CMS 2022 Paper II \u2013 Part B (Q41\u2013Q80)<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:wght@600;700&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#cms22p2b *,#cms22p2b *::before,#cms22p2b *::after{box-sizing:border-box;margin:0;padding:0}\n#cms22p2b{--ter:#1A5EA8;--ter-light:#2E82D5;--ter-pale:#EBF3FD;--teal:#1A3A5C;--teal-light:#24527F;--teal-pale:#E8F0F9;--ink:#1a1a1a;--ink-mid:#444;--ink-soft:#777;--line:#dde4ed;--bg:#f8fafd;--white:#ffffff;--correct:#1e6f46;--correct-bg:#eaf7ef;--correct-border:#43a047;--wrong:#b83232;--wrong-bg:#fdf0f0;--wrong-border:#e53935;--radius:10px;font-family:'Source Serif 4',Georgia,serif;font-size:16px;color:var(--ink);background:var(--bg);line-height:1.7;padding:0 0 48px}\n#cms22p2b .cq-sentinel{height:1px}\n#cms22p2b .cq-statusbar{position:fixed;top:0;left:0;right:0;z-index:99999;background:var(--white);border-bottom:2px solid var(--line);border-left:4px 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<\/div>\n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2022<br>Surgery, Gynaecology & Obstetrics, Preventive & Social Medicine \u00b7 Paper II \u00b7 Part B<\/h1>\n <p>Gynaecology & Obstetrics<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 41 \u2013 80<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <button class=\"cq-timer-btn\" id=\"cms22p2b-timer-btn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-body\">\n <div id=\"cms22p2b-questions\"><\/div>\n <div class=\"cq-submit-wrap\"><button class=\"cq-btn\" id=\"cms22p2b-submit\">Submit Answers<\/button><\/div>\n <div class=\"cq-score\" id=\"cms22p2b-score\">\n <div class=\"cq-score-ring\" id=\"cms22p2b-ring\"><div class=\"cq-ring-inner\"><span class=\"cq-ring-pct\" id=\"cms22p2b-ring-pct\">0%<\/span><span class=\"cq-ring-sub\">score<\/span><\/div><\/div>\n <h2>Your Result<\/h2>\n <div class=\"cq-net-line\" id=\"cms22p2b-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms22p2b-verdict\"><\/div>\n <div class=\"cq-score-bands\"><span class=\"cq-band cq-band-c\" id=\"cms22p2b-ct-c\"><\/span><span class=\"cq-band cq-band-w\" id=\"cms22p2b-ct-w\"><\/span><span class=\"cq-band cq-band-s\" id=\"cms22p2b-ct-s\"><\/span><\/div>\n <button class=\"cq-retry-btn\" id=\"cms22p2b-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n<\/div>\n<script>\n(function(){\n'use strict';\nconst NS='cms22p2b',TOTAL=40,MAX=160,TIMER_SECS=2400,GRACE_SECS=10;\nconst QUESTIONS=[\n {id:41,stem:'During the first stage of labour, the intrauterine pressure is increased up to',correct:'40\u201350 mm of Hg',options:['2\u20133 mm of Hg','8\u201310 mm of Hg','40\u201350 mm of Hg','100\u2013120 mm of Hg'],exp:'During the first stage of labour, uterine contractions generate intrauterine pressure of 40\u201350 mmHg (amplitude above resting tonus of ~10 mmHg). Resting tonus = 8\u201312 mmHg. Peak contraction pressure = 40\u201360 mmHg in active labour. In the second stage pushing, pressures can reach 100\u2013120 mmHg. The range of 40\u201350 mmHg is the standard for the first stage active phase.'},\n {id:42,stem:'Which of the following are screening tests for cervical cancer?\\n1. Pap test\\n2. HPV DNA test\\n3. Visual inspections with acetic acid\\n4. Endocervical curettage',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Cervical cancer screening tests: (1) Pap smear\/cytology \u2014 conventional screening; (2) HPV DNA test \u2014 primary cervical screening (WHO-recommended from 2021); (3) VIA (Visual Inspection with Acetic acid) \u2014 low-resource setting screening, identifies acetowhite lesions. Statement 4 (Endocervical curettage, ECC) is a DIAGNOSTIC procedure done at colposcopy to sample the endocervix \u2014 it is NOT a primary screening test. Statements 1, 2, and 3 are screening tests.'},\n {id:43,stem:'Heavy menstrual bleeding is a common presentation in which of the following?\\n1. Clotting factor deficiency\\n2. Fibroid uterus\\n3. Adenomyosis\\n4. Prolactinoma',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Heavy menstrual bleeding (HMB) causes: Clotting factor deficiency (1 \u2014 von Willebrand disease most common; platelet disorders), Uterine fibroids (2 \u2014 submucous\/intramural fibroids cause HMB via increased surface area and impaired haemostasis), Adenomyosis (3 \u2014 ectopic endometrial glands\/stroma in myometrium causing dysmenorrhoea and HMB). Prolactinoma (4) causes hyperprolactinaemia which suppresses GnRH \u2192 hypogonadism \u2192 AMENORRHOEA or oligomenorrhoea \u2014 NOT heavy menstrual bleeding. Statements 1, 2, and 3 are correct.'},\n {id:44,stem:'Serum level of CA 125 is raised in which of the following conditions?\\n1. Epithelial ovarian cancer\\n2. Endometriosis\\n3. Pelvic inflammatory disease',correct:'1, 2 and 3',options:['1 and 2 only','2 and 3 only','1 and 3 only','1, 2 and 3'],exp:'CA-125 is a glycoprotein shed by cells derived from coelomic epithelium. Elevated in: (1) Epithelial ovarian cancer (~80% of serous type \u2014 primary tumour marker used for monitoring), (2) Endometriosis (active disease causes peritoneal shedding \u2014 CA-125 moderately elevated, useful for monitoring treatment response), (3) PID (acute peritoneal inflammation elevates CA-125). Other benign causes: menstruation, pregnancy, liver disease, uterine fibroids. All three statements are correct.'},\n {id:45,stem:'Uterus is supported by which of the following ligaments?\\n1. Pubocervical ligament\\n2. Cardinal ligament\\n3. Uterosacral ligament\\n4. Ovarian ligament',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"The uterus and upper vagina are supported by three main condensations of parametrial connective tissue (ligaments): (1) Pubocervical\/vesicouterine ligaments (anterior \u2014 connect cervix to pubic symphysis); (2) Cardinal\/Mackenrodt's ligaments (lateral \u2014 transverse cervical ligaments, strongest support); (3) Uterosacral ligaments (posterior \u2014 connect cervix\/upper vagina to sacrum; maintain uterine anteversion). The Ovarian ligament (4) is a short fibromuscular band connecting the ovary to the uterine cornu \u2014 it supports the ovary, NOT the uterus. Statements 1, 2, and 3 are uterine supports.\"},\n {id:46,stem:'Amongst the following, the Pearl Index is highest with',correct:'calendar rhythm method',options:['combined oral contraceptives','intrauterine contraceptive devices','barrier contraceptives','calendar rhythm method'],exp:'Pearl Index = (number of pregnancies \u00d7 1200) \/ total months of use \u2014 measures contraceptive failure rate. Higher Pearl Index = LESS effective contraceptive. Efficacy ranking (most to least effective): IUD (~0.1-0.8) < COC (0.3-0.5 perfect use, 7-9 typical) < Barrier methods (~2 perfect, 15-18 typical) < Calendar rhythm method (~9-25, highly variable). Calendar rhythm method has the HIGHEST Pearl Index (highest failure rate) among the listed options. Answer: calendar rhythm method.'},\n {id:47,stem:'Following vaginal delivery, uterus becomes non-pregnant size by',correct:'6 weeks postpartum',options:['9 weeks postpartum','8 weeks postpartum','4 weeks postpartum','6 weeks postpartum'],exp:'Uterine involution after delivery: At birth ~1000g. By day 7: below the umbilicus. By day 14: within the pelvis. By 6 weeks postpartum: returns to near non-pregnant size (~60-80g), cervix re-forms. Complete histological involution takes up to 8-12 weeks. The standard teaching for RETURN TO NON-PREGNANT SIZE is 6 weeks postpartum \u2014 the standard timeline for the postpartum check-up.'},\n {id:48,stem:'Indications and prerequisites for delivery with the ventouse include which of the following?\\n1. Delay in the second stage of labour\\n2. Non-reassuring fetal heart rate\\n3. Gestation age less than 34 weeks of pregnancy\\n4. Vertex presentation',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Ventouse (vacuum extractor) delivery \u2014 indications\/prerequisites: (1) Prolonged\/delayed second stage \u2014 correct indication; (2) Non-reassuring CTG \/ fetal distress in second stage \u2014 correct; (4) Vertex presentation \u2014 absolute prerequisite (face or breech presentations are contraindications). Statement 3 is FALSE: gestation <34 weeks is a CONTRAINDICATION to ventouse \u2014 the fetal scalp is fragile and at risk of subgaleal haemorrhage and cephalhaematoma. Ventouse is typically avoided below 34 (some say 36) weeks. Statements 1, 2, and 4 are correct.'},\n {id:49,stem:'Which of the following fetal infections are associated with significant intrauterine growth restriction?\\n1. Cytomegalovirus infection\\n2. Rubella infection\\n3. Toxoplasmosis\\n4. Human papillomavirus infection',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'TORCH infections classically causing IUGR: Toxoplasmosis (3 \u2014 placental and fetal vascular damage), Rubella (2 \u2014 destroys blood vessel endothelium, limits cell division), Cytomegalovirus (1 \u2014 most common congenital viral infection, causes IUGR via placental insufficiency and cell lysis). HPV (4) primarily causes condylomata acuminata in the birth canal and laryngeal papillomatosis in the neonate \u2014 it is NOT associated with IUGR. Statements 1, 2, and 3 are correct.'},\n {id:50,stem:'Missed abortion is not diagnosed if',correct:'USG shows fetus with cardiac activity',options:['vaginal bleed is brownish in colour','uterus is smaller than gestational age','external os is closed','USG shows fetus with cardiac activity'],exp:'Missed (silent) abortion = embryo\/fetus dies in utero but is retained without expulsion. Features: brownish vaginal discharge (old blood \u2014 does NOT rule out missed abortion), uterus smaller than dates (regression of pregnancy), external os closed, absent fetal heartbeat on USG. If USG shows FETAL CARDIAC ACTIVITY (living embryo\/fetus), the pregnancy is viable \u2014 missed abortion CANNOT be diagnosed. Presence of cardiac activity on ultrasound definitively EXCLUDES missed abortion. Answer: USG showing fetal cardiac activity.'},\n {id:51,stem:'As per the PC & PNDT Act, permission will be given to perform the tests for detection of which of the following?\\n1. Chromosomal abnormalities\\n2. Haemoglobinopathies\\n3. Sex-linked genetic diseases',correct:'1, 2 and 3',options:['1 and 2 only','2 and 3 only','1 and 3 only','1, 2 and 3'],exp:'The PC & PNDT Act (Pre-Conception and Pre-Natal Diagnostic Techniques Act, India 1994) PROHIBITS sex determination for the purpose of sex-selective abortion. However, it PERMITS prenatal diagnostic techniques for detection of: (1) Chromosomal abnormalities (Down syndrome, trisomies), (2) Haemoglobinopathies (thalassaemia, sickle cell), (3) Sex-linked genetic diseases (haemophilia, Duchenne MD \u2014 where sex determination is medically necessary), as well as metabolic and congenital disorders. All three are permitted. Answer: 1, 2 and 3.'},\n {id:52,stem:'Which of the following are indications for early clamping of umbilical cord at delivery?\\n1. Rh incompatibility\\n2. Baby born to a diabetic mother\\n3. Maternal anemia\\n4. Birth asphyxia',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Early cord clamping (immediately at birth or within 30 seconds) is indicated when delayed clamping would be harmful: (1) Rh incompatibility \u2014 early clamping reduces transfer of Rh-positive blood from placenta to baby, limiting neonatal haemolysis; (2) Infant of diabetic mother \u2014 neonatal polycythaemia risk (delayed clamping increases blood volume further); (4) Birth asphyxia \u2014 immediate resuscitation needed, cord should be clamped to allow CPR. Maternal anaemia (3) is a reason for DELAYED clamping (to maximise blood transfusion to baby). Statement 3 is incorrect. Statements 1, 2, and 4 are correct.'},\n {id:53,stem:'The definition of gestational hypertension includes which of the following?\\n1. Sustained rise of blood pressure to 140\/90 mm of Hg or more at least on two occasions 12 hours apart at any period of pregnancy\\n2. Sustained rise of blood pressure to 140\/90 mm of Hg beyond 40 hours of delivery\\n3. Sustained rise of blood pressure to 140\/90 mm of Hg on two occasions 4 or more hours apart\\n4. Pregnancy should be more than 20 weeks',correct:'3 and 4',options:['2 and 4','3 and 4','1','3 only'],exp:'Gestational hypertension (GHT) definition: New onset BP \u2265140\/90 mmHg on TWO occasions at least 4 hours apart (statement 3), after 20 weeks of gestation (statement 4), WITHOUT proteinuria, normalising within 12 weeks postpartum. Statement 1 is incorrect (threshold gap should be 4 hours, not 12 hours; and it should be after 20 weeks, not \"any period\"). Statement 2 describes postpartum hypertension. The correct components are 3 and 4. Answer: 3 and 4.'},\n {id:54,stem:'A 27-year-old female is complaining of grayish white discharge with fishy odour. There is no history of itching associated with discharge. Which one of the following is the most likely diagnosis?',correct:'Bacterial vaginosis',options:['Trichomoniasis','Candidiasis','Urinary tract infection','Bacterial vaginosis'],exp:\"Bacterial vaginosis (BV): grayish-white thin, homogeneous discharge with characteristic fishy (amine) odour (due to anaerobes producing amines \u2014 putrescine, cadaverine). Absence of itching or burning. pH >4.5. Clue cells on wet mount. Whiff test positive. Amsel criteria (3 of 4): homogeneous discharge, pH >4.5, clue cells, positive whiff test. Trichomonas: frothy yellow-green discharge, itching, pH >4.5. Candidiasis: thick white 'cottage cheese' discharge WITH itching. BV is the most common vaginal infection in reproductive-age women.\"},\n {id:55,stem:'Which of the following are contra-indications for insertion of Intrauterine Contraceptive Device (IUCD)?\\n1. Age > 35 years\\n2. Suspected pregnancy\\n3. Acute pelvic infection\\n4. Severe dysmenorrhea',correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"IUCD contraindications (WHO MEC Category 3-4): Confirmed or suspected pregnancy (2 \u2014 absolute, Category 4), Acute\/purulent cervicitis or PID (3 \u2014 Category 4), Unexplained vaginal bleeding, uterine cavity distortion, trophoblastic disease. Severe dysmenorrhoea (4) is a relative contraindication particularly for copper IUDs (can worsen dysmenorrhoea) \u2014 Category 2-3. Age >35 years (1) is NOT a contraindication for IUDs \u2014 IUCDs are excellent options for women over 35. Statement 1 is false. Statements 2, 3, and 4 are contraindications.\"},\n {id:56,stem:\"Regarding the phenomenon of 'lightening' in primigravida at term pregnancy, which one of the following statements is correct?\",correct:'It is a welcome sign since it indicates descent fetal head into pelvis.',options:['It is a welcome sign since it indicates descent fetal head into pelvis.','There are no bladder or bowel symptoms associated with this phenomenon.','It occurs later and just before labour in primigravida compared to multigravida.','It is associated with worsening of cardiorespiratory embarrassment in mother.'],exp:\"Lightening = engagement of the fetal head into the pelvis, occurring at ~36-38 weeks in primigravidae (2-4 weeks before labour). It is a WELCOME sign (1 correct) indicating the fetal head has engaged. However, it is associated with: increased urinary frequency (bladder compression), constipation, pelvic pressure, leg cramps \u2014 so bladder AND bowel symptoms DO occur (option 2 is false). It RELIEVES cardiorespiratory symptoms (diaphragmatic pressure reduces \u2014 option 4 is false). In primigravida it occurs EARLIER than in multigravida (option 3 is false \u2014 it's the opposite). Answer: option (a).\"},\n {id:57,stem:'The first-line treatment of Group \u03b2 Streptococcal (GBS) infection in pregnancy is',correct:'penicillin',options:['penicillin','azithromycin','doxycycline','vancomycin'],exp:'Group B Streptococcus (Streptococcus agalactiae) treatment in pregnancy: Intrapartum antibiotic prophylaxis or treatment \u2014 PENICILLIN G IV is the first-line drug of choice (or ampicillin IV as alternative). GBS is exquisitely sensitive to penicillin. For penicillin-allergic patients: clindamycin (if susceptible) or erythromycin; cefazolin for low-risk allergy. Vancomycin is reserved for high-risk penicillin allergy and resistant strains. Azithromycin and doxycycline are NOT used for GBS. Answer: penicillin.'},\n {id:58,stem:'Which of the following are included in the combined prenatal screening tests in first trimester?\\n1. \u03b2-hCG\\n2. MS AFP (\u03b1-Fetoprotein)\\n3. Nuchal translucency\\n4. PAPP-A',correct:'1, 3 and 4 only',options:['1, 2, 3 and 4','1, 2 and 3 only','1, 3 and 4 only','2 and 4 only'],exp:'First trimester combined screening (11-13+6 weeks): (1) Free \u03b2-hCG (serum), (3) Nuchal translucency (NT) \u2014 ultrasound measurement, (4) PAPP-A (Pregnancy-Associated Plasma Protein-A). Together, these three achieve ~85-90% detection rate for trisomy 21. MS AFP (maternal serum alpha-fetoprotein, statement 2) is a SECOND TRIMESTER marker (15-20 weeks) used in the quadruple\/triple screen. AFP is NOT part of first trimester combined screening. Statements 1, 3, and 4 are the first trimester combined screen components.'},\n {id:59,stem:\"In hyperemesis gravidarum, Wernicke's encephalopathy is seen due to the deficiency of\",correct:'vitamin B1',options:['vitamin B6','vitamin B1','vitamin B12','vitamin B4'],exp:\"Hyperemesis gravidarum (intractable vomiting of pregnancy) causes severe nutritional deficiency. Wernicke's encephalopathy \u2014 the classic triad of ophthalmoplegia, ataxia, and confusion \u2014 results specifically from Vitamin B1 (THIAMINE) deficiency. Prolonged vomiting depletes thiamine stores (body stores last only 3-4 weeks). Thiamine is essential for pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase \u2014 key enzymes in carbohydrate metabolism; neurons are particularly vulnerable. IV thiamine (100 mg) must be given BEFORE glucose infusion to prevent precipitating Wernicke's. Answer: Vitamin B1 (thiamine).\"},\n {id:60,stem:'Which of the following are correct regarding Placental Site Trophoblastic Tumour (PSTT)?\\n1. Low serum \u03b2-hCG\\n2. Composed mainly of cytotrophoblast\\n3. Highly responsive to chemo radiation\\n4. Local invasion into myometrium',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'PSTT arises from implantation site intermediate trophoblast. (1) Low serum \u03b2-hCG (relative to tumour mass) \u2014 correct; intermediate trophoblasts secrete lower \u03b2-hCG than syncytiotrophoblasts. (2) Composed mainly of intermediate trophoblast cells (sometimes described as cytotrophoblast-like) \u2014 accepted. (3) Statement FALSE: PSTT is POORLY RESPONSIVE to chemotherapy (unlike choriocarcinoma) \u2014 treatment is surgical hysterectomy. (4) Local myometrial invasion is characteristic \u2014 correct. Statements 1, 2, and 4 are correct.'},\n {id:61,stem:'Metroplasty is the surgical procedure done for which one of the following uterine anomalies?',correct:'Septate uterus',options:['Septate uterus','Arcuate uterus','Uterus didelphys','Imperforate hymen'],exp:\"Metroplasty (uterine reconstruction surgery) is performed for a SEPTATE UTERUS (complete or partial midline septum dividing the uterine cavity) to improve reproductive outcomes (recurrent miscarriage, preterm labour). The operation: hysteroscopic metroplasty (Tompkins or Jones technique) incises and removes the septum. Arcuate uterus is a minor variant, usually not treated. Uterus didelphys (complete duplication) \u2014 no standard metroplasty; Strassman procedure for bicornuate uterus if needed. Imperforate hymen is treated by surgical incision, not metroplasty. Answer: Septate uterus.\"},\n {id:62,stem:'Which of the following are the clinical features of hyperprolactinaemia?\\n1. Hypergonadotropic hypogonadism\\n2. Hypogonadotropic hypogonadism\\n3. Oligomenorrhea\\n4. Heavy menstruation',correct:'2 and 3',options:['1 and 3','1 and 4','2 and 3','2 and 4'],exp:'Hyperprolactinaemia: elevated prolactin inhibits GnRH pulsatility \u2192 decreased LH and FSH \u2192 (2) HYPOGONADOTROPIC hypogonadism (low gonadotropins, NOT high \u2014 Statement 1 is FALSE). Consequences: amenorrhoea (40%), oligomenorrhoea (3 correct), galactorrhoea (30%), infertility, loss of libido. Statement 4 (heavy menstruation) is FALSE \u2014 hyperprolactinaemia causes oligo\/amenorrhoea due to anovulation, NOT heavy menstrual bleeding. Correct features: hypogonadotropic hypogonadism (2) and oligomenorrhoea (3).'},\n {id:63,stem:'Which of the following are effective in the management of premenstrual syndrome?\\n1. Niacin (vitamin B3)\\n2. Combined oral contraceptive pills\\n3. Diuretics\\n4. Hysterectomy with oophorectomy',correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'PMS\/PMDD management: (2) COCPs (particularly drospirenone-containing) suppress ovarian hormone cycling \u2014 effective; (3) Diuretics (spironolactone, thiazides) for bloating and breast tenderness \u2014 effective; (4) Hysterectomy + bilateral oophorectomy \u2014 definitive surgical cure for severe refractory PMDD (eliminates ovarian cycle completely). Statement 1 (niacin\/vitamin B3) is NOT a recognised standard treatment for PMS \u2014 it lacks evidence in guidelines. Statements 2, 3, and 4 are effective.'},\n {id:64,stem:'Which one of the following blood tests is the marker of ovarian reserve?',correct:'Anti-Mullerian hormone',options:['\u03b2-hCG','Anti-Mullerian hormone','Placental alkaline phosphatase','Serum estradiol'],exp:'Anti-M\u00fcllerian hormone (AMH) is the single best serum marker of ovarian reserve. Produced exclusively by granulosa cells of small antral and pre-antral follicles, AMH levels directly reflect the size of the remaining primordial follicle pool. Key advantages: stable throughout the menstrual cycle (can be measured on any day), does not fluctuate with FSH pituitary feedback. Low AMH = poor ovarian reserve (poor IVF prognosis). Other markers: antral follicle count (AFC) on ultrasound is equally valuable. \u03b2-hCG = pregnancy marker; placental alkaline phosphatase = seminoma marker; Serum estradiol is used in early follicular monitoring but not as a reserve marker.'},\n {id:65,stem:'In the PALM-COEIN classification by FIGO for abnormal uterine bleeding, o\u2014ovulatory dysfunction is the cause in which one of the following conditions?',correct:'Polycystic ovarian syndrome',options:['Adenomyosis','Pelvic inflammatory disease','Polycystic ovarian syndrome','Ovarian cancer'],exp:\"PALM-COEIN: P=Polyp, A=Adenomyosis, L=Leiomyoma, M=Malignancy\/hyperplasia (structural \u2014 PALM), C=Coagulopathy, O=Ovulatory dysfunction, E=Endometrial, I=Iatrogenic, N=Not yet classified (non-structural \u2014 COEIN). 'O' = Ovulatory dysfunction encompasses conditions where irregular ovulation causes abnormal bleeding without an identified structural cause. PCOS is the classic cause of ovulatory dysfunction (anovulatory cycles \u2192 irregular, often heavy, unpredictable bleeding). Adenomyosis = 'A'; PID and ovarian cancer are not PALM-COEIN categories. Answer: Polycystic ovarian syndrome.\"},\n {id:66,stem:'Which of the following are correct regarding genital warts (condyloma acuminata)?\\n1. It is usually single.\\n2. It is related to HPV Types 6 and 11.\\n3. It can be transmitted sexually.\\n4. It can involve vagina and anus.',correct:'2, 3 and 4 only',options:['1, 2, 3 and 4','2, 3 and 4 only','1, 2 and 3 only','1 and 4 only'],exp:'Condyloma acuminata (anogenital warts): (1) Statement FALSE \u2014 typically MULTIPLE, soft, fleshy, exophytic lesions; rarely single. (2) Caused by HPV types 6 and 11 (low-risk, non-oncogenic types) \u2014 correct. (3) Sexually transmitted (most common STI) \u2014 correct. (4) Can involve vulva, vagina, cervix, anus, perianal skin, urethra \u2014 correct. Treatment: podophyllin, trichloroacetic acid, cryotherapy, surgical excision, imiquimod. Prevention: HPV vaccine (types 6 and 11 covered in quadrivalent vaccine). Statements 2, 3, and 4 are correct.'},\n {id:67,stem:'Which of the following are correct regarding endometrial cancer?\\n1. Persistent progesterone stimulation is an important etiology.\\n2. It is more common in white population.\\n3. HNPCC (Hereditary Nonpolyposis Colorectal Cancer) syndrome is a high risk factor.\\n4. Adenocarcinoma is the commonest histopathology.',correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Statement 1 is FALSE: the primary etiology is prolonged UNOPPOSED OESTROGEN stimulation (not progesterone) \u2014 obesity, anovulation, HRT without progestogen, oestrogen-secreting tumours. Progesterone is PROTECTIVE. Statements 2 (more common in white women in Western countries), 3 (HNPCC\/Lynch syndrome \u2014 MLH1, MSH2 mutations \u2014 gives ~40-60% lifetime risk, second most common Lynch-associated cancer), and 4 (endometrioid adenocarcinoma ~80% of all endometrial cancers) are all correct. Statements 2, 3, and 4 are correct.'},\n {id:68,stem:\"The reference point 'zero' in POPQ (Pelvic Organ Prolapse Quantification) classification is taken as\",correct:'hymen',options:['ischial spine','perineal body','mid-vagina','hymen'],exp:\"The POPQ (Pelvic Organ Prolapse Quantification) system uses the HYMEN as the fixed reference point (zero landmark). Measurements above (inside) the hymen = negative values. Measurements below (outside) the hymen = positive values. Six specific anatomical points (Aa, Ba, C, D, Ap, Bp) are measured in centimetres relative to the hymen. This allows standardised, reproducible, objective staging. Stage 0: no prolapse. Stage IV: complete procidentia (maximum prolapse). Answer: hymen.\"},\n {id:69,stem:'Which of the following are the various treatment options for Twin-Twin Transfusion Syndrome (TTTS)?\\n1. Septostomy\\n2. Laser photocoagulation\\n3. Selective fetal reduction',correct:'1, 2 and 3',options:['1 and 2 only','2 and 3 only','1 and 3 only','1, 2 and 3'],exp:'Twin-Twin Transfusion Syndrome (TTTS) \u2014 imbalanced blood flow through placental anastomoses in monochorionic twins. Treatment options: (1) Septostomy (needling the dividing membrane \u2014 controversial, equalises amniotic fluid pressures), (2) Selective laser photocoagulation of communicating placental vessels \u2014 current standard of care for Quintero stage II-IV, best outcomes (Senat 2004), (3) Selective fetal reduction (termination of one twin \u2014 last resort for severe, early, or refractory cases). Serial amnioreduction is another option. All three are recognised treatment options. Answer: 1, 2 and 3.'},\n {id:70,stem:'Which of the following drugs should be avoided in labouring women with bronchial asthma?\\n1. Opioid analgesics\\n2. Prostaglandin F2\u03b1\\n3. Prostaglandin E1\\n4. Ergometrine',correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Drugs to AVOID in labouring asthmatic women: (2) Prostaglandin F2\u03b1 (carboprost\/15-methyl PGF2\u03b1) \u2014 potent BRONCHOCONSTRICTOR; absolutely contraindicated in asthma; (3) Prostaglandin E1 (misoprostol) \u2014 can cause bronchospasm in susceptible asthmatic patients; (4) Ergometrine\/Ergometrine-oxytocin \u2014 causes bronchospasm via serotonin receptor stimulation; should be avoided. Safe agents: Oxytocin is the agent of choice for PPH prophylaxis. PGE2 (dinoprostone) is a bronchodilator and safe. Opioids (1) may cause histamine release (morphine) but meperidine\/pethidine is frequently used; they are not absolutely contraindicated. Statements 2, 3, and 4 are the agents to avoid.'},\n {id:71,stem:'Which of the following are the complications of malaria in pregnancy?\\n1. Thrombocytopenia\\n2. Metabolic alkalosis\\n3. Hypoglycemia\\n4. Disseminated intravascular coagulation',correct:'1, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Malaria in pregnancy (especially P. falciparum) complications: (1) Thrombocytopenia \u2014 platelet sequestration, immune-mediated destruction; (3) Hypoglycaemia \u2014 increased glucose consumption by parasites + quinine-stimulated insulin release; (4) DIC \u2014 severe falciparum malaria releases tissue factor, activates coagulation cascade. Statement 2 (metabolic alkalosis) is FALSE \u2014 malaria causes METABOLIC ACIDOSIS (lactic acidosis from tissue hypoxia and anaerobic metabolism) and hypoglycaemia-induced acidosis. Additional complications: placental parasitaemia, preterm labour, IUGR, maternal death. Statements 1, 3, and 4 are correct.'},\n {id:72,stem:'Which of the following are correct regarding drospirenone?\\n1. It is a fourth generation progestin.\\n2. It has antiandrogenic property.\\n3. It has antimineralocorticoid action.\\n4. It is safe in renal failure patients.',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Drospirenone: a synthetic progestin derived from 17\u03b1-spirolactone. (1) 4th generation progestin \u2014 correct. (2) Has significant anti-androgenic activity (blocks androgen receptors) \u2014 useful for PCOS, acne, hirsutism \u2014 correct. (3) Antimineralocorticoid activity (similar to spironolactone) \u2014 counteracts aldosterone, preventing fluid retention \u2014 correct. (4) Statement FALSE: due to its antimineralocorticoid\/anti-aldosterone effect, drospirenone promotes potassium retention. In RENAL FAILURE, it can cause dangerous HYPERKALAEMIA \u2014 it is CONTRAINDICATED in renal insufficiency. Statements 1, 2, and 3 are correct.'},\n {id:73,stem:'Which of the following symptoms are related to ectopic pregnancy?\\n1. Acute abdominal pain following amenorrhea\\n2. Abdominal pain with bleeding P\/V\\n3. Fainting attack with shoulder pain\\n4. Painless continuous bleeding',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"Ectopic pregnancy symptoms: (1) Acute abdominal pain following a period of amenorrhoea (6-8 weeks) \u2014 classic presentation of tubal ectopic; (2) Abdominal pain with vaginal bleeding \u2014 the classic 'triad' with amenorrhoea; (3) Fainting attack (syncope from internal haemorrhage) + shoulder tip pain (diaphragmatic irritation from haemoperitoneum \u2192 phrenic nerve irritation) \u2014 indicate rupture. Statement 4 (painless continuous bleeding) is characteristic of PLACENTA PRAEVIA, NOT ectopic pregnancy \u2014 ectopic bleeding is irregular and usually accompanied by pain. Statements 1, 2, and 3 are correct.\"},\n {id:74,stem:'Premenstrual Syndrome (PMS) should fulfil which of the following criteria?\\n1. It is not related to any organic lesion.\\n2. It regularly occurs during the luteal phase and each ovulatory menstruation cycle.\\n3. Symptoms must be severe enough to disturb the lifestyle of women and seeks medical help.\\n4. Symptoms persist after the period also.',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'PMS diagnostic criteria: (1) No underlying organic pathology (functional, not structural) \u2014 correct; (2) Cyclical occurrence restricted to the luteal phase (after ovulation), resolving with menstruation \u2014 correct; (3) Symptoms severe enough to cause functional impairment and require medical attention \u2014 correct. Statement 4 is FALSE: PMS symptoms RESOLVE with menstruation onset (within 4 days). If symptoms PERSIST after the period, the diagnosis shifts to PMDD or another psychiatric\/medical condition. The cessation of symptoms with menstruation is a defining diagnostic criterion.'},\n {id:75,stem:'Which of the following statements are correct regarding constriction ring?\\n1. Premature rupture of membranes is a high risk factor.\\n2. It is situated at the junction of upper and lower uterine segment.\\n3. Uterus never ruptures.\\n4. The ring is felt per abdomen.',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Constriction ring (pathological retraction ring): (1) PROM is a risk factor (dry labour, forceful contractions on empty uterus) \u2014 correct; (2) Located at the junction of upper and lower uterine segments (not necessarily at the equator of the fetus) \u2014 correct; (3) Statement FALSE: uterine rupture CAN and DOES occur if the constriction ring is not relieved \u2014 it is a risk, not an impossibility; (4) The ring is palpable per abdomen as a transverse band \u2014 correct. Note: Bandl\\'s ring (physiological retraction ring) is the exaggerated pathological form visible\/palpable per abdomen. Statements 1, 2, and 4 are correct.'},\n {id:76,stem:'A patient delivered a live healthy baby 4 hours back. Now she has developed persistent severe pain in the perineal region and rectal tenesmus. Local examination reveals a tense and tender purple swelling at the vulva. What is her probable diagnosis?',correct:'Pelvic hematoma',options:['Cervical tear','Perineal tear','Pelvic hematoma','Ruptured uterus'],exp:'Tense, tender, purple\/bluish swelling at the vulva in the immediate postpartum period with pain and rectal tenesmus (from pressure) = VULVAR\/PARAVAGINAL HAEMATOMA (pelvic haematoma). This occurs from injury to blood vessels (pudendal vessels) during delivery without external laceration. The blood accumulates in the loose areolar tissue of the vulva\/ischiorectal fossa. Small haematomas can be managed conservatively; large haematomas require surgical evacuation and haemostasis. Ruptured uterus would present with haemodynamic compromise; perineal tear is visible.'},\n {id:77,stem:'Which of the following are included in the management of cord prolapse during delivery?\\n1. Bladder emptying\\n2. Knee-chest position of the patient\\n3. Preferably caesarean delivery\\n4. Lifting up the presenting part of the cord',correct:'2, 3 and 4',options:['2 and 3 only','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"Cord prolapse management: (2) Knee-chest (or Trendelenburg) position \u2014 gravity relieves cord compression; (3) Emergency CS if not fully dilated (most cases) \u2014 correct; (4) Digital elevation of the PRESENTING PART (fetal head\/buttocks) to relieve cord compression \u2014 correct (note: statement says 'presenting part of the cord' but clinical practice is to elevate the fetal presenting part off the cord). Statement 1 (bladder EMPTYING) is INCORRECT \u2014 management uses RETROGRADE BLADDER FILLING (500 mL saline retrograde via catheter) to elevate the fetal presenting part. Bladder emptying would do the opposite. Statements 2, 3, and 4 are correct.\"},\n {id:78,stem:'Which of the following statements have obstetric significance at the level of plane of least pelvic dimensions?\\n1. It is a landmark used for pudendal nerve block analgesia.\\n2. Deep transverse arrest usually occurs at this plane.\\n3. It is at this plane that the internal rotation of the fetal head occurs during labour.\\n4. It marks the beginning of the backward curve of the pelvic axis.',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Plane of least pelvic dimensions (midpelvis at level of ischial spines): (1) Ischial spines are the landmark for PUDENDAL nerve block analgesia (injection lateral to ischial spines) \u2014 correct; (2) Deep transverse arrest occurs at the midpelvis when the occiput fails to rotate \u2014 correct; (4) The backward curve of the pelvic axis begins here (pelvic axis curves posteriorly) \u2014 correct. Statement 3 is FALSE: internal rotation of the fetal head occurs as the head descends to the PELVIC FLOOR (at the outlet level, not at the midpelvis plane of least dimensions). Statements 1, 2, and 4 are correct.'},\n {id:79,stem:'Which surgery is most likely to disturb the paracervical nerve plexus resulting in atonicity of the bladder?',correct:'Radical hysterectomy',options:['Vaginal hysterectomy','Radical hysterectomy','Simple hysterectomy','Myomectomy'],exp:\"Radical hysterectomy (Wertheim's operation) for cervical cancer involves excision of the parametrium, upper vagina, and paracervical tissues \u2014 which contain the inferior hypogastric plexus (pelvic plexus \/ paracervical nerve plexus). Damage to these autonomic fibres (which supply the bladder detrusor and internal sphincter) causes voiding dysfunction: bladder atonicity, urinary retention, overflow incontinence. This is the most significant urological complication of radical hysterectomy (~20-40% of patients). Simple hysterectomy and vaginal hysterectomy rarely disturb these deep nerve plexuses.\"},\n {id:80,stem:'The patency of fallopian tubes can be clinically tested by which of the following methods?\\n1. Sonosalpingogram\\n2. Hysterosalpingogram\\n3. CT scan\\n4. Laparoscopic chromotubation',correct:'1, 2 and 4',options:['1, 2 and 4','1, 3 and 4','1, 2 and 3','2, 3 and 4'],exp:'Fallopian tube patency tests: (1) Sonosalpingography (HyCoSy \u2014 Hysterocontrast Sonography) \u2014 instils contrast or air under ultrasound guidance \u2014 effective outpatient test; (2) Hysterosalpingogram (HSG) \u2014 fluoroscopic X-ray with contrast through the cervix \u2014 gold standard for outpatient tubal assessment; (4) Laparoscopic chromotubation (direct visualisation + methylene blue dye instillation through cervix) \u2014 gold standard overall but invasive. CT scan (3) is NOT a standard test for tubal patency \u2014 it exposes the patient to radiation and cannot reliably assess dynamic patency. Statements 1, 2, and 4 are correct.'}\n];\n\nconst LETTERS=['A','B','C','D'];\nlet userAnswers={},answered=0,shuffledOpts={};\nlet timerRunning=false,timerRemaining=TIMER_SECS,timerInterval=null,graceInterval=null,quizSubmitted=false;\nfunction shuffle(a){const b=a.slice();for(let i=b.length-1;i>0;i--){const j=Math.floor(Math.random()*(i+1));[b[i],b[j]]=[b[j],b[i]];}return b;}\nfunction fmtTime(s){const m=Math.floor(s\/60),sec=s%60;return(m<10?'0':'')+m+':'+(sec<10?'0':'')+sec;}\nfunction g(id){return document.getElementById(NS+'-'+id);}\nfunction startTimer(){\n if(timerRunning||quizSubmitted)return;timerRunning=true;\n g('timer-btn').textContent='\u23f1 '+fmtTime(timerRemaining);g('timer-btn').classList.add('running');\n g('timer-item').classList.add('active');\n timerInterval=setInterval(()=>{\n timerRemaining--;const d=fmtTime(timerRemaining);\n g('timer-display').textContent=d;g('timer-btn').textContent='\u23f1 '+d;\n 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.cq-band-c{background:var(--correct-bg);color:var(--correct)}\n#cms22p2b .cq-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#cms22p2b .cq-band-s{background:var(--teal-pale);color:var(--teal)}\n#cms22p2b .cq-retry-btn{margin-top:22px;background:transparent;border:2px solid var(--ter);color:var(--ter);border-radius:8px;padding:10px 28px;font-family:'Playfair Display',serif;font-size:0.95rem;font-weight:700;cursor:pointer;transition:background 0.2s,color 0.2s}\n#cms22p2b .cq-retry-btn:hover{background:var(--ter);color:var(--white)}\n@media(max-width:480px){#cms22p2b .cq-header h1{font-size:1.15rem}#cms22p2b .cq-qtext{font-size:0.88rem}#cms22p2b .cq-opt-text{font-size:0.84rem}}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms22p2b\">\n <div class=\"cq-sentinel\" id=\"cms22p2b-sentinel\"><\/div>\n <div class=\"cq-statusbar\" id=\"cms22p2b-statusbar\">\n <div class=\"cq-sb-stats\">\n <div class=\"cq-timer-item\" id=\"cms22p2b-timer-item\">\u23f1 <strong id=\"cms22p2b-timer-display\">40:00<\/strong><\/div>\n <div class=\"cq-sb-item\">\u2705 <strong id=\"cms22p2b-sc\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u274c <strong id=\"cms22p2b-sw\">0<\/strong><\/div>\n <div class=\"cq-sb-item\">\u23f3 <strong id=\"cms22p2b-sr\">40<\/strong> left<\/div>\n <div class=\"cq-sb-sep\"><\/div>\n <div class=\"cq-sb-item\">Net <strong id=\"cms22p2b-sn\">0<\/strong> \/ <strong id=\"cms22p2b-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"cq-sb-progress\"><div class=\"cq-sb-fill\" id=\"cms22p2b-fill\"><\/div><\/div>\n <\/div>\n <div class=\"cq-grace\" id=\"cms22p2b-grace\">\n <div class=\"cq-grace-box\"><h3>Time's Up!<\/h3><p>Submitting in<\/p><div class=\"cq-grace-count\" id=\"cms22p2b-grace-count\">10<\/div><button class=\"cq-grace-btn\" id=\"cms22p2b-grace-now\">Submit Now<\/button><\/div>\n <\/div>\n <div class=\"cq-header\">\n <h1>Combined Medical Services Examination 2022<br>Surgery, Gynaecology & Obstetrics, Preventive & Social Medicine \u00b7 Paper II \u00b7 Part B<\/h1>\n <p>Gynaecology & Obstetrics<\/p>\n <div class=\"cq-meta\">\n <span class=\"cq-badge\">Questions 41 \u2013 80<\/span>\n <span class=\"cq-badge\">Options reshuffled<\/span>\n <button class=\"cq-timer-btn\" id=\"cms22p2b-timer-btn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n <\/div>\n <div class=\"cq-body\">\n <div id=\"cms22p2b-questions\"><\/div>\n <div class=\"cq-submit-wrap\"><button class=\"cq-btn\" id=\"cms22p2b-submit\">Submit Answers<\/button><\/div>\n <div class=\"cq-score\" id=\"cms22p2b-score\">\n <div class=\"cq-score-ring\" id=\"cms22p2b-ring\"><div class=\"cq-ring-inner\"><span class=\"cq-ring-pct\" id=\"cms22p2b-ring-pct\">0%<\/span><span class=\"cq-ring-sub\">score<\/span><\/div><\/div>\n <h2>Your Result<\/h2>\n <div class=\"cq-net-line\" id=\"cms22p2b-net-line\"><\/div>\n <div class=\"cq-verdict\" id=\"cms22p2b-verdict\"><\/div>\n <div class=\"cq-score-bands\"><span class=\"cq-band cq-band-c\" id=\"cms22p2b-ct-c\"><\/span><span class=\"cq-band cq-band-w\" id=\"cms22p2b-ct-w\"><\/span><span class=\"cq-band cq-band-s\" id=\"cms22p2b-ct-s\"><\/span><\/div>\n <button class=\"cq-retry-btn\" id=\"cms22p2b-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n <\/div>\n<\/div>\n<script>\n(function(){\n'use strict';\nconst NS='cms22p2b',TOTAL=40,MAX=160,TIMER_SECS=2400,GRACE_SECS=10;\nconst QUESTIONS=[\n {id:41,stem:'During the first stage of labour, the intrauterine pressure is increased up to',correct:'40\u201350 mm of Hg',options:['2\u20133 mm of Hg','8\u201310 mm of Hg','40\u201350 mm of Hg','100\u2013120 mm of Hg'],exp:'During the first stage of labour, uterine contractions generate intrauterine pressure of 40\u201350 mmHg (amplitude above resting tonus of ~10 mmHg). Resting tonus = 8\u201312 mmHg. Peak contraction pressure = 40\u201360 mmHg in active labour. In the second stage pushing, pressures can reach 100\u2013120 mmHg. The range of 40\u201350 mmHg is the standard for the first stage active phase.'},\n {id:42,stem:'Which of the following are screening tests for cervical cancer?\\n1. Pap test\\n2. HPV DNA test\\n3. Visual inspections with acetic acid\\n4. Endocervical curettage',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Cervical cancer screening tests: (1) Pap smear\/cytology \u2014 conventional screening; (2) HPV DNA test \u2014 primary cervical screening (WHO-recommended from 2021); (3) VIA (Visual Inspection with Acetic acid) \u2014 low-resource setting screening, identifies acetowhite lesions. Statement 4 (Endocervical curettage, ECC) is a DIAGNOSTIC procedure done at colposcopy to sample the endocervix \u2014 it is NOT a primary screening test. Statements 1, 2, and 3 are screening tests.'},\n {id:43,stem:'Heavy menstrual bleeding is a common presentation in which of the following?\\n1. Clotting factor deficiency\\n2. Fibroid uterus\\n3. Adenomyosis\\n4. Prolactinoma',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Heavy menstrual bleeding (HMB) causes: Clotting factor deficiency (1 \u2014 von Willebrand disease most common; platelet disorders), Uterine fibroids (2 \u2014 submucous\/intramural fibroids cause HMB via increased surface area and impaired haemostasis), Adenomyosis (3 \u2014 ectopic endometrial glands\/stroma in myometrium causing dysmenorrhoea and HMB). Prolactinoma (4) causes hyperprolactinaemia which suppresses GnRH \u2192 hypogonadism \u2192 AMENORRHOEA or oligomenorrhoea \u2014 NOT heavy menstrual bleeding. Statements 1, 2, and 3 are correct.'},\n {id:44,stem:'Serum level of CA 125 is raised in which of the following conditions?\\n1. Epithelial ovarian cancer\\n2. Endometriosis\\n3. Pelvic inflammatory disease',correct:'1, 2 and 3',options:['1 and 2 only','2 and 3 only','1 and 3 only','1, 2 and 3'],exp:'CA-125 is a glycoprotein shed by cells derived from coelomic epithelium. Elevated in: (1) Epithelial ovarian cancer (~80% of serous type \u2014 primary tumour marker used for monitoring), (2) Endometriosis (active disease causes peritoneal shedding \u2014 CA-125 moderately elevated, useful for monitoring treatment response), (3) PID (acute peritoneal inflammation elevates CA-125). Other benign causes: menstruation, pregnancy, liver disease, uterine fibroids. All three statements are correct.'},\n {id:45,stem:'Uterus is supported by which of the following ligaments?\\n1. Pubocervical ligament\\n2. Cardinal ligament\\n3. Uterosacral ligament\\n4. Ovarian ligament',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"The uterus and upper vagina are supported by three main condensations of parametrial connective tissue (ligaments): (1) Pubocervical\/vesicouterine ligaments (anterior \u2014 connect cervix to pubic symphysis); (2) Cardinal\/Mackenrodt's ligaments (lateral \u2014 transverse cervical ligaments, strongest support); (3) Uterosacral ligaments (posterior \u2014 connect cervix\/upper vagina to sacrum; maintain uterine anteversion). The Ovarian ligament (4) is a short fibromuscular band connecting the ovary to the uterine cornu \u2014 it supports the ovary, NOT the uterus. Statements 1, 2, and 3 are uterine supports.\"},\n {id:46,stem:'Amongst the following, the Pearl Index is highest with',correct:'calendar rhythm method',options:['combined oral contraceptives','intrauterine contraceptive devices','barrier contraceptives','calendar rhythm method'],exp:'Pearl Index = (number of pregnancies \u00d7 1200) \/ total months of use \u2014 measures contraceptive failure rate. Higher Pearl Index = LESS effective contraceptive. Efficacy ranking (most to least effective): IUD (~0.1-0.8) < COC (0.3-0.5 perfect use, 7-9 typical) < Barrier methods (~2 perfect, 15-18 typical) < Calendar rhythm method (~9-25, highly variable). Calendar rhythm method has the HIGHEST Pearl Index (highest failure rate) among the listed options. Answer: calendar rhythm method.'},\n {id:47,stem:'Following vaginal delivery, uterus becomes non-pregnant size by',correct:'6 weeks postpartum',options:['9 weeks postpartum','8 weeks postpartum','4 weeks postpartum','6 weeks postpartum'],exp:'Uterine involution after delivery: At birth ~1000g. By day 7: below the umbilicus. By day 14: within the pelvis. By 6 weeks postpartum: returns to near non-pregnant size (~60-80g), cervix re-forms. Complete histological involution takes up to 8-12 weeks. The standard teaching for RETURN TO NON-PREGNANT SIZE is 6 weeks postpartum \u2014 the standard timeline for the postpartum check-up.'},\n {id:48,stem:'Indications and prerequisites for delivery with the ventouse include which of the following?\\n1. Delay in the second stage of labour\\n2. Non-reassuring fetal heart rate\\n3. Gestation age less than 34 weeks of pregnancy\\n4. Vertex presentation',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Ventouse (vacuum extractor) delivery \u2014 indications\/prerequisites: (1) Prolonged\/delayed second stage \u2014 correct indication; (2) Non-reassuring CTG \/ fetal distress in second stage \u2014 correct; (4) Vertex presentation \u2014 absolute prerequisite (face or breech presentations are contraindications). Statement 3 is FALSE: gestation <34 weeks is a CONTRAINDICATION to ventouse \u2014 the fetal scalp is fragile and at risk of subgaleal haemorrhage and cephalhaematoma. Ventouse is typically avoided below 34 (some say 36) weeks. Statements 1, 2, and 4 are correct.'},\n {id:49,stem:'Which of the following fetal infections are associated with significant intrauterine growth restriction?\\n1. Cytomegalovirus infection\\n2. Rubella infection\\n3. Toxoplasmosis\\n4. Human papillomavirus infection',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'TORCH infections classically causing IUGR: Toxoplasmosis (3 \u2014 placental and fetal vascular damage), Rubella (2 \u2014 destroys blood vessel endothelium, limits cell division), Cytomegalovirus (1 \u2014 most common congenital viral infection, causes IUGR via placental insufficiency and cell lysis). HPV (4) primarily causes condylomata acuminata in the birth canal and laryngeal papillomatosis in the neonate \u2014 it is NOT associated with IUGR. Statements 1, 2, and 3 are correct.'},\n {id:50,stem:'Missed abortion is not diagnosed if',correct:'USG shows fetus with cardiac activity',options:['vaginal bleed is brownish in colour','uterus is smaller than gestational age','external os is closed','USG shows fetus with cardiac activity'],exp:'Missed (silent) abortion = embryo\/fetus dies in utero but is retained without expulsion. Features: brownish vaginal discharge (old blood \u2014 does NOT rule out missed abortion), uterus smaller than dates (regression of pregnancy), external os closed, absent fetal heartbeat on USG. If USG shows FETAL CARDIAC ACTIVITY (living embryo\/fetus), the pregnancy is viable \u2014 missed abortion CANNOT be diagnosed. Presence of cardiac activity on ultrasound definitively EXCLUDES missed abortion. Answer: USG showing fetal cardiac activity.'},\n {id:51,stem:'As per the PC & PNDT Act, permission will be given to perform the tests for detection of which of the following?\\n1. Chromosomal abnormalities\\n2. Haemoglobinopathies\\n3. Sex-linked genetic diseases',correct:'1, 2 and 3',options:['1 and 2 only','2 and 3 only','1 and 3 only','1, 2 and 3'],exp:'The PC & PNDT Act (Pre-Conception and Pre-Natal Diagnostic Techniques Act, India 1994) PROHIBITS sex determination for the purpose of sex-selective abortion. However, it PERMITS prenatal diagnostic techniques for detection of: (1) Chromosomal abnormalities (Down syndrome, trisomies), (2) Haemoglobinopathies (thalassaemia, sickle cell), (3) Sex-linked genetic diseases (haemophilia, Duchenne MD \u2014 where sex determination is medically necessary), as well as metabolic and congenital disorders. All three are permitted. Answer: 1, 2 and 3.'},\n {id:52,stem:'Which of the following are indications for early clamping of umbilical cord at delivery?\\n1. Rh incompatibility\\n2. Baby born to a diabetic mother\\n3. Maternal anemia\\n4. Birth asphyxia',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Early cord clamping (immediately at birth or within 30 seconds) is indicated when delayed clamping would be harmful: (1) Rh incompatibility \u2014 early clamping reduces transfer of Rh-positive blood from placenta to baby, limiting neonatal haemolysis; (2) Infant of diabetic mother \u2014 neonatal polycythaemia risk (delayed clamping increases blood volume further); (4) Birth asphyxia \u2014 immediate resuscitation needed, cord should be clamped to allow CPR. Maternal anaemia (3) is a reason for DELAYED clamping (to maximise blood transfusion to baby). Statement 3 is incorrect. Statements 1, 2, and 4 are correct.'},\n {id:53,stem:'The definition of gestational hypertension includes which of the following?\\n1. Sustained rise of blood pressure to 140\/90 mm of Hg or more at least on two occasions 12 hours apart at any period of pregnancy\\n2. Sustained rise of blood pressure to 140\/90 mm of Hg beyond 40 hours of delivery\\n3. Sustained rise of blood pressure to 140\/90 mm of Hg on two occasions 4 or more hours apart\\n4. Pregnancy should be more than 20 weeks',correct:'3 and 4',options:['2 and 4','3 and 4','1','3 only'],exp:'Gestational hypertension (GHT) definition: New onset BP \u2265140\/90 mmHg on TWO occasions at least 4 hours apart (statement 3), after 20 weeks of gestation (statement 4), WITHOUT proteinuria, normalising within 12 weeks postpartum. Statement 1 is incorrect (threshold gap should be 4 hours, not 12 hours; and it should be after 20 weeks, not \"any period\"). Statement 2 describes postpartum hypertension. The correct components are 3 and 4. Answer: 3 and 4.'},\n {id:54,stem:'A 27-year-old female is complaining of grayish white discharge with fishy odour. There is no history of itching associated with discharge. Which one of the following is the most likely diagnosis?',correct:'Bacterial vaginosis',options:['Trichomoniasis','Candidiasis','Urinary tract infection','Bacterial vaginosis'],exp:\"Bacterial vaginosis (BV): grayish-white thin, homogeneous discharge with characteristic fishy (amine) odour (due to anaerobes producing amines \u2014 putrescine, cadaverine). Absence of itching or burning. pH >4.5. Clue cells on wet mount. Whiff test positive. Amsel criteria (3 of 4): homogeneous discharge, pH >4.5, clue cells, positive whiff test. Trichomonas: frothy yellow-green discharge, itching, pH >4.5. Candidiasis: thick white 'cottage cheese' discharge WITH itching. BV is the most common vaginal infection in reproductive-age women.\"},\n {id:55,stem:'Which of the following are contra-indications for insertion of Intrauterine Contraceptive Device (IUCD)?\\n1. Age > 35 years\\n2. Suspected pregnancy\\n3. Acute pelvic infection\\n4. Severe dysmenorrhea',correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"IUCD contraindications (WHO MEC Category 3-4): Confirmed or suspected pregnancy (2 \u2014 absolute, Category 4), Acute\/purulent cervicitis or PID (3 \u2014 Category 4), Unexplained vaginal bleeding, uterine cavity distortion, trophoblastic disease. Severe dysmenorrhoea (4) is a relative contraindication particularly for copper IUDs (can worsen dysmenorrhoea) \u2014 Category 2-3. Age >35 years (1) is NOT a contraindication for IUDs \u2014 IUCDs are excellent options for women over 35. Statement 1 is false. Statements 2, 3, and 4 are contraindications.\"},\n {id:56,stem:\"Regarding the phenomenon of 'lightening' in primigravida at term pregnancy, which one of the following statements is correct?\",correct:'It is a welcome sign since it indicates descent fetal head into pelvis.',options:['It is a welcome sign since it indicates descent fetal head into pelvis.','There are no bladder or bowel symptoms associated with this phenomenon.','It occurs later and just before labour in primigravida compared to multigravida.','It is associated with worsening of cardiorespiratory embarrassment in mother.'],exp:\"Lightening = engagement of the fetal head into the pelvis, occurring at ~36-38 weeks in primigravidae (2-4 weeks before labour). It is a WELCOME sign (1 correct) indicating the fetal head has engaged. However, it is associated with: increased urinary frequency (bladder compression), constipation, pelvic pressure, leg cramps \u2014 so bladder AND bowel symptoms DO occur (option 2 is false). It RELIEVES cardiorespiratory symptoms (diaphragmatic pressure reduces \u2014 option 4 is false). In primigravida it occurs EARLIER than in multigravida (option 3 is false \u2014 it's the opposite). Answer: option (a).\"},\n {id:57,stem:'The first-line treatment of Group \u03b2 Streptococcal (GBS) infection in pregnancy is',correct:'penicillin',options:['penicillin','azithromycin','doxycycline','vancomycin'],exp:'Group B Streptococcus (Streptococcus agalactiae) treatment in pregnancy: Intrapartum antibiotic prophylaxis or treatment \u2014 PENICILLIN G IV is the first-line drug of choice (or ampicillin IV as alternative). GBS is exquisitely sensitive to penicillin. For penicillin-allergic patients: clindamycin (if susceptible) or erythromycin; cefazolin for low-risk allergy. Vancomycin is reserved for high-risk penicillin allergy and resistant strains. Azithromycin and doxycycline are NOT used for GBS. Answer: penicillin.'},\n {id:58,stem:'Which of the following are included in the combined prenatal screening tests in first trimester?\\n1. \u03b2-hCG\\n2. MS AFP (\u03b1-Fetoprotein)\\n3. Nuchal translucency\\n4. PAPP-A',correct:'1, 3 and 4 only',options:['1, 2, 3 and 4','1, 2 and 3 only','1, 3 and 4 only','2 and 4 only'],exp:'First trimester combined screening (11-13+6 weeks): (1) Free \u03b2-hCG (serum), (3) Nuchal translucency (NT) \u2014 ultrasound measurement, (4) PAPP-A (Pregnancy-Associated Plasma Protein-A). Together, these three achieve ~85-90% detection rate for trisomy 21. MS AFP (maternal serum alpha-fetoprotein, statement 2) is a SECOND TRIMESTER marker (15-20 weeks) used in the quadruple\/triple screen. AFP is NOT part of first trimester combined screening. Statements 1, 3, and 4 are the first trimester combined screen components.'},\n {id:59,stem:\"In hyperemesis gravidarum, Wernicke's encephalopathy is seen due to the deficiency of\",correct:'vitamin B1',options:['vitamin B6','vitamin B1','vitamin B12','vitamin B4'],exp:\"Hyperemesis gravidarum (intractable vomiting of pregnancy) causes severe nutritional deficiency. Wernicke's encephalopathy \u2014 the classic triad of ophthalmoplegia, ataxia, and confusion \u2014 results specifically from Vitamin B1 (THIAMINE) deficiency. Prolonged vomiting depletes thiamine stores (body stores last only 3-4 weeks). Thiamine is essential for pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase \u2014 key enzymes in carbohydrate metabolism; neurons are particularly vulnerable. IV thiamine (100 mg) must be given BEFORE glucose infusion to prevent precipitating Wernicke's. Answer: Vitamin B1 (thiamine).\"},\n {id:60,stem:'Which of the following are correct regarding Placental Site Trophoblastic Tumour (PSTT)?\\n1. Low serum \u03b2-hCG\\n2. Composed mainly of cytotrophoblast\\n3. Highly responsive to chemo radiation\\n4. Local invasion into myometrium',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'PSTT arises from implantation site intermediate trophoblast. (1) Low serum \u03b2-hCG (relative to tumour mass) \u2014 correct; intermediate trophoblasts secrete lower \u03b2-hCG than syncytiotrophoblasts. (2) Composed mainly of intermediate trophoblast cells (sometimes described as cytotrophoblast-like) \u2014 accepted. (3) Statement FALSE: PSTT is POORLY RESPONSIVE to chemotherapy (unlike choriocarcinoma) \u2014 treatment is surgical hysterectomy. (4) Local myometrial invasion is characteristic \u2014 correct. Statements 1, 2, and 4 are correct.'},\n {id:61,stem:'Metroplasty is the surgical procedure done for which one of the following uterine anomalies?',correct:'Septate uterus',options:['Septate uterus','Arcuate uterus','Uterus didelphys','Imperforate hymen'],exp:\"Metroplasty (uterine reconstruction surgery) is performed for a SEPTATE UTERUS (complete or partial midline septum dividing the uterine cavity) to improve reproductive outcomes (recurrent miscarriage, preterm labour). The operation: hysteroscopic metroplasty (Tompkins or Jones technique) incises and removes the septum. Arcuate uterus is a minor variant, usually not treated. Uterus didelphys (complete duplication) \u2014 no standard metroplasty; Strassman procedure for bicornuate uterus if needed. Imperforate hymen is treated by surgical incision, not metroplasty. Answer: Septate uterus.\"},\n {id:62,stem:'Which of the following are the clinical features of hyperprolactinaemia?\\n1. Hypergonadotropic hypogonadism\\n2. Hypogonadotropic hypogonadism\\n3. Oligomenorrhea\\n4. Heavy menstruation',correct:'2 and 3',options:['1 and 3','1 and 4','2 and 3','2 and 4'],exp:'Hyperprolactinaemia: elevated prolactin inhibits GnRH pulsatility \u2192 decreased LH and FSH \u2192 (2) HYPOGONADOTROPIC hypogonadism (low gonadotropins, NOT high \u2014 Statement 1 is FALSE). Consequences: amenorrhoea (40%), oligomenorrhoea (3 correct), galactorrhoea (30%), infertility, loss of libido. Statement 4 (heavy menstruation) is FALSE \u2014 hyperprolactinaemia causes oligo\/amenorrhoea due to anovulation, NOT heavy menstrual bleeding. Correct features: hypogonadotropic hypogonadism (2) and oligomenorrhoea (3).'},\n {id:63,stem:'Which of the following are effective in the management of premenstrual syndrome?\\n1. Niacin (vitamin B3)\\n2. Combined oral contraceptive pills\\n3. Diuretics\\n4. Hysterectomy with oophorectomy',correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'PMS\/PMDD management: (2) COCPs (particularly drospirenone-containing) suppress ovarian hormone cycling \u2014 effective; (3) Diuretics (spironolactone, thiazides) for bloating and breast tenderness \u2014 effective; (4) Hysterectomy + bilateral oophorectomy \u2014 definitive surgical cure for severe refractory PMDD (eliminates ovarian cycle completely). Statement 1 (niacin\/vitamin B3) is NOT a recognised standard treatment for PMS \u2014 it lacks evidence in guidelines. Statements 2, 3, and 4 are effective.'},\n {id:64,stem:'Which one of the following blood tests is the marker of ovarian reserve?',correct:'Anti-Mullerian hormone',options:['\u03b2-hCG','Anti-Mullerian hormone','Placental alkaline phosphatase','Serum estradiol'],exp:'Anti-M\u00fcllerian hormone (AMH) is the single best serum marker of ovarian reserve. Produced exclusively by granulosa cells of small antral and pre-antral follicles, AMH levels directly reflect the size of the remaining primordial follicle pool. Key advantages: stable throughout the menstrual cycle (can be measured on any day), does not fluctuate with FSH pituitary feedback. Low AMH = poor ovarian reserve (poor IVF prognosis). Other markers: antral follicle count (AFC) on ultrasound is equally valuable. \u03b2-hCG = pregnancy marker; placental alkaline phosphatase = seminoma marker; Serum estradiol is used in early follicular monitoring but not as a reserve marker.'},\n {id:65,stem:'In the PALM-COEIN classification by FIGO for abnormal uterine bleeding, o\u2014ovulatory dysfunction is the cause in which one of the following conditions?',correct:'Polycystic ovarian syndrome',options:['Adenomyosis','Pelvic inflammatory disease','Polycystic ovarian syndrome','Ovarian cancer'],exp:\"PALM-COEIN: P=Polyp, A=Adenomyosis, L=Leiomyoma, M=Malignancy\/hyperplasia (structural \u2014 PALM), C=Coagulopathy, O=Ovulatory dysfunction, E=Endometrial, I=Iatrogenic, N=Not yet classified (non-structural \u2014 COEIN). 'O' = Ovulatory dysfunction encompasses conditions where irregular ovulation causes abnormal bleeding without an identified structural cause. PCOS is the classic cause of ovulatory dysfunction (anovulatory cycles \u2192 irregular, often heavy, unpredictable bleeding). Adenomyosis = 'A'; PID and ovarian cancer are not PALM-COEIN categories. Answer: Polycystic ovarian syndrome.\"},\n {id:66,stem:'Which of the following are correct regarding genital warts (condyloma acuminata)?\\n1. It is usually single.\\n2. It is related to HPV Types 6 and 11.\\n3. It can be transmitted sexually.\\n4. It can involve vagina and anus.',correct:'2, 3 and 4 only',options:['1, 2, 3 and 4','2, 3 and 4 only','1, 2 and 3 only','1 and 4 only'],exp:'Condyloma acuminata (anogenital warts): (1) Statement FALSE \u2014 typically MULTIPLE, soft, fleshy, exophytic lesions; rarely single. (2) Caused by HPV types 6 and 11 (low-risk, non-oncogenic types) \u2014 correct. (3) Sexually transmitted (most common STI) \u2014 correct. (4) Can involve vulva, vagina, cervix, anus, perianal skin, urethra \u2014 correct. Treatment: podophyllin, trichloroacetic acid, cryotherapy, surgical excision, imiquimod. Prevention: HPV vaccine (types 6 and 11 covered in quadrivalent vaccine). Statements 2, 3, and 4 are correct.'},\n {id:67,stem:'Which of the following are correct regarding endometrial cancer?\\n1. Persistent progesterone stimulation is an important etiology.\\n2. It is more common in white population.\\n3. HNPCC (Hereditary Nonpolyposis Colorectal Cancer) syndrome is a high risk factor.\\n4. Adenocarcinoma is the commonest histopathology.',correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Statement 1 is FALSE: the primary etiology is prolonged UNOPPOSED OESTROGEN stimulation (not progesterone) \u2014 obesity, anovulation, HRT without progestogen, oestrogen-secreting tumours. Progesterone is PROTECTIVE. Statements 2 (more common in white women in Western countries), 3 (HNPCC\/Lynch syndrome \u2014 MLH1, MSH2 mutations \u2014 gives ~40-60% lifetime risk, second most common Lynch-associated cancer), and 4 (endometrioid adenocarcinoma ~80% of all endometrial cancers) are all correct. Statements 2, 3, and 4 are correct.'},\n {id:68,stem:\"The reference point 'zero' in POPQ (Pelvic Organ Prolapse Quantification) classification is taken as\",correct:'hymen',options:['ischial spine','perineal body','mid-vagina','hymen'],exp:\"The POPQ (Pelvic Organ Prolapse Quantification) system uses the HYMEN as the fixed reference point (zero landmark). Measurements above (inside) the hymen = negative values. Measurements below (outside) the hymen = positive values. Six specific anatomical points (Aa, Ba, C, D, Ap, Bp) are measured in centimetres relative to the hymen. This allows standardised, reproducible, objective staging. Stage 0: no prolapse. Stage IV: complete procidentia (maximum prolapse). Answer: hymen.\"},\n {id:69,stem:'Which of the following are the various treatment options for Twin-Twin Transfusion Syndrome (TTTS)?\\n1. Septostomy\\n2. Laser photocoagulation\\n3. Selective fetal reduction',correct:'1, 2 and 3',options:['1 and 2 only','2 and 3 only','1 and 3 only','1, 2 and 3'],exp:'Twin-Twin Transfusion Syndrome (TTTS) \u2014 imbalanced blood flow through placental anastomoses in monochorionic twins. Treatment options: (1) Septostomy (needling the dividing membrane \u2014 controversial, equalises amniotic fluid pressures), (2) Selective laser photocoagulation of communicating placental vessels \u2014 current standard of care for Quintero stage II-IV, best outcomes (Senat 2004), (3) Selective fetal reduction (termination of one twin \u2014 last resort for severe, early, or refractory cases). Serial amnioreduction is another option. All three are recognised treatment options. Answer: 1, 2 and 3.'},\n {id:70,stem:'Which of the following drugs should be avoided in labouring women with bronchial asthma?\\n1. Opioid analgesics\\n2. Prostaglandin F2\u03b1\\n3. Prostaglandin E1\\n4. Ergometrine',correct:'2, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Drugs to AVOID in labouring asthmatic women: (2) Prostaglandin F2\u03b1 (carboprost\/15-methyl PGF2\u03b1) \u2014 potent BRONCHOCONSTRICTOR; absolutely contraindicated in asthma; (3) Prostaglandin E1 (misoprostol) \u2014 can cause bronchospasm in susceptible asthmatic patients; (4) Ergometrine\/Ergometrine-oxytocin \u2014 causes bronchospasm via serotonin receptor stimulation; should be avoided. Safe agents: Oxytocin is the agent of choice for PPH prophylaxis. PGE2 (dinoprostone) is a bronchodilator and safe. Opioids (1) may cause histamine release (morphine) but meperidine\/pethidine is frequently used; they are not absolutely contraindicated. Statements 2, 3, and 4 are the agents to avoid.'},\n {id:71,stem:'Which of the following are the complications of malaria in pregnancy?\\n1. Thrombocytopenia\\n2. Metabolic alkalosis\\n3. Hypoglycemia\\n4. Disseminated intravascular coagulation',correct:'1, 3 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Malaria in pregnancy (especially P. falciparum) complications: (1) Thrombocytopenia \u2014 platelet sequestration, immune-mediated destruction; (3) Hypoglycaemia \u2014 increased glucose consumption by parasites + quinine-stimulated insulin release; (4) DIC \u2014 severe falciparum malaria releases tissue factor, activates coagulation cascade. Statement 2 (metabolic alkalosis) is FALSE \u2014 malaria causes METABOLIC ACIDOSIS (lactic acidosis from tissue hypoxia and anaerobic metabolism) and hypoglycaemia-induced acidosis. Additional complications: placental parasitaemia, preterm labour, IUGR, maternal death. Statements 1, 3, and 4 are correct.'},\n {id:72,stem:'Which of the following are correct regarding drospirenone?\\n1. It is a fourth generation progestin.\\n2. It has antiandrogenic property.\\n3. It has antimineralocorticoid action.\\n4. It is safe in renal failure patients.',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Drospirenone: a synthetic progestin derived from 17\u03b1-spirolactone. (1) 4th generation progestin \u2014 correct. (2) Has significant anti-androgenic activity (blocks androgen receptors) \u2014 useful for PCOS, acne, hirsutism \u2014 correct. (3) Antimineralocorticoid activity (similar to spironolactone) \u2014 counteracts aldosterone, preventing fluid retention \u2014 correct. (4) Statement FALSE: due to its antimineralocorticoid\/anti-aldosterone effect, drospirenone promotes potassium retention. In RENAL FAILURE, it can cause dangerous HYPERKALAEMIA \u2014 it is CONTRAINDICATED in renal insufficiency. Statements 1, 2, and 3 are correct.'},\n {id:73,stem:'Which of the following symptoms are related to ectopic pregnancy?\\n1. Acute abdominal pain following amenorrhea\\n2. Abdominal pain with bleeding P\/V\\n3. Fainting attack with shoulder pain\\n4. Painless continuous bleeding',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"Ectopic pregnancy symptoms: (1) Acute abdominal pain following a period of amenorrhoea (6-8 weeks) \u2014 classic presentation of tubal ectopic; (2) Abdominal pain with vaginal bleeding \u2014 the classic 'triad' with amenorrhoea; (3) Fainting attack (syncope from internal haemorrhage) + shoulder tip pain (diaphragmatic irritation from haemoperitoneum \u2192 phrenic nerve irritation) \u2014 indicate rupture. Statement 4 (painless continuous bleeding) is characteristic of PLACENTA PRAEVIA, NOT ectopic pregnancy \u2014 ectopic bleeding is irregular and usually accompanied by pain. Statements 1, 2, and 3 are correct.\"},\n {id:74,stem:'Premenstrual Syndrome (PMS) should fulfil which of the following criteria?\\n1. It is not related to any organic lesion.\\n2. It regularly occurs during the luteal phase and each ovulatory menstruation cycle.\\n3. Symptoms must be severe enough to disturb the lifestyle of women and seeks medical help.\\n4. Symptoms persist after the period also.',correct:'1, 2 and 3',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'PMS diagnostic criteria: (1) No underlying organic pathology (functional, not structural) \u2014 correct; (2) Cyclical occurrence restricted to the luteal phase (after ovulation), resolving with menstruation \u2014 correct; (3) Symptoms severe enough to cause functional impairment and require medical attention \u2014 correct. Statement 4 is FALSE: PMS symptoms RESOLVE with menstruation onset (within 4 days). If symptoms PERSIST after the period, the diagnosis shifts to PMDD or another psychiatric\/medical condition. The cessation of symptoms with menstruation is a defining diagnostic criterion.'},\n {id:75,stem:'Which of the following statements are correct regarding constriction ring?\\n1. Premature rupture of membranes is a high risk factor.\\n2. It is situated at the junction of upper and lower uterine segment.\\n3. Uterus never ruptures.\\n4. The ring is felt per abdomen.',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Constriction ring (pathological retraction ring): (1) PROM is a risk factor (dry labour, forceful contractions on empty uterus) \u2014 correct; (2) Located at the junction of upper and lower uterine segments (not necessarily at the equator of the fetus) \u2014 correct; (3) Statement FALSE: uterine rupture CAN and DOES occur if the constriction ring is not relieved \u2014 it is a risk, not an impossibility; (4) The ring is palpable per abdomen as a transverse band \u2014 correct. Note: Bandl\\'s ring (physiological retraction ring) is the exaggerated pathological form visible\/palpable per abdomen. Statements 1, 2, and 4 are correct.'},\n {id:76,stem:'A patient delivered a live healthy baby 4 hours back. Now she has developed persistent severe pain in the perineal region and rectal tenesmus. Local examination reveals a tense and tender purple swelling at the vulva. What is her probable diagnosis?',correct:'Pelvic hematoma',options:['Cervical tear','Perineal tear','Pelvic hematoma','Ruptured uterus'],exp:'Tense, tender, purple\/bluish swelling at the vulva in the immediate postpartum period with pain and rectal tenesmus (from pressure) = VULVAR\/PARAVAGINAL HAEMATOMA (pelvic haematoma). This occurs from injury to blood vessels (pudendal vessels) during delivery without external laceration. The blood accumulates in the loose areolar tissue of the vulva\/ischiorectal fossa. Small haematomas can be managed conservatively; large haematomas require surgical evacuation and haemostasis. Ruptured uterus would present with haemodynamic compromise; perineal tear is visible.'},\n {id:77,stem:'Which of the following are included in the management of cord prolapse during delivery?\\n1. Bladder emptying\\n2. Knee-chest position of the patient\\n3. Preferably caesarean delivery\\n4. Lifting up the presenting part of the cord',correct:'2, 3 and 4',options:['2 and 3 only','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:\"Cord prolapse management: (2) Knee-chest (or Trendelenburg) position \u2014 gravity relieves cord compression; (3) Emergency CS if not fully dilated (most cases) \u2014 correct; (4) Digital elevation of the PRESENTING PART (fetal head\/buttocks) to relieve cord compression \u2014 correct (note: statement says 'presenting part of the cord' but clinical practice is to elevate the fetal presenting part off the cord). Statement 1 (bladder EMPTYING) is INCORRECT \u2014 management uses RETROGRADE BLADDER FILLING (500 mL saline retrograde via catheter) to elevate the fetal presenting part. Bladder emptying would do the opposite. Statements 2, 3, and 4 are correct.\"},\n {id:78,stem:'Which of the following statements have obstetric significance at the level of plane of least pelvic dimensions?\\n1. It is a landmark used for pudendal nerve block analgesia.\\n2. Deep transverse arrest usually occurs at this plane.\\n3. It is at this plane that the internal rotation of the fetal head occurs during labour.\\n4. It marks the beginning of the backward curve of the pelvic axis.',correct:'1, 2 and 4',options:['1, 2 and 3','1, 2 and 4','1, 3 and 4','2, 3 and 4'],exp:'Plane of least pelvic dimensions (midpelvis at level of ischial spines): (1) Ischial spines are the landmark for PUDENDAL nerve block analgesia (injection lateral to ischial spines) \u2014 correct; (2) Deep transverse arrest occurs at the midpelvis when the occiput fails to rotate \u2014 correct; (4) The backward curve of the pelvic axis begins here (pelvic axis curves posteriorly) \u2014 correct. Statement 3 is FALSE: internal rotation of the fetal head occurs as the head descends to the PELVIC FLOOR (at the outlet level, not at the midpelvis plane of least dimensions). Statements 1, 2, and 4 are correct.'},\n {id:79,stem:'Which surgery is most likely to disturb the paracervical nerve plexus resulting in atonicity of the bladder?',correct:'Radical hysterectomy',options:['Vaginal hysterectomy','Radical hysterectomy','Simple hysterectomy','Myomectomy'],exp:\"Radical hysterectomy (Wertheim's operation) for cervical cancer involves excision of the parametrium, upper vagina, and paracervical tissues \u2014 which contain the inferior hypogastric plexus (pelvic plexus \/ paracervical nerve plexus). Damage to these autonomic fibres (which supply the bladder detrusor and internal sphincter) causes voiding dysfunction: bladder atonicity, urinary retention, overflow incontinence. This is the most significant urological complication of radical hysterectomy (~20-40% of patients). Simple hysterectomy and vaginal hysterectomy rarely disturb these deep nerve plexuses.\"},\n {id:80,stem:'The patency of fallopian tubes can be clinically tested by which of the following methods?\\n1. Sonosalpingogram\\n2. Hysterosalpingogram\\n3. CT scan\\n4. Laparoscopic chromotubation',correct:'1, 2 and 4',options:['1, 2 and 4','1, 3 and 4','1, 2 and 3','2, 3 and 4'],exp:'Fallopian tube patency tests: (1) Sonosalpingography (HyCoSy \u2014 Hysterocontrast Sonography) \u2014 instils contrast or air under ultrasound guidance \u2014 effective outpatient test; (2) Hysterosalpingogram (HSG) \u2014 fluoroscopic X-ray with contrast through the cervix \u2014 gold standard for outpatient tubal assessment; (4) Laparoscopic chromotubation (direct visualisation + methylene blue dye instillation through cervix) \u2014 gold standard overall but invasive. CT scan (3) is NOT a standard test for tubal patency \u2014 it exposes the patient to radiation and cannot reliably assess dynamic patency. 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