
investigation would you recommend?
a) Laparoscopy and dye test
b) Hysterosalpingogram
c) Pelvic ultrasound
d) Repeat semen analysis
e) Male hormone profile including testosterone

45. In management of chronic pelvic pain which one is FALSE?

A. Unnecessary surgery should be avoided
B. Requires a multidisciplinary approach
C. Patients with pain syndrome and depression are likely to have their
depression identified and treated.
D. Biofeedback and hypnosis are helpful
E. Narcotics should be used.

46. A 39 years old woman para 6 has presented with complaint of post-coital
bleeding for the past three months. Your first investigation should be:
 a) Dilatation and curettage
b) Cone biopsy of cervix
c) Pap smear test
d) Colposcopy
e) Pelvic Ultrasound Scan.
47. Which of the following types of endometrial carcinoma has the BEST
prognosis:
a) Adenosquamous carcinoma.
b) Clear-cell adenocarcinoma.
c) Serous carcinoma.
d) Secretory carcinoma.
e) Squamous-cell carcinoma.

48. A 29 year old woman who is 33 weeks gestation presents to the labour ward. The
patient reports a sudden clear fluid discharge from the vagina. You suspect preter
m prelabour rupture of membranes. How should the diagnosis be confirmed?
a) Sterile speculum examination
b) Nitrazine test
c) Examination for lanugo hair
d) Nile blue fetal epithelial cells stain
e) Digital vaginal examination

49. What is the presenting diameter in a Brow presentation?

a) Mentovertical
b) Suboccipito‐frontal
c) Suboccipito‐bregmatic
d) Occipito‐frontal
e) Submento‐bregmatic.

50. About Stage II of Vulvar Carcinoma. Which of the following isTRUE?

a) The tumor spread to lower urethra or vagina.

b) Tumor confined to the vulva or perineum more than 2 cm.
c) There is unilateral regional lymph node metastasis.
d) Lesion <2 cm in size, confined the vulva or perineum.
e) Lesion <1 cm in size, confined the vulva or perineum.
SECTION B

1. Briefly discuss prolonged active phase of labour (10 marks)

Diagnosis( 2 marks)

The diagnosis of prolonged active phase is made retrospectively based on findings from
vaginal examinations to asses the rate of cervical dilatation. In this condition, the
plotting of cervical dilatation on the partogram crosses to the right of the alert line.

Immediate and emergency treatment

• If the plotting of cervical dilatation crosses over to the right of the alert line and the
patient is in a maternity centre, transfer her to hospital unless delivery is imminent.

• In hospital, carry out through evaluation to differentiate obstructed labour from

inefficient uterine action, and exclude malposition or malpresentation. If no
abnormalities exist, rupture membranes and observe closely.

• Carry out any other appropriate interventions such as IV fluids if the patient is
dehydrated, catheterisation of the bladder.

• Augment with oxytocin if contractions are inadequate

• Continue monitoring labour

• Expected outcome is vaginal delivery. In case of failure of progress or foetal distress,

deliver by caesarean section.

Precautions to Take in Order to Avoid Complications

• Limit the number of vaginal examinations

• Use the partogram correctly and make decisions promptly

1 marks for each item

2. Briefly expalin the different types of long acting reversible contraceptives ( 10 marks)

Hormonal methods.

1.Jadelle. Two subdermal implants containing levonegesterone. Provide contraception

for 5 years.

2.Implanon. One subdermal implant. Containig 68mg etonergesterone provide

contraception for 3 years
3. Norplant. 6 subdermal implants containing levonersterone,Provide contrception for 5
years.

4. mirena. Also known as progesteron IUD. Inserted in the endometrial cavity.Contain

levonergesterone.Povide contraception for 5 years.

5. Copper T IUD. Has copper ions, inserted in the endometrial cavity,provide

contraception for 10-12 years.

( 1 mark for correct method,1 mark for corect explanation.total 10 marks)

2. Outline the aetilogy of Vulvar carcinoma.

The etiology remains unclear.1mark, But the following factors are often related.

✓ Usuallyoccurring in postmenopausalwomenwith a median age of 60.

✓ More commonamongstwhites.
✓ Increasedassociationwithobesity, hypertension, diabetes and nulliparity.
✓ Associatedvulvalepithelialdisorders (lichensclerosus) specially of atypicaltype are
theriskfactors.
✓ Human papilloma virus (HPV) DNA (type 16, 18) has beendetected in
patientswithinvasivevulvalcancer.
✓ Vulvalcancermayhave a causal relationwithcondylomaaccuminata (HPV 6, 11),
syphilis and lymphogranulomavenereum.
✓ Chronicpruritususuallyprecedsinvasivevulvalcancer.
✓ Chronicirritation of the vulva bychemicalorphysical trauma
associatedwithpoorhygienemay be a predisposing factor.
✓ Otherprimarymalignancieshavebeenobserved in about 20 percent of cases
withvulvalcancer. Cervixismostcommonlyaffected; othersites are breast, skin or
colon.
Each point above is 1 mark

SECTION C

Section C ( 20 marks)
A 35 years old women P3 have delivered 30 minutes ago by normal vaginal delivery a
female baby 3.2 kg, Apgar score 9/10. Now you have been called by the midwife because
she has significant bleeding per vagina. OE: BP 90/60 mm-hg, PR: 120 pm. Abdomen:
uterus 2 cm above to the umbilicus, per vaginal no vaginal laceration, no cervical
laceration, profuse fresh blood is coming from inside the uterus. According to the history
and the examination finding:

ANSWER:
a) Primary post-partum Haemorrhage ( 2 marks)
b) Management ( 10marks).

- Call for help. 0.5 mark

- Insert two bore cannula. 0.5 mark

- Take blood sample for emergency investigation: Hb estimation, Grouping and cross
matching, clotting profile. 0.5 mark

- Start crystalloid solutions infusion: normal saline 2 L in the first hour. 1 mark
- Administer high doses of uterotonic: 30 to 40 IU of oxytocin in 1 L N/S, or
ergometrine 0.4 to 0.8 mg IV, or misoprostol 800 microgram rectal. 1.5 mark
- Do bimanual uterine compression: one hand closed inside of vagina and the other
one over the abdominal wall. 0.5 mark
- Do aorta artery compression. 0.5 mark

If with this measure the bleeding continuous, then surgical treatment is

mandatory:

Alternative of surgical treatment according to the priority:

- Hypogastric artery ligation. 1 mark

- Uterine artery ligation. 1 mark

- Be-Lynch Suture. 1 mark

- Subtotal Hysterectomy. 2 mark

c) Complication. 8 marks. Students have to mention 4 complications each of them 2

marks.
1. Hypovolemic shock

2. Severe anaemia
3. Sheehan syndrome hysterectomy.

4. Cerebral hypoxia
5. Infertility secondary